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Chapter list for your book:
UNIT 1 Principles of Nursing Practice
Chapter 1
Professional Nursing Practice
Chapter 2
Medical-Surgical Nursing
Chapter 3
Health Education and Health Promotion
Chapter 4
Adult Health and Physical, Nutritional, and Cultural Assessment
Chapter 5
Stress and Inflammatory Responses
Chapter 6
Genetics and Genomics in Nursing
Chapter 7
Disability and Chronic Illness
Chapter 8
Management of the Older Adult Patient
UNIT 2 Concepts and Principles of Patient Management
Chapter 9
Pain Management
Chapter 10
Fluid and Electrolytes
Chapter 11
Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Chapter 12
Oncologic Management
Chapter 13
Palliative and End-of-Life Care
UNIT 3 Perioperative Concepts and Nursing Management
Chapter 14
Preoperative Nursing Management
Chapter 15
Intraoperative Nursing Management
Chapter 16
Postoperative Nursing Management
UNIT 4 Gas Exchange and Respiratory Function
Chapter 17
Assessment of Respiratory Function
Chapter 18
Management of Patients With Upper Respiratory Tract Disorders
Chapter 19
Management of Patients With Chest and Lower Respiratory Tract Disorders
Chapter 20
Management of Patients With Chronic Pulmonary Disease
UNIT 5 Cardiovascular and Circulatory Function
Chapter 21
Assessment of Cardiovascular Function
Chapter 22
Management of Patients With Arrhythmias and Conduction Problems
Chapter 23
Management of Patients With Coronary Vascular Disorders
Chapter 24
Management of Patients With Structural, Infectious, and Inflammatory Cardiac Disorders
Chapter 25
Management of Patients With Complications From Heart Disease
Chapter 26
Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation
Chapter 27
Assessment and Management of Patients With Hypertension
UNIT 6 Hematologic Function
Chapter 28
Assessment of Hematologic Function and Treatment Modalities
Chapter 29
Management of Patients With Nonmalignant Hematologic Disorders
Chapter 30
Management of Patients With Hematologic Neoplasms
UNIT 7 Immunologic Function
Chapter 31
Assessment of Immune Function
Chapter 32
Management of Patients With Immune Deficiency Disorders
Chapter 33
Assessment and Management of Patients With Allergic Disorders
Chapter 34
Assessment and Management of Patients With Inflammatory Rheumatic Disorders
UNIT 8 Musculoskeletal Function
Chapter 35
Assessment of Musculoskeletal Function
Chapter 36
Management of Patients With Musculoskeletal Disorders
Chapter 37
Management of Patients With Musculoskeletal Trauma
UNIT 9 Digestive and Gastrointestinal Function
Chapter 38
Assessment of Digestive and
Chapter 39
Management of Patients With Oral and Esophageal Disorders
Chapter 40
Management of Patients With Gastric and Duodenal Disorders
Chapter 41
Management of Patients With Intestinal and Rectal Disorders
UNIT 10 Metabolic and Endocrine Function
Chapter 42
Assessment and Management of Patients With Obesity
Chapter 43
Assessment and Management of Patients With Hepatic Disorders
Chapter 44
Management of Patients With Biliary Disorders
Chapter 45
Assessment and Management of Patients With Endocrine Disorders
Chapter 46
Management of Patients With Diabetes
UNIT 11 Kidney and Urinary Tract Function
Chapter 47
Assessment of Kidney and Urinary Function
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Chapter 48
Management of Patients With Kidney Disorders
Chapter 49
Management of Patients With Urinary Disorders
UNIT 12 Reproductive Function
Chapter 50
Assessment and Management of Patients With Female Physiologic Processes
Chapter 51
Management of Patients With Female Reproductive Disorders
Chapter 52
Assessment and Management of Patients With Breast Disorders
Chapter 53
Assessment and Management of Patients With Male Reproductive Disorders
Chapter 54
Assessment and Management of Patients Who Are LGBTQ
UNIT 13 Integumentary Function
Chapter 55
Assessment of Integumentary Function
Chapter 56
Management of Patients With Dermatologic Disorders
Chapter 57
Management of Patients With Burn Injury
Assessment and Management of Patients With Eye and Vision Disorders
Chapter 59
Assessment and Management of Patients With Hearing and Balance
Disorders
UNIT 15 Neurologic Function
Chapter 60
Assessment of Neurologic Function
Chapter 61
Management of Patients With Neurologic Dysfunction
Chapter 62
Management of Patients With Cerebrovascular Disorders
Chapter 63
Management of Patients With Neurologic Trauma
Chapter 64
Management of Patients With Neurologic Infections, Autoimmune
Disorders, and Neuropathies
Chapter 65
Management of Patients With Oncologic or Degenerative Neurologic
Disorders
UNIT 16 Acute Community Based Challenges
Chapter 66
Management of Patients With Infectious Diseases
Chapter 67
Emergency Nursing
Chapter 68
Disaster Nursing
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UNIT 1 PRINCIPLES OF NURSING PRACTICE
Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 1: Professional Nursing Practice
When the nurse encourages a patient with heart failure to alternate rest and activity periods to reduce cardiac
workload, which phase of the nursing process is being used?
Planning
Diagnosis
Evaluation
Implementation
D. Implementation
Carrying out a specific, individualized plan constitutes the implementation phase of the nursing process. The nurse's
action of encouragement and instruction to the patient is part of carrying out a plan of action.
When planning care for a patient, the nurse may use a visual diagram of patient problems and interventions to
illustrate the relationships among pertinent clinical data. This format is called a
concept map.
critical pathway.
clinical pathway.
nursing care plan.
A. concept map
A concept map is another method of recording a nursing care plan. In a concept map, the nursing process is recorded in
a visual diagram of patient problems and interventions. A clinical (critical) pathway is a prewritten plan that directs the
entire interprofessional care team in the daily care goals for select health care problems.
A nurse is providing care for a patient who had a transurethral resection of his prostate this morning. The patient is
receiving continuous bladder irrigation, and the urinary catheter is now occluded. The nurse is planning to contact
the patientts health care provider and communicate using the SBAR (Situation-Background-AssessmentRecommendation) format. Which statement is a component of communication using SBAR?
"What do you think could be causing this occlusion?"
"I think that we should manually irrigate his catheter."
"What do you know about this patient and his history?"
"Could you please provide some direction for his care?"
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B."I think that we should manually irrigate his catheter."
Proposing a recommendation is a component of the "R" component of SBAR communication. Asking the health care
provider for possible contributing factors to the problem or for general direction may be appropriate in some
circumstances, but these are not explicit components of SBAR. The nurse should briefly identify the patient and his
circumstances, not ask an open-ended question regarding the health care provider's familiarity.
What factor has been most clearly identified as an influence on the future of nursing practice?
Aging of the American population and increases in chronic illnesses Correct
Increasing birth rates coupled with decreased average life expectancy
Increased awareness of determinants of health and improved self-care
Apathy around health behaviors and the relationship of lifestyle to health
A. Aging of the American population and increases in chronic illnesses
The American population is aging at the same time that the incidence of chronic health conditions is increasing. There is
no noted increase in the overall awareness of the determinants of health, but at the same time, observers have not
identified apathy as a predominant attitude. Life expectancy is increasing, not decreasing.
A registered nurse (RN) has delegated the administration of IV medications to a licensed practical/vocational nurse
(LPN/LVN). Which statement accurately describes delegation?
The RN must teach the LPN how to administer the IV medications.
Ultimate responsibility for administering the medication lies with the LPN..
The RN is responsible for observing the LPN administer the IV medication
The RN is the one accountable for the quality of care that the patient receives.
D. The RN is the one accountable for the quality of care that the patient receives.
Delegation entails a redistribution of nursing work, but the RN remains ultimately responsible and accountable for the
execution of the task. It would be inappropriate to delegate if the LPN was unfamiliar with the task. The RN is not obliged
to observe the LPN's execution of the task.
In which patient care delivery model does the nurse plan and coordinate the aspects of patient care with other
disciplines focusing on continuity of care and interprofessional collaboration even if the nurse is absent?
Team nursing model
Primary nursing model
Total patient care model
Case management nursing model
B. Primary nursing model
The primary nursing model includes planning the patient's care and coordinating and communicating all aspects of care
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with other disciplines and those providing care in the nurse's absence. The focus is on continuity of care and
interprofessional collaboration. Team nursing uses the RN as the team leader to organize and manage the care for a
group of patients with other ancillary workers. The RN has authority and accountability for the quality of care delivered by
the team only during the work period. In a total patient care model, the nurse is accountable for the complete care of the
patient during the assigned shift. Case management is not a model of care delivery but a collaborative process that
involves assessing, planning, facilitating, and advocating for health services with a variety of resources to promote costeffective outcomes.
A nurse with an associate or baccalaureate degree who meets licensing requirements is qualified to practice as
a nurse practitioner.
a certified specialist.
an entry-level generalist.
an advanced practice nurse.
C. an entry-level generalist
Entry-level nurses with an associate or baccalaureate degree are prepared to function as generalists. With experience and
continued study, nurses may specialize in an area of practice and may obtain certification in nursing specialties.
Certification usually requires clinical experience and successful completion of an examination. A nurse practitioner is an
example of an advanced practice nurse. An advanced practice nurse has a minimum of a master's degree with advanced
education in pharmacology and physical assessment as well as expertise in a specialized area of practice.
When nurses disagree about the effectiveness of a commonly practiced nursing intervention, the best evidence for
determining which intervention to use is
A. a systematic review of randomized controlled trials. B. a qualitative research study with a large sample size
C. a methodological Internet search using key medical terms.
D. anecdotal evidence retrieved from two or more case studies.
A. a systematic review of randomized controlled trials.
Systematic reviews of randomized controlled trials (RCTs) are considered the strongest level of evidence to answer
questions about interventions (i.e., cause and effect).
The nurse establishes priorities and determines outcomes for an individual patient during which phase of the
nursing process?
Analysis
Planning
Evaluation
Assessment
B. Planning
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During the planning phase of the nursing process, patient outcomes or goals are developed and nursing interventions are
identified to accomplish the outcomes. The assessment phase of the nursing process includes the collection of subjective
and objective patient information on which to base the plan of care. The evaluation phase of the nursing process
determines if the patient outcomes have been met as a result of nursing interventions. Nursing diagnosis is the act of
analyzing the assessment data and making a judgment about the nature of the data.
A nurse is monitoring all of the patients in an outpatient procedure area for complications of administering IV
fluids. What type of nursing function is being demonstrated by the nurse?
Dependent
Independent
Autonomous
Collaborative
D. Collaborative
A collaborative nursing function is demonstrated when the nurse monitors patients for complications of acute illness,
administers IV fluids and medications per health care provider's orders, and implements nursing interventions such as
providing emotional support or teaching about specific procedures. Nursing functions may be dependent, collaborative, or
independent. The nurse functions dependently when carrying out medical orders. Physician-initiated nursing functions may
include administering medications, performing or assisting with certain medical treatments, and assisting with diagnostic
tests and procedures. Independent nursing functions include interventions such as promotion and optimization of health,
prevention of illness, and patient advocacy.
A patient is being prepared for discharge home after a laparoscopic cholecystectomy. Which team member can be
assigned to complete a discharge assessment and provide patient teaching for post-discharge care?
Registered nurse (RN)
Nursing technician (NT)
Unlicensed assistive personnel (UAP)
Licensed practical/vocational nurse (LPN/LVN)
A. Registered nurse (RN)
Nursing interventions that require independent nursing knowledge, skill, or judgment such as assessment, patient
teaching, and evaluation of care cannot be delegated. These interventions are the responsibility of the RN. The scope of
practice for LPN/LVNs is determined by each state board of nursing. The RN must know the legal scope of
practical/vocational nursing practice and delegates and assigns nursing functions appropriately. In most states LPN/LVNs
may administer medications, perform sterile procedures, and provide a wide variety of interventions planned by the RN.
UAP are unlicensed individuals who serve in an assistive role to the RN and may include nursing assistants or
technicians. The RN may delegate specific activities such as obtaining routine vital signs on stable patients,
feeding/assisting patients at mealtimes, ambulating stable patients, and helping patients with bathing and hygiene.
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A group of nurses has a plan to implement evidence-based practice (EBP) for care of patients with pressure ulcers.
What will this change in practice encompass (select all that apply.)?
Consulting with the wound care and ostomy nurse
Nursest expertise and bodies of experience and knowledge C. The preferences of patients and their particular
circumstances
D. The traditions that surround pressure ulcer practices on the unit.
E. Journal articles that address the care of patients with pressure ulcers
Consulting with the wound care and ostomy nurse
Nurses' expertise and bodies of experience and knowledge
The preferences of patients and their particular circumstances
E. Journal articles that address the care of patients with pressure ulcers
EBP draws on research, data from local quality improvement, professional organization standards, patient preferences,
and clinical expertise. The particular traditions on the nursing unit are not part of EBP.
Telehealth devices are commonly used to provide which types of patient care (select all that apply.)?
Evaluation of weight loss
Medication administration
Video assessment of wounds
Monitoring peak flow meter results
Real-time blood pressure assessment
A. Evaluation of weight loss
Video assessment of wounds
Monitoring peak flow meter results
Real-time blood pressure assessment
Telehealth enables the nurse to provide distance assessment, planning, intervention, and evaluation of outcomes of
nursing care using technologies such as the Internet, digital assessment tools, and telemonitoring equipment. Among the
many uses of telehealth are monitoring patients with chronic or critical conditions and helping patients manage symptoms.
Which interventions are independent nursing actions (select all that apply.)?
Reinserting an IV
Assessing lung sounds
Obtaining informed consent
Administering IV medication
Turning a patient every two hours
Reinserting an IV
Assessing lung sounds
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E. Turning a patient every two hours
Independent nursing actions are those that a nurse is legally able to order or begin independently (e.g., turn every two
hours, monitor for complications). Dependent interventions are physician-initiated. Medication administration is
collaborative care as the health care provider must order the medication. The health care provider legally must obtain
informed consent from the patient, although the nurse may witness the consent.
A patient with coronary artery disease is admitted to the hospital. An electronic health record (EHR) is generated for
the patient. Which information will be present in the EHR? Select all that apply.
Medications
Laboratory data
Financial background
Educational qualifications
Medical and surgical history
Medications
Laboratory data
Medical and surgical history
The electronic health record (EHR) is a computerized record of protected health information (PHI). It includes information
such as patient demographics, progress notes, problems and medications, vital signs, medical history, immunizations, and
laboratory and radiology reports. The educational qualifications of the patient are not included in EHR. Similarly, the
financial background of the patient is not mentioned in the EHR.
When planning care for a patient, the nurse may use a visual diagram of patient problems and interventions to
illustrate the relationships among pertinent clinical data. What is this format called?
Concept map
Critical pathway
Clinical pathway
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Nursing care plan
Concept map
A concept map is another method of recording a nursing care plan. In a concept map, the nursing process is recorded in
a visual diagram of client problems and interventions. A clinical (critical) pathway is a prewritten plan that directs the entire
health care team in the daily care goals for select health care problems. A nursing care plan is a documented plan of care
for a patient.
A nurse is dispensing medications to patients. What precaution should the nurse take to ensure the safe use of
medications?
Discard all unlabeled medicines.
Use hand sanitizer only after contact with the patient.
To increase efficiency, place the medicines for the next dose at the bedside.
To verify that medicines have been checked, relabel medicines which already have a label provided by Pharmacy.
Discard all unlabeled medicines.
The nurse should discard all unlabeled medicines to ensure the safety of medications. Unlabeled medicines are difficult to
identify. The nurse should avoid placing medicines that are scheduled for a later time at the bedside; the patient may
accidentally consume them and this may result in an overdose. Relabeling medicines that are already labeled should be
avoided because it can lead to inaccurate administration. Soap, water, and hand sanitizer should be used before and after
contact with the patient to reduce the risk of infections.
The nurse is reviewing the use of linkages among NANDA-I nursing diagnoses, Nursing Outcomes Classification
(NOC) patient outcomes, and Nursing Interventions Classification (NIC) nursing interventions. Which statement
best describes the use of these linkages?
They are used to evaluate data.
They help the nurse to predict the results of nursing care.
They provide guidance and are the basis for planning care.
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These linkages help to reduce the length of written care plans.
They provide guidance and are the basis for planning care.
NANDA, Nursing Outcomes Classification (NOC), and Nursing Interventions Classification (NIC) (NNN) linkages show how
the three distinct nursing terminologies can be connected and used together when planning care for patients. Linkages
may assist in planning nursing care by determination of a nursing diagnosis, projection of a desired outcome, or selection
of interventions to achieve the desired outcome. The linkages are not used to evaluate data, to predict the results of
nursing care, or to reduce the length of written care plans.
According to the American Nurses Association (ANA), to which of these should nursing diagnosis and treatment be
directed?
Patient complaints and concerns
Signs and symptoms of the health issue
Medical diagnoses upon presentation for care
Human response to actual or potential health problems
Human response to actual or potential health problems
The American Nurses Association (ANA) defines nursing as dealing with the human response to health issues, not
specifically medical diagnoses, signs and symptoms, or patient complaints and concerns. Although these may be related
to or contribute to the human response, by this definition nurses deal with the human response.
Which of the following provides nursing interventions that are selected to achieve patient outcomes for which
nursing is accountable?
Nursing diagnosis
Nursing assessment
NANDA International (NANDA-I)
Nursing Outcomes Classification (NOC)
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Nursing diagnosis
The nursing diagnosis provides nursing interventions that are selected to achieve patient outcomes for which nursing is
accountable. NANDA-I is the organization that develops and maintains the standard classification system for nursing
diagnosis. The nursing assessment is part of the nursing process. The NOC is a list of patient outcomes developed to
evaluate the effects of interventions provided by nurses.
What communication tool will the nurse utilize to provide safe, effective care when reporting a change in a patientts
condition?
Clinical pathway
Nursing care plan
Nursing diagnosis
Situation-Background-Assessment-Recommendation (SBAR) tool
Situation-Background-Assessment-Recommendation (SBAR) tool
The SBAR tool is a structured technique that provides a way for members of the healthcare team to talk about a patient's
condition. A nursing diagnosis provides a basis for selecting nursing interventions to achieve patient outcomes for which a
nurse is accountable. A nursing care plan is a guide for routine nursing care. A clinical pathway is an interprofessional
nursing care plan that specifies care and desired outcomes during a specific time period for patients with particular
diagnoses or health conditions.
What is a serious reportable event (SRE)?
A serious reportable event is an event that happens to a patient that is considered preventable and can affect
reimbursement to the health care organization from insurance companies. Health care error event, adverse health care
event, and serious preventable event are not terms that refer to an event that happens to a patient and is considered
preventable.
On what do the nursing terminologies, Nursing Interventions Classification (NIC), NANDA International (NANDA-I),
and Nursing Outcomes Classification (NOC) specifically focus?
Specific phases of the nursing process
The nursing terminologies, Nursing Interventions Classification (NIC), NANDA International (NANDA-I), and Nursing
Outcomes Classification (NOC) focus on the specific phases of the nursing process. Quality patient care relates to highquality healthcare. A nursing care plan provides an individualized plan of care for a patient. Classifications of outcomes
are in the Nursing Outcomes Classification (NOC), which is a list of patient outcomes developed to evaluate the effects of
interventions provided by nurses.
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What is case management?
Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and
advocacy for options and services to meet an individual's and family's comprehensive health needs through
communication and available resources to promote quality, cost-effective outcomes. Primary care is a holistic approach
involving one nurse caring for a patient or family. Team care is the distribution of aspects of patient care among a team of
health care professionals, often composed of a registered nurse, licensed practical nurse, and unlicensed assistive
personnel. The interprofessional team is composed of providers from various healthcare disciplines, working together and
sharing ideas to meet the needs of individual patients.
A patient is hospitalized for the treatment of asthma. Which phases of the nursing process are required for
complete analysis of the patient? Select all that apply.
Planning
Evaluation
Assessment
Rehabilitation
Implementation
Nursing diagnosis
Assessment, Diagnosis, Planning, Implementation, Evaluation
The nursing process consists of five phases. All five phases are involved in the complete analysis of the patient.
Assessment is the first phase of the nursing process. This process involves collection of subjective and objective
information of the patient. The second phase is nursing diagnosis, which is helpful for identifying the health problem. The
third phase is planning. In this phase, the nursing diagnosis directs the development of patient outcomes or goals. It helps
in the identification of nursing interventions to accomplish nursing outcomes. The fourth phase is implementation. It is the
process of activation of the plan with the use of nursing interventions. The last phase is evaluation, which is a continual
activity in the nursing process. Rehabilitation is not a part of the nursing process framework.
What activities contributing to leadership fall under the scope of professional nursing practice? Select all that
apply.
Prescription of drug therapies
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Diagnosis of medical conditions
Assessment of patients, families, and communities
Administration of interventions to help resolve issues
Participation in an interprofessional health care team
Assessment of patients, families, and communities
Administration of interventions to help resolve issues
Participation in an interprofessional health care team
The essential core of nursing practice is to deliver holistic, patient-centered care. It includes assessment and evaluation,
administration of a variety of interventions, patient and family teaching, and participation in an interprofessional health care
team. Diagnosis of medical conditions is the role of the primary health care provider or advanced practice personnel as is
prescription of drug therapies. Diagnosis and prescription are legally out of the nurse's scope of practice.
A nurse has worked on an ortho unit for several years and Is encouraged by the nurse manager to get certified in
ortho nursing. What will the certification require/provide? Select all that apply.
A certain amount of clinical experience
Successful completion of an exam
membership in specialty nursing organizations
d. professional recognition of expertise in a specialty area
e. an advanced practice role that requires graduate education
A. A certain amount of clinical experience
B. Successful completion of an exam
d. professional recognition of expertise in a specialty area
When guiding nurses in how to perform professionally, which describes a competent level of nursing care based on
the nursing process?
A. standards of professional perfromance
standards of practice
quality and safety education for nurses
state nurse practice act
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b. standards of practice
6 competencies from QSEN expected of new nursing grads
pt centered care
teamwork & collaboration
safety
quality improvement
informatics
EBP
Steps of EBP process
Ask a clinically meaningful question
Collect the evidence
Critically appraise/analyza the evidence
Use evidence, clinical expertise & pt preferences to determine care
Evaluate outcomes
Make recommendations for practice/generate data
PICOT
Population
Intervention
Comparison
Outcome
Time
which standardized nursing terminologies specifically relate to steps of the nursing progress? Select all that apply
Omaha system
Nurising minimum data set (NMDS)
Perioperative nursing data set (PNDS)
Nursing outcomes classification (NOC)
Nursing interventions classification (NIC)
NANDA International nursing dx
Nursing outcomes classification (NOC)
Nursing interventions classification (NIC)
NANDA International nursing dx
Assessment phase
data collection
Diagnosis phase
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analysis of data
identifying pt strengths
identifying health problems
Planning phase
priority setting
setting goals
implementation phase
nursing interventions
documenting care provided
evaluation phase
measuring pt achievement goals
modifying plan of care5
rights of delegation
right task
right person
right circumstance
right supervision & evaluation
right directions & communication
Nursing Care Plan descr.
used as guides for routine nursing care
used in nursing education to teach nursing process and care planning
should be personalized & specific to each pt
Concept map descr.
used in nursing education to teach nursing process and care planning
a visual diagram respersneting relationships among pt problems, interventions & data
clinical pathway
a plan that directs an entire healthcare team
a description of pt care needed at specific times during tx
used for high volume or high risk & predictable case types
example of nursing activity that best reflects ANA definition of nursing
treating dysrythmias that occur in a pt in the coronary care unit
dx a pt with a feeding tube as being at risk for aspiration
setting up protocols for tx pts in the ED
offering anti anxiety drugs to a pt with a disturbed sleep pattern
B. dx a pt with a feeding tube as being at risk for aspiration
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a nurse working on the med-surg unit would like to become certified in med-surg nursing. This would require
a bachelorts degree in nursing
formal education in advanced practice nursing
experience for a specific period in medsurg
membership in a med surg nursing specialty organization
C. experience for a specific period in medsurg
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Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 2: Medical-Surgical Nursing
The nurse navigator is coordinating the transition from the hospital to a rehabilitation facility of a client who had a
total hip replacement. Which activity would be an example of the nurse navigator role for this client?
Ensuring cost-effective care
Communicating with the medical insurance company
Educating the client on the goals of rehabilitation
Providing direct care to the client
C
The nursing instructor is preparing a group of students for their home care rotation. Which of the following types of
care are the students most likely to provide?
Primary care
Assistance with food shopping
Performing household chores
Skilled nursing care
D
The community health nurse is preparing to conduct a home visit on a client without an active infection. When
performing the home visit, how should the nurse best implement the principles of infection control?
Perform hand hygiene before and after giving direct client care.
Remove the clientts soiled wound dressings from the home promptly.
Use transmission-based precautions with the client.
Establish a sterile field in the clientts home before providing care.
A
An adult client with a history of diabetes is scheduled for a transmetatarsal amputation. When should the clientts
discharge planning begin?
The day prior to discharge
The day of estimated discharge
The day that the client is admitted
Once the nursing care plan has been finalized
C
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A home health nurse is preparing to make the initial visit to a new clientts home. When planning educational
interventions, what information should the nurse provide to the client and family? Select all that apply.
Available community resources to meet their needs
Information on other clients in the area with similar health care needs
The nursets contact information
Dates and times of scheduled home care visits
The goals of care established by the nurse
A, C, D
At the beginning of a day that will involve several home visits, the nurse has ensured that the health care agency
has a copy of the nursets daily schedule. What is the rationale for this action?
It allows the agency to keep track for billing purposes.
It supports safety precautions for the nurse when making a home care visit.
It allows for greater flexibility for the nurse and colleagues for changes in assignments.
It allows the client to cancel or change appointments with minimal inconvenience.
B
There are specific legal guidelines and regulations for the documentation related to home care. When providing
care for a client who is a Medicaid recipient, what is most important for the nurse to document?
The medical diagnosis and the supplies needed to care for the client
A summary of the clientts income tax paid during the previous year
The specific quality of nursing care that is needed
The clientts homebound status and the specific need for skilled nursing care
D
A client has had a total knee replacement and will need to walk with a two-wheeled walker for 6 weeks. The client is
being discharged home with a referral for home health care. What assessment should the nurse prioritize during
the initial nursing assessment in the home?
Assistance of family and neighbors
Qualification for government subsidies
Costs related to the visits
Characteristics of the home environment
D
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A nurse who has an advanced degree in primary care for a pediatric population is employed in a health clinic. In
what role is this nurse functioning?
Nurse practitioner
Case coordinator
Clinical nurse specialist
Clinic supervisor
A
A masterts degree-prepared nurse is helping other nurses on a medical-surgical unit integrate evidence and
research into their practice. Which role is this nurse performing?
Case manager
Clinical nurse leader
Nurse navigator
Critical care nurse
B
A recent nursing school graduate has chosen to pursue a community nursing position because of increasing
opportunities for nurses in community settings. What change(s) in the American health care system have created
an increased need for nurses to practice in community-based settings? Select all that apply.
Tighter insurance regulations
Younger population
Increased rural population
Changes in federal legislation
Decreasing hospital revenues
A, D, E
A nursing student has taught a colleague that nursing practice is not limited to hospital settings, explaining that
nurses are now working in ambulatory health clinics, hospice settings, and homeless shelters and clinics. What
factor has most influenced this increased diversity in practice settings for nurses?
Population shift to more rural areas
Shift of health care delivery into the community
Advent of primary care clinics
Increased use of rehabilitation hospitals
B
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A nurse is collaborating with a team of community nurses to identify the vision and mission for community care.
What is the central focus of nursing?
Increased health literacy in the community
Distributing ownership for the health of the community
Promoting and maintaining the health of individuals and families
Identifying links between lifestyle and health
C
A nurse provides community-based care and acts as the case manager for a small town about 60 miles (100 km)
from a major health care center. When planning care in the community, what is the most important variable in
community-based nursing that the nurse should integrate into planning?
Eligibility requirements for services
Community resources available to clients
Transportation costs to the medical center
Possible charges for any services provided
B
The community-based care manager works in a medium-sized community that does not have an up-to-date
discharge planning directory, so the nurse has been given the task of beginning to compile one. What will need to
be included with the discharge plan? Select all that apply.
Links to online health sciences journals
Collaboration of referring agency with community resources
Eligibility requirements for services
Lists of the most commonly used resources
Discharge plan communication
B, C, D, E
The nurse is assessing a new client and the clientts home environment following a referral for community-based
care. What action should the nurse prioritize during this initial visit?
Help the client and family to become more involved in their community.
Encourage the client and family to delegate someone to contact community resources.
Educate the client and family about how to evaluate online supports.
Encourage the client and family to connect with appropriate community resources.
D
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A community-based case manager is sending a community nurse to perform an initial home assessment of a newly
referred client. To ensure safety, the case manager must make the nurse aware of which of the following?
The potential for at-risk working environments
Self-defense strategies
Locations of emergency services in the area
Standard precautions for infection control
A
A home health nurse is making a visit to a new client who is receiving home care following a mastectomy. During
the visit, the clientts husband arrives home in an intoxicated state and speaks to both the nurse and the client in an
abusive manner. What is the nursets best response?
Ignore the husband and focus on the client.
Return to the agency and notify the supervisor.
Call 911 immediately.
Remove the client from the home immediately.
B
The community-health nurse has received a referral for a new client who resides in a high-crime area. What is the
most important request that the nurse should make of the agency to ensure safety?
An early morning or late afternoon appointment
An assigned parking space in the neighborhood
A colleague to accompany the nurse on the visit
Someone to wait in the car while the nurse makes the visit
C
A home health nurse is admitting a new client to home care services. Which action(s) should the nurse perform
during medication reconciliation? Select all that apply.
Check for duplicate medications.
Assess for use of herbal remedies.
Encourage the use of multiple pharmacies
Check that the correct dose is being administered.
Assure the proper frequency of administration.
A, B, D, E
The nurse is performing initial visits to two new clients of the local home health care service. These clients live
within two blocks of each other and both homes are in a high-crime area. What action best protects the nursets
personal safety?
Drive a car that is hard to break into.
Keep your satchel close at hand at all times.
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Do not leave anything in the car that might be stolen.
Do not wear expensive jewelry.
D
In 2 days the nurse is scheduled to discharge a client home after left hip replacement. The nurse has initiated a
home health referral and met with a team of people who have been involved with this clientts discharge planning.
Knowing that the client lives alone, who would be appropriate people to be on the discharge planning team? Select
all that apply.
Home health nurse
Physical therapist
Pharmacy technician
Social worker
Meals-on-Wheels provider
A, B, D
A home health nurse is conducting a home visit to a client who receives wound care twice weekly for a diabetic foot
ulcer. While performing the dressing change, the nurse realizes that the nurse has forgotten to bring the adhesive
gauze specified in the wound-care regimen. What is the nursets best action?
Phone a colleague to bring the required supplies as soon as possible.
Improvise, if possible, using sterile gauze and adhesive tape.
Leave the wound open to air and teach the client about infection control.
Schedule a return visit for the following day.
B
The hospital nurse is planning for a clientts discharge. What is the initial action the nurse should take when
planning discharge for a client?
Identifying the clientts specific needs
Making a social services referral
Getting physical therapy involved in care
Asking the dietitian to meet with the client
A
Within the public health system there has been an increased demand for medical, nursing, and social services. The
nurse should recognize what phenomenon as the basis for this increased demand?
Increased use of complementary and alternative therapies
The growing number of older adults in the population
The rise in income disparity
Increasing profit potential for home health services
B
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Nursing care is provided in an increasingly diverse variety of settings. Despite the variety in settings, some
characteristics of professional nursing practice are required in any and every setting. These characteristics
include:
advanced education.
certification in a chosen specialty.
cultural competence.
independent practice.
C
The nurse is planning discharge for a client receiving Medicare. The Medicare program facilitates what aspect of
home health care for the client?
Providing care without the oversight of a health care provider
Writing necessary medication orders for the client
Prescribing physical, occupational, and speech therapy if needed
Providing outcome-based client care
D
A home health nurse has been working for several months with a client who is receiving rehabilitative services. The
nurse is aware that maintaining the clientts confidentiality is a priority. How can the nurse best protect the clientts
right to confidentiality?
Avoid bringing the clientts medical record to the home.
Discuss the clientts condition and care only when the client is alone in the home.
Keep the clientts medical record secured at all times.
Ask the client to avoid discussing the clientts home care with friends and neighbors.
C
A home health nurse has completed a visit to a client and has immediately begun to document the visit. Accurate
documentation that is correctly formatted is necessary for what reason?
Guarantees that the nurse will not be legally liable for unexpected outcomes
Ensures that the agency is correctly reimbursed for the visit
Allows the client to gauge progress over time
Facilitates safe delegation of care to unlicensed caregivers
B
A home health nurse has completed a scheduled home visit to a client with a chronic sacral ulcer. The nurse is now
evaluating and documenting the need for future visits and the frequency of those visits. What question should the
nurse use when attempting to determine this need?
"How does the client describe the clientts coping style?"
"When was the client first diagnosed with this wound?"
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"Is the clientts family willing to participate in care?"
"Is the client willing to create a plan of care?"
C
A home health nurse is conducting an assessment of a client who may qualify for Medicare. Consequently, the
nurse is utilizing the Outcome and Assessment Instrument Set (OASIS). When performing an assessment using this
instrument, the nurse should assess what domain of the clientts current status?
Psychiatric status
Spiritual state
Compliance with care
Functional status
D
The home care nurse is assessing a clientts use of crutches in the home. Which of the following actions by the
client indicates that the client is using the crutches effectively?
Placing the crutches on the unaffected side to rise from a sitting position
Placing the crutches on lower step and moving the affected leg first when descending stairs
Advancing affected leg first, then crutches, then unaffected leg when ascending stairs
Placing the unaffected leg forward when sitting down
B
The home health nurse receives a referral from the hospital for a client who needs a home visit for wound care.
After obtaining the referral, what action should the nurse first take?
Have community services make contact with the client.
Obtain a health care providerts prescription for the visit.
Call the client to obtain permission to visit.
Arrange for a home health aide to initially visit the client.
C
A hospital nurse is transitioning to a home health nurse position. The nurse has that the client smokes while at
home. What will the nurse need to do to work therapeutically with the client in the home setting?
Request another assignment if there is dissonance with the clientts lifestyle.
Ask the client to come to the agency to receive treatment, if possible.
Resolve to convey respect for the clientts beliefs and choices.
Try to adapt the clientts home to the norms of a hospital environment.
C
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A nurse has been working with a client whose poorly controlled type 1 diabetes has led to numerous health
problems. Over the past several years the client has had several admissions to the hospital medical unit, and the
nurse has often carried out health promotion interventions. Who is ultimately responsible for maintaining and
promoting this clientts health?
The client
An 82-year-old client has come to the clinic for a scheduled follow-up appointment. The nurse learns from the
clientts child that the client is not following the instructions the client received upon discharge from the hospital
last month. What is the most likely factor causing the client not to adhere to the therapeutic regimen?
Costs of the prescribed regimen
A gerontologic nurse has observed that clients often fail to adhere to their therapeutic regimen. What strategy
should the nurse adopt to best assist an older adult in adhering to a therapeutic regimen involving wound care?
Demonstrate a dressing change and allow the client to practice.
A 20-year-old client newly diagnosed with type 1 diabetes needs to learn how to self-administer insulin. When
planning the appropriate educational interventions and considering variables that will affect the clientts learning,
the nurse should prioritize what factor?
Client's culture
The nurse is planning to teach a 75-year-old client with coronary artery disease about administering the prescribed
antiplatelet medication. How can the nurse best enhance the clientts ability to learn?
Make the information directly relevant to the client's condition.
A nurse is planning care for an older adult who lives with a number of chronic health problems. Which nursing
diagnosis would educate the client and be the priority intervention?
Ineffective health maintenance related to nonadherence to therapeutic regimen
A class of nursing students has been asked to break into groups of four and complete a health-promotion teaching
project and present a report to their fellow students. What project most clearly demonstrates the principles of
health promotion teaching?
Discussing prevention of sexually transmitted infections (STI) to high school students
Based on current knowledge of health promotion, what factor should the nurse prioritize in an effort to promote
health, longevity, and weight control in clients?
Good nutrition
The nursing profession and nurses as individuals have a responsibility to promote activities that foster well-being.
What factor has most influenced nursest abilities to play this vital role?
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Nurses have long-established credibility with the public.
The nurse is teaching a local community group about the importance of disease prevention. Why is the nurse
justified in emphasizing disease prevention as a component of health promotion?
Prevention is emphasized as the link between personal behavior and health.
The nurse is preparing discharge teaching for an adult client diagnosed with urinary retention secondary to
multiple sclerosis. The nurse will teach the client to self-catheterize at home upon discharge. What teaching method
is most likely to be effective for this client?
A discussion and demonstration between the nurse and the client
The nurse is planning to teach tracheostomy care to a client who will be discharged home following a spinal cord
injury. When preparing to teach, which component of the teaching plan should the nurse prioritize?
Determining the client's readiness to learn new information
The occupational health nurse is preparing health promotion programs for the workplace. Which program is the
occupational health nurse most likely to develop to promote wellness?
Cholesterol screening
A nurse is teaching a community program about the association between stress levels and negative health
outcomes. The nurse should include the cause-and-effect relationship that stress has with which type of condition?
Infectious diseases
Traumatic injuries
Chronic illnesses
A public health nurse understands that health promotion should continue across the lifespan. When planning
health promotion initiatives, when in the lifespan should health promotion begin?
Before birth
A nurse is working with a client who was recently diagnosed with asthma. During the current session, the nurse
taught the client how to administer the bronchodilator by metered-dose inhaler. How should the nurse best evaluate
the teaching-learning process?
Directly observe the client using the inhaler to self-administer a dose.
A team of public health nurses is doing a strategic plan and discussing health promotion activities for the next
year. What initiative best demonstrates the principles of health promotion?
A family planning clinic at a community center
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who has just received a new
diagnosis of diabetes. Which client behavior demonstrates to the nurse the clientts emotional readiness to learn?
The client is asking questions about diabetes management.
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A nurse is planning an educational event for a local group of citizens who live with a variety of physical and
cognitive disabilities. What variable should the nurse prioritize when planning this event?
Health-promotion needs of the group
A public health nurse is planning educational interventions that are based on Beckerts Health Belief Model. When
identifying the variables that affect local residentst health promotion behaviors, what question should the nurse
seek to answer?
"Do residents believe that they have ready access to health promotion resources?"
How should the nurse best define health?
Health is a condition that enables people to function at their optimal potential.
A parish nurse is describing the relationship between health and physical fitness to a group of older adults who all
attend the same church. What potential benefits of a regular exercise program should the nurse describe?
Decreased cholesterol levels
Delayed degenerative changes
Improved overall muscle strength
A nurse is discussing health promotion strategies with a client with elevated lipid levels. Which client response
best indicates to the nurse that the client is exhibiting self-responsibility?
"I will need to learn to read food labels when food shopping."
The nurse is assessing the nutritional awareness of a client who is overweight. What outcome most clearly
demonstrates that the client possesses nutritional awareness?
The client avoids processed foods.
A nurse has planned a teaching-learning interaction that is aimed at middle-school-aged students. To foster
successful health education, the nursets planning should prioritize what component?
Social and cultural patterns
Positive client outcomes are the ultimate goal of nurse-client interactions, regardless of the particular setting.
Which of the following factors has the most direct influence on positive health outcomes?
Health education
A school nurse is facilitating a health screening program among middle school students. What purpose of health
screening should the nurse prioritize when planning this program?
To promote positive health practices
A nurse recognizes that individuals of different ages have specific health promotion needs. When planning to
promote health among young adults, what subject is most likely to meet the learning needs of the demographic
group?
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Family planning
Middle-aged adults are part of an age group that is known to be interested in health and health promotion, and the
nurse is planning health promotion activities accordingly. To what suggestions do members of this age group
usually respond with enthusiasm?
Lifestyle practices that can improve health
Healthier eating practices
Life benefits of exercise
A community health nurse has been asked to participate in a health fair that is being sponsored by the local senior
center. Which principle of health promotion for older adults should the nurse use when developing educational
activities?
Older adults benefit from practices that help them maintain independence.
Which concept should the nurse use when performing health teaching?
Health teaching is an independent nursing function.
A nurse who provides care at the campus medical clinic of a large university puts much effort into health
promotion. What purpose of health promotion should guide the nursets efforts?
To influence people's behaviors in ways that reduce risks
Which of the following factors has most influenced the growing emphasis on health promotion in nursing?
A changing definition of health
A nurse is working with a client who has recently received a diagnosis of human immunodeficiency virus (HIV).
When performing client education during discharge planning, what goal should the nurse prioritize?
Encourage the client to adhere to the client's therapeutic regimen.
A client with a recent diagnosis of which condition would most likely benefit from health education that emphasizes
adherence?
Multiple sclerosis
The nurse is providing client education to a client who was diagnosed 6 months ago with type 1 diabetes. The
clientts hemoglobin A1c results suggest the client has not been adhering to the prescribed treatment regimen. To
help this client better adhere to the treatment regimen, the nurse should assess variables that affect the clientts
ability to perform which tasks?
Obtain resources.
Maintain a healthy social environment.
Adopt specific behaviors
The nurse is working with a 15-year-old client who has diabetes and who is struggling with the necessary
behavioral changes. Which of the following motivators is most likely to be effective?
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Learning Contract
A nurse working in a gerontology clinic as a member of a health care team recognizes that some older adults do not
adhere to therapeutic regimens because of chronic illnesses that require long-term treatment by several health care
providers. Which responsibility of the nurse is most important in this situation?
Working collaboratively with other team members to provide coordinated care
A client will be receiving outpatient intravenous antibiotic therapy for the treatment of endocarditis. The nurse is
preparing health education to promote the clientts adherence to the course of treatment. What cultural
consideration should the nurse use when developing a teaching plan for the client?
Perform an individual cultural assessment with the client.
The nurse is working with a client who has diagnoses of coronary artery disease and angina pectoris. During a
clinic visit, the nurse learns that the client has only been taking the prescribed antiplatelet medication when the
client experiences chest pain and fatigue. What nursing diagnosis is most relevant to this assessment finding?
Ineffective health maintenance related to inappropriate medication use
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Brunner & Suddarth's Textbook of Medical Surgical Nursing 15th Edition
Chapter 3:Health Education and Health Promotion
A nurse is providing discharge teaching for an elderly patient who is fully dressed, watching television, and waiting
for family. The nurse sits in a chair facing the patient and shows the patient a handout. The patient squints while
reading and periodically looks at the television. The nurse is about to review the information and determine the
patientts understanding of the material when the family enters the room. The nurse determines the need for further
education due to learning barriers. Which barriers affected the patientts ability to comprehend the information?
Select all that apply.
1- Patient is watching television.
2- The patient is elderly.
The patient squints while reading.
The family entered the room while teaching.5The patient is fully dressed.
1,2,3
The nurse is to provide discharge teaching to a patient with newly diagnosed coronary artery disease. In what order
should the following steps be prioritized and completed?
Implement teaching plan.
Collect and analyze data regarding the patientts knowledge of coronary artery disease.3Form nursing diagnoses related to patient teaching.
4- Reassess patientts knowledge as needed.
5- Develop teaching plan.
6- Identify learning needs.
7- Update and change plan.
2, 6, 3, 5, 1, 4, 7
The nurse is discussing postoperative discharge instructions with an Asian American patient. The patient looks at
the floor, smiles, and then nods his head. Using cultural awareness, how should the nurse interpret this behavior?
1- Acceptance of the instructions
2- Understanding of the material
3- A reflection of cultural values
4- The patientts ability to follow through on the instructions
3
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When constructing a teaching plan, the steps of the nursing process are utilized. In which step are teaching
strategies identified?
Assessment
Planning
Implementation
Evaluation
2
Which of the following is an accurate statement with regard to adult learner readiness?
1- Learning readiness is based solely on past life experiences.
2- Physical skills play little role in learner readiness.
Experimental readiness is not related to emotional readiness.
Learner readiness is based on culture, attitude, and personal values.
4
The nurse is teaching a client with diabetes how to perform checks of blood glucose level. To optimize learning, it
is best for the nurse to
Verbally tell the client.
Demonstrate to the client.
Provide written instructions.
Have the client return demonstrate.
4
The nurse is preparing discharge teaching for a patient diagnosed with urinary retention secondary to multiple
sclerosis. The nurse will teach the patient to self-catheterize at home upon discharge. What teaching method is
most effective for this patient?
Providing the most up-to-date information available
Alleviating the patientts guilt associated with not knowing appropriate self-care3Determining the patientts readiness to learn new information
4- Building on previous information
3
In many situations, measurement of which of the following is the most accurate measurement technique to identify
changes in patient behavior?
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1- Direct observation of behavior
2- Use of rating scales
3- Use of checklists
4- Anecdotal notes
1
A health care provider asked a nurse to teach a patient how to self-administer subcutaneous insulin. After
collecting her assessment data and drafting her plan, the nurse selected the teaching strategy that research has
indicated has the highest chance of reinforcing knowledge. Which of the following strategies did the nurse select?
1- Providing reading materials with illustrations of how to perform the injection
2- Showing the equipment and explaining the procedure
3- Asking the patient to hold the syringe and insulin while viewing a slide show about the process
4- Assisting the patient to perform the skill in a simulated setting
4
The home care nurse is evaluating a clientts technique for self administration of medication. The nurse identifies a
clientts inability to pour a liquid medication into a measuring spoon. What is this teaching part of the nursing
process called?
assessment
planning
implementation
evaluation
1
Which step of the nursing process determines whether the client understands the health teaching that is provided?
Evaluation
Assessment
Planning
Implementation
1
The nursing instructor has given an assignment to a group of nurse practitioner students. They are to break into
groups of four and complete a health-promotion teaching project and present a report back to their fellow students.
What project is the best example of health-promotion teaching?
Demonstrating an injection technique to a patient for anticoagulant therapy
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Explaining the side effects of a medication to an adult patient
Discussing the importance of preventing sexually transmitted infections (STIs) to a group of 12th-grade students 4Instructing an adolescent patient about safe food preparation
3
A nurse is planning a health education program for a group of high school students regarding the dangers of
texting and driving. Which action by the nurse illustrates the understanding of health education as a primary
nursing responsibility?
The nurse gathers evidenced-based information related to texting and driving and coordinates the education with
the school.
The nurse obtains the name of the schoolts medical director and obtains a health care providerts order to conduct
the education program. 3- After consulting the literature and preparing the educational program, the nursecontacts
the schoolts medical director for approval of the planned educational program.
4- The nurse prepares a permission slip for all students to have signed by their parents, allowing the student to
participate in the educational program.
1
The home health nurse reviews a medication administration calendar with an elderly patient. In order to consider
sensory changes that occur with aging, how should the nurse proceed?
Print directions in large, bold type, preferably using black ink.
Highlight or shade important dates and times with contrasting colors.3Use several different colors to emphasize special dates.
4- Type out the information on the computer.
1
The nurse develops outcome criteria for a patient with chronic obstructive pulmonary disease. Which outcome
criteria are appropriate for this patient?
1- The patient will have the ability to climb a flight of stairs without experiencing difficulty in breathing.
2- The patient will not experience an alteration in skin integrity.
3- The patient will perform passive range-of-motion exercises once daily.
4- The nurse will obtain a pulse oximetry reading twice a day.
1
The nurse is educating the client about management of diabetes. Which statement by the student would indicate to
the nurse that further teaching is necessary?
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1- "You will need to ingest an 1800-calorie diet every day."
2- "Exenatide (Byetta) is prescribed twice a day."
3- "Checks of blood glucose level are to be done ac and hs."
4- "Avoid alcohol ingestion while taking glimeperide."
3
A hospitalized client reports right lower quadrant abdominal pain at a level of 8 on a 0 to 10 scale. The client is
scheduled for an appendectomy. The nurse is teaching the client about use of the incentive spirometer
postoperatively verbally and by demonstration. The client is on his side, clutching his abdomen. Learning is not
occurring. The nurse has primarily failed to consider the clientts
Emotional readiness
Learning environment
Physical readiness
Experiential readiness
3
Ms. Jimenez is a 27-year-old first-time mother who developed mastitis in the weeks following the birth of her infant.
She was prescribed antibiotics and has informed the nurse that her symptoms of breast pain, redness, and swelling
ceased 2 days after she began antibiotic therapy. As a result, Ms. Jimenez stopped taking her antibiotics and did
not complete the ordered course. What nursing diagnoses should the nurse identify when planning health
education for Ms. Jimenez? Select all that apply.
Deficient knowledge
Ineffective therapeutic regimen management3Ineffective coping
4- Health-seeking behaviors Impaired adjustment
1,2
A community health nurse is well aware that taking responsibility for oneself is the key to successful health
promotion. Which of the following actions by the nursets patients best demonstrates self-responsibility and health
promotion?
A woman takes action to quit smoking cigarettes.
A man seeks care because of an apparent cognitive decline.
A man questions his pharmacist when having a prescription refilled.4A woman reluctantly agrees to have her infant immunized.
1
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There are many goals for health teaching. Which of the following is the primary goal of family and patient
education?
Increase knowledge
Motivate people to learn
Improve patient outcomes4Establish trust
3
A nurse developed a program of increased ambulation for a patient with an orthopedic disorder. This goal setting is
a component of the nursing process known as:
Assessment
Planning
Implementation
Evaluation
2
A nurse is aware of the fact that nonadherence to prescribed therapy is both common and harmful. How can a
nurse best promote adherence to therapeutic regimens among patients?
1- Establish a system of rewards and punitive measures that is linked to adherence
2- Provide examples of the harmful consequences of nonadherence to therapy
3- Help individuals be aware of the benefits of adhering to their prescribed therapy
4- Make adherence a requirement for treatment in early interactions with patients
3
A 51-year-old woman is distraught about her new diagnosis of multiple sclerosis (MS). During a recent discussion
with her nurse, the nurse mentioned the concept of wellness, which prompted the patient to state, "How can you be
talking about wellness at the same time that Itve got MS?" Which of the following principles should underlie the
nursets response to the patient?
Wellness is synonymous with health.
Wellness involves maximizing function despite limitations.3Wellness is defined as acceptance of onets disabilities.
4- Wellness is a concept that is understood better by people who have chronic illnesses than by healthy
individuals.
2
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The school nurse informs the mother of a second-grade student that lice were found in the childts hair. The mother
explains to the nurse that she has another child to pick up and cannot stay to receive education related to the
treatment of lice at this time. The mother reassures the nurse that she will "look up treatment options on the
Internet and take care of the child." What would be the best action of the school nurse in this situation?
Provide the mother with a list of credible websites related to the treatment of lice
Instruct the mother to treat the other child for lice in the same manner as the second-grade child3Perform hand hygiene and notify the second-grade teacher to wash down the classroom
4- Notify the social worker of suspected child neglect and make a referral to child protective services
1
A nurse is planning discharge instructions for a client from another culture. What does the nurse understand about
the relationship of values and beliefs and the clientts readiness to learn?
The client will likely accept health education regardless of values and beliefs.
The client will be less likely to accept health education unless the nurse and client share values and beliefs. 3The client will be less likely to accept health education unless values and beliefs are respected.
4- The client will likely accept health education, but will take longer to learn.
3
The nurse is developing a health-promotion program at a company in which many employees are women in their
20s and 30s. For this population, the nurse plans to include information about
Bone-density screening
Parenting issues
Mammography
3- Values training
2
A nurse who works in a retirement village uses the Rapid Estimate of Adult Literacy in Medicine-Short Form
(REALM-SF) to estimate a patientts ability to read and comprehend medication directions. A recent patient scored a
grade of 3 on a scale of 0-7. Which of the following indicates the nursets interpretation of that score?
Will need repeated oral instructions
May not be able to read prescription labels 3Will struggle understanding most directions4May not be able to read most materials
2
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A recommended approach to planning health teaching is applying the trans-theoretical model, which considers the
stages of behavioral change. The stage in which the patient engages in calorie counting to reduce weight is called:
Contemplation
Preparation
Action
Maintenance
3
A nurse is aware of both the importance of health education and the fact that it is an independent function of
nursing practice. Under which of the following circumstances should a nurse consider providing health education?
1- When a patient or patientts condition has a reasonable chance of resolution
2- During each contact that the nurse has with a health care consumer
3- When health education is specified in a health care consumerts plan of nursing care
4- When the nurse possesses advanced practice credentials in health education
2
Which of the following is a nursing diagnosis related to health education?
1- Ineffective health maintenance
2- Ineffective airway clearance
3- Altered nutrition, less than body requirements
4- Self-esteem disturbance
1
Which statement by the client indicates the clientts experiential readiness to learn?
"Do you have a video about my disease? I dontt like to read."
"Can we take a minute to pray before learning about my treatment plan?"
"Now that I am more comfortable, I am ready to learn about pain management techniques."
"I understand that I have diabetes and will need to learn how to administer my daily insulin injections."
1
A nursing student observes the home care nurse provide education to a client with congestive heart failure (CHF).
The nurse teaches the client how to read food labels and calculate sodium content. The nursing student recognizes
that the home care nurse is aware of which basic principle of patient education?
Patient instruction related to self-care activities promotes patient independence
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Patients are required to learn about their therapeutic nutritional regimen3The home care nurse has a physician order to teach a 2-g sodium diet
4- The home care nurse is providing hospital discharge instructions
1
The termination stage of the Transtheoretical Model of Change occurs when:
1- The person has the ability to resist relapse back to unhealthy behavior.
2- The person takes steps to operationalize the plan of action.
3- The person constructs a plan to change behavior. 4- The person is not thinking about making a change.
1
Which phase of the nursing process encompasses the establishment of expected outcomes?
Planning
Assessment
Implementation
Evaluation
1
What is the priority responsibility for the nurse providing patient teaching? (Select all that apply.)
1- Determining individual needs for teaching
2- Motivating each person to learn
Giving a test at the end of a teaching session
Waiting until the patient expresses a desire to learn5Presenting information at the level of the learner
1,2,5
A current trend in health education that significantly influences nursing practice is:
1- Increased emphasis on patient involvement in their own care.
2- Improved distribution of health information materials.
Increased numbers of health care providers.
Increased emphasis on the diversity of patient needs.
1
The Healthy People 2020 initiative targets the improvement of health for all. In addition to eliminating health
disparities, what are the broad goals of this plan?
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1- Increasing technological innovations
2- Preventing treatable problems
3- Applying a systematic approach to health improvement
4- Increasing the quality and length of a healthy life
4
Which action would be incorporated in a teaching strategy for a hearing-impaired client?
1- Use of slow, directed, and deliberate speech
2- Use of large-print materials
Arrangement of materials in a clockwise pattern
Having the person perform a return demonstration
1
When providing discharge instructions, the nurse recognizes that which client is most likely to comply with the
therapeutic treatment regimen?
The client with pneumonia who requires 1 week of oral antibiotics
The patient with newly diagnosed type 2 diabetes who requires nutritional counseling 3The client with a positive tuberculosis skin test who requires 9 months of isoniazid T 4he client with kidney failure who requires hemodialysis
1
An example of evidence-based practice would be:
Morning insulin coverage for hospitalized patients is given at 6:45 AM so report can be given before breakfast
trays arrive.
Patients on bed rest are turned every 2 hours to prevent the formation of bedsores.
Shower baths are given to nursing home residents weekly so that total skin assessments can be performed.4Hospitalized patients are assisted out of bed to the chair for 60 minutes, twice daily, to promote increased
gastrointestinal transit time.
2
The nurse is planning to teach a client who was recently diagnosed with migraine headaches. It is best to teach the
client
1- During the headache recovery phase
2- In a quiet room
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With her spouse and children present
Immediately following a headache experience
2
A nurse is planning a smoking-cessation program for a client and incorporates stages from the Transtheoretical
Model of Change in the program. For the client to be successful, the client follows the stages in this order from
steps 1 to 5:
1- Thinks about smoking cessation
2- Makes a plan to cease smoking
3- Takes steps to stop smoking
4- Works to prevent relapse of smoking
5- Resists relapsing into smoking
A nurse is preparing teaching for a client with an auditory perceptual disorder. Which educational strategy will be
most effective?
1- Explain important information verbally.
2- Repeat and reinforce words frequently.
3- Explain noises associated with procedures.
4- Avoid medical terminology.
2
A nurse is discussing the need for a client to increase activity level and eat a heart-healthy diet. The client tells the
nurse, "I eat just fine and Itm not that fond of exercising." The nurse would identify this client at which stage of
change?
Precontemplation
Contemplation
Preparation
Action
1
A nurse is evaluating education provided to various clients being discharged to home. The nurse assesses that
client most likely to be nonadherent with treatment is the one who
Has tuberculosis and is taking multiple antitubercular medications
Has pneumonia and is prescribed an oral antibiotic 3- Had abdominal surgery and will be changing the dressing
daily
4- Has a duodenal ulcer and is prescribed a histamine-2 receptor blocker
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1
A nurse on a postsurgical unit has performed health education on the correct technique for emptying a drain for a
woman who will be discharged home with a drain in situ. The nurse has asked the patient to demonstrate the
correct technique and will now provide feedback. Which of the following statements provides the most effective
feedback for the patient?
1- "You did a really good job of emptying your drain. Youtll do great when you get home."
2- "How did you feel about that?"
"You should be proud of yourself; this certainly isntt a skill that comes naturally to anyone."
"You kept the drain clean when you emptied it, and you restored the negative pressure effectively."
4
Which stage of the transtheoretical model occurs when the patient has serious consideration of change, but it is
sometime in the future?
Contemplation
Precontemplation
Action
Maintenance
1
Based on the nursets knowledge of nonadherence to therapeutic regimens, which nurse needs to place extra
emphasis on adherence to the treatment plan?
1- The nurse planning to teach adults aged 65 about congestive heart failure management
2- The nurse planning to teach a group of children about healthy eating
3- The nurse planning to teach middle-aged adults about stress management
4- The nurse planning to teach teenagers about mononucleosis
1
Which of the following is a leading health indicator to be used to measure the health of the nation?
1- Overweight and obesity
2- Intelligence
Cultural awareness
Religion
1
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Which statement made by the client indicates understanding of the Centers for Disease Control and Prevention and
U.S. Preventive Services Task Force recommendation for prostate screening frequency?
"I will see you next year for my prostate exam."
"I will make plans to see you every 6 months to keep an eye on my PSA levels." 3"When I turn 50 I will need to have my PSA level checked every 5 years."
4- "I will schedule my prostate exam every 5 years after I am 50."
1
Which is an example of a direct measurement technique used to evaluate the teaching-learning process?
Behavioral observation
Patient satisfaction surveys3Attitude surveys
4- Instruments that evaluate specific health status variables
1
The home health nurse is planning teaching for a client with COPD and a history of noncompliance to the
medication regimen. Which factor does the nurse recognize as having the most influence to enabling complete
adherence of a health regimen?
Motivation
Self-esteem
Cost of medication4Education level
1
The nurse is providing preoperative information about hip replacement to a group of clients scheduled for this
surgery. One of the clients is slightly hearing impaired. What is the best action of the nurse?
Speak in a loud voice.
Position the hearing-impaired client 8 feet away.3Turn to any client who asks questions.
4- Use a model of the hip.
4
Part of health promotion in the adolescent population is health screening. What is the goal of health screening in
this population?
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1- To teach teenagers about health risks
2- To teach coping strategies
To discuss chronic health problems
To detect health problems at an early age, so that they can be treated at this time
4
Research has shown that patient adherence to prescribed regimens is generally low, especially when the patient
will have to follow the regimen for a long period of time. What is one diagnosis in which adherence rates are low?
1- Methicillin-resistant Staphylococcus aureus (MRSA)
2- Sudden acute respiratory syndrome (SARS)
Multiple sclerosis
Beta hemolytic strep infection
3
Health education is an integral component of all nurse-person interactions. However, certain individuals have a
greater need for health education than others. Which one of the following individuals likely has the greatest need
for health education?
1- An IV drug user who is receiving antibiotics for the treatment of endocarditis
2- A young adult who has suffered traumatic injuries in a motorcycle accident
3- The parents of an infant who has been admitted for treatment of respiratory syncytial virus (RSV)
4- An elderly woman who has just been diagnosed with congestive heart failure (|CHF)
4
A nurse is providing feedback to a client who demonstrates how to use an incentive spirometer. What primary role
does feedback have in the adult learning process?
Increases self-esteem
Decreases questions
Enhances nurse-client relationship4Motivates learning
4
A 35-year-old client with a developmental age of 10 years is being taught to take medication every morning. The
nurse assesses that the client brushes his teeth every morning. For learning to occur, which of the following
techniques should the nurse employ? Select all answers that apply.
Use simple explanations.
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Repeat information frequently.
Encourage the client to take the medication after brushing his teeth.4Provide written 8th-grade level information.
5- Look directly at the client when speaking.
1,2,3,5
What percentage of people older than 65 years have one or more chronic disease(s)?
1- 80
2- 50
3- 60
4- 70
1
A nurse is preparing an in-service education program for a group of nurses involved in health education. When
describing the connection between health teaching and health promotion, which information would the nurse most
likely include?
1- Both are linked by the common goal of achieving high-level wellness.
2- Health teaching goals are achieved before those for health promotion.
Health teaching, not health promotion, is the major determinant of health policy.
Health care professionals are the primary managers of health conditions addressed by health teaching.
1
A nurse is teaching an older adult about a medication that the client will take at home. The nurse assesses which of
the following factors as promoting adherence to the medication regimen?
The client has a hearing impairment and wears bilateral hearing aids.
The clientts daughter is present and provides care to the client at home.3The client has Social Security benefits and no other source of income.
4- The client asks for information in writing and states "I tend to forget things."
2
A 36-year-old man who has chewed tobacco since he was a teenager is having a discussion about this habit with
his nurse practitioner. What statement would suggest that the man is in the contemplation stage of change?
"I know I have to quit, and Itm sure that I will at some point."
"From what Itve seen, chewing is a lot better for you than smoking."
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"You can say what you want, but I just cantt see myself kicking the habit."4"I know itts bad for me, and Itm going to quit at the end of the month."
1
A patient with a visual impairment would benefit from which of the following teaching strategies?
Magnifying lenses
Sign language
Telecommunication devices
Captioned videos
1
Which of the following teaching strategies may be used with a patient diagnosed with a developmental disability?
Select all that apply.
1- Encourage active participation.
2- Use nonverbal cues as needed.
3- Use simple explanations.
4- Demonstrate information followed by return demonstration.
5- Base information on chronologic age.
1,2,3,4
Which of the following are effective teaching strategies for elderly persons? Select all that apply.
Slow-paced presentation
Frequent repetition
Use of reinforcement techniques4Use of written materials
5- Workplace has become a center for health promotion
1,2,3,4
An example of a nursing action that modifies a teaching program because a learner is not experientially ready is:
Changing the wording in a teaching pamphlet so that a patient with a fourth-grade reading level can read and
understand the sentences.
Contacting family members to assist in goal development to help stimulate motivation.
Postponing the session with a patient until all major distractors have been eliminated (i.e., pain, noise). 4Preventing a detailed outline of the content to be discussed prior to the teaching session.
1
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The nurse is performing discharge teaching for an elderly client with mild visual impairment. The nurse provides
written instructions with large print and highlighted parts. The nurse also sits near the client, faces the client, and
speaks in a lower-pitched voice. When the client arrives home, the client has difficulty following instructions. What
error in teaching did the nurse commit?
1- Providing written instructions that are highlighted
2- Speaking in a lower-pitched voice
3- Using instructions with large print
4- Sitting near and facing the client
1
Health education is important for all patients and families. Of the four groups listed below, which group is most in
need of health teaching?
Patients under 21 years of age, because new behaviors can be practiced for many years
Patients who are diagnosed with acute infections, because treatment and future prevention can be immediately
addressed
Patients with chronic illnesses, because life-long interventions and adjustments can improve the quality of life 4Patients with a terminal illness, because the process of dying can be managed with dignity
3
A community health nurse is organizing community training on healthy behavior change. Which action will the
nurse focus on when using the transtheoretical model of change as guidance for the teaching?
Resources of health
Determinants of health
Motivation of individuals
Reasons for choosing healthy behaviors
3
The nurse is administering a new medication to an elderly male client and begins instruction about the medication.
The client states, "Tell my wife. She takes care of all this kind of stuff." The nurse replies
"It is necessary that you learn about this medication."
"When your wife comes in to visit, I will return and provide the information to both of you." 3"I will print the information about this medication and leave it with you to give to her."
4- "I will have to return when she arrives."
2
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The process of health education closely parallels the nursing process with its discrete phases of assessment,
diagnosis, planning, implementation, and evaluation. What activity would the nurse perform during the planning
phase of health education?
1- Determining the patientts current knowledge level and willingness to learn
2- Identifying the patientts learning needs
Documenting the goals of the health education
Demonstrating a necessary technique for the patient
3
Which patient is most in need of health education by the nurse?
A 28-year-old female with abdominal pain
A 62-year-old male with chronic kidney injury3A 42-year-old male with acute pericarditis
4- A 72-year-old female with a respiratory infection
2
A nurse is evaluating a clientts motivation to make decisions that promote healthy behavior change, using the
transtheoretical model of change. Which description best describes the decision making stage of this model?
The client constructs a plan to change behavior.
The client is thinking about change in the near future. 3- The client takes steps to put the plan into action. 4The client works to sustain gains made from actions taken.
1
Specifying the immediate, intermediate, and long-term goals of learning is an integral component of the teachinglearning process. Which of the following individuals should be included in this goal-setting process? Select all that
apply.
An advanced practice nurse
The nurse who will conduct the teaching3The patient himself or herself
The patientts family members
The patientts primary care provider
2,3,4
A client with multiple sclerosis is learning to perform intermittent self-catherizations of the urinary bladder. The
nurse obtains the following equipment for teaching. Select all that apply.
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Forceps
Syringe with sterile water
Anatomically correct model416-French catheters
5- Foley bag
3,4
A nurse is exploring various barriers to adult learning in order to promote and enhance learning readiness and
comprehension. Which situation does the nurse recognize as being a potential experiential barrier to learning?
1- An older adult experiencing acute pain
2- An adolescent from another culture
3- An adult with no formal education
4- An adult who lacks motivation
3
A nurse has been assigned to care for a client with newly diagnosed insulin-dependent diabetes mellitus. When
teaching the client proper injection techniques, which statement will the nurse use to promote emotional readiness
in the client?
"Do you feel comfortable with injections?"
"Can you teach me what I just showed you?"3"What scares you the most about this?"
4- "How do you feel about needles?"
2
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Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
A school nurse is teaching a 14-year-old girl of normal weight some of the key factors necessary to maintain good
nutrition in this stage of growth and development. What interventions should the nurse prioritize to the client?
Decreasing her calorie intake and encouraging her to maintain her weight to avoid obesity
Increasing her BMI, taking a multivitamin, and discussing body image
Increasing calcium intake, eating a balanced diet, and discussing eating disorders
Obtaining a food diary along with providing close monitoring for anorexia
C
The nurse is performing an admission assessment of a client with minimal understanding of the dominant
language. An interpreter who speaks the clientts language is unavailable and no members of the care team speak
the language. How will the nurse best perform data collection?
Have a family member provide the data.
Obtain the data from the old chart and health care providerts assessment.
Obtain the data only from the client.
Collect all possible data from the client and wait for a health facility interpreter.
D
The nurse is assessing a 28-year-old client who has presented to the emergency department with vague reports of
malaise. The nurse observes bruising to the clientts upper arm that corresponds to the outline of fingers as well as
yellow bruising around the left eye. The client makes minimal eye contact during the assessment. How should the
nurse best inquire about the bruising?
"Is anyone physically hurting you?"
"Tell me about your relationships."
"Do you want to see a social worker?"
"Is there something you want to tell me?"
A
The nurse is taking a health history on an adult client who is new to the clinic. The client states that the clientts
mother has type 1 diabetes. What is the primary significance of this information to the health history?
The client may be at risk for developing diabetes.
The client may need teaching on the effects of diabetes.
The client may need to attend a support group for individuals with diabetes.
The client may benefit from a dietary regimen that tracks glucose intake.
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A
A nurse is performing the admission assessment of a client who will be treated for pancreatitis on the medical
unit. During the nursing assessment, the nurse asks the client questions related to the clientts spirituality. The
primary rationale for this aspect of the nursets assessment is that the clientts spiritual environment can affect
which area of life?
Physical activity
Ability to communicate
Quality of sexual relationships
Response to illness
D
The school nurse is working with a high school junior whose body mass index (BMI) is 31. When working
collaboratively with the client on the care plan, the nurse should propose which goal?
Continuation of current diet and activity level
Increase in exercise and reduction in calorie intake
Possible referral to an eating disorder clinic
Increase in daily calorie intake
B
A home care nurse is teaching meal planning to a clientts adult child who is caring for the client during recovery
from hip replacement surgery. Which daily menus suggested by the clientts child indicates a correct understanding
of proper nutrition, based on the U.S. Department of Agriculturets MyPlate?
Cheeseburger, carrot sticks, and mushroom soup with whole wheat crackers
Spaghetti and meat sauce with garlic bread and a salad
Chicken and pepper stir fry on a bed of rice
Ham sandwich with tomato on rye bread with peaches and yogurt
D
The nurse is assessing a 76-year-old client who has presented with an unintended weight loss of 10 lb over the
past 8 weeks. During the assessment, the nurse learns that the client has ill-fitting dentures and a limited intake of
high-fiber foods. What other health problem is the client at risk to develop?
Constipation
Deficient fluid volume
Infection
Excessive intake of convenience foods
A
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The nurse is teaching a nutrition education class for a group of older adults at a senior center. When planning this
education, the nurse should be aware that individuals at this point in the lifespan have which of the following?
A decreased need for calcium
An increased need for glucose
An increased need for sodium
A decreased need for calories
D
The emergency department nurse is obtaining a health history from a client who reported experiencing
intermittent abdominal pain. Which question should the nurse ask to elicit the probable reason for the visit and
identify the clientts chief issue?
"Why do you think your abdomen is painful?"
"Where exactly is your abdominal pain and when did it start?"
"What brings you to the hospital today?"
"What is wrong with you today?"
C
The nurse is caring for a client who identifies as Native American/First Nations. The client arrives at the clinic for
treatment related to type 2 diabetes. Which question would best provide information about the role of food in the
clientts cultural practices and identify how the clientts food preferences could be related to the current condition?
"Do you feel any of your cultural practices have a negative impact on your disease process?"
"What types of foods are served as a part of your cultural practices, and how are they prepared?"
"As a non-Native, I am unaware of your cultural practices. Could you teach me a few practices that may affect
your care?"
"Tell me about foods that you eat and how you feel they influence managing your diabetes."
D
A 30-year-old client is in the clinic for a yearly physical. The client states, "I found out that two of my uncles had
heart attacks when they were young." This alerts the nurse to complete a genetic-specific assessment. In addition
to a complete health history, which components should the nurse include in this assessment?
A genogram along with any history of cholesterol testing or screening and a complete physical exam
A complete physical exam with an emphasis on genetic abnormalities
A focused physical exam followed by safety-related education
A family history focused on the paternal family with focused physical exam and genetic profile
A
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The school nurse is performing a sports physical on a healthy adolescent girl who is planning to try out for the
volleyball team. When it comes time to listen to the studentts heart and lungs, what is the best nursing action?
Perform auscultation with the stethoscope placed firmly over the clothing to protect the client’s privacy.
Perform auscultation by holding the diaphragm lightly on the client’s clothing to eliminate the "scratchy noise".
Perform auscultation with the diaphragm placed firmly on the client’s skin to minimize extra noise.
Defer the exam because the girl is known to be healthy and chest auscultation may cause anxiety.
C
A nurse who provides care in a campus medical clinic is performing an assessment of a 21-year-old student who
has presented for care. After assessment, the nurse determines that the client has a body mass index (BMI) of
What does this indicate?
The client is of normal weight.
The client is extremely obese.
The client is overweight.
The client is mildly obese.
B
A nurse is conducting a home visit as part of the community health assessment of a client who will receive
scheduled wound care. During assessment, the nurse should prioritize what variable(s)?
Availability of home health care, current government subsidies, and family support
The community and home environment, support systems or family care, and the availability of needed resources
The future health status of the individual, and community and hospital resources
The characteristics of the neighborhood, and the clientts socioeconomic status and insurance coverage
B
The nurse is performing a health history on a client. Which question will the nurse ask to elicit information
about past health history?
"Have you ever had surgery?"
"What brought you to the hospital today?"
"How is the health of your parents?"
"Are you in any pain?"
A
The nurse is admitting a 75-year-old client who is accompanied by a spouse. The spouse wants to know where the
information being obtained is going to be kept, and the nurse describes the system of electronic health records. The
spouse states, "I sure am not comfortable with that. It is too easy for someone to break into computer records
these days." What is the nurse’s best response?
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"The government has called for the implementation of the computerized health record so all hospitals are doing
it."
"Wetve been doing this for several years with good success, so I can assure you that our records are very safe."
"This hospital is concerned about keeping our clientst records private, so we take special precautions to prevent
unauthorized access."
"Your spousets records will be safe, because only people who work in the hospital have the credentials to
access them."
C
A family whose religion limits the use of some forms of technology is admitting their grandparent to the nursets
unit. They express skepticism about the fact that the nurse is recording the admission data on a laptop computer.
What would be the nursets best response to their concerns?
"Itts been found that using computers improves our clientst care and improves communication."
"We have found that it is easier to keep track of our clientst information this way rather than with pen and paper."
"Youtll find that all the hospitals are doing this now, and that writing information with a pen is rare."
"The government is telling us we have to do this, even though most people, like yourselves, are opposed to it."
A
The nurse is performing a dietary assessment with a client who has been admitted to the medical unit with
community-acquired pneumonia. The client asks if the nurse is posing so many questions about the client’s dietary
practices because the client is from another country. What is the nursets best response to this client?
"We always try to abide by foreign-born clientst dietary preferences to make them comfortable."
"We know that some cultural and religious practices include dietary guidelines, and we do not want to violate
these."
"We wouldntt want to feed you anything you only eat on certain holidays."
"We know that clients who grew up in other countries often have unusual diets, and we want to accommodate
this."
B
In the course of performing an admission assessment, the nurse has asked questions about the clientts first-and
second-order relatives. What is the primary rationale for the nursets line of questioning?
To determine how many living relatives the client has
To identify the familyts level of health literacy
To identify potential sources of social support
To identify diseases that may be genetic
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D
The nurse is completing a family history for a client who is admitted for exacerbation of chronic obstructive
pulmonary disease (COPD). The nurse should include questions that address which health problem? Select all that
apply.
Allergies
Alcohol use disorder
Fractures
Hypervitaminosis
Obesity
A,B,E
Which action would the nurse perform during the inspection phase of the physical examination?
Gather as many psychosocial details as possible by questioning the client.
Pay attention to the details while visually observing the client.
Document the clientts breath sounds.
Avoid letting the client know that the client is being assessed.
B
During a comprehensive health assessment, which structure can the nurse best assess
Brain
Heart
Thyroid gland
Lungs
C
A 51-year-old clientts recent reports of fatigue are thought to be caused by iron-deficiency anemia. The client
undergoes testing of the transferrin levels. This biochemical assessment would be performed by assessing which
type of specimen?
Urine
Serum
Cerebrospinal fluid (CSF)
Synovial fluid
B
A school nurse at a middle school is planning a health promotion initiative for girls. The nurse has identified a
need for nutritional teaching. What problem is most likely to relate to nutritional problems in girls of this age?
Protein intake in this age group often falls below recommended levels.
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Total calorie intake is often insufficient at this age.
Calcium intake is above the recommended levels.
Folate intake is below the recommended levels in this age group.
D
A team of community health nurses has partnered with the staff at a youth drop-in center to address some ofthe
nutritional needs of adolescents. Which situation most often occurs during the adolescent years?
Lifelong eating habits are acquired.
Peer pressure influences growth.
BMI is determined.
Culture begins to influence diet.
A
A nurse who has practiced in the hospital setting for several years will now transition to a new role in the
community. How does a physical assessment in the community compare with that in the hospital?
It consists of largely the same techniques.
It does not require privacy.
It is less comfortable for the client.
It is less structured.
A
The nurse is conducting an assessment of a client in the clientts home. The client is 91 years old, lives alone,and
has no family members living close by. What should the nurse be aware of to aid in providing care to this
client?
Where the closest relative lives
What resources are available to the client
What the clientts financial status is
How many children the client has
B
What is the nursets rationale for prioritizing biochemical assessment when appraising a clientts nutritional
status?
It identifies abnormalities in the chemical structure of nutrients.
It predicts abnormal utilization of nutrients.
It reflects the tissue level of a given nutrient.
It predicts metabolic abnormalities in nutritional intake.
C
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The nurse is providing care for a client who has several missing teeth. What is the most likely nutritional
consequence the nurse should anticipate for this client?
Inadequate intake of high-fiber foods
Inadequate caloric intake
Loss of fluid
Malabsorption of nutrients
A
When caring for a client who predominantly identifies with another culture than the nurse, how can the
nurse best demonstrate an awareness of culturally congruent care?
Maintain eye contact at all times.
Try to speak the clientts primary language.
Use touch when communicating.
Establish effective communication.
D
The nurse is preparing a discharge teaching session with a client to evaluate the clientts ability to change a
dressing. The client speaks and understands the dominant language only minimally. What would be the best way to
promote understanding during the teaching session?
Ask the client to repeat the instructions carefully.
Write the procedure out for the client in simple language.
Use an interpreter during the teaching session.
Have the client demonstrate the dressing change.
C
The nurse is admitting a client with uncontrolled hypertension and type 1 diabetes to the unit. During the initial
assessment, the client reports seeking assistance and care from the shaman in the client’s community. What is the
nursets best response to the clientts indication that the care provider is a shaman?
"Thank you for providing the information about the shaman, but we will keep that information and approach
separate from your current hospitalization."
"It seems that the care provided by your shaman is not adequately managing your hypertension and diabetes, sowe
will try researched medical approaches."
"Dontt worry about insulting your shaman; the health care provider will explain to the shaman that the shaman’s
approach to your hypertension and diabetes was not working."
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"I understand that you value the care provided by the shaman, but we would like you to consider medications
and dietary changes that may lower your blood pressure and blood sugar levels."
D
The nurse is performing a cultural nursing assessment of a newly admitted client. What should the nurse
include in the assessment? Select all that apply.
Family structure
Subgroups
Cultural beliefs
Health practices
Values
A,C,D,E
The quality improvement team at the hospital has recognized the need to better integrate the principles of
transcultural nursing into client care. When explaining the concept of transcultural nursing to uninitiated nurses,
how should the team members describe it?
The comparative analysis of the health benefits and risks of recognizable ethnic groups
Research-focused practice that focuses on client-centered, culturally competent nursing
A systematic and evidence-based effort to improve health outcomes in clients who are immigrants
Interventions that seek to address language barriers in nursing practice
B
During an orientation class, the medical unitts nursing educator is presenting education on transcultural
nursing to a group of newly licensed nurses. What should the staff educator identify as the underlying focus of
transcultural nursing?
To enhance the cultural environment of institutions
To promote the health of communities
To provide culture-specific and culture-universal care
To promote the well-being of discrete, marginalized groups
C
The future of transcultural nursing care lies in finding ways to promote cultural competence in nursing
students. How can this goal be best accomplished?
By offering multicultural health studies in nursing curricula
By enhancing the content of community nursing classes
By requiring students to care primarily for clients from other ethnic groups
By screening applicants according to their cultural competence
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A
Computed tomography of a 72-year-old client reveals lung cancer with metastasis to the liver. The clientts adult
child has been adamant that any "bad news" be withheld from the client to protect the client from stress, stating
that this is a priority in their family’s culture. How should the nurse and the other members of the care
team best respond?
Explain to the adult child the teamts ethical obligation to inform the client.
Refer the family to social work.
Have a nurse or health care provider from the clientts culture make contact with the client and adult child.
Speak with the child to explore the rationale and attempt to reach a consensus.
D
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Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 5: Stress and Inflammatory Responses
A nurse is counseling a client with an opioid addiction who is now ready for discharge. What factors would the
nurse emphasize to build resilience and prevent relapse?
Finding a fulfilling job that they enjoy and setting new goals
Having a supportive relationship with family members and role model exposure
Taking an inexpensive, short vacation to unwind and reevaluate problems
Promoting a strenuous exercise program that emphasizes weight loss
B
The nurse is caring for an adult client who has just received a diagnosis of prostate cancer. The client states, "I will
never be able to cope with this situation." How should the nurse best understand the concept of stress when
attempting to meet this clientts needs?
It is a physiologic measurement used to deal with change, and the client will physically adapt.
It is a physiologic or psychological process that the client implements to adapt to change.
It is an external event or situation that produces change that does not contribute to growth.
It is a disruptive condition produced by a change that influences the clientts dynamic balance.
D
The nurse is with a client who has learned that they have glioblastoma multiforme, a brain tumor associated with an
exceptionally poor prognosis. The clientts heart rate increases, eyes dilate, and blood pressure increases. The
nurse recognizes these changes as being attributable to what response?
Part of the limbic system response
Sympathetic nervous response
Hypothalamic-pituitary response
Local adaptation syndrome
B
A hospitalized client tells the nurse about feeling anxious about "being in this place." The clientts blood pressure
and heart rate are elevated but return to normal after 10 minutes. The client asks the nurse whether there is a
concern for hypertension. What statement will guide the nursets response?
The client should not worry because the increased blood pressure was stress-related and the clientts regular
blood pressure is good.
The first blood pressure reading was part of a stress response; the long-term blood pressure is controlled by
negative feedback systems.
Blood pressure is the only measure of hypertension; the client needs to recheck it regularly.
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A respiratory infection is probably the cause of the elevated blood pressure and will return to normal after
treatment.
B
A client presents to the health center and is diagnosed with an enlarged thyroid. The health care provider believes
the thyroid cells may be undergoing hyperplasia. How should the nurse explain this condition to the client?
Hyperplasia is the abnormal decrease in cell and organ size and is a precursor to cancer.
Hyperplasia is an abnormal increase in new cells and is reversible with the stimulus for cell growth removed.
Hyperplasia is the change in appearance of the thyroid due to a chronic irritation and will reverse with the
stimulus removed.
Hyperplasia is a cancerous growth and will be removed surgically.
B
A parent has brought a 6-year-old child to the emergency department. The parent tells the triage nurse that the child
was stung by a bee about an hour ago. The parent explains to the nurse that the site of the sting hurts badly and
looks swollen, red, and infected. What can the triage nurse teach the parent?
The pain, redness, and swelling are part of the inflammatory process, but it is probably too early for an infection.
Bee stings frequently cause infection, pain, and swelling; with treatment, the infection should begin to subside
late today.
The infection was probably caused by the stinger, which may still be in the wound.
The parentts assessment is accurate and the child will probably be prescribed antibiotics to fix the problem.
A
The nurse is caring for an older adult client who is being treated for acute anxiety. The client has a nursing
diagnosis of Ineffective Coping related to a feeling of helplessness. What would be the most appropriate nursing
intervention?
Put the primary onus for planning care on the client.
Assess and provide constructive outlets for anger and hostility.
Assess the clientts sources of social support.
Encourage an attitude of realistic hope to help the client deal with helpless feelings.
D
A female client has presented to the local health center with a large mass in the right breast. The client has felt the
lump for about a year but was afraid to come to the clinic because the client was sure it was cancer. What is the
most appropriate nursing diagnosis for this client?
Self-esteem disturbance related to late diagnosis
Ineffective individual coping related to reluctance to seek care
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Altered family process related to inability to obtain treatment
Ineffective denial related to reluctance to seek care
B
The nurse at the student health center is seeing a group of students who are interested in reducing their stress
levels. The nurse identifies guided imagery as an appropriate intervention. What should the nurse include in this
intervention?
Progressive tensing and relaxing of muscles to release tension in each muscle group
Encouraging a positive self-image to increase and intensify physical exercise, which decreases stress
The mindful use of a word, phrase, or visual, which allows oneself to be distracted and temporarily escape from
stressful situations
The use of music and humor to create a calm and relaxed demeanor, which allows escape from stressful
situations
C
The nurse is assessing a client and palpates two enlarged supraclavicular lymph nodes. The nurse asks the client
how long these nodes have noticeably enlarged. The client states, "I cantt remember. A long time I think. Do I have
cancer?" Which of the following is an immediate physiologic response to stress the nurse would expect this client
to experience?
Vasodilation of peripheral blood vessels
Increased blood pressure
Decrease in blood glucose levels
Pupil constriction
B
A client reports just having been told that the computed tomography results were abnormal and looks worried.
What hormone will the nurse expect the clientts adrenal gland to release in response to this news?
Endorphins
Dopamine
Epinephrine
Erythropoietin
C
The nurse walks into a clientts room and finds the client sobbing uncontrollably. The client states, "I am so scared. I
have never known anyone who goes into a hospital and comes out alive." On the clientts care plan, the nurse reads
that there is a preexisting nursing diagnosis of Ineffective Coping related to stress. What outcome is most
appropriate to this clientts care?
Client will adopt coping mechanisms to reduce stress.
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Client will be stress-free for the duration of treatment.
Client will avoid all stressful situations.
Client will be treated with an antianxiety agent.
A
The nurse is assessing a client and learns that the client and new spouse were married just 3 weeks earlier. What
principle should underlie the nursets care planning for this client?
The client and spouse should seek counseling to ease their transition.
The client will have better coping skills being in a stable relationship.
Happy events do not normally cause stress.
Marriage causes transition, which has the potential to cause stress.
D
The nurse is assessing a client who is experiencing stress because of a recent fall resulting in hip surgery. The
clientts blood pressure is low with an increased heart rate postoperatively. What is an expected example of a bodily
function, in this instance, that restores homeostasis?
Body temperature
Pupil dilation
Diuresis
Blood clotting
A
A client who has a history of smoking 40 packs per-year may have dysplasia of the epithelial cells in the bronchi.
What should the nurse tell the client about this process?
It is a benign process that occurs as lung tissue regenerates.
It is a bizarre cell growth that carries an increased risk of malignancy.
It is a process that involves a rapid increase in the number of cells.
It may cause uncontrolled growth of scar tissue in other areas of the body.
B
A 16-year-old client experienced a near-drowning and has been admitted to the emergency department. The client
was submerged for 5 minutes and remained unconscious. What pathophysiologic process has occurred as a result
of the submersion?
Atrophy of brain cells
Cellular lysis
Hypoxia to the brain
Necrosis to the brain
C
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A 55-year-old client has been diagnosed with urosepsis and has a temperature of 39.7°C (103.4°F). The nurse must
anticipate that the clientts respiratory rate will change in what direction and why?
Increase due to hypermetabolism
Decrease due to thermoregulatory dysfunction
Increase due to protein coagulation
Decrease due to vasoconstriction
A
A client is admitted to the hospital with left leg deep vein thrombosis (DVT). The client informs the nurse that the
leg "must be infected because it is red, swollen, and very painful." Based on the nursets knowledge of
inflammation, which response would be best?
"Your leg is injured on a peripheral level, and inflammation is the typical response to infection."
"Your leg is probably infected and reacting by swelling. Antibiotics will be part of your treatment plan."
"Your leg is injured on a cellular level, and inflammation does not always mean infection."
"Your leg is not infected and the inflammation may be related more to your sodium intake."
C
An older adult client tells the nurse about a spouse who died 14 months ago and reports continued grieving over
the loss. What should the nurse encourage the client to do?
Improve nutritional intake.
Make an appointment at a wellness clinic.
Walk on a daily basis.
Increase interactions within the clientts social network.
D
The nurse is caring for a client whose spouse died 4 months ago. The client states feelings of "not doing well" and
that friends and family seem hesitant to talk about the loss of the spouse. What type of referral would be most
helpful for the nurse to make for the client?
A consciousness-raising group
A psychiatrist
A support group
A church or temple
C
A client will undergo a bilateral mastectomy later today and the nurse in surgical admitting has begun the process
of client education. What positive outcome of providing the client with information should the nurse expect?
Increased concentration
Decreased depression levels
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Sharing personal details
Building interdependent relationships
A
The nurse is caring for a client who has just been informed of a diagnosis of colon cancer. The clientts vital signs
are initially elevated but after the nurse speaks with the client, the clientts vital signs become closer to normal
range. What biological action is occurring that would explain this phenomenon?
Cortisol levels fluctuate and become unstable.
Endocrine activity has increased.
The client is adapting to noxious stressors.
The sympathetic response has been activated.
C
While talking with the parents of conjoined twins who are medically unstable, the nurse observes one parent of the
babies has an aggressive stance, is speaking in a loud voice, and makes several hostile statements such as, "Itd
sure like to have words with that doctor who told us our babies would be okay." The nurse knows that this parentts
cognitive appraisal has led to what feelings?
Harm/loss feelings
Feelings of challenge
A positive adjustment to the possible loss of the children
The development of negative emotions
D
The nurse is caring for an older adult client who has been admitted 5 times for hypertension since the death of a
spouse 2 years ago. The client does not understand why the blood pressure returns to normal after a day or two in
the hospital when taking the same outpatient prescribed medications. What should the nurse know about the
probable cause of this clientts hypertension?
The emotional stress of losing a spouse and a perceived role in life could contribute to physical illness.
Physical illness is caused by prolonged and unrelenting stress and anxiety.
Older adults are at increased risk for hypertension due to stress and prolonged disability.
Stress exacerbates the physiologic processes of older adults.
A
A psychiatric-mental health nurse is caring for a client whose sister and niece were recently killed in a motor
vehicle accident. The client is making arrangements for the funerals, and the nurse knows that the client has insight
into current stressors. What process is occurring with this client?
The mediating process is occurring.
The client is experiencing an expected level of denial.
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The clientts awareness of stress makes it more acute.
The client is emotionally overwhelmed.
A
A client with diabetes is concerned because of a recent increase in blood glucose readings requiring additional
insulin. The client is busy starting a second business and moving to a smaller home since the children are off to
college. What internal stress reduction methods would benefit this client?
Hire a moving company and accountant to manage personal requirements.
Develop a broad social network and encourage strong family ties.
Promote healthy eating habits and the development of relaxation techniques.
Complete a health risk assessment and receive education on coping.
C
An area nurse is caring for a client in the urgent care center who presented with reports of lethargy, malaise,
aching, weakness, and loss of appetite. During the assessment, the nurse identifies an area on the clientts right
posterior calf that is edematous and warm and tender to touch. What is the most probable cause of this clientts
symptoms?
Local inflammatory response
Systemic shock response
Local infectious response
Systemic inflammatory response
D
The nurse is discharging a 4-year-old client from the emergency department. The client was seen for an insect bite
that became swollen, reddened, warm, and painful to touch. The clientts vital signs are all within normal range for
age. While the nurse is giving discharge instructions to the clientts parent, the parent asks why the child is not
going to get antibiotics for the infected insect bite. What would be the nursets best response?
"This is a local inflammatory response to the insect bite; it is not an infection, so antibiotics will not help."
"In children who are previously healthy, inflammation and infections usually resolve without the need for drugs."
"Itll make sure the doctor is made aware that youtd like your child to have a course of antibiotics."
"Infection is not the same as inflammation. What your son has is inflammation."
A
A group of nursing students are applying the concept of steady state to the nursing care plan of a client who is
undergoing chemotherapy and radiotherapy for the treatment of lung cancer. What would be the most complete
statement by the students about the concept of steady state?
"The concept of steady state preserves life."
"The mechanisms of steady state work to maintain balance in the body."
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"This concept compensates for biologic and environmental attacks on the body."
"Steady state is the same as adaptation."
B
A nursing student has presented a concept map of a medical clientts health that demonstrates the maintenance of a
steady state. The student has elaborated on the relationship of individual cells to compensatory mechanisms. How
often does the compensatory mechanism direct bodily functions?
Each diurnal cycle
When needed
Continuously
Sporadically
C
A nurse is planning the care of a client who has been admitted to the medical unit following an ischemic
cerebrovascular accident. What should the nurse recognize as the longest-acting phase of the clientts physiologic
response to stress and its cause?
Sympathetic nervous system discharge
Immunologic neuroendocrine discharge
Sympathetic-adrenal-medullary discharge
Hypothalamic-pituitary discharge
D
Selyets general adaptation syndrome (GAS) is a theory of adaptation to biologic stress. Selye compared the GAS
with the life process: childhood, adulthood, and later years. What would occur during "adulthood" in the GAS?
Stressful events occur and resistance or adaptation occurs.
Successful avoidance of stressful life events leaves the body vulnerable.
The accumulation of lifets stressors causes resistance to fall.
Vulnerability leads to eventual death.
A
The nurse is auditing the electronic health record of a young adult client who was treated for a postpartum
hemorrhage. When reviewing the clientts records, the nurse sees various demonstrations of negative feedback
loops. Which of the following constitute negative feedback loops? Select all that apply.
Serum glucose levels
Acid-base balance
Temperature
Blood clotting
Labor onset
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A, B, C
In a state of chronic arousal, what can happen within the body?
Blood pressure decreases.
Serum glucose levels drop.
Arteriosclerosis may develop.
Tissue necrosis may occur.
C
A client admits to using drugs and alcohol to reduce stress. What is most important for the nurses to know about
these coping behaviors?
They are effective, but alternative, coping behaviors.
They do not directly influence stress in the body.
They are adaptive behaviors.
They increase the risk of illness.
D
The nurse is assessing an older adult clientts post-myocardial infarction. The nurse attempts to identify the clientts
health patterns and to assess if these health patterns are achieving the clientts goals. How should the nurse best
respond if it is found that the clientts health patterns are not achieving their goals?
Seek ways to promote balance in the client.
Refer the client to social work.
Identify alternative models of health care.
Provide insight into the clientts physiologic failings.
A
A client is experiencing intense stress during a current hospital admission for the exacerbation of chronic
obstructive pulmonary disease. Which of the clientts behaviors best demonstrates adaptive coping?
Becoming controlling
Reprioritizing needs and roles
Using spousets benzodiazepines
Withdrawing
B
A 64-year-old client has returned from surgery after a right mastectomy and is very anxious. The client doesntt want
any medications. What is the best intervention the nurse could employ to manage the clientts anxiety at this time?
Encourage a brisk walk around the nursets station.
Review post-operational orders and procedural information.
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Use guided imagery and deep breathing exercises.
Turn off the television and lights and encourage rest.
C
The nurse is admitting a client to the medical-surgical unit after a diagnosis of cellulitis of the calf. What factor(s)
does the nurse know impact the processes of inflammation, repair, and replacement? Select all that apply.
Severity of the injury
Social relationships
Condition of the host
Familial support
Nature of the injury
A, C, E
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Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 6: Genetics and Genomics in Nursing
Which of the following is the first step in establishing the pattern of inheritance?
Pedigree
Mutation
Genotype
Transcription
pedigree
The nurse working in the labor and delivery unit prepares to test for which of the following as a part normal
newborn screening?
Phenylketonuria
Sickle cell anemia
Cystic fibrosis
Down syndrome
Phenylketonuria
A nurse is assessing a patient with an autosomal-dominant inherited condition. When discussing the risk of
transmission to the patientts offspring, which of the following would the nurse include?
The patientts partner must also have the genetic mutation.
Females will be carriers for the condition.
Each child has a 50% risk of inheriting the gene.
The risk for inheritance depends on the presence of other gene mutations.
Each child has a 50% risk of inheriting the gene.
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What target cultural population is a priority for the nurse to educate about prevention of hypertension?
African Americans
Hispanics
Native Americans
Italian Americans
African Americans
Nursing students are reviewing legislation about the use of genetic information. The students demonstrate a need
for additional review when they identify which of the following as being prohibited by the Genetic Information
Nondiscrimination Act (GINA)?
Use of genetic information to establish insurance eligibility
Employers from using genetic information to make a decision about promotions
Health insurers from charging higher rates for people at risk for a genetic condition
Health insurers from denying coverage to a healthy person at risk for a genetic condition
Use of genetic information to establish insurance eligibility
Which type of genetic test would be used to detect the possibility of Down syndrome?
DNA analysis
Complete blood count (CBC)
Chromosomal analysis
Hemoglobin electrophoresis
Chromosomal analysis
The nurse is obtaining health history from a client with a genetic disorder. Which of the following would be most
appropriate for the nurse to establish the pattern of inheritance?
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Obtain information about the clientts parents.
Investigate for possible signs and symptoms of the disorder.
Determine if the condition is dominant or recessive.
Construct a pedigree of the clientts family.
Construct a pedigree of the client's family.
After assessing a clientts family history, the nurse determines the need for a genetic referral based on which of the
following?
Absence of consanguinity of family members
Sister infertility problems due to spousets low sperm count
History of an unexplained miscarriage
Several relatives diagnosed with colon cancer
Several relatives diagnosed with colon cancer
A nurse is preparing a presentation for a local community group about familial Alzheimerts disease. As part of the
presentation, the nurse is planning to discuss the possible genetic basis for this condition. The nurse would
describe the inheritance as which of the following?
X-linked
Multifactoral
Autosomal recessive
Autosomal dominant
Multifactoral
A client has an autosomal-dominant disorder. His wife is unaffected. When explaining the risk for inheritance of the
disorder in their offspring, which statement by the nurse would be most appropriate?
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"There is a 50% chance that each of your children will have the condition."
"The female determines whether your children will have the disorder."
"Any child you have would most likely have the disorder."
"You have a 1 in 4 chance of a child being affected by the disorder."
There is a 50% chance that each of your children will have the condition
A nurse is working with a client who is undergoing genetic testing. The nurse would least likely be responsible for
which of the following?
Advocating for confidentiality of the results
Obtaining the clientts family history
Educating the client about the testing procedures
Informing the client about the testing results
Informing the client about the testing results
A patient has been identified as a poor metabolizer for a drug that undergoes CYP 450 metabolism. The nurse
interprets this information as indicating which of the following?
The patient will need a higher dosage of medication.
The therapeutic response would be less.
Drug absorption would be more rapid.
The patient is at increased risk for toxicity.
The patient is at increased risk for toxicity
The daughter of a patient with Huntington disease has requested that she be tested for the disease even though
she has no symptoms at this time. What type of test does the nurse anticipate the physician will order?
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Prenatal testing
Presymptomatic testing
A family pedigree
Predisposition testing
Presymptomatic testing
A nurse working as part of a genetics counseling team is preparing a presentation for a career day discussion at a
local college of nursing. When describing the genomic framework for nursing, which of the following would the
nurse include as being most important?
Experiencing first-hand providing care for a wide range of genetic conditions
Having a thorough understanding of the various technologies available
Being keenly aware of onets own attitudes and assumptions about genetics and genomics
Obtaining in-depth knowledge about the variety of cultural beliefs related to the causes of illness
Being keenly aware of one's own attitudes and assumptions about genetics and genomics
The nurse is working with a 40-year-old pregnant woman about to undergo amniocentesis. The nurse provides
appropriate education by stating that amniocentesis is performed for a prenatal diagnosis of which of the
following?
Thalassemia
Cystic fibrosis
Diabetes
Cleft palate
Cystic fibrosis
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Which of the following best reflects the interpretation of the Health Insurance Portability and Accountability Act
(HIPAA) and genetic information.
Employers are not allowed to use a clientts genetic information for hiring decisions.
Group insurance plans can increase premiums for clients with a genetic condition.
A lifetime cap on benefits cannot be instituted for a specific genetic disorder.
Genetic information cannot be used to establish insurance eligibility.
Genetic information cannot be used to establish insurance eligibility.
The aim of genomic medicine is
improving predictions about individualst susceptibility to diseases.
cure of disease.
cloning.
reproduction.
Improving predictions about individuals' susceptibility to diseases
The nurse is assessing a child with Turner syndrome. The nurse anticipates which of the following findings?
Short stature
Progressive dementia
Painful joints
Chorealike movements
Short stature
The nurse is conducting a community education program on genetics/genomics. The nurse determines that
participants are understanding the information when the class states that diagnostic test used to detect small
chromosomal abnormalities and characterizing chromosomal rearrangement is which of the following?
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DNA analysis
Hemoglobin electrophoresis
Fluorescent in situ hybridization (FISH)
Hexosaminidase A activity testing
Fluorescent in situ hybridization (FISH)
A nurse is assessing a couple of Ashkenazi Jewish descent. The nurse understands that carrier testing for which
condition would be least appropriate for this couple?
Cystic fibrosis
Tay-Sachs disease
Canavan disease
Sickle-cell disease
Sickle-cell disease
To ensure ethical nursing care when dealing with genetic and genomic information, which principle would the
nurse integrate as the foundation for all nursing care?
Justice
Fidelity
Veracity
Respect for people
Respect for people
A nurse is obtaining a genetic family history of a client. The nurse collects information about family members going
back at least how many generations?
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3
2
4
5
3
The nurse is working with a mother whose unborn child was diagnosed as having Down syndrome. The nurse
explains to the mother that Down syndrome occurs due to which of the following?
Germ-line mutation
Structural gene mutation
Chromosome nondisjunction
Phenotype nondisjunction
Chromosome nondisjunction
While assessing a client, the nurse notes that the client has numerous freckles on his skin. The nurse interprets
this finding as which of the following?
Genotype
Genome
Variable expression
Phenotype
Phenotype
Choice Multiple question - Select all answer choices that apply.
The nurse is determining if a pregnant patient is an appropriate candidate for a genetics referral. The nurse makes
the referral based on which of the following findings? Select all that apply.
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Child with Down syndrome
Previous miscarriage
Positive alpha-fetoprotein test
Maternal age of 30
-Positive alpha-fetoprotein test
-Child with down syndrome
A group of students are reviewing information about genomics and how things are changing toward a genomic era
of personalized medicine. The students demonstrate understanding of this information when they identify which of
the following as a characteristic?
Treatment of the symptoms of the presenting disease
Evaluation of a single gene as responsible for a disease
Optimization of risk reduction related to genetic predisposition
Strategy of waiting for disease symptoms to appear
Optimization of risk reduction related to genetic predisposition
The nurse, planning an educational program on cystic fibrosis, should include information explaining that cystic
fibrosis is an example of which of the following types of inherited conditions?
Autosomal dominant
Multifactorial
Autosomal recessive
X-linked recessive
Autosomal recessive
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A nurse working at a clinic interprets which of the following treatment plans as a sign that clinic has transitioned to
a genomic approach for personalized medicine?
Trial and error approach to disease treatment
Treatment of presenting disease symptoms
Treatment of underlying genetic cause of disease
Waiting to treat until disease symptoms appear
treatment of underlying genetic cause of disease
Parents request that a test be done to determine if the fetus has Down syndrome. What type of test does the nurse
anticipate the physician will order?
Presymptomatic testing
Prenatal screening
Predisposition testing
A family pedigree
Prenatal screening
A patient has an autosomal recessive inherited condition. For what type of disorder does the nurse anticipate the
patient will be treated?
Huntington disease
Familial hypercholesterolemia
Hereditary breast cancer
Cystic fibrosis
Cystic fibrosis
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A client is at risk for breast cancer. Which of the following would reflect the clientts genotype for this disorder?
Evidence of a lump in the breast
Family history of breast cancer
Positive breast biopsy
Carrier of BRCA1 mutation
carrier of BRCA1 mutation
Choice Multiple question - Select all answer choices that apply.
A client has hypercholesterolemia. The nurse understands that which of the following reflects the phenotype of the
disease? Select all that apply.
Family history of heart disease
Early onset of cardiovascular disease
Mutations in low-density lipoprotein (LDL) receptors
Low levels of low-density lipoproteins (LDLs)
Skin xanthoma
Early onset of cardiovascular disease
Skin xanthoma
Family history of heart disease
During a community education program on genetics and genomics, the nurse uses which of the following as an
example of a small gene mutation that affects protein structure-producing hemoglobin S?
Marfan syndrome
Tay-Sachs disease
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Hemophilia
Sickle cell anemia
Hemophilia
A nurse is working with a couple who will be undergoing genetic testing. Which of the following would the nurse
prepare the couple for as the first genetic test?
DNA analysis
Chromosomal analysis
Family history
Carrier testing
family history
Students are reviewing information about genes and chromosomes. They demonstrate understanding of this
information when they identify each person as having how many pairs of chromosomes in each cell?
47
18
23
46
23
Nondisjunction of a chromosome results in which of the following diagnoses?
Duchenne muscular dystrophy
Marfan syndrome
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Huntington disease
Down syndrome
Down syndrome
A group of nursing students are reviewing information about issues associated with genetic counseling throughout
the lifespan. The students demonstrate understanding of the issues when they identify which of the following as an
issue related to the newborn period?
Potential for disrupted bonding
Potential for social stigmatization
Possible decreased self-esteem
Implications of reproductive choices
Potential for disrupted bonding
A 32-year-old patient has just been told that she has the BRCA1 hereditary breast cancer gene mutation. What is
her risk of developing cancer by the age of 65 years?
a) 25%
b) 50%
c) 100%
d) 80%
80%
Choice Multiple question - Select all answer choices that apply.
Students are reviewing information about genetic tests and associated conditions. They demonstrate
understanding of this information when they identify which conditions as being identified by DNA analysis? Select
all that apply.
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Fragile X syndrome
Sickle-cell anemia
Down syndrome
Huntington disease
Cystic fibrosis
Huntington disease
Cystic fibrosis
Fragile X syndrome
A nurse is working as part of a genetic counseling team. Which of the following tasks would the nurse most likely
perform?
Complete a physical examination.
Identify the clientts support systems.
Prepare a written summary for the client.
Discuss the specific test findings.
Identify the client's support systems
Cystic fibrosis is an example of which type of inheritance?
Autosomal dominant
Autosomal recessive
Multifactorial
X-linked recessive
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Autosomal recessive
Which of the following would be least appropriate to include when conducting the psychosocial component of the
genetics health assessment?
Familyts educational level
Family rules about information disclosure
Informed decision making ability
Ethnic background of all family members
Ethnic background of all family members
Upon assessment, the nurse determines that all four children in a family are known to carry a gene for a particular
condition. Two of the children actually manifest the condition. Which of the following terms should the nurse use to
document the percentage of family members that manifest the condition?
Variable expression
Pedigree
Penetrance
Genotype
penetrance
A nurse is preparing a presentation for a local community group about familial Alzheimerts disease. As part of the
presentation, the nurse is planning to discuss the possible genetic basis for this condition. The nurse would
describe the inheritance as which of the following?
X-linked
Autosomal dominant
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Multifactoral
Autosomal recessive
Multifactoral
The nurse is evaluating a patientts drug blood level for a medication. The patient is identified as a cytochrome P450
(CYP) ultrarapid metabolizer. The nurse anticipates that the patientts drug blood level will be which of the
following?
Subtherapeutic
Therapeutic
High
Toxic
Subtherapeutic
The nurse is reviewing the chart of a client who was diagnosed with a cleft lip and palate at birth. The nurse
demonstrates understanding of this disorder, identifying it as involving which type of inheritance pattern?
Multifactorial
X-linked recessive
Autosomal dominant
Autosomal recessive
Multifactorial
After teaching nursing students about autosomal-dominant and autosomal-recessive inherited disorders, the
instructor determines that the teaching was successful when the class identifies which of the following as true
about autosomal-dominant inherited conditions?
The percentage of people with a trait who manifest it is variable.
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The severity of the manifestations often varies in degrees.
Horizontal transmission is more commonly seen in families.
Males and females are equally affected by this pattern of inheritance.
Males and females are equally affected by this pattern of inheritance.
A patient understands that her diagnosis of ovarian cancer syndrome is an autosomal-dominant inherited
condition. What is the chance that her daughter will inherit the gene mutation for this disease?
a) 80%
b) 10%
c) 25%
d) 50%
50%
A female client is a carrier for a gene mutation on one of her X chromosomes. Her spouse is unaffected. The nurse
understands that which of the following is most likely?
The risk of transmitting the disorder is negligible.
Any daughters of the client would be carriers for the disorder.
The clientts sons have a 50% chance of being affected.
The client has signs and symptoms of the condition.
the client's sons have a 0% chance of being affected
Which type of Mendelian inherited condition results in both genders being affected equally in a vertical pattern?
X-linked inheritance
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Multifactorial genetic inheritance
Automosomal dominant inheritance
Automosomal recessive inheritance
X-linked inheritance
A client has an autosomal-dominant disorder. His wife is unaffected. When explaining the risk for inheritance of the
disorder in their offspring, which statement by the nurse would be most appropriate?
"The female determines whether your children will have the disorder."
"You have a 1 in 4 chance of a child being affected by the disorder."
"Any child you have would most likely have the disorder."
"There is a 50% chance that each of your children will have the condition."
There is a 50% chance that each of your children will have the condition
During a class, a student asks the instructor, "I read something that said that in some conditions, the presence of a
gene mutation may not actually lead the person to actually show the trait. How can this be?" The instructor
interprets the studentts statement as reflecting which of the following?
Translocation
Penetrance
Deletion
Variable expression
Penetrance
A client is at risk for breast cancer. Which of the following would reflect the clientts genotype for this disorder?
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Evidence of a lump in the breast
Positive breast biopsy
Carrier of BRCA1 mutation
Family history of breast cancer
Carrier of BRCA 1 mutation
The nurse is conducting a prenatal class for expectant parents on conception. The nurse provides additional
teaching when a parent states which of the following?
Meiosis is the result of haploid cells.
The result of mitosis is diploid cells.
Meiosis involves chromosome recombination.
Reproductive cells are formed through mitosis.
Reproductive cells are formed through mitosis
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Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 7: Disability and Chronic Illness
A client who uses a wheelchair was unable to enter a health care clinic because the pavement was too high. The
client filed a formal complaint stating that reasonable accommodations were not met. What is an example of a
reasonable accommodation under the 1990 American Disabilities Act (ADA)?
Priority medical appointments and grab bars
Low-cost transportation and elevated toilet seats
Accessible facilities and equipment
Alternate communication methods and medical home visits
C
A client tells the nurse that the doctor just told the client that a new diagnosis of rheumatoid arthritis is considered
to be a "chronic condition." The client asks the nurse what "chronic condition" means. What would be the nursets
best response?
"It is a health problem that require managements of several months or longer."
"Chronic conditions are disabilities that require medical treatments that limit activity."
"Medical conditions are chronic when they culminate in disabilities that require hospitalization."
"Chronic conditions are conditions that require short-term management in extended-care facilities."
A
A medical-surgical nurse is teaching a client about the health implications of the clientts recently diagnosed type 2
diabetes. The nurse should teach the client to be proactive with glycemic control to reduce the risk of what health
problem?
Urinary tract infections
Renal failure
Pneumonia
Inflammatory bowel disease
B
An international nurse has noted that a trend in emerging countries is a decrease in mortality from some acute
conditions. What has contributed to this decrease in mortality from some acute conditions?
Improved nutrition
Integration of alternative health practices
Stronger international security measures
Decreases in obesity
A
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A 37-year-old client with multiple sclerosis is married and has three children. The nurse has worked extensively
with the client and family to plan appropriate care. What is the nursets most important role with this client?
Ensure the client adheres to all treatments.
Provide the client with advice on alternative treatment options.
Provide a detailed plan of activities of daily living (ADLs) for the client.
Help the client develop strategies to implement treatment regimens.
D
A client has recently been diagnosed with type 2 diabetes. The client is clinically obese and has a sedentary
lifestyle. How can the nurse best begin to help the client increase their activity level?
Set up appointment times at a local fitness center for the client to attend.
Have a family member ensure the client follows a suggested exercise plan.
Construct an exercise program and have the client follow it.
Identify barriers with the client that inhibit lifestyle changes.
D
A home care nurse is making an initial visit to a 68-year-old client. The nurse finds the client tearful and emotionally
withdrawn. Even though the client lives alone and has no family, the client has been managing well at home until
now. What would be the most appropriate action for the nurse to take?
Reassess the clientts psychosocial status and make the necessary referrals.
Have the client volunteer in the community for social contact.
Arrange for the client to be reassessed by a social worker.
Encourage the client to focus on the positive aspects of life.
A
The nurse is caring for a male client with a history of chronic angina. The client states that after breakfast he
usually takes a shower and shaves. It is at this time, the client says, that he tends to experience chest pain. What
should the nurse counsel the client to do to decrease the likelihood of angina in the morning?
Shower in the evening and shave before breakfast.
Skip breakfast and eat an early lunch.
Take a nitroglycerin tab prior to breakfast.
Shower once a week and shave prior to breakfast.
A
A client uses a wheelchair. The client wants to attend a church-sponsored support group for parents of children
diagnosed with autism spectrum disorder. The client arrives at the church and realizes there are no ramps or
elevators to the basement. What type of barrier did this client encounter?
A structural barrier
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A barrier to health care
An institutional barrier
A transportation barrier
A
A client who is legally blind is being admitted to the hospital. The client informs the nurse that they need to have
their guide dog present during hospitalization. What is the nursets best response to the client?
"Arrangements can be made for your guide dog to be at the hospital with you during your stay."
"I will need to check with the care team before that decision can be made."
"Because of infection control, your guide dog will likely not be allowed to stay in your room during your
hospitalization."
"Your guide dog can stay with you during your hospitalization, but it will need to stay in a cage or crate that you
will need to provide."
A
A nurse is taking an Advanced Cardiovascular Life Support class. The nurse has dyslexia and is given an extra
hour to complete the exam. What type of disability best defines the nursets condition?
Intellectual disability
Sensory disability
Psychiatric disability
Cognitive disability
B
A 19-year-old client with a diagnosis of Down syndrome is being admitted to the unit for the treatment of
community-acquired pneumonia. When planning this clientts care, the nurse recognizes that this clientts disability
is categorized as what type?
A sensory disability
A developmental disability
An acquired disability
An age-associated disability
B
The nurse is reviewing the importance of preventive health care with a client who has a disability. The client
describes intense financial pressures associated with being disabled. What is the nursets best response?
"Limited finances are a common problem for clients with a disability."
"Is there anyone who you might be able to borrow money from in the short term?"
"Itll look into federal assistance programs that provide financial assistance for health-related expenses for
people with disabling conditions."
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"Many of your expenses should be tax deductible, so you should consult with your accountant and then make
your appointments."
C
As a case manager, the nurse oversees the multidisciplinary care of several clients living with chronic conditions.
Two of the nursets clients are living with spina bifida. The center of care for these two clients will typically exist
where?
In the hospital
In the health care providerts office
In the home
In the rehabilitation facility
C
A nurse is planning the care of a client who has been diagnosed with asthma, which the nurse recognizes as being
a chronic condition. Which of the following descriptors apply to chronic conditions? Select all that apply.
Resolve slowly
Rarely are completely cured
Have a short, unpredictable course
Do not resolve spontaneously
Have a prolonged course
B, D, E
A 55-year-old woman with multiple sclerosis is deficient in completing health screening and health promotion tests.
Based on the information provided, and statistical data, what is the most likely test that the client missed?
Yearly physical
Pelvic examination
Colonoscopy
Hearing test
B
A client who has recently been diagnosed with chronic heart failure is being taught by the nurse how to live
successfully with the chronic condition. The clientts ability to meet this goal will primarily depend on the clientts
ability to do which of the following?
Lower the clientts expectations for quality of life and level of function.
Access community services to eventually cure the disease.
Adapt a lifestyle to accommodate the clientts symptoms.
Establish good rapport with the clientts primary care provider.
C
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A major cause of health-related problems is the increase in the incidence of chronic conditions. Which factor has
contributed to the increased incidence of chronic diseases in developing countries?
A decrease in average life expectancy
Increasing amounts of health research
A lack of health infrastructure to manage illness
Adoption of a more sedentary lifestyle, which is increasing obesity
D
A client with a spinal cord injury is being assessed by the nurse prior to being discharged from the rehabilitation
facility. The nurse is planning care through the lens of the interface model of disability. Within this model, the nurse
will plan care based on what belief?
The client has the potential to function effectively despite the disability.
The clientts condition does not have to affect their lifestyle.
The client will not require care from professional caregivers in the home setting.
The clientts disability is the most significant aspect of the clientts personal identity.
A
During the care conference for a client who has multiple chronic conditions, the case manager has alluded to the
principles of the interface model of disability. What statement is most characteristic of this model?
"This client should be free to plan their care without our interference."
"This client can be empowered and doesntt have to be dependent."
"This client was a very different person before the emergence of these health problems."
"This clientts physiologic problems are the priority over their psychosocial status."
B
The nurse is caring for a 25-year-old client with a traumatic brain injury and severe disabilities caused by a motor
vehicle accident. The client asks the nurse for education about sex in regards to their condition. How should the
nurse respond?
"I can have another health care provider discuss it with you tomorrow."
"Try to focus on the bigger picture of getting physically stronger. We can talk about sex once you are more
stable."
"First, I think you should talk to your significant other to discuss the limits of your physical relationship."
"Do you have specific questions first? I can bring additional resources into the discussion as needed."
D
The nurse is caring for a 25-year-old client who has Down syndrome and who has just been diagnosed with type 2
diabetes. What consideration should the nurse prioritize when planning this clientts nursing care?
How the new diagnosis affects health attitudes
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How diabetes affects the course of Down syndrome
How the chromosomal disorder affects the clientts glucose metabolism
How the developmental disability influences the clientts health management
D
The nurse is caring for a young mother who has a longstanding diagnosis of multiple sclerosis (MS). The parent
was admitted with a postpartum infection 3 days ago, and the plan is to discharge the client home when the client
has finished 5 days of IV antibiotic therapy. What information would be most useful for the nurse to provide at
discharge?
A long discussion and overview of postpartum infections
How the response to infection never differs in clients with MS
The same information you would provide to a client without a chronic condition
Information on effective management of MS in the home setting
C
A new client has been admitted with a diagnosis of stage IV breast cancer. The client has a comorbidity of
myasthenia gravis. During the initial assessment, the client states that they felt the lump in the breast about 9
months ago. The nurse asks the client why they did not see the health care provider when first finding the lump in
breast. What would be a factor that is known to influence the client in seeking health care services?
Lack of insight due to the success of self-managing a chronic condition
Lack of knowledge about treatment options
Overly sensitive client reactions to health care services
Unfavorable interactions with health care providers
D
The community nurse is caring for a client who has paraplegia following a farm accident when they were an
adolescent. This client is now 64 years old and has just been diagnosed with congestive heart failure. The client
states, "Itm so afraid about what is going to happen to me." What would be the best nursing intervention for this
client?
Assist the client in making suitable plans for care.
Take the client to visit appropriate long-term care facilities.
Give the client pamphlets about available community resources.
Have the client visit with other clients who have congestive heart failure.
A
An initiative has been launched in a large hospital to promote the use of "people-first" language in formal and
informal communication. What is the significance to the client when the nurse uses "people-first" language?
The nurse clearly defines how the disability shapes the clientts character.
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The client is of more importance to the nurse than the disability.
The clientts disability mandates their relationships and life choices.
The nurse knows that the clientts disability is a curable condition.
B
A client who is recovering from a stroke expresses frustration about their care to the nurse, stating, "It seems like
everyone sees me as just a problem that needs fixing." This clientts statement is suggestive of what model of
disability?
Biopsychosocial model
Social model
Rehabilitation model
Interface model
C
The interface model of disability is being used to plan the care of a client who is living with the effects of a stroke.
Why should the nurse prioritize this model?
It fosters dependency and rapport between the caregiver and the client.
It encourages the provision of care that is based specifically on the disability.
It promotes interactions with clients focused on the root cause of the disability.
It promotes the idea that clients are capable and responsible.
D
A nurse knows that clients with "invisible" disabilities like chronic pain often feel that their chronic conditions are
more challenging to deal with than more visible disabilities. Why would they feel this way?
Invisible disabilities create negative attitudes in the health care community.
Despite appearances, invisible disabilities can be as disabling as visible disabilities.
Disabilities, such as chronic pain, are apparent to the general population.
Disabilities, such as chronic pain, may not be curable, unlike visible disabilities.
B
A couple who are in their early 80s have provided constant care for their 44-year-old child who has Down
syndrome. When planning this familyts care, the nurse should be aware that the parents most likely have concerns
around what question?
"What could we have done better for our child?"
"Why was our child born with Down syndrome while our other children are healthy?"
"Who will care for our child once wetre unable?"
"Will we experience the effects of developmental disabilities late in life?"
C
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Many individuals with disabilities are employed. What has research shown about this employed population?
Their salaries are commensurate with their experience.
They enjoy their jobs more than people who do not have disabilities.
Employment rates are higher among people with a disability than those without.
People with disabilities earn less money than people without disabilities.
D
A 43-year-old female client with epilepsy is admitted to the hospital. The client has been on seizure medications
most of their adult life. What would be an appropriate care plan for this client?
Altered mental status related to history of seizures
Increased fall risk related to medication regimen
Risk for aspiration related to swallowing difficulties
Self-care deficit related to cognitive impairment
B
A nurse is presenting at a health fair and is promoting the benefits of maintaining a healthy body weight. The nurse
should refer to reductions in the risks of what diseases? Select all that apply.
Heart disease
Stroke
Neurologic cancers
Diabetes
Hypertension
A, B, D, E
A nurse is aware that the number of people in the United States who are living with disabilities is expected to
continue increasing. What is considered to be one of the factors contributing to this increase?
The decrease in the number of people with early-onset disabilities
The increased inability to cure chronic disorders
Changes in infection patterns resulting from antibiotic resistance
Increased survival rates among people who experience trauma
D
A 45-year-old client was diagnosed with schizophrenia at the age of 20. The client is having trouble finding
community-based services to help increase their quality of life. Which program would most benefit the client?
Medicaid
Tricare
American Disabilities Act
Medicare
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A
A 39-year-old client with paraplegia has been admitted to the hospital for the treatment of a sacral pressure injury.
The nurse is aware that the client normally lives alone in an apartment and manages their ADLs independently.
Before creating the clientts plan of care, how should the nurse best identify the level of assistance that the client
will require in the hospital?
Make referrals for assessment to occupational therapy and physical therapy.
Talk with the client about the type and level of assistance that the client desires.
Obtain the clientts previous medical record and note what was done during their most recent admission.
Apply a standardized care plan that addresses the needs of a client with paraplegia.
B
A community health nurse has drafted a program that will address the health promotion needs of members of the
community who live with one or more disabilities. Which area of health promotion education is known to be
neglected among adults with disabilities?
Blood pressure screening
Diabetes testing
Nutrition
Sexual health
D
definitions of disability
WHO (2001) - International Classification of Functioning, Disability and Health (dynamic between a persons health
condition and their environment)
Americans With Disabilities Act of 1990 (physical or mental impairment that substantially limits one or more major life
activities)
prevalence of disabilities
20% of persons in the US have a disability and 10% of persons in the US have a severe disability
examples are chronic conditions
heart disease
stroke
cancer
obesity
arthritis
diabetes
COPD
risk factors for chronic diseases
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smoking
hypertension
chronic stress
sedentary lifestyle
examples of disability
difficulty talking, hearing, seeing, walking, climbing stairs, lifting or carrying objects, performing ADLs, such as feeding
oneself, bathing, dressing, grooming, toileting, doing school work, or working a job
severe disability
person is unable to perform one or more activities, uses an assistive device for mobility, or needs help from another
person to accomplish basic activities (also if they receive federal aid)
impairment
a loss or abnormality in body structure or physiological function, including mental function
Americans with Disabilities Act of 1990 defines a person with a disability as one who:
has a physical or mental impairment that substantially limits one or more major life activities
has a record of such an impairment
regarding as having such an impairment
prevalence of disability
higher in men <65 years old
higher in women >65 years old
higher among American Indians and Alaskan natives, adults with incomes below the poverty level, and people living inthe
south western US census region
in the US, is higher for AA and whites than for Hispanics and Asians
categories and types of disabilities
cognitive
developmental
intellectual
sensory
psychiatric
acquired
cognitive disability
limitations in mental functioning and difficulties with communication, self care, and difficulties with social skills
developmental disability
occurs any time from birth-22 years of age and results in impairment of physical or mental health, cognition, speech,
language, or self care
an umbrella term that includes intellectual disabilities but can be a physical disability only
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some can occur as a result of birth trauma or severe illness or injury at a very young age and some are genetic
some can overlap with cognitive and/or intellectual disabilities that affect intellectual functioning and adaptive behavior
examples of developmental disabilities
spina bifida, cerebral palsy, down syndrome, muscular dystrophy, dwarfism, and osteogenesis imperfecta
intellectual disability
occurs before 18 years of age and is characterized by significant limitations in both intellectual functioning and adaptive
behavior, including many every day social and practical skills
sensory disability
characterized by impairment of the sense of sight, hearing, smell, touch, and/or taste
most commonly affect hearing and vision, but they also include learning disabilities that affect the ability to learn,
remember, or concentrate; disabilities that affect the ability to speak or communicate; and diabilities that affect the ability
to work, shop, and care for oneself, or access to healthcare
risks for sensory disability
isolation, reduced cognitive function, poor physical and and psychological health, and increase risk of falls and
hospitalization
psychiatric disability
a mental illness or impairment that substantially limits on'e ability to complete major life activities, such as learning,
working, and communicating
acquired disability
may occur as a result of an acute and sudden injury (TBI, spinal cord injury, amputations, from crashes, falls, burns, etc),
acute non traumatic disorders (stroke, MI), or progression of chronic disorder (arthritis, MS, PD, COPD, heart disease,
diabetic retinopathy)
interface model of disability
Promotes the view that people can function effectively with adaptive equipment and functional substitution (developed by
a nurse, promotes care designed to be empowering rather than care that promotes dependency)
The Rehabilitation Act of 1973
protects people from discrimination based on their disability
The Americans with Disabilities Act of 1990
mandates that people with disabilities have access to job opportunities and to the community without discrimination based
on having a disability
right of access to healthcare
people with disabilities have the right of access to healthcare that is equal in quality to that of other people
challenges to healthcare providers = communicating effectively, addressing the additional physical requirements for
mobility, and how to ensure sufficient time to provide assistance with self care routines during hospitalization
people with disabilities shouldn't be expected to provide their own accommodations
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barriers to healthcare
structural barriers
negative and stereotypical attitudes
women with disabilities are at higher risk for receiving a lower level of healthcare than men
rural areas (fewer resources and less access)
costs of care
race, gender, and type of disability also affect prevalence, health status, and receipt of healthcare and screening
nursing considerations during hospitalization for people with disabilities
patients should be asked preferences about approaches to carry out their ADLs and assistive devices they require
should be readily available
arrange hospital room according to their needs
establishing effective communication strategies is crucial
health promotion and prevention for disability
nurses should take every opportunity to emphasize the importance of participation in health promotion activities (healthydiet,
exercise, social interactions) and preventative health screenings
regular screenings are a MUST
effect of the disabling condition on health risks should be considered
classes on nutrition and weight management = wheelchair users and transfer patients
safer sex classes = adolescents and young adults who have spinal cord injuries, TBI, or developmental disabilities due
to STIs and unplanned pregnancy risk
avoiding alcohol and nonprescription meds while taking antispasmodic and anticonvulsant meds = neurological
disabilities
people first language
seeing individuals as people first and not as being defined by their disorder/disability/illness/etc
gerontologic considerations for disability
age related disabilities include osteoarthritis, osteoporosis, and hearing loss
disability occurs across the lifespan
aging affects people with preexisting disabilities = age earlier
the nurse must also consider the effects of aging on a preexisting disability and in turn the effects of disability on aging
disability in med surg nursing practice
people with disabilities are at risk for the same acute illnesses that can affect everyone and are at an increased risk for
aging related chronic diseases due to smoking, obesity, lack of physical activity
also at an increased risk for unintentional injuries (falls)
when a patient with a disability is admitted, their needs for these modifications should be assessed and addressed
med surg nurses need to be knowledgeable about the disability and how it affects people across the lifespan
patient education on self care
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follow up appts, patient education, transportation, etc. should occur when a patient is being discharged
the nurse should recognize the effect that the disability has on the patient's ability to follow up
share resources with patient and family
chronic disease
refers to noncommunicable diseases (conditions not caused by an acute infection or injury), chronic conditions, and
chronic disorders
chronic illness
refers to the human experience of living with a chronic disease or condition
includes the person's perception of the experience of having a chronic disease or condition and the person's and others'
responses to it, including healthcare professionals
values and beliefs affect perception, which affect their illness and wellness behaviors
chronic diseases are
long term health conditions that affect one's well being and function in an episodic, continuous, or progressive way over
many years of life
common symptoms of chronic diseases
pain
fatigue
sleep disturbances
difficulty adjusting to the onset and uncertainty of a a chronic condition
having multiple chronic conditions (MCC)...
increases the complexity of care and often necessitates care by multiple healthcare specialists, a variety of treatment
regimens, and prescription meds that may not interact
at risk for conflicting medical advice, adverse effects of meds, unnecessary and duplicative tests, and preventable
hospitalizations, all of which can negatively affect their health
cost increases with more chronic conditions a person has
health disparities and chronic disease
poverty and inadequate health insurance decreases likelihood of people with chronic illnesses or disability receive
healthcare and preventative screenings
chronic conditions can lead to poverty
disparities are associated with increase incidence and prevalence, earlier onset, faster progression, and poorer
outcomes of disease and conditions
not all disabilities are a result of chronic illness and not all chronic illnesses cause disability
adjustment to chronic illness (and disability) is affected by
suddenness, extent, and duration of lifestyle changes necessitated by illness
fam and individual resources for dealing with stress
availability of support
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stages of individual/fam life cycle
previous experience with illness and crises
underlying personality characteristics
unresolved anger and/or grief from the past
symptoms associated with chronic diseases...
are often unpredictable and may be perceived as crisis events by patients and their families, who must contend with both
the uncertainty of chronic illness and the changes it brings to their lives
the main social determinants of health (SDOH)
income and social status
employment and working conditions
education and literacy
childhood experiences
physical environment
social supports and coping skills
healthy behaviors
access to services
biology and genetic makeup
gender, culture, race, and ethnicity
most chronic diseases are caused by
tobacco
electronic nicotine delivery systems (ENDS)
exposure to second hand smoke
poor nutrition
lack of physical activity
excessive alcohol consumption
physiologic changes in the body often occur
the appearance of symptoms of chronic disease
before
characteristics of chronic conditions
Psychological/social issues (disrupts life)
Course of chronic disease (acute periods, stable/unstable periods, flare ups, remissions)
Progression of chronic disease (rapid vs slow; relapses)
Therapeutic regimens (keeping under control requires adherence to treatment plan)
Development of other chronic conditions
Family life (affects ENTIRE family - role changes, loss of income, etc)
Home life (day to day management)
Self-management (continuous process)
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Health care costs (expensive)
Loss of income (due to higher expenses)
Ethical issues (how to control costs, how to allocate resources, what constitutes quality of life, and if/when life support
will be withdrawn)
Living with uncertainty (predictability is difficult)
implications of managing chronic conditions
fix lifestyle
once a chronic condition has occurred, the focus shifts to managing symptoms, avoiding complications, and preventing
other acute illnesses
gerontologic considerations for chronic diseases
increase in chronic conditions
more in women than men
most have at least one chronic condition and 3 in every 4 have MCC
most occurring --> arthritis, cancer, cardiac disease, type 2 diabetes, and hypertension
treatment = major health expenditure
increased risk of death due to influenza and pneumonia
nursing care of patients with chronic conditions
care varies
care may be direct or supportive
direct care
supportive care
direct care
assessing physical status, providing wound care, managing and overseeing medication regimens, providing education to
the patient and family, and performing technical tasks
supportive care
ongoing monitoring, education, counseling, serving as an advocate for the patient, making referrals, and case
management
nurses often provide supportive care at home
giving supportive care is just as important as giving direct physical care
home, community-based, and transitional care
prevention and care
education
promotion of healthy lifestyle
begin early and continue throughout life
educated patients are more likely to manage symptoms, recognize the onset of complications, and seek health care
early
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education must be planned carefully so that it is not acute
assess patient's knowledge
education MUST be individually oriented
collaborative process = chronic illness management
keeping illness stable requires careful monitoring of symptoms and attention to management regimens
Telehealth
Telehealth
Use of technology to deliver health-related services and information, including telemedicine
has been used effectively to provide care for patients with chronic illnesses
useful in monitoring patients with chronic conditions in rural areas
also to deliver counseling and provide ongoing education and support
special populations with chronic illness
can be targeting for special education and monitoring programs
people of different cultures and genders can respond differently
consider effects of preexisting disability on the patient's ability to manage ADLs, self care, and therapeutic regimen
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Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 8: Management of the Older Adult Patient
The nurse is providing care for an 82-year-old client whose signs and symptoms of Parkinson disease have
worsened over the past several months. The client reports no longer being able to do as many things as in the past.
Based on this statement, what issue is of most concern to the client?
Neurologic deficits
Loss of independence
Age-related changes
Tremors and decreased mobility
B
Which age-related physiologic change contributes to heart disease being the leading cause of death in older
adults?
Heart muscle and arteries lose their elasticity.
Systolic blood pressure decreases.
Resting heart rate decreases with age.
Atrial-septal defects develop with age.
A
An occupational health nurse overhears an employee talking to a manager about a 65-year-old coworker. Which
phenomenon should the nurse identify when hearing the employee state to the coworker, "You should just retire
and make way for some new blood"?
Intolerance
Ageism
Dependence
Nonspecific prejudice
B
An 80-year-old client is being admitted for dehydration and syncope. The client is found to be hypotensive, and
intravenous fluids are ordered. What are some teaching strategies that the nurse should review with this client?
Before ambulation the client should rise slowly and take mini breaks between lying, sitting, and standing.
Increase consumption of meals to three times a day, with the largest meal being at breakfast.
The client must use a rolling walker and call for assistance with any change in position.
The temperature in the room should stay very hot, and bathing in hot water is appropriate.
A
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A 76-year-old client is in the emergency department with reports of nausea, dyspnea, and shoulder pain. The
spouse stated the client woke up confused, slightly unsteady, and pale. Which problem or condition is most likely
occurring?
Myocardial ischemia
Urinary tract infection (UTI)
Lung cancer
Chronic obstructive pulmonary disease (COPD)
A
A 65-year-old client has come to the clinic for a yearly physical. The client reports enjoying good health, but also
reports having occasional episodes of constipation over the past 6 months. What intervention should the nurse
first suggest?
Reduce the amount of stress the client currently experiences.
Increase carbohydrate intake and reduce protein intake.
Take herbal laxatives, such as senna, each night at bedtime.
Increase daily intake of water.
D
An 80-year-old client has been admitted to the hospital for hypertension and now requires oxygen. The client asks
the nurse why oxygen is needed because they have never smoked and feel fine. The client requires oxygen in the
hospital because of which respiratory changes or requirements?
As a therapeutic measure to encourage coughing and deep breathing
Diminished respiratory efficiency and declining aerobic capacity
To increase inspiratory and expiratory force of lungs
Lung mass increases and residual volume decreases
B
The nurse is providing education to a client with early-stage Alzheimer disease (AD) and the family members. The
client has been prescribed donepezil hydrochloride. What should the nurse explain to the client and family about
this drug?
It slows the progression of AD.
It cures AD in a small minority of clients.
It removes the clientts insight that they have AD.
It eliminates the physical effects of AD and other dementias.
A
A nurse is caring for an 81-year-old client who has become increasingly frail and unsteady when standing. During
the assessment, the client reports having fallen three times in the month, though the client did not suffer any injury.
The nurse should take action in the knowledge that this client is at a high risk for which type of injury?
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A hip fracture
A femoral fracture
Pelvic dysplasia
Tearing of a meniscus or bursa
A
The case manager is working with an 84-year-old client newly admitted to a rehabilitation facility. When developing
a care plan for this client, which factors should the nurse identify as positive attributes that enhance coping in this
age group? Select all that apply.
Decreased risk taking
Effective adaptation skills
Avoiding participation in untested roles
Increased life experience
Resilience during change
B, D, E
A nurse will conduct an influenza vaccination campaign at an extended care facility. The nurse will be administering
intramuscular (IM) doses of the vaccine. Which age-related change should the nurse be aware of when planning the
appropriate administration of this drug? An older adult client has:
less subcutaneous tissue and less muscle mass than a younger client.
more subcutaneous tissue and less durable skin than a younger client.
more superficial and tortuous nerve distribution than a younger client.
a higher risk of bleeding after an IM injection than a younger client.
A
The admissions department at a local hospital is registering a 78-year-old client for an outpatient diagnostic test.
The admissions nurse asks if the client has an advance directive. The client reports not wanting to complete an
advance directive because they do not want anyone controlling their finances. What would be appropriate
information for the nurse to share with this client?
"Advance directives are not legal documents, so you have nothing to worry about."
"Advance directives are limited only to health care instructions and directives."
"Your finances cannot be managed without an advance directive."
"Advance directives are implemented when you become incapacitated, when you will use a living will to allow
the state to manage your money."
B
A nurse is planning discharge education for an 81-year-old client with mild short-term memory loss. The discharge
education will include how to perform basic wound care for the venous ulcer on the clientts lower leg. When
planning the necessary health education for this client, the nurse should take which action?
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Set long-term goals with the client.
Provide a list of useful websites to supplement learning.
Keep visual cues to a minimum to enhance the clientts focus.
Keep teaching periods short.
D
The nurse is planning an educational event for the nurses on a subacute medical unit on the topic of normal, agerelated physiologic changes. What phenomenon should the nurse address?
A decrease in cognition, judgment, and memory
A decrease in muscle mass and bone density
The disappearance of sexual desire for both men and women
An increase in sebaceous and sweat gland function in both men and women
B
A home health nurse makes a home visit to a 90-year-old client who has cardiovascular disease. During the visit the
nurse observes that the client has begun exhibiting subtle and unprecedented signs of confusion and agitation.
What should the home health nurse do?
Increase the frequency of the clientts home care.
Have a family member check in on the client in the evening.
Arrange for the client to see their primary care provider.
Refer the client to an adult day program.
C
The home health nurse is making an initial home visit to a 71-year-old client who is widowed. The client reports
having begun taking some herbal remedies. Which should the nurse be sure to include in the clientts education?
Herbal remedies are consistent with holistic health care.
Herbal remedies are often cheaper than prescribed medication.
It is safest to avoid the use of herbal remedies.
There is a need to inform the primary care provider and pharmacist about the herbal remedies.
D
A 54-year-old female client visiting her gynecologist is postmenopausal and reports painful intercourse. What is a
physical change that is occurring to the clientts reproductive system to account for this problem?
Thickening of the vaginal wall
Increased vaginal secretions
Shortening of the vagina
Increased pubococcygeal muscle tone
C
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A 62-year-old woman started experiencing urinary incontinence six months ago and now wears disposable
incontinent panties. The client does not drink any fluids after 5 pm and considers this problem part of aging. What
priority modifications and advice should be given to this client?
"While urinary incontinence is part of the aging process, you should still see your health care provider (HCP)
about this condition."
"You probably have a urinary tract infection and should start drinking cranberry juice."
"You could purchase pads to place into washable panties. This would decrease costs and feel less like a diaper."
"Urinary incontinence is not part of the aging process. You should see your HCP and increase your water
intake."
D
A 59-year-old client has come to the health care providerts office for an annual physical and is being assessed by
the office nurse. The nurse who is performing routine health screening for this client should be aware that one of
the first physical signs of aging is what?
Having more frequent aches and pains
Failing eyesight, especially close vision
Increasing loss of muscle tone
Accepting limitations while developing assets
B
A gerontologic nurse is aware of the demographic changes that affect the provision of health care. Which
demographic change has the biggest impact?
More families are having to provide care for their aging members.
Adult children find themselves participating in chronic disease management.
A growing number of people live to a very old age.
Older adults are having more accidents, increasing the costs of health care.
C
A 76-year-old client with Parkinson disease has been admitted with aspiration pneumonia and constipation. Which
nursing intervention would help both diagnoses?
Sitting upright for meals
Good oral hygiene
Prolonged laxative usage
Increase dietary fat
A
A gerontologic nurse is making an effort to address some of the misconceptions about older adults that exist
among health care providers. The nurse has made the point that most people aged 75 years and over remain
functionally independent. The nurse should attribute this trend to what factor?
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Early detection of disease and increased advocacy by older adults
Application of health-promotion and disease-prevention activities
Changes in the medical treatment of hypertension and hyperlipidemia
Genetic changes that have resulted in increased resiliency to acute infection
B
After a sudden decline in cognition, a 77-year-old client who has been diagnosed with vascular dementia is
receiving care at home. To reduce this clientts risk of future infarcts, which action should the nurse most strongly
encourage?
Activity limitation and falls reduction efforts
Adequate nutrition and fluid intake
Rigorous control of the clientts blood pressure and serum lipid levels
Use of mobility aids to promote independence
C
Nurses and members of other health disciplines at a statets public health division are planning programs for the
next 5 years. The group has made the decision to focus on diseases that are experiencing the sharpest increases in
their contributions to the overall death rate in the state. This team should plan health promotion and disease
prevention activities to address what health problem?
Stroke
Cancer
Respiratory infections
Alzheimer disease
D
A 72-year-old client has returned to the community following knee replacement surgery. The client takes nine
different medications and has experienced dizziness since discharge. The nurse should identify which nursing
diagnosis?
Risk for infection related to polypharmacy and hypotension
Risk for falls related to polypharmacy and impaired balance
Adult failure to thrive related to chronic disease and circulatory disturbance
Disturbed thought processes related to adverse drug effects and hypotension
B
A 55-year-old client is preparing to retire in the next five years. The client has made both financial and social plans
to make a successful transition. What are some examples of social change that the client could plan?
Additional reliance on the spouse and family to fill in leisure time
Developing routines and friends not associated with work
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Planning several vacations to expand the clientts social circle
Starting an online social network to keep the client connected with co-workers
B
The nurse is caring for a 77-year-old client who was recently admitted to the geriatric medical unit. Since
admission, the client has spoken frequently of becoming a burden to their children and the challenge of "staying
afloat" financially. When planning this clientts care, the nurse should recognize a heightened risk of what nursing
diagnosis?
Disturbed thought processes
Impaired social interaction
Decisional conflict
Anxiety
D
For several years, a community health nurse has been working with a 78-year-old man who requires a wheelchair
for mobility. The nurse is aware that the interactions between disabilities and aging are not yet clearly understood.
This interaction varies depending on what variable?
Socioeconomics
Ethnicity
Education
Pharmacotherapy
A
Gerontologic nursing is a specialty area of nursing that provides care for older adults in our population. Which goal
of care should a gerontologic nurse prioritize when working with this population? Helping older adults:
determine how to reduce their use of external resources.
use their strengths to optimize independence.
promote social integration.
identify the weaknesses that most limit them.
B
The presence of a gerontologic advanced practice nurse in a long-term care facility has benefited both the clients
and the larger community in which they live. Nurses in this advanced practice role have been shown to cause which
outcome?
Greater interaction between younger adults and older adults occurs.
Older adults recover more quickly from acute illnesses.
Less deterioration takes place in the overall health of clients.
Older adults are happier in long-term care facilities than at home.
C
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A gerontologic nurse is basing the therapeutic programs at a long-term care facility on Millerts Functional
Consequences Theory. To put this theory into practice, the nurse should prioritize which task?
Attempting to control age-related physiologic changes
Lowering expectations for recovery from acute and chronic illnesses
Helping older adults accept the inevitability of death
Differentiating between age-related changes and modifiable risk factors
D
A 69-year-old client is readmitted with heart failure. The client reports taking all medications as prescribed. The
clientts grandchild usually helps to set up a weekly organizer pill container but is away at college. What should the
nurse first do with this information?
Call the clientts home to solicit another family member to help with the medications on discharge.
Explain the current inpatient orders and make a note on the chart for discharge
Contact the clientts health care provider (HCP) for assistance and direction on how to proceed.
Complete a comprehensive assessment reviewing the clientts medication history, including over-the-counter
medications
D
The nurse is caring for a 78-year-old client with cardiovascular disease. The client comes to the clinic with a
suspected respiratory infection and is diagnosed with pneumonia. What should the nurse recognize about the
altered responses of older adults?
Treatments for older adults need to be more holistic than treatments used in the younger population.
Increased and closer monitoring of older adultst body systems must occur to identify possible systemic
complications.
The aging process of older adults must define all nursing interventions with the client.
Older adults become hypersensitive to antibiotic treatments for infectious disease states.
B
The nurse is caring for clients in the urology clinic. A new, 73-year-old client presents with reports of urinary
incontinence and is prescribed an anticholinergic. Why might this type of medication be an inappropriate choice in
the older adult population?
Gastrointestinal hypermotility can be an adverse effect of this medication.
Detrusor instability can be an adverse effect of this medication.
Confusion can be an adverse effect of this medication.
Increased symptoms of urge incontinence can be an adverse effect of this medication.
C
A gerontologic nurse is overseeing the care in a large, long-term care facility. The nurse is educating staff about the
significant threat posed by influenza in older, frail adults. What action should the nurse prioritize to reduce the
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incidence and prevalence of influenza in the facility?
Teach staff how to administer prophylactic antiviral medications effectively.
Ensure that residents receive a high-calorie, high-protein diet during the winter.
Make arrangements for residents to limit social interaction during winter months.
Ensure that residents receive influenza vaccinations in the fall of each year.
D
When implementing a comprehensive plan to reduce the incidence of falls on a gerontologic unit, what risk factors
should the nurse identify? Select all that apply.
Medication effects
Overdependence on assistive devices
Poor lighting
Sensory impairment
Ineffective use of coping strategies
A, C, D
When the nurse observes physical indicators of illness in the older population, that nurse should be aware of which
of the following principles?
Potential life-threatening problems in the older adult population are not as serious as they are in a middle-aged
population.
Indicators that are useful and reliable in younger populations cannot be relied on as indications of potential lifethreatening problems in older adults.
The same physiologic processes that indicate serious health care problems in a younger population indicate
mild disease states in older adults.
Middle-aged people do not react to disease states the same way a younger population does.
B
The nurse is caring for a 91-year-old client who reports urge incontinence and sometimes falling when trying to get
to the bathroom at home. The nurse identifies the nursing diagnosis of Risk for Falls related to impaired mobility
and urinary incontinence. This clientts risk for falls is considered to be which of the following?
The result of impaired cognitive functioning
The accumulation of environmental hazards
A geriatric syndrome
An age-related health deficit
C
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UNIT 2 Concepts and Principles of Patient Management
Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 9: Pain Management
An 18-year-old pregnant woman, gravida 1, is admitted to the labor and birth unit with moderate contractions every
5 minutes that last 40 seconds. The woman states, My contractions are so strong that I dont know what to do with
myself. The nurse should:
Assess for fetal well-being.
Encourage the woman to lie on her side.
Disturb the woman as little as possible.
Recognize that pain is personalized for each individual.
ANS: D
Each womans pain during childbirth is unique and is influenced by a variety of physiologic, psychosocial, and
environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the woman during
labor and birth. Assessing for fetal well-being includes no information that would indicate fetal distress or a logical reason
to be overly concerned about the well-being of the fetus. The left lateral position is used to alleviate fetal distress, not
maternal stress. The nurse has an obligation to provide physical, emotional, and psychosocial care and support to the
laboring woman. This client clearly needs support.
PTS: 1 DIF: Cognitive Level: Application REF: 357
OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity
Nursing care measures are commonly offered to women in labor. Which nursing measure reflects
application of the gate-control theory?
Massaging the womans back
Changing the womans position
Giving the prescribed medication
Encouraging the woman to rest between contractions
ANS: A
According to the gate-control theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited
number of sensations, or messages, can travel through these nerve pathways at one time. Distraction techniques such as
massage or stroking, music, focal points, and imagery reduce or completely block the capacity of nerve pathways to
transmit pain. These distractions are thought to work by closing down a hypothetic gate in the spinal cord and thus
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preventing pain signals from reaching the brain. The perception of pain is thereby diminished. Changing the womans
position, giving prescribed medication, and encouraging rest do not reduce or block the capacity of nerve pathways to
transmit pain using the gate-control theory.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 362
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
A woman in active labor receives an analgesic opioid agonist. Which medication relieves severe, persistent,
or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but
should be used cautiously in women with cardiac disease?
Meperidine (Demerol)
Promethazine (Phenergan)
Butorphanol tartrate (Stadol)
Nalbuphine (Nubain)
ANS: A
Meperidine is the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes
inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine
is used cautiously in women with cardiac disease. Phenergan is an ataractic (tranquilizer) that may be used to augment
the desirable effects of the opioid analgesics but has few of the undesirable effects of those drugs. Stadol and Nubain are
opioid agonist-antagonist analgesics.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 368
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
A laboring woman received an opioid agonist (meperidine) intravenously 90 minutes before she gave birth. Which
medication should be available to reduce the postnatal effects of Demerol on the neonate?
Fentanyl (Sublimaze)
Promethazine (Phenergan)
Naloxone (Narcan)
Nalbuphine (Nubain)
ANS: C
An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of
central nervous system (CNS) depression in the newborn produced by an opioid. Opioid antagonists such as naloxone
(Narcan) can promptly reverse the CNS depressant effects, especially respiratory depression. Fentanyl, promethazine,
and nalbuphine do not act as opioid antagonists to reduce the postnatal effects of Demerol on the neonate. Although
meperidine (Demerol) is a low-cost medication and readily available, the use of Demerol in labor has been controversial
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because of its effects on the neonate.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 370
OBJ: Nursing Process: Planning, Implementation
MSC: Client Needs: Physiologic Integrity
A woman in labor has just received an epidural block. The most important nursing intervention is to:
Limit parenteral fluids.
Monitor the fetus for possible tachycardia.
Monitor the maternal blood pressure for possible hypotension.
Monitor the maternal pulse for possible bradycardia.
ANS: C
The most important nursing intervention for a woman who has received an epidural block is to monitor the maternal blood
pressure frequently for signs of hypotension. Intravenous fluids are increased for a woman receiving an epidural, to
prevent hypotension. The nurse observes for signs of fetal bradycardia. The nurse monitors for signs of maternal
tachycardia secondary to hypotension.
PTS: 1 DIF: Cognitive Level: Application REF: 373
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
The nurse should be aware that an effective plan to achieve adequate pain relief without maternal risk is
most effective if:
The mother gives birth without any analgesic or anesthetic.
The mother and familys priorities and preferences are incorporated into the plan.
The primary health care provider decides the best pain relief for the mother and family.
The nurse informs the family of all alternative methods of pain relief available in the hospital setting.
ANS: B
The assessment of the woman, her fetus, and her labor is a joint effort of the nurse and the primary health care providers,
who consult with the woman about their findings and recommendations. The needs of each woman are different, and
many factors must be considered before a decision is made whether pharmacologic methods, nonpharmacologic methods,
or a combination of the two will be used to manage labor pain.
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PTS: 1 DIF: Cognitive Level: Comprehension REF: 380
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about
twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her
fingers are tingling. The nurse should:
Notify the womans physician.
Tell the woman to slow the pace of her breathing.
Administer oxygen via a mask or nasal cannula.
Help her breathe into a paper bag
ANS: D
This woman is experiencing the side effects of hyperventilation, which include the symptoms of
lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the woman breathe into a paper bag
held tightly around her mouth and nose may eliminate respiratory alkalosis. This enables her to rebreathe carbon dioxide
and replace the bicarbonate ion.
PTS: 1 DIF: Cognitive Level: Application REF: 362
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief
measure would be to use:
Counterpressure against the sacrum.
Pant-blow (breaths and puffs) breathing techniques.
Effleurage.
Conscious relaxation or guided imagery.
ANS: A
Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This
technique helps the woman cope with the sensations of internal pressure and pain in the lower back. The pain
management techniques of pant-blow, effleurage, and conscious relaxation or guided imagery are usually helpful for
contractions per the gate-control theory.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 362
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
If an opioid antagonist is administered to a laboring woman, she should be told that:
Her pain will decrease.
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Her pain will return.
She will feel less anxious.
She will no longer feel the urge to push.
ANS: B
The woman should be told that the pain that was relieved by the opioid analgesic will return with
administration of the opioid antagonist. Opioid antagonists, such as Narcan, promptly reverse the central nervous system
(CNS) depressant effects of opioids. In addition, the antagonist counters the effect of the stress-induced levels of
endorphins. An opioid antagonist is especially valuable if labor is more rapid than expected and birth is anticipated when
the opioid is at its peak effect.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 370
OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a
vertex position and is engaged. The nurse increases the womans intravenous fluid for a preprocedural bolus.
She reviews her laboratory values and notes that the womans hemoglobin is 12 g/dL, hematocrit is 38%,
platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an
epidural for the woman?
She is too far dilated.
She is anemic.
She has thrombocytopenia.
She is septic.
ANS: C
The platelet count indicates a coagulopathy, specifically, thrombocytopenia (low platelets), which is a contraindication to
epidural analgesia/anesthesia. Typically epidural analgesia/anesthesia is used in the laboring woman when a regular labor
pattern has been achieved, as evidenced by progressive cervical change. The laboratory values show that the womans
hemoglobin and hematocrit are in the normal range and show a slight increase in the WBC count that is not uncommon in
laboring women.
PTS: 1 DIF: Cognitive Level: Analysis REF: 375
OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity
The role of the nurse with regard to informed consent is to:
Inform the client about the procedure and have her sign the consent form.
Act as a client advocate and help clarify the procedure and the options.
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Call the physician to see the client.
Witness the signing of the consent form.
ANS: B
Nurses play a part in the informed consent process by clarifying and describing procedures or by acting as the womans
advocate and asking the primary health care provider for further explanations. The physician is responsible for informing
the woman of her options, explaining the procedure, and advising the client about potential risk factors. The physician
must be present to explain the procedure to the client. However, the nurses responsibilities go further than simply asking
the physician to see the client. The nurse may witness the signing of the consent form. However, depending on the states
guidelines, the womans husband or another hospital health care employee may sign as witness.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 377
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
A first-time mother is concerned about the type of medications she will receive during labor. She is in a fair
amount of pain and is nauseous. In addition, she appears to be very anxious. You explain that opioid analgesics
often are used with sedatives because:
The two together work the best for you and your baby.
Sedatives help the opioid work better, and they also will assist you to relax and relieve your nausea.
They work better together so you can sleep until you have the baby.
This is what the doctor has ordered for you.
ANS: B
Sedatives can be used to reduce the nausea and vomiting that often accompany opioid use. In addition, some ataractics
reduce anxiety and apprehension and potentiate the opioid analgesic affects. A potentiator may cause the two drugs to
work together more effectively, but it does not ensure maternal or fetal complications will not occur. Sedation may be a
related effect of some ataractics, but it is not the goal. Furthermore, a woman is unlikely to be able to sleep through
transitional labor and birth. This is what the doctor has ordered for you may be true, but it is not an acceptable comment
for the nurse to make.
PTS: 1 DIF: Cognitive Level: Application REF: 367
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OBJ: Nursing Process: Planning, Implementation
MSC: Client Needs: Physiologic Integrity
To help clients manage discomfort and pain during labor, nurses should be aware that:
The predominant pain of the first stage of labor is the visceral pain located in the lower portion of the abdomen.
Referred pain is the extreme discomfort between contractions.
The somatic pain of the second stage of labor is more generalized and related to fatigue.
Pain during the third stage is a somewhat milder version of the second stage.
ANS: A
This pain comes from cervical changes, distention of the lower uterine segment, and uterine ischemia. Referred pain
occurs when the pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac
crests, and gluteal area. Second-stage labor pain is intense, sharp, burning, and localized. Thirdstage labor pain is similar
to that of the first stage.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 356
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
Which statement correctly describes the effects of various pain factors?
Higher prostaglandin levels arising from dysmenorrhea can blunt the pain of childbirth.
Upright positions in labor increase the pain factor because they cause greater fatigue.
Women who move around trying different positions are experiencing more pain.
Levels of pain-mitigating b-endorphins are higher during a spontaneous, natural childbirth.
ANS: D
Higher endorphin levels help women tolerate pain and reduce anxiety and irritability. Higher prostaglandin levels
correspond to more severe labor pains. Upright positions in labor usually result in improved comfort and less pain. Moving
freely to find more comfortable positions is important for reducing pain and muscle tension.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 357
OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity
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Nurses with an understanding of cultural differences regarding likely reactions to pain may be better able
to help clients. Nurses should know that
women may be stoic until late in labor, when they may become
vocal and request pain relief.
Chinese
Arab or Middle Eastern
Hispanic
African-American
ANS: C
Hispanic women may be stoic early and more vocal and ready for medications later. Chinese women may not show
reactions to pain. Medical interventions must be offered more than once. Arab or Middle Eastern women may be vocal in
response to labor pain from the start. They may prefer pain medications. African-American women may express pain
openly; use of medications for pain is more likely to vary with the individual.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 358
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
With regard to a pregnant womans anxiety and pain experience, nurses should be aware that:
Even mild anxiety must be treated.
Severe anxiety increases tension, which increases pain, which in turn increases fear and anxiety, and so on.
Anxiety may increase the perception of pain, but it does not affect the mechanism of labor.
Women who have had a painful labor will have learned from the experience and have less anxiety
the second time because of increased familiarity.
ANS: B
Anxiety and pain reinforce each other in a negative cycle. Mild anxiety is normal for a woman in labor and likely needs no
special treatment other than the standard reassurances. Anxiety increases muscle tension and ultimately can build
sufficiently to slow the progress of labor. Unfortunately, an anxious, painful first labor is likely to carry over, through
expectations and memories, into an anxious and painful experience in the second pregnancy.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 358
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
Nurses should be aware of the differences experience can make in labor pain such as:
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Sensory pain for nulliparous women often is greater than for multiparous women during early
labor.
Affective pain for nulliparous women usually is less than for multiparous women throughout the
first stage of labor.
Women with a history of substance abuse experience more pain during labor.
Multiparous women have more fatigue from labor and therefore experience more pain.
ANS: A
Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is
greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second
stage. Women with a history of substance abuse experience the same amount of pain as those without such a history.
Nulliparous women have longer labors and therefore experience more fatigue.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 358
OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity
In the current practice of childbirth preparation, emphasis is placed on:
The Dick-Read (natural) childbirth method.
The Lamaze (psychoprophylactic) method.
The Bradley (husband-coached) method.
Having expectant parents attend childbirth preparation in any or no specific method.
ANS: D
Encouraging expectant parents to attend childbirth preparation class is most important because preparation increases a
womans confidence and thus her ability to cope with labor and birth. Although still popular, the method format of classes
is being replaced with other offerings such as Hypnobirthing and Birthing from Within.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 360
OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
With regard to breathing techniques during labor, maternity nurses should understand that:
Breathing techniques in the first stage of labor are designed to increase the size of the abdominal
cavity to reduce friction.
By the time labor has begun, it is too late for instruction in breathing and relaxation.
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Controlled breathing techniques are most difficult near the end of the second stage of labor.
The patterned-paced breathing technique can help prevent hyperventilation.
ANS: A
First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity.
Instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing
techniques are most difficult in the transition phase at the end of the first stage of labor when the cervix is dilated 8 to 10
cm. Patterned-paced breathing sometimes can lead to hyperventilation.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 360
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
Maternity nurses often have to answer questions about the many, sometimes unusual ways people have
tried to make the birthing experience more comfortable. For instance, nurses should be aware that:
Music supplied by the support person has to be discouraged because it could disturb others or upset
the hospital routine.
Women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer
than 15 minutes at a time.
Effleurage is permissible, but counterpressure is almost always counterproductive.
Electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate
the release of endorphins.
ANS: D
Transcutaneous electrical nerve stimulation does help. Music may be very helpful for reducing tension and certainly can
be accommodated by the hospital. Women can stay in a bath as long as they want, although repeated baths with breaks
may be more effective than a long soak. Counterpressure can help the woman cope with lower back pain.
PTS: 1 DIF: Cognitive Level: Application REF: 363
OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
With regard to systemic analgesics administered during labor, nurses should be aware that:
Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain
barrier.
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Effects on the fetus and newborn can include decreased alertness and delayed sucking.
Intramuscular administration (IM) is preferred over intravenous (IV) administration.
IV patient-controlled analgesia (PCA) results in increased use of an analgesic.
ANS: B
Effects depend on the specific drug given, the dosage, and the timing. Systemic analgesics cross the fetal blood-brain
barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because
the drug acts faster and more predictably. PCA results in decreased use of an analgesic.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 367
OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
With regard to nerve block analgesia and anesthesia, nurses should be aware that:
Most local agents are related chemically to cocaine and end in the suffix -caine.
Local perineal infiltration anesthesia is effective when epinephrine is added, but it can be injected
only once.
A pudendal nerve block is designed to relieve the pain from uterine contractions.
A pudendal nerve block, if done correctly, does not significantly lessen the bearing-down reflex.
ANS: A
Common agents include lidocaine and chloroprocaine. Injections can be repeated to prolong the anesthesia. A pudendal
nerve block relieves pain in the vagina, vulva, and perineum but not the pain from uterine contractions, and it lessens or
shuts down the bearing-down reflex.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 370
OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
With regard to spinal and epidural (block) anesthesia, nurses should know that:
This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births.
A high incidence of after-birth headache is seen with spinal blocks.
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Epidural blocks allow the woman to move freely.
Spinal and epidural blocks are never used together.
ANS: B
Headaches may be prevented or mitigated to some degree by a number of methods. Spinal blocks may be used for
vaginal births, but the woman must be assisted through labor. Epidural blocks limit the womans ability to move freely.
Combined use of spinal and epidural blocks is becoming increasingly popular.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 373
OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity
A woman in labor is breathing into a mouthpiece just before the start of her regular contractions. As she
inhales, a valve opens, and gas is released. She continues to inhale the gas slowly and deeply until the
contraction starts to subside. When the inhalation stops, the valve closes. This procedure is:
Not used much anymore.
Likely to be used in the second stage of labor but not in the first stage.
An application of nitrous oxide.
A prelude to cesarean birth.
ANS: C
This is an application of nitrous oxide, which could be used in either the first or second stage of labor (or both) as part of
the preparation for a vaginal birth. Nitrous oxide is self-administered and found to be very helpful.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 376
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
In assessing a woman for pain and discomfort management during labor, a nurse most likely would:
Have the woman use a visual analog scale (VAS) to determine her level of pain.
Note drowsiness as a sign that the medications were working.
Interpret a womans fist clenching as an indication that she is angry at her male partner and the
physician.
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Evaluate the womans skin turgor to see whether she needs a gentle oil massage.
ANS: A
The VAS is a means of adding the womans assessment of her pain to the nurses observations. Drowsiness is a side
effect of medications, not usually (sedatives aside) a sign of effectiveness. The fist clenching likely is a sign of
apprehension that may need attention. Skin turgor, along with the moistness of the membranes and the concentration of
the urine, is a sign that helps the nurse evaluate hydration.
PTS: 1 DIF: Cognitive Level: Application REF: 379
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
After change-of-shift report the nurse assumes care of a multiparous client in labor. The woman is complaining of
pain that radiates to her abdominal wall, lower back, and buttocks and down her thighs. Before implementing a plan
of care, the nurse should understand that this type of pain is:
Visceral.
Referred.
Somatic.
Afterpain.
ANS: B
As labor progresses the woman often experiences referred pain. This occurs when pain that originates in the uterus
radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has
pain only during a contraction and is free from pain between contractions. Visceral pain is that which predominates in the
first stage of labor. This pain originates from cervical changes, distention of the
lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. Somatic pain
is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the
pelvic floor. This occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward
during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 356
OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
It is important for the nurse to develop a realistic birth plan with the pregnant woman in her care. The nurse
can explain that a major advantage of nonpharmacologic pain management is:
Greater and more complete pain relief is possible.
No side effects or risks to the fetus are involved.
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The woman remains fully alert at all times.
A more rapid labor is likely.
ANS: B
Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to
the mother and the fetus. There is less pain relief with nonpharmacologic pain management during
childbirth. The womans alertness is not altered by medication; however, the increase in pain will decrease alertness. Pain
management may or may not alter the length of labor. At times when pain is decreased, the mother relaxes and labor
progresses at a quicker pace.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 359
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
The nurse providing newborn stabilization must be aware that the primary side effect of maternal narcotic
analgesia in the newborn is:
Respiratory depression.
Bradycardia.
Acrocyanosis.
Tachypnea.
ANS: A
An infant delivered within 1 to 4 hours of maternal analgesic administration is at risk for respiratory depression from the
sedative effects of the narcotic. Bradycardia is not the anticipated side effect of maternal analgesics. Acrocyanosis is an
expected finding in a newborn and is not related to maternal analgesics. The infant who is having a side effect to maternal
analgesics normally would have a decrease in respirations, not an increase.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 367
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
The nerve block used in labor that provides anesthesia to the lower vagina and perineum is called:
An epidural.
A pudendal.
A local.
A spinal block.
ANS: B
A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low
forceps if needed. An epidural provides anesthesia for the uterus, perineum, and legs. A local provides anesthesia for the
perineum at the site of the episiotomy. A spinal block provides anesthesia for the uterus, perineum, and down the legs.
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PTS: 1 DIF: Cognitive Level: Knowledge REF: 370
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
Which method of pain management is safest for a gravida 3 para 2 admitted at 8 cm cervical dilation?
Epidural anesthesia
Narcotics
Spinal block
Breathing and relaxation techniques
ANS: D
Nonpharmacologic methods of pain management may be the best option for a woman in advanced labor. It is unlikely that
enough time remains to administer epidural or spinal anesthesia. A narcotic given at this time may reach its peak about
the time of birth and result in respiratory depression in the newborn.
PTS: 1 DIF: Cognitive Level: Application REF: 361
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
The laboring woman who imagines her body opening to let the baby out is using a mental technique called:
Dissociation.
Effleurage.
Imagery.
Distraction.
ANS: C
Imagery is a technique of visualizing images that will assist the woman in coping with labor. Dissociation helps the woman
learn to relax all muscles except those that are working. Effleurage is self-massage. Distraction can be used in the early
latent phase by having the woman engage in another activity.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 360
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
The obstetric nurse is preparing the patient for an emergency cesarean birth, with no time to administer
spinal anesthesia. The nurse is aware and prepared for the greatest risk of administering general anesthesia to
the patient. This risk is:
Respiratory depression.
Uterine relaxation.
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Inadequate muscle relaxation.
Aspiration of stomach contents.
ANS: D
Aspiration of acidic gastric contents with possible airway obstruction is a potentially fatal complication of general
anesthesia. Respirations can be altered during general anesthesia, and the anesthesiologist will take precautions to
maintain proper oxygenation. Uterine relaxation can occur with some anesthesia; however, this can be monitored and
prevented. Inadequate muscle relaxation can be improved with medication.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 376
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
To assist the woman after delivery of the infant, the nurse knows that the blood patch is used after spinal
anesthesia to relieve:
Hypotension.
Headache.
Neonatal respiratory depression.
Loss of movement.
ANS: B
The subarachnoid block may cause a postspinal headache resulting from loss of cerebrospinal fluid from the puncture in
the dura. When blood is injected into the epidural space in the area of the dural puncture, it forms a seal over the hole to
stop leaking of cerebrospinal fluid. Hypotension is prevented by increasing fluid volume before the procedure. Neonatal
respiratory depression is not an expected outcome with spinal anesthesia. Loss of movement is an expected outcome of
spinal anesthesia.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 371
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing
interventions could you use to raise the clients blood pressure (Select all that apply)?
Place the woman in a supine position.
Place the woman in a lateral position.
Increase intravenous (IV) fluids.
Administer oxygen.
Perform a vaginal examination.
ANS: B, C, D
Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral
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position, increasing IV fluids, administering oxygen via face mask, elevating the womans legs, notifying the physician,
administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until these are
stable. Placing the client in a supine position would cause venous compression, thereby limiting blood flow to and
oxygenation of the placenta and fetus. A sterile vaginal examination has no bearing on maternal blood pressure.
PTS: 1 DIF: Cognitive Level: Application REF: 373
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
The class of drugs known as opioid analgesics (butorphanol, nalbuphine) is not suitable for administration to
women with known opioid dependence. The antagonistic activity could precipitate withdrawal symptoms
(abstinence syndrome) in both mothers and newborns. Signs of opioid/narcotic withdrawal in the mother would
include (Select all that apply):
Yawning, runny nose.
Increase in appetite.
Chills and hot flashes.
Constipation.
Irritability, restlessness.
ANS: A, C, E
The woman experiencing maternal opioid withdrawal syndrome will exhibit yawning, runny nose, sneezing, anorexia, chills
or hot flashes, vomiting, diarrhea, abdominal pain, irritability, restlessness, muscle spasms, weakness, and drowsiness. It
is important for the nurse to assess both mother and baby and to plan care
accordingly.
PTS: 1 DIF: Cognitive Level: Application REF: 369
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
While developing an intrapartum care plan for the patient in early labor, it is important that the nurse
recognize that psychosocial factors may influence a womans experience of pain. These include (Select all that
apply):
Culture.
Anxiety and fear.
Previous experiences with pain.
Intervention of caregivers.
Support systems.
ANS: A, B, C, E
Culture: a womans sociocultural roots influence how she perceives, interprets, and responds to pain during childbirth.
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Some cultures encourage loud and vigorous expressions of pain, whereas others value self-control.
The nurse should avoid praising some behaviors (stoicism) while belittling others (noisy expression). Anxiety and fear:
extreme anxiety and fear magnify sensitivity to pain and impair a womans ability to tolerate it.
Anxiety and fear increase muscle tension in the pelvic area, which counters the expulsive forces of uterine contractions
and pushing efforts. Previous experiences with pain: fear and withdrawal are a natural response to pain during labor.
Learning about these normal sensations ahead of time helps a woman suppress her natural reactions of fear regarding
the impending birth. If a woman previously had a long and difficult labor, she is likely to be anxious. She may also have
learned ways to cope and may use these skills to adapt to the present Labor experience. Support systems: an anxious
partner is less able to provide help and support to a woman during labor. A womans family and friends can be an
important source of support if they convey realistic and positive information about labor and delivery.
Although the intervention of caregivers may be necessary for the well-being of the woman and her fetus, some
interventions add discomfort to the natural pain of labor (i.e., fetal monitor straps, intravenous lines).
PTS: 1 DIF: Cognitive Level: Application REF: 357
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
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Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 10:Fluid and Electrolytes
A nurse is providing client teaching about the bodyts plasma pH and the client asks the nurse what is the major
chemical regulator of plasma pH. What is the best response by the nurse?
renin-angiotensin-aldosterone system
bicarbonate-carbonic acid buffer system
sodium-potassium pump
ADH-ANP buffer system
bicarbonate-carbonic acid buffer system
The major chemical regulator of plasma pH is the bicarbonate-carbonic acid buffer system. The renin-angiotensinaldosterone system regulates blood pressure. The sodium-potassium pump regulate homeostasis. The ADH-ANP buffer
system regulates water balance in the body.
A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further
action?
Polyuria
Weight loss
Tetanic contractions
Jugular vein distention
Jugular vein distention
Jugular vein distention requires further action because this finding signals vascular fluid overload. Tetanic contractions
aren't associated with this disorder, but weight gain and fluid retention from oliguria are. Polyuria is associated with
diabetes insipidus, which occurs with inadequate production of antidiuretic hormone.
A nurse is reviewing a report of a clientts routine urinalysis. Which value requires further investigation?
Absence of protein
Urine pH of 3.0
Specific gravity of 1.02
Absence of glucose
Urine pH of 3.0
A client is taking spironolactone to control hypertension. The clientts serum potassium level is 6 mEq/L. What is the
nursets priority during assessment?
electrocardiogram (ECG) results
neuromuscular function
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bowel sounds
respiratory rate
electrocardiogram (ECG) results
Explanation:
Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can
indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's
neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.
Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate?
Teach client behaviors that decrease urination.
Give medications that promote fluid retention.
Assess for dehydration.
Limit sodium and water intake.
Limit sodium and water intake.
Implement prescribed interventions such as limiting sodium and water intake and administering ordered medications that
promote fluid elimination. Assessing for dehydration and teaching to decrease urination would not be appropriate
interventions.
Clients diagnosed with hypervolemia should avoid sweet or dry food because it
obstructs water elimination.
can lead to weight gain.
can cause dehydration.
increases the clientts desire to consume fluid.
increases the client's desire to consume fluid.
Explanation:
The management goal in hypervolemia is to reduce fluid volume. For this reason, fluid is rationed and the client is advised
to take a limited amount of fluid when thirsty. Sweet or dry food can increase the client's desire to consume fluid. Sweet
or dry food does not obstruct water elimination or cause dehydration. Weight regulation is not part of hypervolemia
management except to the extent it is achieved on account of fluid reduction.
The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium
concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further
teaching?
"I will take a potassium supplement daily as prescribed."
"A good breakfast for me will include milk and a couple of bananas."
"I will be sure to buy frozen vegetables when I grocery shop."
"I can use laxatives and enemas but only once a week."
"I can use laxatives and enemas but only once a week."
The client is experiencing hypokalemia, most likely due to the diagnosis of bulimia. Hypokalemia is defined as a serum
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potassium concentration <3.5 mEq/L (3.5 mmol/L), and usually indicates a deficit in total potassium stores. Clients
diagnosed with bulimia frequently suffer increased potassium loss through self-induced vomiting and misuse of laxatives,
diuretics, and enemas; thus, the client should avoid laxatives and enemas. Prevention measures may involve encouraging
the client at risk to eat foods rich in potassium (when the diet allows), including fruit juices and bananas, melon, citrus
fruits, fresh and frozen vegetables, lean meats, milk, and whole grains. If the hypokalemia is caused by abuse of laxatives
or diuretics, client education may help alleviate the problem.
Which solution is hypotonic?
0.9% NaCl
5% NaCl
Lactated Ringer solution
0.45% NaCl
0.45% NaCl
Half-strength saline is hypotonic. Lactated Ringer solution and normal saline (0.9% NaCl) are isotonic. A 5% NaCl solution
is hypertonic.
A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea
nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L;
CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately?
CO2
Chloride
Sodium
Potassium
Potassium
The nurse should identify potassium: 2.2 mEq/L as critical because a normal potassium level is 3.5 to 5.0 mEq/L. Severe
hypokalemia can cause cardiac and respiratory arrest, possibly leading to death. Hypokalemia also depresses the release
of insulin and results in glucose intolerance. The glucose level is above normal (normal is about 75 to 110 mg/dl), and the
chloride level is a bit low (normal is about 100 to 110 mEq/L). Although these levels should be reported, neither is lifethreatening. The BUN (normal is ~ 8 to 26 mg/dl) and creatinine (normal is ~ 0.8 to 1.4 mg/dl) are within normal range.
A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that
the compensatory mechanisms associated with hypovolemia would cause what clinical manifestations? (Select all
that apply.)
Tachycardia
Oliguria
Tachypnea
Hypertension
Bradycardia
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Tachycardia
Oliguria
Tachypnea
Explanation:
Hypovolemia, or fluid volume deficit, is indicated by decreased, not increased, blood pressure (hypotension), oliguria,
tachycardia (not bradycardia), and tachypnea.
Which of the following is a function of calcitonin? Select all that apply.
Decreases urinary excretion of phosphate
Reduces bone resorption
Decreases deposition of phosphorous in bones
Increases urinary excretion of calcium
Increases deposition of calcium in bones
Reduces bone resorption
Increases urinary excretion of calcium
Increases deposition of calcium in bones
Which is the most common cause of symptomatic hypomagnesemia?
Sedentary lifestyle
Alcoholism
Intravenous drug use
Burns
Alcoholism
Which is considered an isotonic solution?
0.45% normal saline
0.9% normal saline
3% NaCl
Dextran in normal saline
0.9% normal saline
A client with hypervolemia asks the nurse by what mechanism the sodium-potassium pump will move the excess
body fluid. What is the nursets best answer?
Passive elimination
Free flow
Active transport
Passive osmosis
Active transport
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Which is the preferred route of administration for potassium?
Subcutaneous
IV (intravenous) push
Oral
Intramuscular
Oral
When the client cannot ingest sufficient potassium by consuming foods that are high in potassium, administering oral
potassium is ideal because oral potassium supplements are absorbed well. Administration by IV is done with extreme
caution using an infusion pump, with the patient monitored by continuous ECG. To avoid replacing potassium too quickly,
potassium is never administered by IV push or intramuscularly. Potassium is not administered subcutaneously.
The nurse is analyzing the arterial blood gas (ABG) results of a client diagnosed with severe pneumonia. Which of
the following ABG results indicates respiratory acidosis?
pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L
pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L
pH: 7.40, PaCO2: 40 mm Hg, HCO3-: 24 mEq /L
pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L
pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood
gas values indicate respiratory acidosis. What should the nurse do first?
Prepare to assist with ventilation.
Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has
suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and
should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely
monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.
A client with emphysema is at a greater risk for developing which acid-base imbalance?
metabolic alkalosis
metabolic acidosis
chronic respiratory acidosis
respiratory alkalosis
chronic respiratory acidosis
Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood
pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis,
bronchial asthma, and cystic fibrosis.
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood
gas values indicate respiratory acidosis. What should the nurse do first?
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Prepare to assist with ventilation.
Obtain a urine specimen for drug screening.
Prepare for gastric lavage.
Monitor the clientts heart rhythm.
Prepare to assist with ventilation.
A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the
clientts laboratory values.
sodium 137 mEq/L (137 mmol/L)potassium 4.6 mEq/L (4.6 mmol/L)chloride 94 mEq/L (94 mmol/L)calcium 12.9
mg/dL (3.2 mmol/L)
What laboratory value is of highest concern to the nurse?
calcium 12.9 mg/dL (3.2 mmol/L)
sodium 137 mEq/L (137 mmol/L)
chloride 94 mEq/L (94 mmol/L)
potassium 4.6 mEq/L (4.6 mmol/L)
calcium 12.9 mg/dL (3.2 mmol/L)
A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of
the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which
acid-base disturbance?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
Respiratory acidosis
A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching,
which of the following will the nurse teach the client and family? Select all that apply.
respond to thirst
Drink alcoholic beverages to help balance fluid volume.
Drink at least eight glasses of fluid each day.
Drink caffeinated beverages to retain fluid.
Drink water as an inexpensive way to meet fluid needs.
Drink at least eight glasses of fluid each day.
respond to thirst
Drink water as an inexpensive way to meet fluid needs.
Explanation:
In addition, the nurse teaches clients who have a potential for hypovolemia and their families to respond to thirst because
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it is an early indication of reduced fluid volume; consume at least 8 to 10 (8 ounce) glasses of fluid each day and more
during hot, humid weather; drink water as an inexpensive means to meet fluid requirements; and avoid beverages with
alcohol and caffeine because they increase urination and contribute to fluid deficits.
When a clientts ventilation is impaired, the body retains which substance?
Oxygen
Carbon dioxide
Nitrous oxide
Sodium bicarbonate
Carbon dioxide
When ventilation is impaired, the body retains carbon dioxide (CO2) because the carbonic acid level increases in the
blood. Sodium bicarbonate is used to treat acidosis. Nitrous oxide, which has analgesic and anesthetic properties,
commonly is administered before minor surgical procedures. When ventilation is impaired, the body doesn't retain oxygen.
Instead, the tissues use oxygen and CO2 results.
A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client
experiencing significant sodium and potassium losses. What drug was most likely prescribed?
furosemide
metolazone
spironolactone
hydrochlorothiazide
furosemide
Explanation:
Furosemide is the only loop diuretic choice. Hydrochlorothiazide and metolazone are thiazide diuretics that block sodium
reabsorption. Spironolactone is a potassium-sparing diuretic that prevents sodium absorption.
A client has been admitted to the hospital unit with signs and symptoms of hypovolemia; however, the client has
not lost weight. The client exhibits a localized enlargement of her abdomen. What condition could the client be
presenting?
anasarca
third-spacing
pitting edema
hypovolemia
third-spacing
The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic alkalosis. Which
nursing actions are required to manage this client? Select all that apply.
Document presenting signs and symptoms.
Suction the clientts airway.
Administer IV bicarbonate.
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Maintain intake and output records.
Compare ABG findings with previous results.
Document presenting signs and symptoms.
Maintain intake and output records.
Compare ABG findings with previous results.
An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse
effect of diuretic use?
Hyperkalemia
Hypernatremia
Hypophosphatemia
Hypokalemia
Hypokalemia
Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium-losing
diuretics, such as furosemide, can induce hypokalemia. Hyperkalemia refers to increased potassium levels. Loop diuretics
can bring about lower sodium levels, not hypernatremia. Furosemide does not affect phosphorus levels.
With which condition should the nurse expect that a decrease in serum osmolality will occur?
Uremia
Influenza
Kidney failure
Hyperglycemia
Kidney failure
Failure of the kidneys results in multiple fluid and electrolyte abnormalities including fluid volume overload. If renal function
is so severely impaired that pharmacologic agents cannot act efficiently, other modalities are considered to remove
sodium and fluid from the body.
Fluid and electrolyte balance is maintained through the process of translocation. What specific process allows
water to pass through a membrane from a dilute to a more concentrated area?
active transport
evaporation
filtration
osmosis
osmosis
A patient is admitted with severe vomiting for 24 hours as well as weakness and "feeling exhausted." The nurse
observes flat T waves and ST-segment depression on the electrocardiogram. Which potassium level does the nurse
observe when the laboratory studies are complete?
5.5 mEq/L
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3.5 mEq/L
4.5 mEq/L
2.5 mEq/L
2.5 mEq/L
A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output,
fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets
when caring for this client?
No, start with the sodium chloride IV.
No, sodium intake should be restricted.
Yes, this will correct the sodium deficit.
Yes, along with the hypotonic IV.
No, sodium intake should be restricted.
A nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions,
and sodium bicarbonate to be used to treat:
hypokalemia.
hypernatremia.
hyperkalemia.
hypercalcemia.
hyperkalemia.
Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse
it. Administering glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest
by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and
hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate.
The nurse is caring for a 72-year-old client who has been admitted to the unit for a fluid volume imbalance. The
nurse knows which of the following is the most common fluid imbalance in older adults?
Fluid volume excess
Hypovolemia
Dehydration
Hypervolemia
Dehydration
The most common fluid imbalance in older adults is dehydration. Because of reduced thirst sensation that often
accompanies aging, older adults tend to drink less water. Use of diuretic medications, laxatives, or enemas may also
deplete fluid volume in older adults. Chronic fluid volume deficit can lead to other problems such as electrolyte
imbalances.
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A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide
(PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic acidosis
Early signs of hypervolemia include
moist breath sounds.
thirst.
a decrease in blood pressure.
increased breathing effort and weight gain.
increased breathing effort and weight gain.
Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid
congestion in the lungs leads to moist breath sounds. One of the earliest symptoms of hypovolemia is thirst.
A client who complains of an "acid stomach" has been taking baking soda (sodium bicarbonate) regularly as a selftreatment. This may place the client at risk for which acid-base imbalance?
respiratory acidosis
metabolic alkalosis
metabolic acidosis
respiratory alkalosis
metabolic alkalosis
A client has chronic hyponatremia, which requires weekly laboratory monitoring to prevent the client lapsing into
convulsions or a coma. What is the level of serum sodium at which a client can experience these side effects?
130 mEq/L
135 mEq/L
114 mEq/L
148 mEq/L
114 mEq/L
A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to
stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a
serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse
determines that the clientts symptoms are most likely associated with which electrolyte imbalance?
Hyperkalemia
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Hypercalcemia
Hypokalemia
Hypocalcemia
Hypercalcemia
The nurse is caring for a client diagnosed with hyperchloremia. Which are signs and symptoms of hyperchloremia?
Select all that apply.
Tachypnea
Dehydration
Lethargy
Weakness
Hypotension
Tachypnea
Lethargy
Weakness
Explanation:
The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and
hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension
occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chlorid
A client weighing 160.2 pounds (72.7 kg), who has been diagnosed with hypovolemia, is weighed every day. The
health care provider asked to be notified if the client loses 1,000 mL of fluid in 24 hours. What weight would be
consistent with this amount of fluid loss?
156.0 lbs (70.8 kg)
157.0 lbs (71.2 kg)
158.0 lbs (71.7 kg)
159.0 lbs (72.1 kg)
158.0 lbs (71.7 kg)
Explanation:
A loss of 0.5 kg, or 1.1 lb, represents a fluid loss of about 500 mL. Therefore, a loss of 1,000 mL would be equivalent to
the loss of 2.2 lbs (1 kg), bringing the client's weight to 158.0 lbs (71.7 kg).
A nurse can estimate serum osmolality at the bedside by using a formula. A patient who has a serum sodium level
of 140 mEq/L would have a serum osmolality of:
250 mOsm/kg.
230 mOsm/kg.
280 mOsm/kg.
210 mOsm/kg.
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280 mOsm/kg.
Explanation:
Serum osmolality can be estimated by doubling the serum sodium or using the formula: Na × 2 = glucose/18 + BUN/3.
Therefore, the nurse could estimate a serum osmolality of 280 mOsm/kg by doubling the serum sodium value of 140
mEq/L.
A nurse is monitoring a client being evaluated who has a potassium level of 7 mEq/L (mmol/L). Which
electrocardiogram changes will the client display?
peaked T waves
prolonged T waves
elevated ST segment
shortened PR interval
peaked T waves
Explanation:
The earliest changes occur when the serum potassium level is 7 mEq/L (mmol/L). Cardiac tracings include peaked and
narrow T waves, ST segment depression, and a shortened QT interval.
An adult client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine
output; fever; a rough tongue; and lethargy. The nurse reconciles the clientts medication list and notes that salt
tablets had been prescribed. What would the nurse do next?
Be prepared to administer a lactated Ringerts IV.
Continue to monitor client with another appointment.
Be prepared to administer a sodium chloride IV.
Consider sodium restriction with discontinuation of salt tablets.
Consider sodium restriction with discontinuation of salt tablets.
Explanation:
The client's symptoms of feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough
tongue; and lethargy suggest hypernatremia. The client needs to be evaluated with serum blood tests soon; a later
appointment will delay treatment. It is necessary to restrict sodium intake. Salt tablets and a sodium chloride IV will only
worsen this condition. A Lactated Ringer's IV is a hypertonic IV and is not used with hypernatremia. A hypotonic solution
IV may be a part of the treatment, but not along with the salt tablets.
The nurse is caring for a client with an arterial blood pH of 7.48 and bicarbonate level of 29 mEq/L (29 mmol/L).
Which treatment will the nurse expect to be prescribed for this client?
Oxygen through a rebreather mask
Potassium supplements
Bronchodilator
Intravenous 0.9% normal saline
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Intravenous 0.9% normal saline
Explanation:
Treatment of both acute and chronic metabolic alkalosis is aimed at correcting the underlying acid-base disorder. Because
volume depletion is commonly present, treatment includes restoring normal fluid volume by administering normal saline.
Bronchodilators are used to treat respiratory acidosis. Potassium supplements would be used to treat metabolic acidosis.
Oxygen delivered through a rebreather mask would be used to treat respiratory alkalosis.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate
which laboratory test result?
Serum blood urea nitrogen (BUN) level of 8.6 mg/dl
Serum sodium level of 124 mEq/L
Hematocrit of 52%
Serum creatinine level of 0.4 mg/dl
Serum sodium level of 124 mEq/L
Explanation:
In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water
excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum
sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains
within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN
level decrease.
The nurse is caring for a client who has been diagnosed with chronic obstructive pulmonary disease (COPD) and is
experiencing respiratory acidosis. The client asks what is making the acidotic state. What does the nurse identify
as the result of the disease process that causes the fall in pH?
The lungs are unable to breathe in sufficient oxygen.
The lungs are not able to regulate carbonic acid levels.
The lungs have ineffective cilia from years of smoking.
The lungs are unable to exchange oxygen and carbon dioxide.
The lungs are not able to regulate carbonic acid levels.
The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is
responsible for regulatory processes and compensation?
Kidney and liver
Pancreas and stomach
Heart and lungs
Lungs and kidney
Lungs and kidney
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A client with cancer is being treated on the oncology unit for bilateral breast cancer. The client is undergoing
chemotherapy. The nurse notes the clientts serum calcium concentration is 12.3 mg/dL (3.08 mmol/L). Given this
laboratory finding, the nurse should suspect that the
malignancy is causing the electrolyte imbalance.
clientts diet is lacking in calcium-rich food products.
client may be developing hyperaldosteronism.
client has a history of alcohol abuse.
A client seeks medical attention for an acute onset of severe thirst, polyuria, muscle weakness, nausea, and bone
pain. Which health history information will the nurse report to the health care provider?
Takes high doses of vitamin D
Explanation:
Hypercalcemia can affect many organ systems and symptoms occur when the calcium level acutely rises. Hypercalcemia
crisis refers to an acute rise in the serum calcium level. Severe thirst and polyuria are often present. Additional findings
include muscle weakness, nausea, and bone pain. Excessive ingestion of vitamin D supplements may cause excessive
absorption of calcium. Therefore, the nurse would report this finding to the health care provider. The client's symptoms are
not associated with occasional alcohol intake, a high-fiber eating plan, or the client's employment status. These findings
would not need to be reported.
A client reports muscle cramps in the calves and feeling "tired a lot." The client is taking ethacrynic acid (Edecrin)
for hypertension. Based on these symptoms, the client will be evaluated for which electrolyte imbalance?
hypokalemia
Explanation:
Hypokalemia causes fatigue, weakness, anorexia, nausea, vomiting, cardiac dysrhythmias, leg cramps, muscle weakness,
and paresthesias. Many diuretics, such as ethacrynic acid (Edecrin), also waste potassium. Symptoms of hyperkalemia
include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias. Signs of hypocalcemia include
tingling in the extremities and the area around the mouth and muscle and abdominal cramps. Hypercalcemia causes deep
bone pain, constipation, anorexia, nausea, vomiting, polyuria, thirst, pathologic fractures, and mental changes.
Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply.
Distended neck veins
Decreased blood pressure
Shortness of breath
Crackles in the lung fields
Bradycardia
Distended neck veins
Shortness of breath
Crackles in the lung fields
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A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which
test result is most significant?
Blood urea nitrogen (BUN) level of 29 mg/dl
Serum potassium level of 3 mEq/L
Serum sodium level of 132 mEq/L
Urine specific gravity of 1.025
Serum potassium level of 3 mEq/L
Which of the following measurable urine outputs indicates the client is maintaining adequate fluid intake and
balance?
30ml/hr
The nurse is assigned to care for a client with a serum phosphorus concentration of 5.0 mg/dL (1.61 mmol/L). The
nurse anticipates that the client will also experience which electrolyte imbalance?
Hypermagnesemia
Hyponatremia
Hyperchloremia
Hypocalcemia
Hypocalcemia
Explanation:
The client is experiencing an elevated serum phosphorus concentration. Hyperphosphatemia is defined as a serum
phosphorus that exceeds 4.5 mg/dL (1.45 mmol/L). Because of the reciprocal relationship between phosphorus and
calcium, a high serum phosphorus concentration tends to cause a low serum calcium concentration.
The nurse notes that a client has lost 5 lbs. (2.27 kg) of body weight over 5 days. Which additional assessment
findings indicate to the nurse that the client is experiencing hypovolemia? Select all that apply.
Lung crackles
Bounding pulse
Flat neck veins
Concentrated urine
Muscle cramps
Explanation:
An acute weight loss of 5 lbs. (2.27 kg) over 5 days can indicate a fluid volume deficit or hypovolemia. Additional
assessment findings that support a loss of fluid include flat neck veins, muscle cramps, and concentrated urine. Lung
crackles and a bounding pulse would occur with an excess of fluid or hypervolemia.
A volume-depleted patient would present with which of the following diagnostic lab results?
Urinary output of 1.2 L/24 hours
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BUN-to-creatinine ratio of 24:1
Urine specific gravity of 1.02
Capillary refill time of 3 seconds
BUN-to-creatinine ratio of 24:1
Which laboratory result does the nurse identify as a direct result of the clientts hypovolemic status with
hemoconcentration?
Abnormal potassium level
Low white blood count
Elevated hematocrit level
Low urine specific gravity
Elevated hematocrit level
Explanation:
When hemoconcentration occurs due to a hypovolemic state, a high ratio of blood components in relation to watery
plasma occurs, thus causing an elevated hematocrit level. A high white blood cell count and urine specific gravity is also
noted. Other causes of an abnormal potassium level may be present.
A patient has a serum osmolality of 250 mOsm/kg. The nurse knows to assess further for:
Hyperglycemia.
Hyponatremia.
Dehydration.
Acidosis.
Hyponatremia.
Explanation:
Decreased serum sodium is a factor associated with decreased serum osmolality. Dehydration and hyperglycemia are
associated with increased serum osmolality; acidosis is associated with increased urine osmolality.
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Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 11: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
Fresh frozen plasma (FFP) is administered to replace:
A.clotting factors.
B.erythrocytes.
C.leukocytes.
D.platelets.
A.clotting factors.
Fresh frozen plasma is administered to replace all clotting factors except platelets. Platelets are given rapidly to help
control bleeding caused by low platelet counts.
In distributive shock, the major physiological problem causing the shock is:
A.blood loss and actual hypovolemia.
B.decreased cardiac output.
C.third spacing of fluids into peritoneal space.
D.vasodilation and relative hypovolemia.
D.vasodilation and relative hypovolemia.
Distributive shock presents with widespread vasodilation and decreased systemic vascular resistance that results in a
relative hypovolemia. Blood loss is associated with hypovolemic shock. Decreased cardiac output is a primary cause of
cardiogenic shock. Primary internal sequestration of fluids that causes internal fluid loss is associated with hypovolemic
shock.
A primary goal in all shock states is to:
ensure adequate cellular hydration.
maintain adequate tissue perfusion.
prevent third spacing of fluids.
support mechanical ventilation.
B.maintain adequate tissue perfusion.
Care of a patient in shock is directed toward correcting or reversing the altered circulatory component and reversing tissue
hypoxia. Restoring circulating intravascular volume is the priority in improving tissue perfusion and oxygen delivery.
The majority of cases of cardiogenic shock are caused by:
A.acute myocardial infarction.
B.myocardial depression in sepsis.
C.pulmonary embolism.
D.significant hypovolemia.
acute myocardial infarction.
The most common cause of cardiogenic shock is an extensive left ventricular myocardial infarction. Myocardial depression
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in sepsis is a secondary problem associated with the acidosis/anaerobic metabolism of septic shock. Pulmonary embolism
is a cause of obstructive shock. Fluid loss is the major cause of hypovolemic shock.
When neurogenic shock occurs, interruption in sympathetic nerve impulses causes:
A.tachycardia.
hypertension.
C.hypoventilation.
D.vasodilation.
D.vasodilation.
In neurogenic shock, there is an interruption of impulse transmission or blockage of sympathetic outflow, resulting in
vasodilation, inhibition of baroreceptor response, and impaired thermoregulation. Interruption of sympathetic nerve
innervation would result in bradycardia. Interruption of sympathetic nerve innervation would result in hypotension.
Hypoventilation is not a physiological mechanism.
Blood pooling in the capillary bed and arterial blood pressure too low to support perfusion of vital organs cause:
A.acute respiratory distress syndrome (ARDS).
B.disseminated intravascular coagulation (DIC).
C.increased cerebral perfusion pressure.
D.multisystem organ failure and/or dysfunction.
D.multisystem organ failure and/or dysfunction.
Maldistribution of blood flow refers to the uneven distribution of flow to various organs and pooling of blood in the capillary
beds. This impaired blood flow leads to impaired tissue perfusion and a decreased oxygen supply to the cells, all of which
contribute to multiple organ failure. Damage to the type II pneumocytes leads to ARDS. Consumption of clotting factors
may cause DIC. Low arterial blood pressure leads to decreased cerebral perfusion pressure.
The nurse is caring for a patient admitted with severe sepsis. The physician orders include the administration of
large volumes of isotonic saline solution as part of early goal-directed therapy. Which of the following best
represents a therapeutic endpoint for goal-directed fluid therapy?
Central venous pressure > 8 mm Hg
Heart rate > 60 beats/min
Mean arterial pressure > 50 mm Hg
Serum lactate level > 6 mEq/L
A.Central venous pressure > 8 mm Hg
Early goal-directed therapy includes administration of IV fluids to keep the central venous pressure at 8 mm Hg or greater.
Additional therapeutic endpoints include a heart rate at less than 110 beats per minute and a mean arterial blood pressure
at 65 mm Hg or greater. Serum lactate levels are elevated in sepsis; target levels should be < 2.2 mEq/L.
The nurse is admitting to the ICU a patient in early sepsis. What is the nursets best understanding of the patientts
nutritional requirements?
Total parenteral nutrition is preferred.
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Enteral nutrition initiated within the first 24 to 48 hours is critical.
The caloric needs of the patient in sepsis are significantly lower.
Early enteral feeding may lead to diarrhea, delaying wound healing.
B.Enteral nutrition initiated within the first 24 to 48 hours is critical.
Early enteral nutrition within 24 to 48 hours of admission to an intensive care unit is supported by evidence and
recommended in patients with severe sepsis, septic shock, or both. Enteral nutrition is the preferred route of
administration, as this method assists the intestinal mucosa in maintaining its barrier function. The caloric needs of a
patient in sepsis are high and require increased caloric intake. Early enteral feeding decreases diarrhea.
Which statement correctly represents hemodynamic values associated with the initial stages of septic shock state?
A.Low heart rate; high blood pressure
B.High heart rate; low right atrial pressure
C.High PAOP; low cardiac output
D.High SVR; normal blood pressure
B.High heart rate; low right atrial pressure
In septic shock, inflammatory mediators damage the endothelial cells that line blood vessels, producing profound
vasodilation and increased capillary permeability. Initially this results in a high heart rate, hypotension, and low SVR, and
subsequently in low right atrial pressure.
Which statement correctly reflects crystalloid fluid replacement therapy in shock states?
A.Lactated Ringerts should not be infused if lactic acidosis is severe.
B.3 mL of crystalloid is administered to replace 10 mL of blood loss.
C.Administration of colloids is preferred over crystalloids.
D.Solutions of 0.45% normal saline are used routinely in shock
A.Lactated Ringer's should not be infused if lactic acidosis is severe.
LR solutions contain lactate, which the liver converts to bicarbonate. If liver function is normal, this will counteract lactic
acidosis. However, LR should not be infused if lactic acidosis is severe. Three mL of crystalloid is administered to replace
every 1 mL of blood loss. There is no evidence to support colloid administration being more beneficial than crystalloid
administration in shock states. Hypotonic solutions such as 0.45% normal saline are not administered in shock states as
these solutions rapidly leave the intravascular space, causing interstitial and intracellular edema.
The nurse admits a patient to the coronary care unit in cardiogenic shock. The nurse anticipates administering
which medication in an effort to improve cardiac output?
A.Dopamine (Intropin)
B.Phenylephrine (Neo-Synephrine)
C.Dobutamine (Dobutrex)
D.Nitroprusside (Nipride)
C.Dobutamine (Dobutrex)
Positive inotropic agents such as dobutamine (Dobutrex) are given to increase the contractile force of the heart in
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cardiogenic shock. Dopamine (Intropin) is used primarily in low cardiac output states to restore vasculare tone and
increase blood pressure. Neo-Synephrine would be contraindicated in cardiogenic shock, as the vasoconstriction it
produces would exacerbate cardiac ischemia. Nitroprusside (Nipride) can improve cardiac performance in shock states by
its reduction of systemic vascular resistance.
Large volume crystalloid solution to treat hypovolemia can be accomplished with which of the following infusions?
(Select all that apply.)
A.5% dextrose
B.Albumin
C.Lactated Ringerts (LR)
D.Normal saline
C.Lactated Ringer's (LR)
D.Normal saline
LR solution and 0.9% normal saline are isotonic solutions that are commonly infused to treat hypovolemia. Solutions of
5% dextrose in water and 0.45% normal saline are hypotonic and are not used for fluid resuscitation. Hypotonic solutions
rapidly leave the intravascular space, causing interstitial and intracellular edema. A systematic review of 30 randomized
controlled trials found no benefit in giving colloids (e.g., albumin) over crystalloids and recommended against the
administration of colloids in most patient populations
After receiving handoff report from the night shift, the nurse completes the morning assessment of a patient with
severe sepsis. Vital sign assessment notes blood pressure 95/60 mm Hg, heart rate 110 beats/min, respirations 32
breaths/min, oxygen saturation (SpO2) 96% on 45% oxygen via Venturi mask, temperature 101.5° F, central venous
pressure (CVP/RAP) 2 mm Hg, and urine output of 10 mL for the last hour. Given this report, the nurse obtains
orders for treatment that include which of the following? (Select all that apply.)
Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is < 5 mm Hg.
Increase supplemental oxygen therapy to 60% venture
mask.
Administer 40 mg furosemide (Lasix) intravenously as needed if the urine output is less than 30 mL/hr.
D.Administer acetaminophen (Tylenol) 650 mg suppository per rectum as needed to treat temperature > 101° F
A.Administer infusion of 500 mL 0.9% normal saline every 4 hours as needed if the CVP is < 5 mm Hg.
Administer acetaminophen (Tylenol) 650 mg suppository per rectum as needed to treat temperature > 101° F
Fluid volume resuscitation is a priority in patients with severe sepsis to maintain circulating blood volume and end organ
perfusion and oxygenation. A 500-mL IV bolus of 0.9% normal saline is appropriate given the patient's CVP of 2 mm Hg
and hourly urine output of 10 mL/hr. There is no evidence to support the need to increase supplemental oxygen.
Administration of furosemide (Lasix) in the presence of a fluid volume deficit is contraindicated. The fever may need to be
treated
In the cardiac cycle, the ventricles contract during:
the refractory period.
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diastole.
repolarization.
systole.
D. systole.
Arterial baroreceptors are located in the:
renal artery.
superior vena cava.
carotid arteries.
circle of Willis.
C. carotid arteries.
Which problem is a pathophysiological consequence common to all shock states?
Hypoperfusion
Vasoconstriction
Pulmonary edema
Hypertension
A. Hypoperfusion
A consequence of switching from aerobic to anaerobic cellular metabolism during shock states is:
increased ATP production.
cellular dehydration.
lactic acidosis.
free radical formation.
C. lactic acidosis.
Which of the following conditions is not a potential cause of cardiogenic shock?
Tension pneumothorax
Spinal cord injury
Tamponade
Cardiac arrhythmias
B. Spinal cord injury
Which of the following shock states manifests with tachycardia, vasoconstriction, and movement of large volumes
of interstitial fluid to the vascular compartment?
Anaphylactic
Hypovolemic
Neurogenic
Septic
B. Hypovolemic
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Which of the following shock states is (are) characterized by vasodilation of the systemic arteries?
Hypovolemic
Cardiogenic
Distributive
All of the above
C. Distributive
Which of the following shock states is (are) characterized by acute, severe bronchoconstriction?
Cardiogenic
Anaphylactic
Hypovolemic
All of the above
B. Anaphylactic
Causes of hypovolemic shock include all of the following except:
dehydration.
blood loss.
brainstem injury.
diuresis.
C. brainstem injury.
Clinical manifestations of hypovolemic shock include all of the following except:
pulmonary edema.
tachycardia.
hypotension.
oliguria.
A. pulmonary edema.
During hemorrhagic shock, the clinical manifestations of pale skin and cool extremities are most directly caused
by:
hypothermia.
accumulation of toxic metabolites.
vasoconstriction of peripheral arterioles.
increased tissue oxygen demand.
C. vasoconstriction of peripheral arterioles.
Neurogenic shock is caused by:
spinal cord injuries below T6.
inhibition of the parasympathetic nervous system.
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injury to the cerebral cortex.
a lack of sympathetic activity.
D. a lack of sympathetic activity.
Which of the following pathophysiological events causes the severe hypotension observed in neurogenic shock?
A. Increased capillary permeability
B. Diuresis
C. Decreased peripheral vascular resistance
D. All of the above
C. Decreased peripheral vascular resistance
Anaphylactic shock occurs in response to severe:
A. viral infections.
B. allergic reactions.
C. brain injuries.
D. burn injuries.
B. allergic reactions.
Anaphylactic shock manifests with the rapid onset of which set of symptoms?
A. Bradycardia, decreased arterial pressure, and oliguria
B. Dyspnea, hypotension, and urticaria
C. Hypertension, anxiety, and tachycardia
D. Fever, hypotension, and erythematous rash
B. Dyspnea, hypotension, and urticaria
Which of the following conditions presents the most significant risk factor for developing septic shock?
A. Use of immunosuppressant medications
B. History of severe allergies
C. Diagnosis of chronic congestive heart failure
D. Genetic predisposition to disorders of hemostasis
A. Use of immunosuppressant medications
What is the primary cause of hypotension in early stages of septic shock?
A. Blood loss
B. Arterial vasodilation
C. Activation of the parasympathetic nervous system
D. Heart failure
B. Arterial vasodilation
Which set of clinical manifestations is highly characteristic of a septic shock state?
A. Tachycardia, hypotension, and warm skin
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B. Confusion, bradycardia, and truncal rash
C. Severe respiratory distress, jugular venous distention, and chest pain
D. Decreased cardiac output, hypertension, and poor skin turgor
A. Tachycardia, hypotension, and warm skin
Which of the following features is highly characteristic of a septic shock state?
A. High peripheral vascular resistance
B. Inhibition of the sympathetic nervous system
C. Metabolic alkalosis
D. Hypermetabolism
D. Hypermetabolism
Low levels of which molecule contribute to the pathophysiology of septic shock?
A. Nitric oxide
B. Interleukin 1
C. Activated protein C
D. Epinephrine
C. Activated protein C
The most common cause of multiple organ dysfunction syndrome (MODS) is:
A. myocardial infarction.
B. septic shock.
C. chronic pulmonary disease.
D. autoimmune disease.
B. septic shock.
Secondary MODS is defined as the progressive dysfunction of two or more organ systems resulting from:
A. a drug overdose.
B. severe hemorrhaging.
C. an uncontrolled inflammatory response.
D. myocardial depression.
C. an uncontrolled inflammatory response.
In MODS, which of the following events contribute to organ failure?
A. Microvascular clotting
B. Interstitial edema
C. Exhaustion of fuel supply
D. All of the above
D. All of the above
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Which of the following laboratory alterations would indicate that a patient is developing renal failure in MODS?
A. Increased serum creatinine
B. Decreased lactate dehydrogenase (LDH) levels
C. Decreased blood urea nitrogen (BUN)
D. Hypokalemia
A. Increased serum creatinine
All of the following alterations would indicate that a patient is developing liver failure in MODS except:
A. increased serum ammonia levels.
B. jaundice.
C. increased levels of liver enzymes.
D. increased serum urea levels.
D. increased serum urea levels.
Which burn injury involves most of the dermis and leaves only a few epidermal appendages intact?
A. First degree
B. Superficial partial thickness (second degree)
C. Deep partial thickness (second degree)
D. Third degree
C. Deep partial thickness (second degree)
Which burn injury is characterized by the immediate appearance of large water-filled blisters and a red wound bed?
A. First degree
B. Superficial partial thickness (second degree)
C. Deep partial thickness (second degree)
D. Third degree
B. Superficial partial thickness (second degree)
Which burn injury is essentially painless in the wound bed?
A. First degree
B. Superficial partial thickness (second degree)
C. Deep partial thickness (second degree)
D. Third degree
D. Third degree
During the first 24 hours after a severe burn injury, which of the following physiologic responses typically occurs?
A. Increased capillary permeability
B. Inhibition of stress hormone release
C. Increased cardiac contractility and cardiac output
D. Increased peripheral vascular resistance
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A. Increased capillary permeability
Which of the following physiological alterations would you expect to see in the delayed response to a severe burn
injury?
A. Hypoglycemia
B. Hypovolemia
C. Hypometabolism
D. Bleeding from wound beds
B. Hypovolemia
Individuals with severe burns are often at risk for becoming hypothermic. Which of the following descriptions best
characterizes the underlying cause of this problem?
A. Burn patients experience hypothermia as a rebound reaction from the heat damage.
B. Burn patients tend to be hypothermic due to hypotension and ischemia.
C. Evaporative heat loss from major burn wounds can lead to hypothermia.
D. Blood coagulation limits the blood circulating to the body core, thereby causing hypothermia.
C. Evaporative heat loss from major burn wounds can lead to hypothermia.
Why do individuals with severe burns have difficulty breathing and often require intubation, even if there was no
smoke inhalation causing acute lung injury?
A. Severe pulmonary edema develops immediately following all severe burn injuries.
B. Pulmonary emboli typically form after severe burn injuries.
C. Airway edema is a common occurrence with severe burn injuries.
D. Pneumothorax and pleural effusions occur with severe burn injuries.
C. Airway edema is a common occurrence with severe burn injuries.
Why would a third-degree, circumferential burn of the thigh require prompt medical attention?
A. Wound contraction and edema can severely impair limb circulation.
B. It is difficult to perform skin grafts of the limbs.
C. Burn shock is inevitable.
D. Third-degree burns are very painful.
A. Wound contraction and edema can severely impair limb circulation.
A patient is treated in the emergency department (ED) for shock of unknown etiology. The first action by the nurse
should be to
a. check the blood pressure.
b. obtain an oxygen saturation.
c. attach a cardiac monitor.
d. check level of consciousness.
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1. Correct Answer: B
Rationale: The initial actions of the nurse are focused on the ABCs, and assessing the airway and ventilation is
necessary. The other assessments should be accomplished as rapidly as possible after the oxygen saturation is
determined and addressed.
2. A diabetic patient who has had vomiting and diarrhea for the past 3 days is admitted to the hospital with a blood
glucose of 748 mg/ml (41.5 mmol/L) and a urinary output of 120 ml in the first hour. The vital signs are blood
pressure (BP) 72/62; pulse 128, irregular and thready; respirations 38; and temperature 97° F (36.1° C). The patient
is disoriented and lethargic with cold, clammy skin and cyanosis in the hands and feet. The nurse recognizes that
the patient is experiencing the
a. progressive stage of septic shock.
b. compensatory stage of diabetic shock.
c. refractory stage of cardiogenic shock.
d. progressive stage of hypovolemic shock.
Correct Answer: D
Rationale: The patient's history of hyperglycemia (and the associated polyuria), vomiting, and diarrhea is consistent with
hypovolemia, and the symptoms are most consistent with the progressive stage of shock. The patient's temperature of 97°
F is inconsistent with septic shock. The history is inconsistent with a diagnosis of cardiogenic shock, and the patient's
neurologic status is not consistent with refractory shock.
3. A patient with hypovolemic shock has a urinary output of 15 ml/hr. The nurse understands that the compensatory
physiologic mechanism that leads to altered urinary output is
a. activation of the sympathetic nervous system (SNS), causing vasodilation of the renal arteries.
b. stimulation of cardiac -adrenergic receptors, leading to increased cardiac output.
c. release of aldosterone and antidiuretic hormone (ADH), which cause sodium and water retention.
d. movement of interstitial fluid to the intravascular space, increasing renal blood flow.
Correct Answer: C
Rationale: The release of aldosterone and ADH lead to the decrease in urine output by increasing the reabsorption of
sodium and water in the renal tubules. SNS stimulation leads to renal artery vasoconstriction. -Receptor stimulation does
increase cardiac output, but this would improve urine output. During shock, fluid leaks from the intravascular space into
the interstitial space.
4. While caring for a seriously ill patient, the nurse determines that the patient may be in the compensatory stage of
shock on finding
a. cold, mottled extremities.
b. restlessness and apprehension.
c. a heart rate of 120 and cool, clammy skin.
d. systolic BP less than 90 mm Hg.
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Correct Answer: B
Rationale: Restlessness and apprehension are typical during the compensatory stage of shock. Cold, mottled extremities,
cool and clammy skin, and a systolic BP less than 90 are associated with the progressive and refractory stages.
5. When assessing the hemodynamic information for a newly admitted patient in shock of unknown etiology, the
nurse will anticipate administration of large volumes of crystalloids when the
a. cardiac output is increased and the central venous pressure (CVP) is low.
b. pulmonary artery wedge pressure (PAWP) is increased, and the urine output is low.
c. heart rate is decreased, and the systemic vascular resistance is low.
d. cardiac output is decreased and the PAWP is high.
Correct Answer: A
Rationale: A high cardiac output and low CVP suggest septic shock, and massive fluid replacement is indicated.
Increased PAWP indicates that the patient has excessive fluid volume (and suggests cardiogenic shock), and diuresis is
indicated. Bradycardia and a low systemic vascular resistance (SVR) suggest neurogenic shock, and fluids should be
infused cautiously.
6. A patient who has been involved in a motor-vehicle crash is admitted to the ED with cool, clammy skin,
tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?
a. Insert two 14-gauge IV catheters.
b. Administer oxygen at 100% per non-rebreather mask.
c. Place the patient on continuous cardiac monitor.
d. Draw blood to type and crossmatch for transfusions.
Correct Answer: B
Rationale: The first priority in the initial management of shock is maintenance of the airway and ventilation. Cardiac
monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished, but only
after actions to maximize oxygen delivery have been implemented.
7. A patient with massive trauma and possible spinal cord injury is admitted to the ED. The nurse suspects that the
patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on the finding of
a. cool, clammy skin.
b. shortness of breath.
c. heart rate of 48 beats/min
d. BP of 82/40 mm Hg.
Correct Answer: C
Rationale: The normal sympathetic response to shock/hypotension is an increase in heart rate. The presence of
bradycardia suggests unopposed parasympathetic function, as occurs in neurogenic shock. The other symptoms are
consistent with hypovolemic shock.
8. The nurse caring for a patient in shock notifies the health care provider of the patientts deteriorating status when
the patientts ABG results include
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a. pH 7.48, PaCO2 33 mm Hg.
b. pH 7.33, PaCO2 30 mm Hg.
c. pH 7.41, PaCO2 50 mm Hg.
d. pH 7.38, PaCO2 45 mm Hg.
Correct Answer: B
Rationale: The patient's low pH in spite of a respiratory alkalosis indicates that the patient has severe metabolic acidosis
and is experiencing the progressive stage of shock; rapid changes in therapy are needed. The values in the answer
beginning "pH 7.48" suggest a mild respiratory alkalosis (consistent with compensated shock). The values in the answer
beginning "pH 7.41" suggest compensated respiratory acidosis. The values in the answer beginning "pH 7.38" are normal.
9. The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine) infusion through a left-forearm
IV. Which assessment information obtained by the nurse indicates a need for immediate action?
a. The patient has an apical pulse rate of 58 beats/min.
b. The patientts urine output has been 28 ml over the last hour.
c. The patientts IV infusion site is cool and pale.
d. The patient has warm, dry skin on the extremities.
Correct Answer: C
Rationale: The coldness and pallor at the infusion site suggest extravasation of the Neo-Synephrine. The nurse should
discontinue the IV and, if possible, infuse the medication into a central line. An apical pulse of 58 is typical for neurogenic
shock but does not indicate an immediate need for nursing intervention. A 28-ml output over 1 hour would require the
nurse to monitor the output over the next hour, but an immediate change in therapy is not indicated. Warm, dry skin
indicates that the patient is in early neurogenic shock.
10. A patient in septic shock has not responded to fluid resuscitation, as evidenced by a decreasing BP and cardiac
output. The nurse anticipates the administration of
a. nitroglycerine (Tridil).
b. dobutamine (Dobutrex).
c. norepinephrine (Levophed).
d. sodium nitroprusside (Nipride).
Correct Answer: C
Rationale: When fluid resuscitation is unsuccessful, administration of vasopressor drugs is used to increase the systemic
vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac
output and BP. Dobutamine will increase stroke volume, but it would also further decrease SVR. Nitroprusside is an
arterial vasodilator and would further decrease SVR.
11. A patient who is receiving chemotherapy is admitted to the hospital with acute dehydration caused by nausea
and vomiting. Which action will the nurse include in the plan of care to best prevent the development of shock,
systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction syndrome (MODS)?
a. Administer all medications through the patientts indwelling central line.
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b. Place the patient in a private room.
c. Restrict the patient to foods that have been well-cooked or processed.
d. Insert a nasogastric (NG) tube for enteral feeding.
Correct Answer: B
Rationale: The patient who has received chemotherapy is immune compromised, and placing the patient in a private room
will decrease the exposure to other patients and reduce infection/sepsis risk. Administration of medications through the
central line increases the risk for infection and sepsis. There is no indication that the patient is neutropenic, and restricting
the patient to cooked and processed foods is likely to decrease oral intake further and cause further malnutrition, a risk
factor for sepsis and shock. Insertion of an NG tube is invasive and will not decrease the patient's nausea and vomiting.
12. All of these collaborative interventions are ordered by the health care provider for a patient stung by a bee who
develops severe respiratory distress and faintness. Which one will the nurse administer first?
a. Epinephrine (Adrenalin)
b. Normal saline infusion
c. Dexamethasone (Decadron)
d. Diphenhydramine (Benadryl)
Correct Answer: A
Rationale: Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks the effects of histamine
and reverses the vasodilation, bronchoconstriction, and histamine release that cause the symptoms of anaphylaxis. The
other interventions are also appropriate but would not be the first ones administered.
13. A patient with a myocardial infarction (MI) and cardiogenic shock has the following vital signs: BP 86/50, pulse
126, respirations 30. Hemodynamic monitoring reveals an elevated PAWP and decreased cardiac output. The nurse
will anticipate
a. administration of furosemide (Lasix) IV.
b. titration of an epinephrine (Adrenalin) drip.
c. administration of a normal saline bolus.
d. assisting with endotracheal intubation.
Correct Answer: A
Rationale: The PAWP indicates that the patient's preload is elevated and furosemide is indicated to reduce the preload
and improve cardiac output. Epinephrine would further increase myocardial oxygen demand and might extend the MI. The
PAWP is already elevated, so normal saline boluses would be contraindicated. There is no indication that the patient
requires endotracheal intubation.
14. The triage nurse receives a call from a community member who is driving an unconscious friend with multiple
injuries after a motorcycle accident to the hospital. The caller states that they will be arriving in 1 minute. In
preparation for the patientts arrival, the nurse will obtain
a. a liter of lactated Ringerts solution.
b. 500 ml of 5% albumin.
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c. two 14-gauge IV catheters.
d. a retention catheter.
Correct Answer: C
Rationale: A patient with multiple trauma may require fluid resuscitation to prevent or treat hypovolemic shock, so the
nurse will anticipate the need for 2 large bore IV lines to administer normal saline. Lactated Ringer's solution should be
used cautiously and will not be ordered until the patient had been assessed for possible liver abnormalities. Although
colloids may sometimes be used for volume expansion, it is generally accepted that crystalloids should be used as the
initial therapy for fluid resuscitation. A catheter would likely be ordered, but in the 1 minute that the nurse has to obtain
supplies, the IV catheters would take priority.
15. The nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective on finding that the patientts
a. urine output is 40 ml over the last hour.
b. hemoglobin is within normal limits.
c. CVP has decreased.
d. mean arterial pressure (MAP) is 65 mm Hg.
Correct Answer: A
Rationale: Assessment of end-organ perfusion, such as an adequate urine output, is the best indicator that fluid
resuscitation has been successful. The hemoglobin level is not useful in determining whether fluid administration has been
effective unless the patient is bleeding and receiving blood. A decrease in CVP indicates that more fluid is needed. The
MAP is at the low normal range, but does not clearly indicate that tissue perfusion is adequate.
16. The nurse is caring for a patient admitted with a urinary tract infection and sepsis. Which information obtained
in the assessment indicates a need for a change in therapy?
a. The patient is restless and anxious.
b. The patient has a heart rate of 134.
c. The patient has hypotonic bowel sounds.
d. The patient has a temperature of 94.1° F.
Correct Answer: D
Rationale: Hypothermia is an indication that the patient is in the progressive stage of shock. The other data are consistent
with compensated shock.
17. Norepinephrine (Levophed) has been ordered for the patient in hypovolemic shock. Before administering the
drug, the nurse ensures that the
a. patientts heart rate is less than 100.
b. patient has received adequate fluid replacement.
c. patientts urine output is within normal range.
d. patient is not receiving other sympathomimetic drugs.
Correct Answer: B
Rationale: If vasoconstrictors are given in a hypovolemic patient, the peripheral vasoconstriction will further decrease
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tissue perfusion. A patient with hypovolemia is likely to have a heart rate greater than 100 and a low urine output, so
these values are not contraindications to vasoconstrictor therapy. Patients may receive other sympathomimetic drugs
concurrently with Levophed.
18. When the nurse is caring for a patient in cardiogenic shock who is receiving dobutamine (Dobutrex) and
nitroglycerin (Tridil) infusions, the best evidence that the medications are effective is that the
a. systolic BP increases to greater than 100 mm Hg.
b. cardiac monitor shows sinus rhythm at 96 beats/min.
c. PAWP drops to normal range.
d. troponin and creatine kinase levels decrease.
Correct Answer: C
Rationale: Because PAWP is increased in cardiogenic shock as a result of the increase in volume and pressure in the left
ventricle, normalization of PAWP is the best indicator of patient improvement. The changes in BP and heart rate could
occur with dobutamine infusion even if patient tissue perfusion was not improved. Troponin and creatine kinase (CK)
levels are indicators of cardiac cellular death and are not used as indicators of improved tissue perfusion.
19. While assessing a patient in shock who has an arterial line in place, the nurse notes a drop in the systolic BP
from 92 mm Hg to 76 mm Hg when the head of the patientts bed is elevated to 75 degrees. This finding indicates a
need for
a. additional fluid replacement.
b. antibiotic administration.
c. infusion of a sympathomimetic drug.
d. administration of increased oxygen.
Correct Answer: A
Rationale: A postural drop in BP is an indication of volume depletion and suggests the need for additional fluid infusions.
There are no data to suggest that antibiotics, sympathomimetics, or additional oxygen are needed.
20. The best nursing intervention for a patient in shock who has a nursing diagnosis of fear related to perceived
threat of death is to
a. arrange for the hospital pastoral care staff to visit the patient.
b. ask the health care provider to prescribe a sedative drug for the patient.
c. leave the patient alone with family members whenever possible.
d. place the patientts call bell where it can be easily reached.
Correct Answer: D
Rationale: The patient who is fearful should feel that the nurse is immediately available if needed. Pastoral care staff
should be asked to visit only after checking with the patient to determine whether this is desired. Providing time for family
to spend with the patient is appropriate, but patients and family should not feel that the nurse is unavailable. Sedative
administration is helpful but does not as directly address the patient's anxiety about dying.
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21. A patient outcome that is appropriate for the patient in shock who has a nursing diagnosis of decreased cardiac
output related to relative hypovolemia is
a. urine output of 0.5 ml/kg/hr.
b. decreased peripheral edema.
c. decreased CVP.
d. oxygen saturation 90% or more.
Correct Answer: A
Rationale: A urine output of 0.5 ml/kg/hr indicates adequate renal perfusion, which is a good indicator of cardiac output.
The patient may continue to have peripheral edema because fluid infusions may be needed despite third-spacing of fluids
in relative hypovolemia. Decreased central venous pressure (CVP) for a patient with relative hypovolemia indicates that
additional fluid infusion is necessary. An oxygen saturation of 90% will not necessarily indicate that cardiac output has
improved.
22. A patient who has just been admitted with septic shock has a BP of 70/46, pulse 136, respirations 32,
temperature 104.0° F, and blood glucose 246 mg/dl. Which order will the nurse accomplish first?
a. Start insulin drip to maintain blood glucose at 110 to 150 mg/dl.
b. Give normal saline IV at 500 ml/hr.
c. Titrate norepinephrine (Levophed) to keep MAP at 65 to 70 mm Hg.
d. Infuse drotrecogin- (Xigris) 24 mcg/kg.
Correct Answer: B
Rationale: Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the
initial therapy. The other actions are also appropriate and should be initiated quickly as well.
23. A patient in compensated septic shock has hemodynamic monitoring with a pulmonary artery catheter and an
arterial catheter. Which information obtained by the nurse indicates that the patient is still in the compensatory
stage of shock?
a. The cardiac output is elevated.
b. The central venous pressure (CVP) is increased.
c. The systemic vascular resistance (SVR) is high.
d. The PAWP is high.
Correct Answer: A
Rationale: In the early stages of septic shock, the cardiac output is high. The other hemodynamic changes would indicate
that the patient had developed progressive or refractory septic shock.
24. When caring for a patient with cardiogenic shock and possible MODS, which information obtained by the nurse
will help confirm the diagnosis of MODS?
a. The patient has crackles throughout both lung fields.
b. The patient complains of 8/10 crushing chest pain.
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c. The patient has an elevated ammonia level and confusion.
d. The patient has cool extremities and weak pedal pulses.
Correct Answer: C
Rationale: The elevated ammonia level and confusion suggest liver failure in addition to the cardiac failure. The crackles,
chest pain, and cool extremities are all consistent with cardiogenic shock and do not indicate that there are failures in
other major organ systems.
25. To monitor a patient with severe acute pancreatitis for the early organ damage associated with MODS, the most
important assessments for the nurse to make are
a. stool guaiac and bowel sounds.
b. lung sounds and oxygenation status.
c. serum creatinine and urinary output.
d. serum bilirubin levels and skin color.
Correct Answer: B
Rationale: The respiratory system is usually the system to show the signs of MODS because of the direct effect of
inflammatory mediators on the pulmonary system. The other assessment data are also important to collect, but they will
not indicate the development of MODS as early.
26. An assessment finding indicating to the nurse that a 70-kg patient in septic shock is progressing to MODS
includes
a. respiratory rate of 10 breaths/min.
b. fixed urine specific gravity at 1.010.
c. MAP of 55 mm Hg.
d. 360-ml urine output in 8 hours.
Correct Answer: B
Rationale: A fixed urine specific gravity points to an inability of the kidney to concentrate urine caused by acute tubular
necrosis. With MODS, the patient's respiratory rate would initially increase. The MAP of 55 shows continued shock, but
not necessarily progression to MODS. A 360-ml urine output over 8 hours indicates adequate renal perfusion.
27. When caring for a patient who has just been admitted with septic shock, which of these assessment data will be
of greatest concern to the nurse?
a. BP 88/56 mm Hg
b. Apical pulse 110 beats/min
c. Urine output 15 ml for 2 hours
d. Arterial oxygen saturation 90%
Correct Answer: C
Rationale: The best data for assessing the adequacy of cardiac output are those that provide information about end-organ
perfusion such as urine output by the kidneys. The low urine output is an indicator that renal tissue perfusion is
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inadequate and the patient is in the progressive stage of shock. The low BP, increase in pulse, and low-normal O2
saturation are more typical of compensated septic shock.
1. A patient with septic shock has a urine output of 20 mL/hr for the past 3 hours. The pulse
rate is 120 and the central venous pressure and pulmonary artery wedge pressure are low.
Which of these orders by the health care provider will the nurse question?
a. Give furosemide (Lasix) 40 mg IV.
b. Increase normal saline infusion to 150 mL/hr.
c. Administer hydrocortisone (SoluCortef) 100 mg IV.
d. Prepare to give drotrecogin alpha (Xigris) 24 mcg/kg/hr.
ANS: A
Furosemide will lower the filling pressures and renal perfusion further for the patient
with septic shock. The other orders are appropriate.
DIF: Cognitive Level: Application REF: 1724-1726 | 1731 | 1733
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
2. A patient with shock of unknown etiology whose hemodynamic monitoring indicates BP
92/54, pulse 64, and an elevated pulmonary artery wedge pressure has the following
collaborative interventions prescribed. Which intervention will the nurse question?
a. Infuse normal saline at 250 mL/hr.
b. Keep head of bed elevated to 30 degrees.
c. Give nitroprusside (Nipride) unless systolic BP <90 mm Hg.
d. Administer dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.
ANS: A
The patient's elevated pulmonary artery wedge pressure indicates volume excess. A
normal saline infusion at 250 mL/hr will exacerbate this. The other actions are
appropriate for the patient.
DIF: Cognitive Level: Application REF: 1719 | 1721-1722 | 1735
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
3. A patient with massive trauma and possible spinal cord injury is admitted to the
emergency department (ED). Which finding by the nurse will help confirm a diagnosis of
neurogenic shock?
a. Cool, clammy skin
b. Inspiratory crackles
c. Apical heart rate 48 beats/min
d. Temperature 101.2° F (38.4° C)
ANS: C
Neurogenic shock is characterized by hypotension and bradycardia. The other findings
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would be more consistent with other types of shock.
DIF: Cognitive Level: Comprehension REF: 1721-1722 | 1723
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
4. A patient with cardiogenic shock is cool and clammy and hemodynamic monitoring
indicates a high systemic vascular resistance (SVR). Which action will the nurse
anticipate taking?
a. Increase the rate for the prescribed dopamine (Intropin) infusion.
b. Decrease the rate for the prescribed nitroglycerin (Tridil) infusion.
c. Decrease the rate for the prescribed 5% dextrose in water (D5W) infusion.
d. Increase the rate for the prescribed sodium nitroprusside (Nipride) infusion.
ANS: D
Nitroprusside is an arterial vasodilator and will decrease the SVR and afterload, which
will improve cardiac output. Changes in the D5W and nitroglycerin infusions will not
directly increase SVR. Increasing the dopamine will tend to increase SVR.
DIF: Cognitive Level: Application REF: 1733-1734 TOP: Nursing Process:
Planning
MSC: NCLEX: Physiological Integrity
5. After receiving 1000 mL of normal saline, the central venous pressure for a patient who
has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. The nurse
will anticipate the administration of
a. nitroglycerine (Tridil).
b. drotrecogin alpha (Xigris).
c. norepinephrine (Levophed).
d. sodium nitroprusside (Nipride).
ANS: C
When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase
the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin
would decrease the preload and further drop cardiac output and BP. Drotrecogin alpha
may decrease inappropriate inflammation and help prevent systemic inflammatory
response syndrome, but it will not directly improve blood pressure. Nitroprusside is an
arterial vasodilator and would further decrease SVR.
DIF: Cognitive Level: Application REF: 1731 | 1733-1735
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
6. To evaluate the effectiveness of the omeprazole (Prilosec) being administered to a patient
with systemic inflammatory response syndrome (SIRS), which assessment will the nurse
make?
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a. Auscultate bowel sounds.
b. Ask the patient about nausea.
c. Monitor stools for occult blood.
d. Check for abdominal distention.
ANS: C
Proton pump inhibitors are given to decrease the risk for stress ulcers in critically ill
patients. The other assessments also will be done, but these will not help in determining
the effectiveness of the omeprazole administration.
DIF: Cognitive Level: Application REF: 1735-1737 | 1742-1743
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
7. A patient with cardiogenic shock has the following vital signs: BP 86/50, pulse 126,
respirations 30. The PAWP is increased and cardiac output is low. The nurse will
anticipate
a. infusion of 5% human albumin.
b. administration of furosemide (Lasix) IV.
c. titration of an epinephrine (Adrenalin) drip.
d. administration of hydrocortisone (SoluCortef).
ANS: B
The PAWP indicates that the patient's preload is elevated and furosemide is indicated to
reduce the preload and improve cardiac output. Epinephrine would further increase heart
rate and myocardial oxygen demand. Normal saline infusion would increase the PAWP
further. Hydrocortisone might be used for septic or anaphylactic shock.
DIF: Cognitive Level: Application REF: 1735 | 1736 TOP: Nursing Process:
Planning
MSC: NCLEX: Physiological Integrity
8. The emergency department (ED) receives notification that a patient who has just been in
an automobile accident is being transported to your facility with anticipated arrival in 1
minute. In preparation for the patientts arrival, the nurse will obtain
a. 500 mL of 5% albumin.
b. lactated Ringerts solution.
c. two 14-gauge IV catheters.
d. dopamine (Intropin) infusion.
ANS: C
A patient with multiple trauma may require fluid resuscitation to prevent or treat
hypovolemic shock, so the nurse will anticipate the need for 2 large bore IV lines to
administer normal saline. Lactated Ringer's solution should be used cautiously and will
lOMoAR cPSD| 30878495
not be ordered until the patient has been assessed for possible liver abnormalities.
Although colloids may sometimes be used for volume expansion, crystalloids should be
used as the initial therapy for fluid resuscitation. Vasopressor infusion is not used as the
initial therapy for hypovolemic shock.
DIF: Cognitive Level: Application REF: 1731 | 1732 | 1733
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
9. Which of these findings is the best indicator that the fluid resuscitation for a patient with
hypovolemic shock has been successful?
a. Hemoglobin is within normal limits.
b. Urine output is 60 mL over the last hour.
c. Pulmonary artery wedge pressure (PAWP) is normal.
d. Mean arterial pressure (MAP) is 65 mm Hg.
ANS: B
Assessment of end organ perfusion, such as an adequate urine output, is the best indicator
that fluid resuscitation has been successful. The hemoglobin level, PAWP, and MAP are
useful in determining the effects of fluid administration, but they are not as useful as data
indicating good organ perfusion.
DIF: Cognitive Level: Application REF: 1733-1735 TOP: Nursing Process:
Evaluation
MSC: NCLEX: Physiological Integrity
10. Which intervention will the nurse include in the plan of care for a patient who has
cardiogenic shock?
a. Avoid elevating head of bed.
b. Check temperature every 2 hours.
c. Monitor breath sounds frequently.
d. Assess skin for flushing and itching.
ANS: C
Since pulmonary congestion and dyspnea are characteristics of cardiogenic shock, the
nurse should assess the breath sounds frequently. The head of the bed is usually elevated
to decrease dyspnea. Elevated temperature and flushing or itching of the skin are not
typical of cardiogenic shock.
DIF: Cognitive Level: Application REF: 1721
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
11. Norepinephrine (Levophed) has been prescribed for a patient who was admitted with
dehydration and hypotension. Which patient information indicates that the nurse should
consult with the health care provider before administration of the norepinephrine?
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a. The patientts central venous pressure is 3 mm Hg.
b. The patient is receiving low dose dopamine (Intropin).
c. The patient is in sinus tachycardia at 100 to 110 beats/min.
d. The patient has had no urine output since being admitted.
ANS: A
Adequate fluid administration is essential before administration of vasopressors to
patients with hypovolemic shock. The patient's low central venous pressure indicates a
need for more volume replacement. The other patient data are not contraindications to
norepinephrine administration.
DIF: Cognitive Level: Application REF: 1733-1735 | 1736
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
12. When the nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion
to treat cardiogenic shock, which finding indicates that the medication is effective?
a. No heart murmur is audible.
b. Skin is warm, pink, and dry.
c. Troponin level is decreased.
d. Blood pressure is 90/40 mm Hg.
ANS: B
Warm, pink, and dry skin indicates that perfusion to tissues is improved. Since
nitroprusside is a vasodilator, the blood pressure may be low even if the medication is
effective. Absence of a heart murmur and a decrease in troponin level are not indicators
of improvement in shock.
DIF: Cognitive Level: Application REF: 1721 | 1723 | 1733-1735
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
13. Which assessment is most important for the nurse to make in order to evaluate whether
treatment of a patient with anaphylactic shock has been effective?
a. Pulse rate
b. Orientation
c. Blood pressure
d. Oxygen saturation
ANS: D
Because the airway edema that is associated with anaphylaxis can affect airway and
breathing, the oxygen saturation is the most critical assessment. Improvements in the
other assessments also will be expected with effective treatment of anaphylactic shock.
DIF: Cognitive Level: Application REF: 1724-1725 | 1732
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
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14. Which information obtained by the nurse when caring for a patient who has cardiogenic
shock indicates that the patient may be developing multiple organ dysfunction syndrome
(MODS)?
a. The patientts serum creatinine level is elevated.
b. The patient complains of intermittent chest pressure.
c. The patient has crackles throughout both lung fields.
d. The patientts extremities are cool and pulses are weak.
ANS: A
The elevated serum creatinine level indicates that the patient has renal failure as well as
heart failure. The crackles, chest pressure, and cool extremities are all consistent with the
patient's diagnosis of cardiogenic shock.
DIF: Cognitive Level: Application REF: 1740-1741
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
15. A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32,
temperature 104° F, and blood glucose 246 mg/dL. Which of these prescribed
interventions will the nurse implement first?
a. Give normal saline IV at 500 mL/hr.
b. Infuse drotrecogin- (Xigris) 24 mcg/kg.
c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.
d. Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) at 65 to
70 mm Hg.
ANS: A
Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid
resuscitation is the initial therapy. The other actions also are appropriate and should be
initiated quickly as well.
DIF: Cognitive Level: Application REF: 1735-1737
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
16. When the charge nurse is evaluating the skills of a new RN, which action by the new RN
indicates a need for more education in the care of patients with shock?
a. Placing the pulse oximeter on the ear for a patient with septic shock
b. Keeping the head of the bed flat for a patient with hypovolemic shock
c. Decreasing the room temperature to 68° F for a patient with neurogenic shock
d. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR
ANS: C
Patients with neurogenic shock may have poikilothermia. The room temperature should
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be kept warm to avoid hypothermia. The other actions by the new RN are appropriate.
DIF: Cognitive Level: Application REF: 1721-1722 | 1724
OBJ: Special Questions: Delegation TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
17. When caring for a patient who has septic shock, which assessment finding is most
important for the nurse to report to the health care provider?
a. BP 92/56 mm Hg
b. Skin cool and clammy
c. Apical pulse 118 beats/min
d. Arterial oxygen saturation 91%
ANS: B
Since patients in the early stage of septic shock have warm and dry skin, the patient's
cool and clammy skin indicates that shock is progressing. The other information also will
be reported, but does not indicate deterioration of the patient's status.
DIF: Cognitive Level: Application REF: 1723
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
18. A patient is treated in the emergency department (ED) for shock of unknown etiology.
The first action by the nurse should be to
a. administer oxygen.
b. attach a cardiac monitor.
c. obtain the blood pressure.
d. check the level of consciousness.
ANS: A
The initial actions of the nurse are focused on the ABCs—airway, breathing, circulation—
and administration of oxygen should be done first. The other actions should be
accomplished as rapidly as possible after oxygen administration.
DIF: Cognitive Level: Application REF: 1729-1731 | 1732 | 1733 | 1736-1737
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
19. During change-of-shift report, the nurse learns that a patient has been admitted with
dehydration and hypotension after having vomiting and diarrhea for 3 days. Which
finding is most important for the nurse to report to the health care provider?
a. Decreased bowel sounds
b. Apical pulse 110 beats/min
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c. Pale, cool, and dry extremities
d. New onset of confusion and agitation
ANS: D
The changes in mental status are indicative that the patient is in the progressive stage of
shock and that rapid intervention is needed to prevent further deterioration. The other
information is consistent with compensatory shock.
DIF: Cognitive Level: Application REF: 1728-1729
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
20. A patient who has been involved in a motor vehicle crash is admitted to the emergency
department (ED) with cool, clammy skin; tachycardia; and hypotension. Which of these
prescribed interventions should the nurse implement first?
a. Place the patient on continuous cardiac monitor.
b. Draw blood to type and crossmatch for transfusions.
c. Insert two 14-gauge IV catheters in antecubital space.
d. Administer oxygen at 100% per non-rebreather mask
ANS: D
The first priority in the initial management of shock is maintenance of the airway and
ventilation. Cardiac monitoring, insertion of IV catheters, and obtaining blood for
transfusions also should be rapidly accomplished, but only after actions to maximize
oxygen delivery have been implemented.
DIF: Cognitive Level: Application REF: 1732
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
21. The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine)
infusion through a left forearm IV. Which assessment information obtained by the nurse
indicates a need for immediate action?
a. The patientts IV infusion site is cool and pale.
b. The patient has warm, dry skin on the extremities.
c. The patient has an apical pulse rate of 58 beats/min.
d. The patientts urine output has been 28 mL over the last hour.
ANS: A
The coldness and pallor at the infusion site suggest extravasation of the phenylephrine.
The nurse should discontinue the IV and, if possible, infuse the medication into a central
line. An apical pulse of 58 is typical for neurogenic shock but does not indicate an
immediate need for nursing intervention. A 28 mL urinary output over 1 hour would
require the nurse to monitor the output over the next hour, but an immediate change in
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therapy is not indicated. Warm, dry skin is consistent with early neurogenic shock, but it
does not indicate a need for a change in therapy or immediate action.
DIF: Cognitive Level: Application REF: 1733-1734
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
22. The following therapies are prescribed by the health care provider for a patient who has
respiratory distress and syncope after a bee sting. Which will the nurse administer first?
a. normal saline infusion
b. epinephrine (Adrenalin)
c. dexamethasone (Decadron)
d. diphenhydramine (Benadryl)
ANS: B
Epinephrine rapidly causes peripheral vasoconstriction, dilates the bronchi, and blocks
the effects of histamine and reverses the vasodilation, bronchoconstriction, and histamine
release that cause the symptoms of anaphylaxis. The other interventions also are
appropriate but would not be the first ones administered.
DIF: Cognitive Level: Application REF: 1736-1737
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
23. Which information about a patient who is receiving vasopressin (Pitressin) to treat septic
shock is most important for the nurse to communicate to the heath care provider?
a. The patientts heart rate is 108 beats/min.
b. The patient is complaining of chest pain.
c. The patientts peripheral pulses are weak.
d. The patientts urine output is 15 mL/hr.
ANS: B
Because vasopressin is a potent vasoconstrictor, it may decrease coronary artery
perfusion. The other information is consistent with the patient's diagnosis and should be
reported to the health care provider but does not indicate a need for a change in therapy.
DIF: Cognitive Level: Application REF: 1735-1736
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
1. A patient with neurogenic shock has just arrived in the emergency department after a
diving accident. He has a cervical collar in place. Which of the following actions should
the nurse take (select all that apply)?
a. Prepare to administer atropine IV.
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b. Obtain baseline body temperature.
c. Prepare for intubation and mechanical ventilation.
d. Administer large volumes of lactated Ringerts solution.
e. Administer high-flow oxygen (100%) by non-rebreather mask.
ANS: A, B, C, E
All of the actions are appropriate except to give large volumes of lactated Ringer's
solution. The patient with neurogenic shock usually has a normal blood volume, and it is
important not to volume overload the patient. In addition, lactated Ringer's solution is
used cautiously in all shock situations because the failing liver cannot convert lactate to
bicarbonate.
DIF: Cognitive Level: Application REF: 1736-1737
OBJ: Special Questions: Alternate Item Format
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
1. The health care provider prescribes these actions for a patient who has possible septic
shock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will the
nurse implement the actions? Put a comma and space between each answer choice (a, b,
c, d, etc.)
a. Obtain blood and urine cultures.
b. Give vancomycin (Vancocin) 1 g IV.
c. Infuse vasopressin (Pitressin) 0.01 units/min.
d. Administer normal saline 1000 mL over 30 minutes.
e. Titrate oxygen administration to keep O2 saturation >95%.
ANS:
E, D, C, A, B
The initial action for this hypotensive and hypoxemic patient should be to improve the
oxygen saturation, followed by infusion of IV fluids and vasopressors to improve
perfusion. Cultures should be obtained before administration of antibiotics.
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Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 12: Oncologic Management
1. The public health nurse is presenting a health-promotion class to a group at a local community center. Which
intervention most directly addresses the leading cause of cancer deaths in North America?
A) Monthly self-breast exams
B) Smoking cessation
C) Annual colonoscopies
D) Monthly testicular exams
Ans:B
2. A nurse who works in an oncology clinic is assessing a patient who has arrived for a 2- month follow-up
appointment following chemotherapy. The nurse notes that the patientts skin appears yellow. Which blood tests
should be done to further explore this clinical sign?
A) Liver function tests (LFTs)
B) Complete blood count (CBC)
C) Platelet count
D) Blood urea nitrogen and creatinine
Ans:A
3. The school nurse is teaching a nutrition class in the local high school. One student states that he has heard that
certain foods can increase the incidence of cancer. The nurse responds, ìResearch has shown that certain foods
indeed appear to increase the risk of cancer.î Which of the following menu selections would be the best choice for
potentially reducing the risks of cancer?
A) Smoked salmon and green beans
B) Pork chops and fried green tomatoes
C) Baked apricot chicken and steamed broccoli
D) Liver, onions, and steamed peas
Ans:C
4. Traditionally, nurses have been involved with tertiary cancer prevention. However, an increasing emphasis is
being placed on both primary and secondary prevention. What would be an example of primary prevention?
A) Yearly Pap tests
B) Testicular self-examination
C) Teaching patients to wear sunscreen
D) Screening mammograms
Ans:C
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5. The nurse is caring for a 39-year-old woman with a family history of breast cancer. She requested a breast tumor
marking test and the results have come back positive. As a result, the patient is requesting a bilateral mastectomy.
This surgery is an example of what type of oncologic surgery?
A) Salvage surgery
B) Palliative surgery
C) Prophylactic surgery
D) Reconstructive surgery
Ans:C
6. The nurse is caring for a patient who is to begin receiving external radiation for a malignant tumor of the neck.
While providing patient education, what potential adverse effects should the nurse discuss with the patient?
A) Impaired nutritional status
B) Cognitive changes
C) Diarrhea
D) Alopecia
Ans:A
7. While a patient is receiving IV doxorubicin hydrochloride for the treatment of cancer, the nurse observes swelling
and pain at the IV site. The nurse should prioritize what action?
A) Stopping the administration of the drug immediately
B) Notifying the patientts physician
C) Continuing the infusion but decreasing the rate
D) Applying a warm compress to the infusion site
Ans:A
8. A patient newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing
anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what
should the nurse describe?
A) Pruritis (itching)
B) Nausea and vomiting
C) Altered glucose metabolism
D) Confusion
Ans:B
9. A patient on the oncology unit is receiving carmustine, a chemotherapy agent, and the nurse is aware that a
significant side effect of this medication is thrombocytopenia. Which symptom should the nurse assess for in
patients at risk for thrombocytopenia?
A) Interrupted sleep pattern
B) Hot flashes
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C) Epistaxis (nose bleed)
D) Increased weight
Ans:C
10. The nurse is orienting a new nurse to the oncology unit. When reviewing the safe administration of
antineoplastic agents, what action should the nurse emphasize?
A) Adjust the dose to the patientts present symptoms.
B) Wash hands with an alcohol-based cleanser following administration.
C) Use gloves and a lab coat when preparing the medication.
D) Dispose of the antineoplastic wastes in the hazardous waste receptacle.
Ans:D
11. A nurse provides care on a bone marrow transplant unit and is preparing a female patient for a hematopoietic
stem cell transplantation (HSCT) the following day. What information should the nurse emphasize to the patientts
family and friends?
A) Your family should likely gather at the bedside in case therets a negative
outcome.
B) Make sure she doesntt eat any food in the 24 hours before the procedure.
C) Wear a hospital gown when you go into the patientts room.
D) Do not visit if youtve had a recent infection.
Ans:D
12. A nurse is creating a plan of care for an oncology patient and one of the identified nursing diagnoses is risk for
infection related to myelosuppression. What intervention addresses the leading cause of infection-related death in
oncology patients?
A) Encourage several small meals daily.
B) Provide skin care to maintain skin integrity.
C) Assist the patient with hygiene, as needed.
D) Assess the integrity of the patientts oral mucosa regularly.
Ans:B
13. You are caring for an adult patient who has developed a mild oral yeast infection following chemotherapy. What
actions should you encourage the patient to perform? Select all that apply.
A) Use a lip lubricant.
B) Scrub the tongue with a firm-bristled toothbrush.
C) Use dental floss every 24 hours.
D) Rinse the mouth with normal saline.
E) Eat spicy food to aid in eradicating the yeast.
Ans:A, C, D
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14. The nurse on a bone marrow transplant unit is caring for a patient with cancer who is preparing for HSCT. What
is a priority nursing diagnosis for this patient?
A) Fatigue related to altered metabolic processes
B) Altered nutrition: less than body requirements related to anorexia
C) Risk for infection related to altered immunologic response
D) Body image disturbance related to weight loss and anorexia
Ans:C
15. An oncology nurse is caring for a patient who has developed erythema following radiation therapy. What should
the nurse instruct the patient to do?
A) Periodically apply ice to the area.
B) Keep the area cleanly shaven.
C) Apply petroleum jelly to the affected area.
D) Avoid using soap on the treatment area.
Ans:D
16. The nurse is caring for a patient has just been given a 6-month prognosis following a diagnosis of extensive
stage small-cell lung cancer. The patient states that he would like to die at home, but the team believes that the
patientts care needs are unable to be met in a home environment. What might you suggest as an alternative?
A) Discuss a referral for rehabilitation hospital.
B) Panel the patient for a personal care home.
C) Discuss a referral for acute care.
D) Discuss a referral for hospice care.
Ans:D
17. The clinic nurse is caring for a 42-year-old male oncology patient. He complains of extreme fatigue and
weakness after his first week of radiation therapy. Which response by the nurse would best reassure this patient?
A) These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory and
x-ray studies.
B) These symptoms are part of your disease and are an unfortunately inevitable part of living with cancer.
C) Try not to be concerned about these symptoms. Every patient feels this way after having radiation therapy.
D) Even though it is uncomfortable, this is a good sign. It means that only the cancer cells are dying.
Ans:A
18. A 16-year-old female patient experiences alopecia resulting from chemotherapy, prompting the nursing
diagnoses of disturbed body image and situational low self- esteem. What action by the patient would best indicate
that she is meeting the goal of improved body image and self-esteem?
A) The patient requests that her family bring her makeup and wig.
B) The patient begins to discuss the future with her family.
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C) The patient reports less disruption from pain and discomfort.
D) The patient cries openly when discussing her disease.
Ans:A
19. A 50-year-old man diagnosed with leukemia will begin chemotherapy. What would the nurse do to combat the
most common adverse effects of chemotherapy?
A) Administer an antiemetic.
B) Administer an antimetabolite.
C) Administer a tumor antibiotic.
D) Administer an anticoagulant.
Ans:A
20. A 58-year-old male patient has been hospitalized for a wedge resection of the left lower lung lobe after a routine
chest x-ray shows carcinoma. The patient is anxious and asks if he can smoke. Which statement by the nurse
would be most therapeutic?
A) Smoking is the reason you are here.
B) The doctor left orders for you not to smoke.
C) You are anxious about the surgery. Do you see smoking as helping?
D) Smoking is OK right now, but after your surgery it is contraindicated.
Ans:C
21. An oncology nurse educator is providing health education to a patient who has been diagnosed with skin
cancer. The patientts wife has asked about the differences between normal cells and cancer cells. What
characteristic of a cancer cell should the educator cite?
A) Malignant cells contain more fibronectin than normal body cells.
B) Malignant cells contain proteins called tumor-specific antigens.
C) Chromosomes contained in cancer cells are more durable and stable than those of
normal cells.
D) The nuclei of cancer cells are unusually large, but regularly shaped.
Ans:B
22. A patientts most recent diagnostic imaging has revealed that his lung cancer has metastasized to his bones and
liver. What is the most likely mechanism by which the patientts cancer cells spread?
A) Hematologic spread
B) Lymphatic circulation
C) Invasion
D) Angiogenesis
Ans:B
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23. The nurse is describing some of the major characteristics of cancer to a patient who has recently received a
diagnosis of malignant melanoma. When differentiating between benign and malignant cancer cells, the nurse
should explain differences in which of the following aspects? Select all that apply.
A) Rate of growth
B) Ability to cause death
C) Size of cells
D) Cell contents
E) Ability to spread
Ans:A, B, E
24. A 54-year-old has a diagnosis of breast cancer and is tearfully discussing her diagnosis with the nurse. The
patient states, ìThey tell me my cancer is malignant, while my coworkerts breast tumor was benign. I just dontt
understand at all.î When preparing a response to this patient, the nurse should be cognizant of what characteristic
that distinguishes malignant cells from benign cells of the same tissue type?
A) Slow rate of mitosis of cancer cells
B) Different proteins in the cell membrane
C) Differing size of the cells
D) Different molecular structure in the cells
Ans:B
25. An oncology patient will begin a course of chemotherapy and radiation therapy for the treatment of bone
metastases. What is one means by which malignant disease processes transfer cells from one place to another?
A) Adhering to primary tumor cells
B) Inducing mutation of cells of another organ
C) Phagocytizing healthy cells
D) Invading healthy host tissues
Ans:D
26. The nurse is performing an initial assessment of an older adult resident who has just relocated to the long-term
care facility. During the nursets interview with the patient, she admits that she drinks around 20 ounces of vodka
every evening. What types of cancer does this put her at risk for? Select all that apply.
A) Malignant melanoma
B) Brain cancer
C) Breast cancer
D) Esophageal cancer
E) Liver cancer
Ans:C, D, E
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28. A public health nurse has formed an interdisciplinary team that is developing an educational program entitled
Cancer: The Risks and What You Can Do About Them. Participants will receive information, but the major focus will
be screening for relevant cancers. This program is an example of what type of health promotion activity?
A) Disease prophylaxis
B) Risk reduction
C) Secondary prevention
D) Tertiary prevention
Ans:C
29. A 62-year-old woman diagnosed with breast cancer is scheduled for a partial mastectomy. The oncology nurse
explained that the surgeon will want to take tissue samples to ensure the disease has not spread to adjacent
axillary lymph nodes. The patient has asked if she will have her lymph nodes dissected, like her mother did several
years ago. What alternative to lymph node dissection will this patient most likely undergo?
A) Lymphadenectomy
B) Needle biopsy
C) Open biopsy
D) Sentinel node biopsy
Ans:D
30. You are caring for a patient who has just been told that her stage IV colon cancer has recurred and metastasized
to the liver. The oncologist offers the patient the option of surgery to treat the progression of this disease. What
type of surgery does the oncologist offer?
A) Palliative
B) Reconstructive
C) Salvage
D) Prophylactic
Ans:A
31. The nurse is caring for a patient with an advanced stage of breast cancer and the patient has recently learned
that her cancer has metastasized. The nurse enters the room and finds the patient struggling to breath and the
nursets rapid assessment reveals that the patientts jugular veins are distended. The nurse should suspect the
development of what oncologic emergency?
A) Increased intracranial pressure
B) Superior vena cava syndrome (SVCS)
C) Spinal cord compression
D) Metastatic tumor of the neck
Ans:B
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32. The hospice nurse is caring for a patient with cancer in her home. The nurse has explained to the patient and
the family that the patient is at risk for hypercalcemia and has educated them on that signs and symptoms of this
health problem. What else should the nurse teach this patient and family to do to reduce the patientts risk of
hypercalcemia?
A) Stool softeners are contraindicated.
B) Laxatives should be taken daily
C) Consume 2-4L of fluid daily
D) Restrict calcium intake
Ans:C
33. The home health nurse is performing a home visit for an oncology patient discharged 3 days ago after
completing treatment for non-Hodgkin lymphoma. The nursets assessment should include examination for the
signs and symptoms of what complication?
A) Tumor lysis syndrome (TLS)
B) Syndrome of inappropriate antiduretic hormone (SIADH)
C) Disseminated intravascular coagulation (DIC)
D) Hypercalcemia
Ans:A
34. The nurse is admitting an oncology patient to the unit prior to surgery. The nurse reads in the electronic health
record that the patient has just finished radiation therapy. With knowledge of the consequent health risks, the nurse
should prioritize assessments related to what health problem?
A) Cognitive deficits
B) Impaired wound healing
C) Cardiac tamponade
D) Tumor lysis syndrome
Ans:B
35. An oncology patient has just returned from the postanesthesia care unit after an open hemicolectomy. This
patientts plan of nursing care should prioritize which of the following?
A) Assess the patient hourly for signs of compartment syndrome.
B) Assess the patientts fine motor skills once per shift.
C) Assess the patientts wound for dehiscence every 4 hours.
D) Maintain the patientts head of bed at 45 degrees or more at all times.
Ans:C
36. The hospice nurse has just admitted a new patient to the program. What principle guides hospice care?
A) Care addresses the needs of the patient as well as the needs of the family.
B) Care is focused on the patient centrally and the family peripherally.
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C) The focus of all aspects of care is solely on the patient.
D) The care team prioritizes the patientts physical needs and the family is
responsible for the patientts emotional needs.
Ans:A
37. A 60-year-old patient with a diagnosis of prostate cancer is scheduled to have an interstitial implant for highdose radiation (HDR). What safety measure should the nurse include in this patientts subsequent plan of care?
A) Limit the time that visitors spend at the patientts bedside.
B) Teach the patient to perform all aspects of basic care independently.
C) Assign male nurses to the patientts care whenever possible.
D) Situate the patient in a shared room with other patients receiving brachytherapy.
Ans:A
38. An oncology patient has begun to experience skin reactions to radiation therapy, prompting the nurse to make
the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses
this nursing diagnosis?
A) Apply an ice pack or heating pad PRN to relieve pain and pruritis
B) Avoid skin contact with water whenever possible
C) Apply phototherapy PRN
D) Avoid rubbing or scratching the affected area
Ans:D
39. A patient with a diagnosis of gastric cancer has been unable to tolerate oral food and fluid intake and her tumor
location precludes the use of enteral feeding. What intervention should the nurse identify as best meeting this
patientts nutritional needs?
A) Administration of parenteral feeds via a peripheral IV
B) TPN administered via a peripherally inserted central catheter
C) Insertion of an NG tube for administration of feeds
D) Maintaining NPO status and IV hydration until treatment completion
Ans:B
40. An oncology nurse is contributing to the care of a patient who has failed to respond appreciably to conventional
cancer treatments. As a result, the care team is considering the possible use of biologic response modifiers (BRFs).
The nurse should know that these achieve a therapeutic effect by what means?
A) Promoting the synthesis and release of leukocytes
B) Focusing the patientts immune system exclusively on the tumor
C) Potentiating the effects of chemotherapeutic agents and radiation therapy
D) Altering the immunologic relationship between the tumor and the patient
Ans:D
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Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 13: Palliative and End-of-Life Care
During admission of a patient diagnosed with metastatic lung cancer, what should the nurse assess for as a key
indicator of clinical depression related to terminal illness?
A. Frustration with pain
B. Anorexia and nausea
C. Feelings of hopelessness
D. Inability to carry out ADLts
Answer: C. Feelings of hopelessness
Rationale: Feelings of hopelessness are likely to present in a patient with a terminal illness who has clinical depression.
This can be attributed to lack of control over the disease process or outcome. The nurse should routinely assess for
depression when working with patients with terminal illness
A patient with terminal cancer tells the nurse, "I know i am going to die pretty soon, perhaps in the next month."
What is the most appropriate response by the nurse?
A; "What are your feelings about being so sick and thinking you may die soon?"
B. "None of us know when we are going to die. Is this particularly difficult day?"
C."Would you like for me to call your spiritual advisor so you can talk about your feelings?"
D."Perhaps you are depress about your illness. I will speak to the doctor about getting some medications for you."
Answer: A "What are your feelings about being sick and thinking you may die soon?"
Rationale: The most appropriate response to psychosocial questions is to acknowledge the patient's feelings and explore
his or her concerns. This option does both and is a helpful response that encourages further communication between the
patient and nurse.
The nurse is caring for a patient who has been admitted to the hospital while receiving home hospice care. The
nurse interprets that a patient has a general prognosis of
?
A. 3 months or less to live
B. 6 months or less to live
C. 12 months or less to live
D. 18 months or less to live
Answer: B. 6 months or less to live
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Rationale: There are two criteria to be eligible for hospice care. The first is that the patient wishes to receive hospice, not
curative care, and the second is that the physician certifies that the patient has a prognosis of 6 months or less to live.
A patient has been receiving palliative care for the past several weeks in light of her worsening condition following
a series of strokes. The caregiver has rung the call bell, stating that the patient now tstops breathing for a while,
then breaths fast and hard, and then stops again." What should the nurse recognize that the patient is
experiencing?
A. Apnea
B. Bradypnea
C. Death rattle
D. Cheyne-stokes respirations
Answer: D Cheyne-stokes respirations
Which aspects of anticipatory grief are associated with positive outcomes for the caregiver of a palliative patient
(Select all that apply)?
A. Strong spiritual beliefs
B. Medical diagnosis of the patient
C. Advanced age of the patient
D. Acceptance of the expected death of the patient
E. Adequate time for the caregiver to prepare for the death
Answer: A, D, & E. Strong spiritual beliefs, acceptance of the expected death of the patient, and adequate time for the
caregiver to prepare for the death.
Rationale: Acceptance of an impending loss, spiritual beliefs, and adequate preparation time are all associated with
positive outcomes regarding anticipatory grief. The age and diagnosis of the patient are not key factors in influencing the
quality of the anticipatory grief of the caregiver.
A man died at the age of 71 following a myocardial infarction that he experienced while performing yard work. What
would indicate that his wife is experiencing prolonged grief disorder?
A. Initially she denied that he died.
B. Talking about her husband extensively in year following his death.
C. Stating that she expects him home soon on the anniversary of his death.
D. Crying uncontrollably and unpredictably in the weeks following her husbandst death
Answer: C. Stating that she expects hime home soon on the anniversary of his death.
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Rationale: Denial of an individual's death that persists beyond 6 months is indicative of prolonged grief disorder. Strong
emotions or denial immediately following death are considered to be expected responses, and talking about the deceased
loved one is not considered to be evidence of the disorder.
How should the nurse provide appropriate cultural and spiritual care for the patient and family to best be able to
help them when nearing the end of the patientts life?
A. Assess the individual patentts wishes
B. Call a pastor or priest for the family to help them cope.
C. Assess the beliefs and preferences of the patient and family
D. Do not insult African Americans by suggesting hospice care.
Answer: C Assess the beliefs and preferences of the patient and family.
Rationale: Differences among spiritual and culture beliefs and values related to death and dying are innumerable. The
individual patient and family must be assessed to avoid stereotyping individuals with different spiritual and cultural belief
systems.
When the nurse assesses the patient, what manifestation indicates to the nurse that the patient is very near death?
A. The patient responds to noises
B. The patientts skin is mottled and waxlike.
C. The hear rate and blood pressure increase.
D. The patient is reviewing his life with his family.
Answer: B. The patient's skin is mottled and waxlike.
Rationale: When a patient is very near death, the skin will be waxlike, cold, clammy, and mottled or cyanotic. Although
hearing is the last sense patients lose before death, it is unlikely that they will be responding to noises when very near
death. Initially the heart rate increases, but later slows and the blood pressure decreases. Near death, speaking may be
slow and unusual and indicate confusion.
When going to the hospital, which forms should patients be taught to bring with them in case of end-of-life care
becomes an ethical or legal issue?
A. Euthanasia
B. Organ donor card
C. Advance directives
D. Do not resuscitate (DNR)
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Answer: C. Advanced directives
Rationale: I'm not writing the rationale for this pretty self explanatory
The dying patient is experiencing confusion, restlessness, and skin breakdown. What nursing interventions will
BEST meet this patientts needs?
A. Encourage more physical activity
B. Asses for pain, constipation, and urinary retention.
C. Assess for spiritual distress and restrain in varying positions.
D. Assess for quality, intensity, location, and contributing factors of discomfort.
Answer: B Assess for pain, constipation, and urinary retention.
Rationale: Assessing for reversible causes of delirium (pain, constipation, urinary retention, dyspnea, sensory
hyperstimulaiton) so they can be reversed may help decrease confusion and restlessness. Encouraging more physical
activity may prevent further skin breakdown, but it will be difficult as weakness and fatigue are expected at the end of life.
Keeping the skin clean and dry and preventing shearing forces will better avoid further skin breakdown. Spiritual distress
may be cause of restlessness, but the patient should not be restrained.
Chapter 10 Book Questions
Page: 152
1. An 80 -year-old female patient is receiving palliative care for heart failure. Primary purpose(s) of her receiving
palliative care is (are) to (select all that apply)
A. Improve her quality of life
B. Assess her coping ability with disease
C. Have time to teach patient and family about disease.
D. Focus on reducing the severity of disease symptoms
E. Provide comfort and support for dying patients and their families.
Answer: A & D
Improve her quality of life & Provide comfort and support for dying patients and their families.
2. The primary purpose of hospice is to:
A. Allow patients to die at home
B. Provide better quality of care than the family can.
C. Coordinate care for dying patients and their families.
D. Provide comfort and support for dying patients and their families
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Answer: D
Provide comfort and support for dying patients and their families.
3. A 67-year-old woman was recently diagnosed with inoperable pancreatic cancer. Before the diagnosis she was
very active in her neighborhood association. Her husband is concerned because his wife is staying at home and
missing her usual community activities. Which common EOL psychologic manifestation is she most likely
demonstrating?
A. Peacefulness
B. Decreased socialization
C. Decreased decision making
D. Anxiety about unfinished business.
Answer: B
Decreased socialization
4. For the past 5 years Tom has repeatedly asked his mother to donate his deceased fatherts belongings to charity,
but his mother has refused. She sits in the bedroom closet, crying and talking to her long-dead husband. What type
of grief is Tomts mother experiencing?
A. Adaptive grief
B. Disruptive greif
C. Anticipatory grief
D. Prolonged grief disorder.
Answer: D
Prolonged grief disorder
5. The home health nurse visits a 40-year-old patient with metastatic breast cancer who is receiving palliative care.
The patient is experiencing pain at a level of 7 (on a 10-point scale). In prioritizing activities for the visit, the nurse
would do which first?
A. Auscultate for breath sounds.
B. Administer PRN pain medication
C. Check pressure points for skin breakdowns.
D. Ask family about patientts food and fluid intake.
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Answer: B
Administer PRN pain medication.
6. While caring for his dying wife, the husband states that his wife is a devout Roman Catholic but he is a Baptist.
Who is considered the most reliable source for spiritual preferences concerning EOL care for the dying wife?
A. A preist
B. Dying wife
C. Hospice staff
D Husband of dying wife.
Answer: B
Dying wife
7. The family attorney informed a patientts adult children and wife that the patient did not have advance directive
after he suffered as serious stroke. Who is responsible for making the decision about EOL measures when the
patient cannot communicate his or her specific wishes?
A. Notary and attorney
B. Physician and family
C. Wife and adult children
D. Physician and nursing staff
Answer: C
Wife and adult children
8. The children caregivers of an elderly patient whose death is imminent have not left the beside for hte past
Answer: A & C
A family cannot express their feelings to one another & A family member is going through a difficult divorce.
9. A nurse has been working full time with terminally ill patients for 3 years. He has been experiencing irritability
and mixed emotions when expressing sadness since four of his patients died on the same day. To optimize the
quality of his nursing care, he should examine his own.
A. Full-time work schedule
B. Past feelings toward death
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C. Patterns for dealing with grief
D. Demands for involvement in patient care.
Answer: C
Patterns for dealings with grief.
Chapter 16 Book Questions
Pages: 282-283
1. Trends in the incidence and death rates of cancer include the fact that...
A. Lung cancer is the most common type of cancer in men
B. A higher percentage of women than men have lung cancer.
C. Breast cancer is the leading cause of cancer deaths in women.
D. African Americans have a higher death rate from cancer than whites
Answer: D
African Americans have a higher death rate from cancer than whites
2. What features of cancer cells distinguish them form normal cells (select all that apply?
A. Cells lack contact inhibition
B. Cells return to previous undifferentiated state
C. Oncogenes maintain normal cell expression.
D. Proliferation occurs when there is a need for more cell
E. New proteins characteristic of embryonic stage emerge on cell membrane.
Answer: A. B. E
Cells lack contact inhibition
Cells return to a previous undifferentiated state
New proteins characteristics of embryonic stage emerge on cell membrane
3. A characteristic of the stage of progression in the development of cancer is
A. Oncogenic viral transformation of target cells
B. A reversible steady growth facilitated by carcinogens.
C. A period of latency before clinical detection of cancer.
D. Proliferation of cancer cells in spite of host control mechanisms
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Answer: D
Proliferation of cancer cells in spite of host control mechanisms
5. The primary differences between benign and malignant neoplasms is the
A. rate of cell proliferation
B. Site of malignant tumor
C. Requirements of cell nutrients.
D. Characteristics of tissue invasiveness.
Answer: D
Characteristics of tissue invasiveness
6. The nurse is caring for a 59-year-old woman who had surgery 1 day for removal of suspected malignant
abdominal mass. The patient is awaiting the pathology report. She is tearful and says that she is scared to die. The
most effective nursing intervention at this point is to use this opportunity to.
A. Motivate change in an unhealthy lifestyle
B. Teach her about the seven warning signs of cancer.
C. Instruct her about healthy stress relief and coping practices
D. Allow her to communicate about the meaning of this experience.
Answer: B
Teacher her about the seven warning signs of cancer.
7. The goals of cancer treatment are based on the principle that
A. Surgery is the single most effective treatment for cancer.
B. Initial treatment is always directed toward cure of the cancer.
C. A combination of treatment modalities is effective for controlling many cancers.
D. Although cancer cure is rare, quality of life can be increased with treatment modalities.
Answer: C
A combination of treatment modalities is effective for controlling many cancers.
8. The most effective method of administering a chemotherapy agent that is a vesicant is to
A. Give it orally
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B. Give intrarterially
C. Use an Ommaya reservoir.
D. Use a central venous access device.
Answer: D
Use a central venous access device
10. A patient on chemotherapy and radiation for head and neck cancer has a WBC count of 1.9 x 10^3 uL. Based on
the CBC results, what is the most serious clinical finding?
A. Cough, rhinitis, and sore throat
B. Fatigue, nausea, and skin redness at site of radiation
C. Temperature of 101.9 F, fatigue, and shortness of breath
D. Skin redness at site of radiation, headache. and constipation
Answer: C
Temperature of 101.9 F, fatigue, and shortness of breath
9. The nurse explains to a patient undergoing brachytherapy of the cervix that she
A. Must undergo simulation to locate the treatment area.
B. Requires the use of radioactive precautions during nursing care.
C. May experience desquamation of the skin on the abdomen and upper legs.
D. Requires shielding of the ovaries during treatment ot prevent ovarian damage.
Answer: B
Requires the use of radioactive precautions during nursing care.
11. To prevent fever fever and shivering during an infusion of rituximab (Rituxan), the nurse should premedicate the
patient with
A. Aspirin.
B. Acetaminophen
C. Sodium Bicarbonate
D. memeridine (Demerol)
Answer: B
Acetaminophen
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12. The nurse counsels the patient receiving radiation therapy or chemotherapy that
A. Effective birth control methods should be used for the rest of the patientts life
B. If nausea and vomiting occur during treatment, the treatment plan will be modified.
C. After successful treatment, a return to the personts previous functional level can be expected.
D. The cycle of fatigue-depression-fatigue that may occur during treatment can be reduced by restricting activity.
Answer: C
After successful treatment, a return to the person's previous functional level can be expected.
13. A patient on chemotherapy for 10 weeks started at a weight of 121 lb. She now weighs 118 lb and has no sense
of taste. Which nursing intervention would be a priority?
A. Advise the patient to eat foods that are fatty, fried, or high in calories
B. Discuss with the physician the need for parenteral or enteral feedings.
C. Advise the patient to drink a nutritional supplement beverage at least three times a day.
D. Advise the patient to experiment with spices and seasonings to enhance the flavor of food.
Answer: D
Advise the patient to experiment with spices and seasonings to enhance the flavor of food
14. A 70-year-old male patient has multiple myeloma. His wife calls to report that he sleeps most of the day, is
confused when awake, and complains of nausea and constipation. Which complication of cancer is the most likely
caused by?
A. Hypercalcemia
B. Tumor lysis syndrome
C. Spinal cord compression
D. Superior vena cava syndrome
Answer: A
Hypercalcemia
15. A patient has recently been diagnosed with early stages of breast cancer. What is most appropriate for the
nurse to focus on?
A. Maintaining the patientts hope
B. Preparing a will and advance directives
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C. Discussing replacement child care for the patientts children
D. Discussing the patientts past experiences with her grandmotherts cancer.
Answer: A
Maintaining the patient's hope.
Chapter 16 Evolve Questions Online
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The nurse is teaching a wellness class to a group of women at their workplace. The nurse knows that which woman
is at highest risk for developing cancer?
A. A woman who obtains regular cancer screenings and consumes a high-fiber diet
B. A woman who has a body mass index of 35 kg/m2 and smoked cigarettes for 20 years Correct
C. A woman who exercises five times every week and does not consume alcoholic beverages
D. A woman who limits fat consumption and has regular mammography and Pap screenings
Answer: B
A woman who has a body mass index of 35 kg/m2 and smoked cigarettes for 20 years Correct
Cancer prevention and early detection are associated with the following behaviors: limited alcohol use; regular physical
activity; maintaining a normal body weight; obtaining regular cancer screenings; avoiding cigarette smoking and other
tobacco use; using sunscreen with SPF 15 or higher; and practicing healthy dietary habits (e.g., reduced fat and
increased fruits and vegetables).
The nurse is caring for an 18-year-old female patient with acute lymphocytic leukemia who is scheduled to receive
hematopoietic stem cell transplantation (HSCT). Which statement, if made by the patient, indicates a correct
understanding of the procedure?
A. "After the transplant I will feel better and can go home in 5 to 7 days."
B. "I understand the transplant procedure has no dangerous side effects."
C. "My brother will be a 100% match for the cells used during the transplant."
D. "Before the transplant I will have chemotherapy and possibly full body radiation."
Answer: D
"Before the transplant I will have chemotherapy and possibly full body radiation."
Hematopoietic stem cell transplantation (HSCT) requires eradication of diseased or cancer cells. This is accomplished by
administering higher-than-usual dosages of chemotherapy with or without radiation therapy. A relative such as a brother
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would not be a perfect match with human leukocyte antigens; only identical twins are an exact match. HSCT is an
intensive procedure with adverse effects and possible death. HSCT recipients can expect a 2- to 4-week hospitalization
after the transplant.
The nurse assesses a 76-year-old man with chronic myeloid leukemia receiving nilotinib (Tasigna). It is most
important for the nurse to ask which question?
A. "Have you had a fever?"
B. "Have you lost any weight?"
C. "Has diarrhea been a problem?"
D. "Have you noticed any hair loss?"
Answer: A "Have you had a fever?"
An adverse effect of nilotinib is neutropenia. Infection is common in neutropenic patients and is the primary cause of
death in cancer patients. Patients should report a temperature of 100.4 F or higher. Other adverse effects of nilotinib are
thrombocytopenia, bleeding, nausea, fatigue, elevated lipase level, fever, rash, pruritus, diarrhea, and pneumonia.
A 64-year-old male patient who is receiving radiation to the head and neck as treatment for an invasive malignant
tumor complains of mouth sores and pain. Which intervention should the nurse add to this patientts plan of care?
A. Weigh the patient every month to monitor for weight loss.
B. Cleanse the mouth every 2 to 4 hours with hydrogen peroxide.
C. Provide high-protein and high-calorie, soft foods every 2 hours.
D. Apply palifermin (Kepivance) liberally to the affected oral mucosa.
Answer: C Provide high-protein and high-calorie, soft foods every 2 hours.
A patient with stomatitis should have soft, nonirritating foods offered frequently. The diet should be high in protein and
high in calories. Saline or water should be used to cleanse the mouth (not hydrogen peroxide). Palifermin is administered
intravenously as a growth factor to stimulate cells on the surface layer of the mouth to grow. Patients should be weighed
at least twice each week to monitor for weight loss.
A 70-year-old man who has end-stage lung cancer is admitted to the hospital with confusion and oliguria for 2 days.
Which finding would the nurse report immediately to the health care provider?
A. Weight gain of 2 lb
B. Urine specific gravity of 1.015
C. Blood urea nitrogen of 20 mg/dL
D. Serum sodium level of 118 mEq/L
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Answer: D Serum sodium level of 118 mEq/L
Lung cancer cells are able to manufacture and release antidiuretic hormone (ADH) with resultant water retention and
hyponatremia. Hyponatremia (serum sodium levels less than 135 mEq/L) may lead to central nervous system symptoms
such as confusion, seizures, coma, and death. A weight gain may be due to fluid retention. The urine specific gravity and
blood urea nitrogen are normal.
The nurse is caring for a patient receiving an initial dose of chemotherapy to treat a rapidly growing metastatic
colon cancer. The nurse is aware that this patient is at risk for tumor lysis syndrome (TLS) and will monitor the
patient closely for which abnormality associated with this oncologic emergency?
A. Hypokalemia
B Hypouricemia
C. Hypocalcemia
D. Hypophosphatemia
Answer: C. Hypocalcemia
TLS is a metabolic complication characterized by rapid release of intracellular components in response to chemotherapy.
This can rapidly lead to acute renal injury. The hallmark signs of TLS are hyperuricemia, hyperphosphatemia,
hyperkalemia, and hypocalcemia.
The nurse is caring for a patient suffering from anorexia secondary to chemotherapy. Which strategy would be
most appropriate for the nurse to use to increase the patientts nutritional intake?
A. Increase intake of liquids at mealtime to stimulate the appetite.
B. Serve three large meals per day plus snacks between each meal.
C. Avoid the use of liquid protein supplements to encourage eating at mealtime.
D Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods
Answer: D Add items such as skim milk powder, cheese, honey, or peanut butter to selected foods
The nurse can increase the nutritional density of foods by adding items high in protein and/or calories (such as peanut
butter, skim milk powder, cheese, honey, or brown sugar) to foods the patient will eat. Increasing fluid intake at mealtime
fills the stomach with fluid and decreases the desire to eat. Small frequent meals are best tolerated. Supplements can be
helpful.
Which item would be most beneficial when providing oral care to a patient with metastatic cancer who is at risk for
oral tissue injury secondary to chemotherapy?
A. Firm-bristle toothbrush
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B. Hydrogen peroxide rinse
C. Alcohol-based mouthwash
D. 1 tsp salt in 1 L water mouth rinse
Answer: D. 1 tsp in 1 L of water mouth rinse
A salt-water mouth rinse will not cause further irritation to oral tissue that is fragile because of mucositis, which is a side
effect of chemotherapy. A soft-bristle toothbrush will be used. One teaspoon of sodium bicarbonate may be added to the
salt-water solution to decrease odor, alleviate pain, and dissolve mucin. Hydrogen peroxide and alcohol-based mouthwash
are not used because they would damage the oral tissue.
Which nursing diagnosis is most appropriate for a patient experiencing myelosuppression secondary to
chemotherapy for cancer treatment?
A. Acute pain
B. Hypothermia
C. Powerlessness
D. Risk for infection
Answer: D Risk for Infection
Myelosuppression is accompanied by a high risk of infection and sepsis. Hypothermia, powerlessness, and acute pain are
also possible nursing diagnoses for patients undergoing chemotherapy, but the threat of infection is paramount.
Previous administrations of chemotherapy agents to a cancer patient have resulted in diarrhea. Which dietary
modification should the nurse recommend?
A. A bland, low-fiber diet
B. A high-protein, high-calorie diet
C. A diet high in fresh fruits and vegetables
D. A diet emphasizing whole and organic foods
Answer: A Bland, low-fiber diet
Patients experiencing diarrhea secondary to chemotherapy and/or radiation therapy often benefit from a diet low in
seasonings and roughage before the treatment. Foods should be easy to digest and low in fat. Fresh fruits and
vegetables are high in fiber and should be minimized during treatment. Whole and organic foods do not prevent diarrhea.
A 33-year-old patient has recently been diagnosed with stage II cervical cancer. What should the nurse understand
about the patientts cancer?
A It is in situ.
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B It has metastasized.
C It has spread locally.
D It has spread extensively.
Answer: C It has spread locally
Stage II cancer is associated with limited local spread. Stage 0 denotes cancer in situ; stage I denotes tumor limited to
the tissue of origin with localized tumor growth. Stage III denotes extensive local and regional spread. Stage IV denotes
metastasis.
Which cellular dysfunction in the process of cancer development allows defective cell proliferation?
A Proto-oncogenes
B Cell differentiation
C Dynamic equilibrium
D Activation of oncogenes
Answer: C Dynamic equilibrium
Dynamic equilibrium is the regulation of proliferation that usually only occurs to equal cell degeneration or death or when
the body has a physiologic need for more cells. Cell differentiation is the orderly process that progresses a cell from a
state of immaturity to a state of differentiated maturity. Mutations that alter the expression of proto-oncogenes can activate
them to function as oncogenes, which are tumor-inducing genes and alter their differentiation.
What can the nurse do to facilitate cancer prevention for the patient in the promotion stage of cancer development?
Teach the patient to exercise daily.
Teach the patient promoting factors to avoid.
Tell the patient to have the cancer surgically removed now.
Teach the patient which vitamins will improve the immune system.
Answer: Teach the patient promoting factors to avoid.
The promotion stage of cancer is characterized by the reversible proliferation of the altered cells. Changing the lifestyle to
avoid promoting factors (dietary fat, obesity, cigarette smoking, and alcohol consumption) can reduce the chance of
cancer development. Daily exercise and vitamins alone will not prevent cancer. Surgery at this stage may not be possible
without a critical mass of cells, and this advice would not be the nurse's role.
A patient has been diagnosed with Burkittts lymphoma. In the initiation stage of cancer, the cells genetic structure
is mutated. Exposure to what may have functioned as a carcinogen for this patient?
Bacteria
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Sun exposure
Most chemicals
Epstein-Barr virus
Answer: Epstein-Barr virus
Burkitt's lymphoma consistently shows evidence of the presence of Epstein-Barr virus in vitro. Bacteria do not initiate
cancer. Sun exposure causes cell alterations leading to melanoma and squamous and basal cell skin carcinoma. Longterm exposure to certain chemicals (e.g., ethylene oxide, chloroform, benzene) is known to initiate cancer.
When caring for the patient with cancer, what does the nurse understand as the response of the immune system to
antigens of the malignant cells?
Metastasis
Tumor angiogenesis
Immunologic escape
Immunologic surveillance
Answer: Immunologic surveillance
Immunologic surveillance is the process where lymphocytes check cell surface antigens and detect and destroy cells with
abnormal or altered antigenic determinants to prevent these cells from developing into clinically detectable tumors.
Metastasis is increased growth rate of the tumor, increased invasiveness, and spread of the cancer to a distant site in the
progression stage of cancer development. Tumor angiogenesis is the process of blood vessels forming within the tumor
itself. Immunologic escape is the cancer cells' evasion of immunologic surveillance that allows the cancer cells to
reproduce.
The patient is told that the adenoma tumor is not encapsulated but has normally differentiated cells and that
surgery will be needed. The patient asks the nurse what this means. What should the nurse tell the patient?
It will recur.
It has metastasized.
It is probably benign.
It is probably malignant.
Answer: It is probably bengin
Benign tumors usually are encapsulated and have normally differentiated cells. They do not metastasize and rarely recur
as malignant tumors do.
The laboratory reports that the cells from the patientts tumor biopsy are Grade II. What should the nurse know
about this histologic grading?
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Cells are abnormal and moderately differentiated.
Cells are very abnormal and poorly differentiated.
Cells are immature, primitive, and undifferentiated.
Cells differ slightly from normal cells and are well-differentiated.
Answer: Cells are abnormal and moderately differentiated.
Grade II cells are more abnormal than Grade I and moderately differentiated. Grade I cells differ slightly from normal cells
and are well-differentiated. Grade III cells are very abnormal and poorly differentiated. Grade IV cells are immature,
primitive, and undifferentiated; the cell origin is difficult to determine.
The patient and his family are upset that the patient is going through procedures to diagnose cancer. What nursing
actions should the nurse use first to facilitate their coping with this situation (select all that apply)?
Maintain hope.
Exhibit a caring attitude.
Plan realistic long-term goals.
Give them antianxiety medications.
Be available to listen to fears and concerns.
Teach them about all the types of cancer that could be diagnosed.
Answer: Maintain hope, exhibit a caring attitude, & be available to listen to fears and concerns.
Maintaining hope, exhibiting a caring attitude, and being available to actively listen to fears and concerns would be the
first nursing interventions to use as well as assessing factors affecting coping during the diagnostic period. Providing relief
from distressing symptoms for the patient and teaching them about the diagnostic procedures would also be important.
Realistic long-term goals and teaching about the type of cancer cannot be done until the cancer is diagnosed. Giving the
family antianxiety medications would not be appropriate.
The patient with breast cancer is having teletherapy radiation treatments after her surgery. What should the nurse
teach the patient about the care of her skin?
Use Dial soap to feel clean and fresh.
Scented lotion can be used on the area.
Avoid heat and cold to the treatment area.
Wear the new bra to comfort and support the area.
Answer: Avoid heat and cold to the treatment area
Avoiding heat and cold in the treatment area will protect it. Only mild soap and unscented, nonmedicated lotions may be
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used to prevent skin damage. The patient will want to avoid wearing tight-fitting clothing such as a bra over the treatment
field and will want to expose the area to air as often as possible.
The female patient is having whole brain radiation for brain metastasis. She is concerned about how she will look
when she loses her hair. What is the best response by the nurse to this patient?
"When your hair grows back it will be patchy."
"Dontt use your curling iron and that will slow down the loss."
"You can get a wig now to match your hair so you will not look different."
"You should contact "Look Good, Feel Better" to figure out what to do about this."
Answer: "You can get a wig now to match your hair so you will not look different."
Hair loss with radiation is usually permanent. The best response by the nurse is to suggest getting a wig before she loses
her hair so she will not look or feel so different. When hair grows back after chemotherapy, it is frequently a different color
or texture. Avoiding use of electric hair dryers, curlers, and curling irons may slow the hair loss but will not answer the
patient's concern. The American Cancer Society's "Look Good, Feel Better" program will be helpful, but this response is
avoiding the patient's immediate concern.
The patient is receiving biologic and targeted therapy for ovarian cancer. What medication should the nurse expect
to administer before therapy to combat the most common side effects of these medications?
Morphine sulfate
Ibuprofen (Advil)
Ondansetron (Zofran)
Acetaminophen (Tylenol)
Answer: Acetaminophen (Tylenol)
Acetaminophen is administered before therapy and every 4 hours to prevent or decrease the intensity of the severe flulike symptoms, especially with interferon which is frequently used for ovarian cancer. Morphine sulfate and ibuprofen will
not decrease flu-like symptoms. Ondansetron is an antiemetic, but not used first to combat flu-like symptoms of headache,
fever, chills, myalgias, etc.
The patient is receiving an IV vesicant chemotherapy drug. The nurse notices swelling and redness at the site. What
should the nurse do first?
Ask the patient if the site hurts.
Turn off the chemotherapy infusion.
Call the ordering health care provider.
Administer sterile saline to the reddened area.
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Answer: Turn of the chemotherapy
Because extravasation of vesicants may cause severe local tissue breakdown and necrosis, with any sign of extravasation
the infusion should first be stopped. Then the protocol for the drug-specific extravasation procedures should be followed to
minimize further tissue damage. The site of extravasation usually hurts, but it may not. It is more important to stop the
infusion immediately. The health care provider may be notified by another nurse while the patient's nurse starts the drugspecific extravasation procedures, which may or may not include sterile saline.
The patient was told that he would have intraperitoneal chemotherapy. He asks the nurse when the IV will be started
for the chemotherapy. What should the nurse teach the patient about this type of chemotherapy delivery?
It is delivered via an Ommaya reservoir and extension catheter.
It is instilled in the bladder via a urinary catheter and retained for 1 to 3 hours.
A Silastic catheter will be percutaneously placed into the peritoneal cavity for chemotherapy administration.
The arteries supplying the tumor are accessed with surgical placement of a catheter connected to an infusion
pump.
Answer: A Silastic catheter will be percutaneously placed into the peritoneal cavity for chemotherapy administration.
Intraperitoneal chemotherapy is delivered to the peritoneal cavity via a temporary percutaneously inserted Silastic catheter
and drained from this catheter after the dwell time in the peritoneum. The Ommaya reservoir is used for intraventricular
chemotherapy. Intravesical bladder chemotherapy is delivered via a urinary catheter. Intraarterial chemotherapy is
delivered via a surgically placed catheter that delivers chemotherapy via an external or internal infusion pump.
The patient is being treated with brachytherapy for cervical cancer. What factors must the nurse be aware
The medications the patient is taking
The nutritional supplements that will help the patient
How much time is needed to provide the patientts care
The time the nurse spends at what distance from the patient
Answer: The time the nurse spends at what distance from the patient
The principles of ALARA (as low as reasonably achievable) and time, distance, and shielding are essential to maintain the
nurse's safety when the patient is a source of internal radiation. The patient's medications, nutritional supplements, and
time needed to complete care will not protect the nurse caring for a patient with brachytherapy for cervical cancer.
The patient has osteosarcoma of the right leg. The unlicensed assistive personnel (UAP) reports that the patientts
vital signs are normal, but the patient says he still has pain in his leg and it is getting worse. What assessment
question should the nurse ask the patient to determine treatment measures for this patientts pain?
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"Where is the pain?"
"Is the pain getting worse?"
"What does the pain feel like?"
"Do you use medications to relieve the pain?"
Answer: "What does the pain feel like"
The unlicensed assistive personnel (UAP) told the nurse the location of the patient's pain and the worsening of pain
(pattern). Asking about the quality of the pain will help in planning further treatment. The nurse should already know if the
patient is using medication to relieve the pain or can check the patient's medication administration record to see if
analgesics have been administered. The intensity of pain using a pain scale should also be assessed.
The patient has been diagnosed with non-small cell lung cancer. Which type of targeted therapy will most likely be
used for this patient to suppress cell proliferation and promote programmed tumor cell death?
Proteasome inhibitors
BCR-ABL tyrosine kinase inhibitors
CD20 monoclonal antibodies (MoAb)
Epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TK)
Answer: Epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TK)
Targeted therapies are more selective for specific molecular targets. Thus they are able to kill cancer cells with less
damage to normal cells than with chemotherapy. Epidermal growth factor receptor (EGFR) is a transmembrane molecule
that works through activation of intracellular tyrosine kinase (TK) to suppress cell proliferation and promote apoptosis of
non-small cell lung cancer and some colorectal, head and neck, and metastatic breast cancers. Proteasome inhibitors
promote accumulation of proteins that promote tumor cell death for multiple myeloma. BCR-ABL tyrosine kinase inhibitors
target specific oncogenes for chronic myeloid leukemia and some GI stromal tumors. CD20 monoclonal antibodies (MoAb)
bind with CD20 antigen causing cytotoxicity in non-Hodgkin's lymphoma and chronic lymphocytic leukemia.
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UNIT 3 Perioperative Concepts and Nursing Management
Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 14: Preoperative Nursing Management
A patient is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting
coffee-ground like emesis. The patient is diagnosed with a perforated gastric ulcer and is informed that
he needs surgery. When can the patient most likely anticipate that the surgery will be scheduled?
A) Within 24 hours
B) Within the next week
C) Without delay because the bleed is emergent
D) As soon as all the days elective surgeries have been completed
Ans: C
Feedback:
Emergency surgeries are unplanned and occur with little time for preparation for the patient or the
perioperative team. An active bleed is considered an emergency, and the patient requires immediate
attention because the disorder may be life threatening. The surgery would not likely be deferred until
after elective surgeries have been completed.
The nurse is performing a preoperative assessment on a patient going to surgery. The patient informs the
nurse that he drinks approximately two bottles of wine each day and has for the last several years. What
postoperative difficulties can the nurse anticipate for this patient?
A) Alcohol withdrawal syndrome immediately following surgery
B) Alcohol withdrawal syndrome 2 to 4 days after his last alcohol drink
C) Alcohol withdrawal syndrome upon administration of general anesthesia
D) Alcohol withdrawal syndrome 1 week after his last alcohol drink
Ans: B
Feedback:
Alcohol withdrawal syndrome may be anticipated between 48 and 96 hours after alcohol withdrawal and
is associated with a significant mortality rate when it occurs postoperatively.
In anticipation of a patients scheduled surgery, the nurse is teaching her to perform deep breathing and
coughing to use postoperatively. What action should the nurse teach the patient?
A) The patient should take three deep breaths and cough hard three times, at least every 15 minutes for
the immediately postoperative period.
B) The patient should take three deep breaths and exhale forcefully and then take a quick short breath
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and cough from deep in the lungs.
C) The patient should take a deep breath in through the mouth and exhale through the mouth, take a
short breath, and cough from deep in the lungs.
D) The patient should rapidly inhale, hold for 30 seconds or as long as possible, and exhale slowly.
Ans: C
Feedback:
The patient assumes a sitting position to enhance lung expansion. The nurse then demonstrates how to
take a deep, slow breath and how to exhale slowly. After practicing deep breathing several times, the
patient is instructed to breathe deeply, exhale through the mouth, take a short breath, and cough from
deep in the lungs.
The nurse is preparing a patient for surgery prior to her hysterectomy without oophorectomy. The nurse
is witnessing the patients signature on a consent form. Which comment by the patient would best
indicate informed consent?
A) I know Ill be fine because the physician said he has done this procedure hundreds of times.
B) I know Ill have pain after the surgery but theyll do their best to keep it to a minimum.
C) The physician is going to remove my uterus and told me about the risk of bleeding.
D) Because the physician isnt taking my ovaries, Ill still be able to have children.
Ans: C
Feedback:
The surgeon must inform the patient of the benefits, alternatives, possible risks, complications,
disfigurement, disability, and removal of body parts as well as what to expect in the early and late
postoperative periods. The nurse clarifies the information provided, and, if the patient requests additional
information, the nurse notifies the physician. In the correct response, the patient is able to tell the nurse
what will occur during the procedure and the associated risks. This indicates the patient has a sufficient
understanding of the procedure to provide informed consent. Clarification of information given may be
necessary, but no additional information should be given. The other listed statements do not reflect an
understanding of the surgery to be performed.
The nurse is planning patient teaching for a patient who is scheduled for an open hemicolectomy. The
nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is
the best time for the nurse to provide teaching?
A) Upon the patients admission to the postanesthesia care unit (PACU)
B) When the patient returns from the PACU
C) During the intraoperative period
D) As soon as possible before the surgical procedure
Ans: D
Feedback:
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Teaching is most effective when provided before surgery. Preoperative teaching is initiated as soon as
possible, beginning in the physicians office, clinic, or at the time of preadmission testing when
diagnostic tests are performed. Upon admission to the PACU, the patient is usually drowsy, making this
an inopportune time for teaching. Upon the patients return from the PACU, the patient may remain
drowsy. During the intraoperative period, anesthesia alters the patients mental status, rendering teaching
ineffective.
6. The nurse is caring for a hospice patient who is scheduled for a surgical procedure to reduce the size of
his spinal tumor in an effort to relieve his pain. The nurse should plan this patient care with the
knowledge that his surgical procedure is classified as which of the following?
A) Diagnostic
B) Laparoscopic
C) Curative
D) Palliative
Ans: D
Feedback:
A patient on hospice will undergo a surgical procedure only for palliative care to reduce pain, but it is
not curative. The reduction of tumor size to relieve pain is considered a palliative procedure. A
laparoscopic procedure is a type of surgery that is utilized for diagnostic purposes or for repair. The
excision of a tumor is classified as curative. This patient is not having the tumor removed, only the size
reduced.
7. A nurse is providing preoperative teaching to a patient who will soon undergo a cardiac bypass. The
nurses teaching plan includes exercises of the extremities. What is the purpose of teaching a patient leg
exercises prior to surgery?
A) Leg exercises increase the patients muscle mass postoperatively.
B) Leg exercises improve circulation and prevent venous thrombosis.
C) Leg exercises help to prevent pressure sores to the sacrum and heels.
D) Leg exercise help increase the patients level of consciousness after surgery.
Ans: B
Feedback:
Exercise of the extremities includes extension and flexion of the knee and hip joints (similar to bicycle
riding while lying on the side) unless contraindicated by type of surgical procedure (e.g., hip
replacement). When the patient does leg exercises postoperatively, circulation is increased, which helps
to prevent blood clots from forming. Leg exercises do not prevent pressure sores to the sacrum, or
increase the patients level of consciousness. Leg exercises have the potential to increase strength and
mobility, but are unlikely to make a change to muscle mass in the short term.
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8. During the care of a preoperative patient, the nurse has given the patient a preoperative benzodiazepine.
The patient is now requesting to void. What action should the nurse take?
A) Assist the patient to the bathroom.
B) Offer the patient a bedpan or urinal.
C) Wait until the patient gets to the operating room and is catheterized.
D) Have the patient go to the bathroom.
Ans: B
Feedback:
If a preanesthetic medication is administered, the patient is kept in bed with the side rails raised because
the medication can cause lightheadedness or drowsiness. If a patient needs to void following
administration of a sedative, the nurse should offer the patient a urinal. The patient should not get out of
bed because of the potential for lightheadedness.
The nurse is preparing a patient for surgery. The patient states that she is very nervous and really does
not understand what the surgical procedure is for or how it will be performed. What is the most
appropriate nursing action for the nurse to take?
A) Have the patient sign the informed consent and place it in the chart.
B) Call the physician to review the procedure with the patient.
C) Explain the procedure clearly to the patient and her family.
D) Provide the patient with a pamphlet explaining the procedure.
Ans: B
Feedback:
While the nurse may ask the patient to sign the consent form and witness the signature, it is the surgeons
responsibility to provide a clear and simple explanation of what the surgery will entail prior to the
patient giving consent. The surgeon must also inform the patient of the benefits, alternatives, possible
risks, complications, disfigurement, disability, and removal of body parts as well as what to expect in the
early and late postoperative periods. The nurse clarifies the information provided, and, if the patient
requests additional information, the nurse notifies the physician. The consent formed should not be
signed until the patient understands the procedure that has been explained by the surgeon. The provision
of a pamphlet will benefit teaching the patient about the surgical procedure, but will not substitute for
the information provided by the physician.
The nurse is caring for a patient who is admitted to the ER with the diagnosis of acute appendicitis. The
nurse notes during the assessment that the patients ribs and xiphoid process are prominent. The patient
states she exercises two to three times daily and her mother indicates that she is being treated for
anorexia nervosa. How should the nurse best follow up these assessment data?
A) Inform the postoperative team about the patients risk for wound dehiscence.
B) Evaluate the patients ability to manage her pain level.
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C) Facilitate a detailed analysis of the patients electrolyte levels.
D) Instruct the patient on the need for a high-sodium diet to promote healing.
Ans: C
Feedback:
The surgical team should be informed about the patients medical history regarding anorexia nervosa.
Any nutritional deficiency, such as malnutrition, should be corrected before surgery to provide adequate
protein for tissue repair. The electrolyte levels should be evaluated and corrected to prevent metabolic
abnormalities in the operative and postoperative phase. The risk of wound dehiscence is more likely
associated with obesity. Instruction on proper nutrition should take place in the postoperative period, and
a consultation should be made with her psychiatric specialist. Evaluation of pain management is always
important, but not particularly significant in this scenario.
The nurse is doing preoperative patient education with a 61-year-old male patient who has a 40-pack per
year history of cigarette smoking. The patient will undergo an elective bunionectomy at a time that fits
his work schedule in a few months. What would be the best instruction to give to this patient?
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 343
A) Reduce smoking by 50% to prevent the development of pneumonia.
B) Stop smoking at least 6 weeks before the scheduled surgery to enhance pulmonary function and
decrease infection.
C) Aim to quit smoking in the postoperative period to reduce the chance of surgical complications
D) Stop smoking 4 to 8 weeks before the scheduled surgery to enhance pulmonary function and
decrease infection.
Ans: D
Feedback:
The reduction of smoking will enhance pulmonary function; in the preoperative period, patients who
smoke should be urged to stop 4 to 8 weeks before surgery.
You are providing preoperative teaching to a patient scheduled for hip replacement surgery in 1 month.
During the preoperative teaching, the patient gives you a list of medications she takes, the dosage, and
frequency. Which of the following interventions provides the patient with the most accurate
information?
A) Instruct the patient to stop taking St. Johns wort at least 2 weeks prior to surgery due to its
interaction with anesthetic agents.
B) Instruct the patient to continue taking ephedrine prior to surgery due to its beneficial effect on
blood pressure.
C) Instruct the patient to discontinue Synthroid due to its effect on blood coagulation and the potential
for heart dysrhythmias.
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D) Instruct the patient to continue any herbal supplements unless otherwise instructed, and inform the
patient that these supplements have minimal effect on the surgical procedure.
Ans: A
Feedback:
Because of the potential effects of herbal medications on coagulation and potential lethal interactions
with other medications, the nurse must ask surgical patients specifically about the use of these agents,
document their use, and inform the surgical team and anesthesiologist, anesthetist, or nurse anesthetist.
Currently, it is recommended that the use of herbal products be discontinued at least 2 weeks before
surgery. Patients with uncontrolled thyroid disorders are at risk for thyrotoxicosis and respiratory failure.
The administration of Synthroid is imperative in the preoperative period. The use of ephedrine in the
preoperative phase can cause hypertension and should be avoided.
13. The nurse is creating the care plan for a 70-year-old obese patient who has been admitted to the
postsurgical unit following a colon resection. This patients age and increased body mass index mean that
she is at increased risk for what complication in the postoperative period?
A) Hyperglycemia
B) Azotemia
C) Falls
D) Infection
Ans: D
Feedback:
Like age, obesity increases the risk and severity of complications associated with surgery. During
surgery, fatty tissues are especially susceptible to infection. In addition, obesity increases technical and
mechanical problems related to surgery. Therefore, dehiscence (wound separation) and wound infections
are more common. A postoperative patient who is obese will not likely be at greater risk for
hyperglycemia, azotemia, or falls.
14. The nurse is caring for a patient in the postoperative period following an abdominal hysterectomy. The
patient states, I dont want to use my pain meds because theyll make me dependent and I wont get better
as fast. Which response is most important when explaining the use of pain medication?
A) You will need the pain medication for at least 1 week to help in your recovery. What do you mean
you feel you wont get better faster?
B) Pain medication will help to decrease your pain and increase your ability to breath. Dependency is
a risk with pain medication, but you are young and wont have any problems.
C) Pain medication can be given by mouth to prevent the risk of dependency that you are worried
about. The pain medication has not been shown to affect your risk of a slowed recovery.
D) You will move more easily and heal more quickly with decreased pain. Dependence only occurs
when it is administered for an extended period of time.
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Ans: D
Feedback:
Postoperatively, medications are administered to relieve pain and maintain comfort without increasing
the risk of inadequate air exchange. In the responses by the nurse, (response D) addresses the patients
concerns about drug dependency and the nurses need to increase the patients ability to move and recover
from surgery. The other responses offer incorrect information, such as increasing the patients ability to
breathe or specifying the time needed to take the medication. Opioids will cause respiratory depression.
15. The nurse admitting a patient who is insulin dependent to the same-day surgical suite for carpal tunnel
surgery. How should this patients diagnosis of type 1 diabetes affect the care that the nurse plans?
A) The nurse should administer a bolus of dextrose IV solution preoperatively.
B) The nurse should keep the patient NPO for at least 8 hours preoperatively.
C) The nurse should initiate a subcutaneous infusion of long-acting insulin.
D) The nurse should assess the patients blood glucose levels vigilantly.
Ans: D
Feedback:
The patient with diabetes who is undergoing surgery is at risk for hypoglycemia and hyperglycemia.
Close glycemic monitoring is necessary. Dextrose infusion and prolonged NPO status are
contraindicated. There is no specific need for an insulin infusion preoperatively.
The nurse is checking the informed consent for a 17-year-old who has just been married and expecting
her first child. She is scheduled for a cesarean section. She is still living with her parents and is on her
parents health insurance. When obtaining informed consent for the cesarean section, who is legally
responsible for signing?
A) Her parents
B) Her husband
C) The patient
D) The obstetrician
Ans: C
Feedback:
An emancipated minor (married or independently earning his or her own living) may sign his or her own
consent form. In this case, the patient is the only person who can provide consent unless she would be
neurologically incapacitated or incompetent, in which case her husband would need to provide consent.
The nurse is providing preoperative teaching to a patient scheduled for surgery. The nurse is instructing
the patient on the use of deep breathing, coughing, and the use of incentive spirometry when the patient
states, I dont know why youre focusing on my breathing. My surgery is on my hip, not my chest. What
rationale for these instructions should the nurse provide?
A) To prevent chronic obstructive pulmonary disease (COPD)
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Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 346
B) To promote optimal lung expansion
C) To enhance peripheral circulation
D) To prevent pneumothorax
Ans: B
Feedback:
One goal of preoperative nursing care is to teach the patient how to promote optimal lung expansion and
consequent blood oxygenation after anesthesia. COPD is not a realistic risk and pneumothorax is also
unlikely. Breathing exercises do not primarily affect peripheral circulation.
One of the things a nurse has taught to a patient during preoperative teaching is to have nothing by
mouth for the specified time before surgery. The patient asks the nurse why this is important. What is the
most appropriate response for the patient?
A) You will need to have food and fluid restricted before surgery so you are not at risk for choking.
B) The restriction of food or fluid will prevent the development of pneumonia related to decreased
lung capacity.
C) The presence of food in the stomach interferes with the absorption of anesthetic agents.
D) By withholding food for 8 hours before surgery, you will not develop constipation in the
postoperative period.
Ans: A
Feedback:
The major purpose of withholding food and fluid before surgery is to prevent aspiration. There is no
scientific basis for withholding food and the development of pneumonia or interference with absorption
of anesthetic agents. Constipation in patients in the postoperative period is related to the anesthesia, not
from withholding food or fluid in the hours before surgery.
19. A patient is scheduled for a bowel resection in the morning and the patients orders include a cleansing
enema tonight. The patient wants to know why this is necessary. The nurse should explain that the
cleansing enema will have what therapeutic effect?
A) Preventing aspiration of gastric contents
B) Preventing the accumulation of abdominal gas postoperatively
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 347
C) Preventing potential contamination of the peritoneum
D) Facilitating better absorption of medications
Ans: C
Feedback:
The administration of a cleansing enema will allow for satisfactory visualization of the surgical site and
to prevent trauma to the intestine or contamination of the peritoneum by feces. It will have no effect on
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aspiration of gastric contents or the absorption of medications. The patient should expect to develop gas
in the postoperative period.
20. The nurse is caring for a patient who is experiencing pain and anxiety following his prostatectomy.
Which intervention will likely best assist in decreasing the patients pain and anxiety?
A) Administration of NSAIDs rather than opioids
B) Allowing the patient to increase activity
C) Use of guided imagery along with pain medication
D) Use of deep breathing and coughing exercises
Ans: C
Feedback:
The use of guided imagery will enhance pain relief and assist in reduction of anxiety. It may be
combined with analgesics. Deep breathing and the increase in activity may produce increased pain.
Replacing opioids with NSAIDs may cause an increase in pain.
A patient is on call to the OR for an aortobifemoral bypass and the nurse administers the ordered
preoperative medication. After administering a preoperative medication to the patient, what should the
nurse do?
A) Encourage light ambulation.
B) Place the bed in a low position with the side rails up.
C) Tell the patient that he will be asleep before he leaves for surgery.
D) Take the patients vital signs every 15 minutes.
Ans: B
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 348
Feedback:
When the preoperative medication is given, the bed should be placed in low position with the side rails
raised. The patient should not get up without assistance. The patient may not be asleep, but he may be
drowsy. Vital signs should be taken before the preoperative medication is given; vital signs are not
normally required every 15 minutes after administration.
22. The nurse is performing a preadmission assessment of a patient scheduled for a bilateral mastectomy. Of
what purpose of the preadmission assessment should the nurse be aware?
A) Verifies completion of preoperative diagnostic testing
B) Discusses and reviews patients health insurance coverage
C) Determines the patients suitability as a surgical candidate
D) Informs the patient of need for postoperative transportation
Ans: A
Feedback:
Purposes of preadmission testing (PAT) include verifying completion of preoperative diagnostic testing.
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The nurses role in PAT does not normally involve financial considerations or addressing transportation.
The physician determines the patients suitability for surgery.
23. A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty. What
should the nurse include in the care given to this patient? Select all that apply.
A) Establishing an IV line
B) Verifying the surgical site with the patient
C) Taking measures to ensure the patients comfort
D) Applying a grounding device to the patient
E) Preparing the medications to be administered in the OR
Ans: A, B, C
Feedback:
In the holding area, the nurse reviews charts, identifies patients, verifies surgical site and marks site per
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 349
institutional policy, establishes IV lines, administers medications, if prescribed, and takes measures to
ensure each patients comfort. A nurse in the preoperative holding area does not prepare medications to
be administered by anyone else. A grounding device is applied in the OR.
24. An OR nurse will be participating in the intraoperative phase of a patients kidney transplant. What
action will the nurse prioritize in this aspect of nursing care?
A) Monitoring the patients physiologic status
B) Providing emotional support to family
C) Maintaining the patients cognitive status
D) Maintaining a clean environment
Ans: A
Feedback:
During the intraoperative phase, the nurse is responsible for physiologic monitoring. The intraoperative
nurse cannot support the family at this time and the nurse is not responsible for maintaining the patients
cognitive status. The intraoperative nurse maintains an aseptic, not clean, environment.
The nurse is doing a preoperative assessment of an 87-year-old man who is slated to have a right lung
lobe resection to treat lung cancer. What underlying principle should guide the nurses preoperative
assessment of an elderly patient?
A) Elderly patients have a smaller lung capacity than younger patients.
B) Elderly patients require higher medication doses than younger patients.
C) Elderly patients have less physiologic reserve than younger patients.
D) Elderly patients have more sophisticated coping skills than younger patients.
Ans: C
Feedback:
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The underlying principle that guides the preoperative assessment, surgical care, and postoperative care is
that elderly patients have less physiologic reserve (the ability of an organ to return to normal after a
disturbance in its equilibrium) than do younger patients. Elderly patients do not have larger lung
capacities than younger patients. Elderly patients cannot necessarily cope better than younger patients
and they often require lower doses of medications.
The PACU nurse is caring for a patient who has been deemed ready to go to the postsurgical floor after
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 350
her surgery. What would the PACU nurse be responsible for reporting to the nurse on the floor? Select
all that apply.
A) The names of the anesthetics that were used
B) The identities of the staff in the OR
C) The patients preoperative level of consciousness
D) The presence of family and/or significant others
E) The patients full name
Ans: C, D, E
Feedback:
The PACU nurse is responsible for informing the floor nurse of the patients intraoperative factors (e.g.,
insertion of drains or catheters, administration of blood or medications during surgery, or occurrence of
unexpected events), preoperative level of consciousness, presence of family and/or significant others,
and identification of the patient by name. The PACU nurse does not tell which anesthetic was used, only
the type and amount used. The PACU nurse does not identify the staff that was in the OR with the
patient.
27. A 77-year-old mans coronary artery bypass graft has been successful and discharge planning is
underway. When planning the patients subsequent care, the nurse should know that the postoperative
phase of perioperative nursing ends at what time?
A) When the patient is returned to his room after surgery
B) When a follow-up evaluation in the clinical or home setting is done
C) When the patient is fully recovered from all effects of the surgery
D) When the family becomes partly responsible for the patients care
Ans: B
Feedback:
The postoperative phase begins with the admission of the patient to the PACU and ends with a follow-up
evaluation in the clinical setting or home.
28. The nurse is caring for a trauma victim in the ED who will require emergency surgery due to injuries.
Before the patient leaves the ED for the OR, the patient goes into cardiac arrest. The nurse assists in the
successful resuscitation and proceeds to release the patient to the OR staff. When can the ED nurse
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Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 351
perform the preoperative assessment?
A)
When he or she has the opportunity to review the patients electronic health record
B) When the patient arrives in the OR
C) When assisting with the resuscitation
D) Preoperative assessment is not necessary in this case
Ans: C
Feedback:
The only opportunity for preoperative assessment may take place at the same time as resuscitation in the
ED. Preoperative assessment is necessary, but the nurse could not normally enter the OR to perform this
assessment. The health record is an inadequate data source.
The admitting nurse in a short-stay surgical unit is responsible for numerous aspects of care. What must
the nurse verify before the patient is taken to the preoperative holding area?
A) That preoperative teaching was performed
B) That the family is aware of the length of the surgery
C) That follow-up home care is not necessary
D) That the family understands the patient will be discharged immediately after surgery.
Ans: A
Feedback:
The nurse needs to be sure that the patient and family understand that the patient will first go to the
preoperative holding area before going to the OR for the surgical procedure and then will spend some
time in the PACU before being discharged home with the family later that day. Other preoperative
teaching content should also be verified and reinforced, as needed. The nurse should ensure that any
plans for follow-up home care are in place.
The clinic nurse is doing a preoperative assessment of a patient who will be undergoing outpatient
cataract surgery with lens implantation in 1 week. While taking the patients medical history, the nurse
notes that this patient had a kidney transplant 8 years ago and that the patient is taking
immunosuppressive drugs. For what is this patient at increased risk when having surgery?
A) Rejection of the kidney
B) Rejection of the implanted lens
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 352
C) Infection
D) Adrenal storm
Ans: C
Feedback:
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Because patients who are immunosuppressed are highly susceptible to infection, great care is taken to
ensure strict asepsis. The patient is unlikely to experience rejection or adrenal storm.
31. The nurse is planning the care of a patient who has type 1 diabetes and who will be undergoing knee
replacement surgery. This patients care plan should reflect an increased risk of what postsurgical
complications? Select all that apply.
A) Hypoglycemia
B) Delirium
C) Acidosis
D) Glucosuria
E) Fluid overload
Ans: A, C, D
Feedback:
Hypoglycemia may develop during anesthesia or postoperatively from inadequate carbohydrates or
excessive administration of insulin. Hyperglycemia, which can increase the risk for surgical wound
infection, may result from the stress of surgery, which can trigger increased levels of catecholamine.
Other risks are acidosis and glucosuria. Risks of fluid overload and delirium are not normally increased.
32. The surgical nurse is preparing to send a patient from the presurgical area to the OR and is reviewing the
patients informed consent form. What are the criteria for legally valid informed consent? Select all that
apply.
A) Consent must be freely given.
B) Consent must be notarized.
C) Consent must be signed on the day of surgery.
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 353
D) Consent must be obtained by a physician.
E) Signature must be witnessed by a professional staff member.
Ans: A, D, E
Feedback:
Valid consent must be freely given, without coercion. Consent must be obtained by a physician and the
patients signature must be witnessed by a professional staff member. It does not need to be signed on the
same day as the surgery and it does not need to be notarized.
You are the nurse caring for an unconscious trauma victim who needs emergency surgery. The patient is
a 55-year-old man with an adult son. He is legally divorced and is planning to be remarried in a few
weeks. His parents are at the hospital with the other family members. The physician has explained the
need for surgery, the procedure to be done, and the risks to the children, the parents, and the fianc. Who
should be asked to sign the surgery consent form?
A) The fianc
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B) The son
C) The physician, acting as a surrogate
D) The patients father
B
Feedback:
The patient personally signs the consent if of legal age and mentally capable. Permission is otherwise
obtained from a surrogate, who most often is a responsible family member (preferably next of kin) or
legal guardian. In this instance, the child would be the appropriate person to ask to sign the consent form
as he is the closest relative at the hospital. The fianc is not legally related to him as the marriage has not
yet taken place. The father would only be asked to sign the consent if no children were present to sign.
The physician would not sign if family members were available.
The ED nurse is caring for an 11-year-old brought in by ambulance after having been hit by a car. The
childs parents are thought to be en route to the hospital but have not yet arrived. No other family
members are present and attempts to contact the parents have been unsuccessful. The child needs
emergency surgery to save her life. How should the need for informed consent be addressed?
A) A social worker should temporarily sign the informed consent.
B) Consent should be obtained from the hospitals ethics committee.
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 354
C) Surgery should be done without informed consent.
D) Surgery should be delayed until the parents arrive.
Ans: C
Feedback:
In an emergency, it may be necessary for the surgeon to operate as a lifesaving measure without the
patients informed consent. However, every effort must be made to contact the patients family. In such a
situation, contact can be made by electronic means. In this scenario, the surgery is considered lifesaving,
and the parents are on their way to the hospital and not available. A delay would be unacceptable.
Neither a social worker nor a member of the ethics committee may sign.
The nurse is caring for a 78-year-old female patient who is scheduled for surgery to remove her brain
tumor. The patient is very apprehensive and keeps asking when she will get her preoperative medicine.
The medicine is ordered to be given on call to OR. When would be the best time to give this medication?
A) As soon as possible, in order to alleviate the patients anxiety
B) As the patient is transferred to the OR bed
C) When the porter arrives on the floor to take the patient to surgery
D) After being notified by the OR and before other preoperative preparations
Ans: D
Feedback:
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The nurse can have the medication ready to administer as soon as a call is received from the OR staff. It
usually takes 15 to 20 minutes to prepare the patient for the OR. If the nurse gives the medication before
attending to the other details of preoperative preparation, the patient will have at least partial benefit
from the preoperative medication and will have a smoother anesthetic and operative course.
The nurse is preparing to send a patient to the OR for a scheduled surgery. What should the nurse ensure
is on the chart when it accompanies the patient to surgery? Select all that apply.
A) Laboratory reports
B) Nurses notes
C) Verification form
D) Social work assessment
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 355
E) Dieticians assessment
Ans: A, B, C
Feedback:
The completed chart (with the preoperative checklist and verification form) accompanies the patient to
the OR with the surgical consent form attached, along with all laboratory reports and nurses records.
Any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted
prominently at the front of the chart. The social work and dieticians assessments are not normally
necessary when the patient goes to surgery.
You are caring for an 88-year-old woman who is scheduled for a right mastectomy. You know that
elderly patients are frequently more anxious prior to surgery than younger patients. What would you
increase with this patient to decrease her anxiety?
A) Analgesia
B) Therapeutic touch
C) Preoperative medication
D) Sleeping medication the night before surgery
Ans: B
Feedback:
Older patients report higher levels of preoperative anxiety; therefore, the nurse should be prepared to
spend additional time, increase the amount of therapeutic touch utilized, and encourage family members
to be present to decrease anxiety. For most patients, nonpharmacologic interventions should be
attempted before administering medications.
The policies and procedures on a preoperative unit are being amended to bring them closer into
alignment with the focus of the Surgical Care Improvement Project (SCIP). What intervention most
directly addresses the priorities of the SCIP?
A) Actions aimed at increasing participation of families in planning care
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B) Actions aimed at preventing surgical site infections
C) Actions aimed at increasing interdisciplinary collaboration
D) Actions aimed at promoting the use of complementary and alternative medicine (CAM)
Ans: B
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 356
Feedback:
SCIP identifies performance measures aimed at preventing surgical complications, including venous
thromboembolism (VTE) and surgical site infections (SSI). It does not explicitly address family
participation, interdisciplinary collaboration, or CAM.
A 90-year-old female patient is scheduled to undergo a partial mastectomy for the treatment of breast
cancer. What nursing diagnosis should the nurse prioritize when planning this patients postoperative
care?
A) Risk for Delayed Growth and Development related to prolonged hospitalization
B) Risk for Decisional Conflict related to discharge planning
C) Risk for Impaired Memory related to old age
D) Risk for Infection related to reduced immune function
Ans: D
Feedback:
The lessened physiological reserve of older adults results in an increased risk for infection
postoperatively. This physiological consideration is a priority over psychosocial considerations, which
may or may not be applicable. Impaired memory is always attributed to a pathophysiological etiology,
not advanced age.
40. A clinic nurse is conducting a preoperative interview with an adult patient who will soon be scheduled to
undergo cardiac surgery. What interview question most directly addresses the patients safety?
A) What prescription and nonprescription medications do you currently take?
B) Have you previously been admitted to the hospital, either for surgery or for medical treatment?
C) How long do you expect to be at home recovering after your surgery?
D) Would you say that you tend to eat a fairly healthy diet?
Ans: A
Feedback:
It is imperative to know a preoperative patients current medication regimen, including OTC medications
and supplements. None of the other listed questions directly addresses an issue with major safety
implications.
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Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 15: Intraoperative Nursing Management
1. The nurse is preparing an elderly patient for a scheduled removal of orthopedic hardware, a procedure to
be performed under general anesthetic. For which adverse effect should the nurse most closely monitor
the patient?
A) Hypothermia
B) Pulmonary edema
C) Cerebral ischemia
D) Arthritis
Ans: A
Feedback:
Inadvertent hypothermia may occur as a result of a low temperature in the OR, infusion of cold fluids,
inhalation of cold gases, open body wounds or cavities, decreased muscle activity, advanced age, or the
pharmaceutical agents used (e.g., vasodilators, phenothiazines, general anesthetics). The anesthetist
monitors for pulmonary edema and cerebral ischemia. Arthritis is not an adverse effect of surgical
anesthesia.
2. The OR nurse acts in the circulating role during a patients scheduled cesarean section. For what task is
this nurse solely responsible?
A) Performing documentation
B) Estimating the patients blood loss
C) Setting up the sterile tables
D) Keeping track of drains and sponges
Ans: A
Feedback:
Main responsibilities of the circulating nurse include verifying consent; coordinating the team; and
ensuring cleanliness, proper temperature and humidity, lighting, safe function of equipment, and the
availability of supplies and materials. The circulating nurse monitors aseptic practices to avoid breaks in
technique while coordinating the movement of related personnel as well as implementing fire safety
precautions. The circulating nurse also monitors the patient and documents specific activities throughout
the operation to ensure the patients safety and well-being. Estimating the patients blood loss is the
surgeons responsibility; setting up the sterile tables is the responsibility of the first scrub; and keeping
track of the drains and sponges is the joint responsibility of the circulating nurse and the scrub nurse.
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3. A 21-year-old patient is positioned on the OR bed prior to knee surgery to correct a sports-related injury. The
anesthesiologist administers the appropriate anesthetic. The OR nurse should anticipate which of the
following events as the teams next step in the care of this patient?
A) Grounding
B) Making the first incision
C) Giving blood
D) Intubating
Ans: D
Feedback:
When the patient arrives in the OR, the anesthesiologist or anesthetist reassesses the patients physical
condition immediately prior to initiating anesthesia. The anesthetic is administered, and the patients
airway is maintained through an intranasal intubation, oral intubation, or a laryngeal mask airway. Grounding or blood
administration does not normally follow anesthetic administration immediately. An
incision would not be made prior to intubation.
4. A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the
day. The nurse should know to monitor which patient most closely during the intraoperative period
because of the increased risk for hypothermia?
A) A 74-year-old woman with a low body mass index
B) A 17-year-old boy with traumatic injuries
C) A 45-year-old woman having an abdominal hysterectomy
D) A 13-year-old girl undergoing craniofacial surgery
Ans: A
Feedback:
Elderly patients are at greatest risk during surgical procedures because they have an impaired ability to
increase their metabolic rate and impaired thermoregulatory mechanisms, which increase susceptibility
to hypothermia. The other patients are likely at a lower risk.
5. The anesthetist is coming to the surgical admissions unit to see a patient prior to surgery scheduled for
tomorrow morning. Which of the following is the priority information that the nurse should provide to
the anesthetist during the visit?
A) Last bowel movement
B) Latex allergy
C) Number of pregnancies
D) Difficulty falling asleep
Ans: B
Feedback:
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Due to the increased number of patients with latex allergies, it is essential to identify this allergy early on
so precautions can be taken in the OR. The anesthetist should be informed of any allergies. This is a
priority over pregnancy history, insomnia, or recent bowel function, though some of these may be
relevant.
6. An OR nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the
restricted zone of the operating suite. What personal protective equipment should the nurse wear at all
times in the restricted zone of the OR?
A) Reusable shoe covers
B) Mask covering the nose and mouth
C) Goggles
D) Gloves
Ans: B
Feedback:
Masks are worn at all times in the restricted zone of the OR. Shoe covers are worn one time only;
goggles and gloves are worn as required, but not necessarily at all times.
7. An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical
department. The nurse should know that a basic guideline for maintaining surgical asepsis is what?
A) Sterile surfaces or articles may touch other sterile surfaces.
B) Sterile supplies can be used on another patient if the packages are intact.
C) The outer lip of a sterile solution is considered sterile.
D) The scrub nurse may pour a sterile solution from a nonsterile bottle.
Ans: A
Feedback:
Basic guidelines for maintaining sterile technique include that sterile surfaces or articles may touch other
sterile surfaces only. The other options each constitute a break in sterile technique.
8. The surgical patient is a 35-year-old woman who has been administered general anesthesia. The nurse
recognizes that the patient is in stage II (the excitement stage) of anesthesia. Which intervention would
be most appropriate for the nurse to implement during this stage?
A) Rub the patients back.
B) Restrain the patient.
C) Encourage the patient to express feelings.
D) Stroke the patients hand.
Ans: B
Feedback:
In stage II, the patient may struggle, shout, or laugh. The movements of the patient may be uncontrolled, so it is essential
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the nurse help to restrain the patient for safety. None of the other listed actions protects
the patients safety.
9. A patient waiting in the presurgical holding area asks the nurse, Why exactly do they have to put a
breathing tube into me? My surgery is on my knee. What is the best rationale for intubation during a
surgical procedure that the nurse should describe?
A) The tube provides an airway for ventilation.
B) The tube protects the patients esophagus from trauma.
C) The patient may receive an antiemetic through the tube.
D) The patients vital signs can be monitored with the tube.
Ans: A
Feedback:
The anesthetic is administered and the patients airway is maintained through an intranasal intubation, oral intubation, or a
laryngeal mask airway. The tube also helps protect aspiration of stomach contents. The tube does not protect the
esophagus. Because the tube goes into the lungs, no medications are given
through the tube. The patients vital signs are not monitored through the tube.
10. The circulating nurse in an outpatient surgery center is assessing a patient who is scheduled to receive
moderate sedation. What principle should guide the care of a patient receiving this form of anesthesia?
A) The patient must never be left unattended by the nurse.
B) The patient should begin a course of antiemetics the day before surgery.
C) The patient should be informed that he or she will remember most of the procedure.
D) The patient must be able to maintain his or her own airway.
Ans: A
Feedback:
The patient receiving moderate sedation should never be left unattended. The patients ability to maintain
his or her airway depends on the level of sedation. The administration of moderate sedation is not a
counter indication for giving an antiemetic. The patient receiving moderate sedation does not remember
most of the procedure.
11. A nurse is caring for a patient following knee surgery that was performed under a spinal anesthetic. What
intervention should the nurse implement to prevent a spinal headache?
A) Have the patient sit in a chair and perform deep breathing exercises.
B) Ambulate the patient as early as possible.
C) Limit the patients fluid intake for the first 24 hours postoperatively.
D) Keep the patient positioned supine.
Ans: D
Feedback:
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Measures that increase cerebrospinal pressure are helpful in relieving headache. These include
maintaining a quiet environment, keeping the patient lying flat, and keeping the patient well hydrated. Having the patient
sit or stand up decreases cerebrospinal pressure and would not relieve a spinal
headache. Limiting fluids is incorrect because it also decreases cerebrospinal pressure and would not
relieve a spinal headache.
12. The OR will be caring for a patient who will receive a transsacral block. For what patient would the use
of a transsacral block be appropriate for pain control?
A) A middle-aged man who is scheduled for a thoracotomy
B) An older adult man who will undergo an inguinal hernia repair
C) A 50-year-old woman who will be having a reduction mammoplasty
D) A child who requires closed reduction of a right humerus fracture
Ans: B
Feedback:
A transsacral block produces anesthesia for the perineum and lower abdomen. Both a thoracotomy and
breast reduction are in the chest region, and a transsacral block would not provide pain control for these
procedures. A closed reduction of a right humerus is a procedure on the right arm, and a transsacral
block would not provide pain control.
13. The circulating nurse will be participating in a 78-year-old patients total hip replacement. Which of the
following considerations should the nurse prioritize during the preparation of the patient in the OR?
A) The patient should be placed in Trendelenburg position.
B) The patient must be firmly restrained at all times.
C) Pressure points should be assessed and well padded.
D) The preoperative shave should be done by the circulating nurse.
Ans: C
Feedback:
The vascular supply should not be obstructed by an awkward position or undue pressure on a body part. During surgical
procedures, the patient is at risk for impairment of skin integrity due to a stationary
position and immobility. An elderly patient is at an increased risk of injury and impaired skin integrity. A Trendelenburg
position is not indicated for this patient. Once anesthetized for a total hip replacement,
the patient cannot move; restraints are not necessary. A preoperative shave is not performed; excess hair
is removed by means of a clipper.
14. The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his
grandmother spiked a 104F temperature in the OR and nearly died 15 years ago. What relevance does
this information have regarding the patient?
A) The patient may be experiencing presurgical anxiety.
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B) The patient may be at risk for malignant hyperthermia.
C) The grandmothers surgery has minimal relevance to the patients surgery.
D) The patient may be at risk for a sudden onset of postsurgical infection.
Ans: B
Feedback:
Malignant hyperthermia is an inherited muscle disorder chemically induced by anesthetic agents.
Identifying patients at risk is imperative because the mortality rate is 50%. The patients anxiety is not
relevant, the grandmothers surgery is very relevant, and all patients are at risk for hypothermia.
15. While the surgical patient is anesthetized, the scrub nurse hears a member of the surgical team make an
inappropriate remark about the patients weight. How should the nurse best respond?
A) Ignore the comment because the patient is unconscious.
B) Discourage the colleague from making such comments.
C) Report the comment immediately to a supervisor.
D) Realize that humor is needed in the workplace.
Ans: B
Feedback:
Patients, whether conscious or unconscious, should not be subjected to excess noise, inappropriate
conversation, or, most of all, derogatory comments. The nurse must act as an advocate on behalf of the
patient and discourage any such remarks. Reporting to a supervisor, however, is not likely necessary.
16. You are caring for a male patient who has had spinal anesthesia. The patient is under a physicians order
to lie flat postoperatively. When the patient asks to go to the bathroom, you encourage him to adhere to
the physicians order. What rationale for complying with this order should the nurse explain to the
patient?
A) Preventing the risk of hypotension
B) Preventing respiratory depression
C) Preventing the onset of a headache
D) Preventing pain at the lumbar injection site
Ans: C
Feedback:
Lying flat reduces the risk of headache after spinal anesthesia. Hypotension and respiratory depression
may be adverse effects of spinal anesthesia associated with the spread of the anesthetic, but lying flat
does not help reduce these effects. Pain at the lumbar injection site typically is not a problem.
17. The nurse is packing a patients abdominal wound with sterile, half-inch Iodoform gauze. During the
procedure, the nurse drops some of the gauze onto the patients abdomen 2 inches (5 cm) away from the
wound. What should the nurse do?
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A) Apply povidone-iodine (Betadine) to that section of the gauze and continue packing the wound.
B) Pick up the gauze and continue packing the wound after irrigating the abdominal wound with
Betadine solution.
C) Continue packing the wound and inform the physician that an antibiotic is needed.
D) Discard the gauze packing and repack the wound with new Iodoform gauze.
Ans: D
Feedback:
Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile; contact with
unsterile objects at any point renders a sterile area contaminated. The sterile gauze became contaminated
when it was dropped on the patients abdomen. It should be discarded and new Iodoform gauze should be
used to pack the wound. Betadine should not be used in the wound unless ordered.
18. The nurse is performing wound care on a 68-year-old postsurgical patient. Which of the following
practices violates the principles of surgical asepsis?
A) Holding sterile objects above the level of the nurses waist
B) Considering a 1 inch (2.5 cm) edge around the sterile field as being contaminated
C) Pouring solution onto a sterile field cloth
D) Opening the outermost flap of a sterile package away from the body
Ans: C
Feedback:
Whenever a sterile barrier is breached, the area must be considered contaminated. Pouring solution onto
a sterile field cloth violates surgical asepsis because moisture penetrating the cloth can carry
microorganisms to the sterile field via capillary action. The other options are practices that help ensure
surgical asepsis.
19. A patient is scheduled for surgery the next day and the different phases of the patients surgical
experience will require input from members of numerous health disciplines. How should the patients
care best be coordinated?
A) By planning care using a surgical approach
B) By identifying the professional with the most knowledge of the patient
C) By implementing an interdisciplinary approach to care
D) By using the nursing process to guide all aspects of care and treatment
Ans: C
Feedback:
An interdisciplinary approach involving the surgeon, anesthesiologist or anesthetist, and nurse is best. This is superior to
each of the other listed options.
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20. Prior to a patients scheduled surgery, the nurse has described the way that members of diverse health
disciplines will collaborate in the patients care. What is the main rationale for organizing perioperative
care in this collaborative manner?
A) Historical precedence
B) Patient requests
C) Physicians needs
D) Evidence-based practice
Ans: D
Feedback:
Collaboration of the surgical team using evidence-based practice tailored to a specific case results in
optimal patient care and improved outcomes. None of the other listed factors is the basis for the
collaboration of the surgical team.
21. An intraoperative nurse is applying interventions that will address surgical patients risks for
perioperative positioning injury. Which of the following factors contribute to this increased risk for
injury in the intraoperative phase of the surgical experience? Select all that apply.
A) Absence of reflexes
B) Diminished ability to communicate
C) Loss of pain sensation
D) Nausea resulting from anesthetic
E) Reduced blood pressure
Ans: A, B, C
Feedback:
Loss of pain sense, reflexes, and ability to communicate subjects the intraoperative patient to possible
injury. Nausea and low blood pressure are not central factors that contribute to this risk, though they are
adverse outcomes.
22. Verification that all required documentation is completed is an important function of the intraoperative
nurse. The intraoperative nurse should confirm that the patients accompanying documentation includes
which of the following?
A) Discharge planning
B) Informed consent
C) Analgesia prescription
D) Educational resources
Ans: B
Feedback:
It is important to review the patients record for the following: correct informed surgical consent, with
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patients signature; completed records for health history and physical examination; results of diagnostic
studies; and allergies (including latex). Discharge planning records and prescriptions are not normally
necessary. Educational resources would not be included at this stage of the surgical process.
23. A patient will be undergoing a total hip arthroplasty later in the day and it is anticipated that the patient
may require blood transfusion during surgery. How can the nurse best ensure the patients safety if a
blood transfusion is required?
A) Prime IV tubing with a unit of blood and keep it on hold.
B) Check that the patients electrolyte levels have been assessed preoperatively.
C) Ensure that the patient has had a current cross-match.
D) Keep the blood on standby and warmed to body temperature.
Ans: C
Feedback:
Few patients undergoing an elective procedure require blood transfusion, but those undergoing high-risk
procedures may require an intraoperative transfusion. The circulating nurse anticipates this need, checks
that blood has been cross-matched and held in reserve, and is prepared to administer blood. Storing the
blood at body temperature or in IV tubing would result in spoilage and potential infection.
24. The circulating nurse is admitting a patient prior to surgery and proceeds to greet the patient and discuss
what the patient can expect in surgery. What aspect of therapeutic communication should the nurse
implement?
A) Wait for the patient to initiate dialogue.
B) Use medically acceptable terms.
C) Give preoperative medications prior to discussion.
D) Use a tone that decreases the patients anxiety.
Ans: D
Feedback:
When discussing what the patient can expect in surgery, the nurse uses basic communication skills, such
as touch and eye contact, to reduce anxiety. The nurse should use language the patient can understand. The nurse
should not withhold communication until the patient initiates dialogue; the nurse most often
needs to initiate and guide dialogue, while still responding to patient leading. Giving medication is not a
communication skill.
25. A patient who underwent a bowel resection to correct diverticula suffered irreparable nerve damage.
During the case review, the team is determining if incorrect positioning may have contributed to the
patients nerve damage. What surgical position places the patient at highest risk for nerve damage?
A) Trendelenburg
B) Prone
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C) Dorsal recumbent
D) Lithotomy
Ans: A
Feedback:
Shoulder braces must be well padded to prevent irreparable nerve injury, especially when the
Trendelenburg position is necessary. The other listed positions are less likely to cause nerve injury.
26. The patients surgery is nearly finished and the surgeon has opted to use tissue adhesives to close the
surgical wound. This requires the nurse to prioritize assessments related to what complication?
A) Hypothermia
B) Anaphylaxis
C) Infection
D) Malignant hyperthermia
Ans: B
Feedback:
Fibrin sealants are used in a variety of surgical procedures, and cyanoacrylate tissue adhesives are used
to close wounds without the use of sutures. These sealants have been implicated in allergic reactions and
anaphylaxis. There is not an increased risk of malignant hyperthermia, hypothermia, or infection because
of the use of tissue adhesives.
27. As an intraoperative nurse, you are the advocate for each of the patients who receives care in the surgical
setting. How can you best exemplify the principles of patient advocacy?
A) By encouraging the patient to perform deep breathing preoperatively
B) By limiting the patients contact with family members preoperatively
C) By maintaining each of your patients privacy
D) By eliciting informed consent from patients
Ans: C
Feedback:
Patient advocacy in the OR entails maintaining the patients physical and emotional comfort, privacy,
rights, and dignity. Deep breathing is not necessary before surgery and obtaining informed consent is the
purview of the physician. Family contact should not be limited.
28. The nurse is caring for a patient who is scheduled to have a needle biopsy of the pleura. The patient has
had a consultation with the anesthesiologist and a conduction block will be used. Which local
conduction block can be used to block the nerves leading to the chest?
A) Transsacral block
B) Brachial plexus block
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C) Peudental block
D) Paravertebral block
Ans: D
Feedback:
Examples of common local conduction blocks include paravertebral anesthesia, which produces
anesthesia of the nerves supplying the chest, abdominal wall, and extremities; brachial plexus block, which produces
anesthesia of the arm; and transsacral (caudal) block, which produces anesthesia of the
perineum and, occasionally, the lower abdomen. A peudental block was used in obstetrics before the
almost-routine use of epidural anesthesia.
29. When creating plans of nursing care for patients who are undergoing surgery using general anesthetic, what
nursing diagnoses should the nurse identify? Select all that apply.
A) Disturbed sensory perception related to anesthetic
B) Risk for impaired nutrition: less than body requirements related to anesthesia
C) Risk of latex allergy response related to surgical exposure
D) Disturbed body image related to anesthesia
E) Anxiety related to surgical concerns
Ans: A, C, E
Feedback:
Based on the assessment data, some major nursing diagnoses may include the following: anxiety related
to surgical or environmental concerns, risk of latex allergy response due to possible exposure to latex in
the OR environment, risk for perioperative positioning injury related to positioning in the OR, risk for
injury related to anesthesia and surgical procedure, or disturbed sensory perception (global) related to
general anesthesia or sedation. Malnutrition and disturbed body image are much less likely.
30. The intraoperative nurse is implementing a care plan that addresses the surgical patients risk for
vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent
surgical complication?
A) Impaired skin integrity
B) Hypoxia
C) Malignant hyperthermia
D) Hypothermia
Ans: B
Feedback:
If the patient aspirates vomitus, an asthma-like attack with severe bronchial spasms and wheezing is
triggered. Pneumonitis and pulmonary edema can subsequently develop, leading to extreme hypoxia. Vomiting can cause
choking, but the question asks about aspirated vomitus. Malignant hyperthermia is
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an adverse reaction to anesthesia. Aspirated vomitus does not cause hypothermia. Vomiting does not
result in impaired skin integrity.
31. The perioperative nurse is constantly assessing the surgical patient for signs and symptoms of
complications of surgery. Which symptom should first signal to the nurse the possibility that the patient
is developing malignant hyperthermia?
A) Increased temperature
B) Oliguria
C) Tachycardia
D) Hypotension
Ans: C
Feedback:
The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal
activity. Tachycardia (heart rate greater than 150 beats per minute) is often the earliest sign. Oliguria, hypotension, and
increased temperature are later signs of malignant hyperthermia.
32. As a perioperative nurse, you know that the National Patient Safety Goals have the potential to improve
patient outcomes in a wide variety of health care settings. Which of these Goals has the most direct
relevance to the OR?
A) Improve safety related to medication use
B) Reduce the risk of patient harm resulting from falls
C) Reduce the incidence of health care-associated infections
D) Reduce the risk of fires
Ans: D
Feedback:
The National Patient Safety Goals all pertain to the perioperative areas, but the one with the most direct
relevance to the OR is the reduction of the risk of surgical fires.
33. The perioperative nurse has completed the presurgical assessment of an 82-year-old female patient who
is scheduled for a left total knee replacement. When planning this patients care, the nurse should address
the consequences of the patients aging cardiovascular system. These include an increased risk of which
of the following?
A) Hypervolemia
B) Hyponatremia
C) Hyperkalemia
D) Hyperphosphatemia
Ans: A
Feedback:
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The aging heart and blood vessels have decreased ability to respond to stress. Reduced cardiac output
and limited cardiac reserve make the elderly patient vulnerable to changes in circulating volume and
blood oxygen levels. There is not an increased risk for hypopnea, hyperkalemia, or hyperphosphatemia
because of an aging cardiovascular system.
34. The nurse knows that elderly patients are at higher risk for complications and adverse outcomes during
the intraoperative period. What is the best rationale for this phenomenon?
A) The elderly patient has a more angular bone structure than a younger person.
B) The elderly patient has reduced ability to adjust rapidly to emotional and physical stress.
C) The elderly patient has impaired thermoregulatory mechanisms, which increase susceptibility to
hyperthermia.
D) The elderly patient has an impaired ability to decrease his or her metabolic rate.
Ans: B
Feedback:
Factors that affect the elderly surgical patient in the intraoperative period include the following:
impaired ability to increase metabolic rate and impaired thermoregulatory mechanisms increase
susceptibility to hypothermia. Bone loss (25% in women, 12% in men) necessitates careful manipulation
and positioning during surgery. Reduced ability to adjust rapidly to emotional and physical stress
influences surgical outcomes and requires meticulous observation of vital functions. Older adults do not
have more angular bones than younger people.
35. As an intraoperative nurse, you know that the patients emotional state can influence the outcome of his
or her surgical procedure. How would you best reinforce the patients ability to influence outcome?
A) Teach the patient strategies for distraction.
B) Pair the patient with another patient who has better coping strategies.
C) Incorporate cultural and religious considerations, as appropriate.
D) Give the patient antianxiety medication.
Ans: C
Feedback:
Because the patients emotional state remains a concern, the care initiated by preoperative nurses is
continued by the intraoperative nursing staff that provides the patient with information and reassurance. The nurse
supports coping strategies and reinforces the patients ability to influence outcomes by
encouraging active participation in the plan of care incorporating cultural, ethnic, and religious
considerations, as appropriate. Buddying a patient is normally inappropriate and distraction may or may
not be effective. Nonpharmacologic measures should be prioritized.
36. Maintaining an aseptic environment in the OR is essential to patient safety and infection control. When
moving around surgical areas, what distance must the nurse maintain from the sterile field?
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A) 2 feet
B) 18 inches
C) 1 foot
D) 6 inches
Ans: C
Feedback:
Sterile areas must be kept in view during movement around the area. At least a 1-foot distance from the
sterile field must be maintained to prevent inadvertent contamination.
37. The OR nurse is providing care for a 25-year-old major trauma patient who has been involved in a
motorcycle accident. The nurse should know that the patient is at increased risk for what complication of
surgery?
A) Respiratory depression
B) Hypothermia
C) Anesthesia awareness
D) Moderate sedation
Ans: C
Feedback:
The Joint Commission has issued an alert regarding the phenomenon of patients being partially awake
while under general anesthesia (referred to as anesthesia awareness). Patients at greatest risk of
anesthesia awareness are cardiac, obstetric, and major trauma patients. This patient does not likely face a
heightened risk of respiratory depression or hypothermia. Moderate sedation is not a complication.
38. The OR nurse is participating in the appendectomy of a 20 year-old female patient who has a
dangerously low body mass index. The nurse recognizes the patients consequent risk for hypothermia. What action
should the nurse implement to prevent the development of hypothermia?
A) Ensure that IV fluids are warmed to the patients body temperature.
B) Transfuse packed red blood cells to increase oxygen carrying capacity.
C) Place warmed bags of normal saline at strategic points around the patients body.
D) Monitor the patients blood pressure and heart rate vigilantly.
Ans: A
Feedback:
Warmed IV fluids can prevent the development of hypothermia. Applying warmed bags of saline around
the patient is not common practice. The patient is not transfused to prevent hypothermia. Blood pressure
and heart rate monitoring are important, but do not relate directly to the risk for hypothermia.
39. A 68-year-old patient is scheduled for a bilateral mastectomy. The OR nurse has come out to the holding
area to meet the patient and quickly realizes that the patient is profoundly anxious. What is the most
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appropriate intervention for the nurse to apply?
A) Reassure the patient that modern surgery is free of significant risks.
B) Describe the surgery to the patient in as much detail as possible.
C) Clearly explain any information that the patient seeks.
D) Remind the patient that the anesthetic will render her unconscious.
Ans: C
Feedback:
The nurse can alleviate anxiety by supplying information as the patient requests it. The nurse should not
assume that every patient wants as much detail as possible and false reassurance must be avoided. Reminding the
patient that she will be unconscious is unlikely to reduce anxiety.
40. A 59-year-old male patient is scheduled for a hemorrhoidectomy. The OR nurse should anticipate
assisting the other team members with positioning the patient in what manner?
A) Dorsal recumbent position
B) Trendelenburg position
C) Sims position
D) Lithotomy position
Ans: D
Feedback:
The lithotomy position is used for nearly all perineal, rectal, and vaginal surgical procedures. The Sims
or lateral position is used for renal surgery and the Trendelenburg position usually is used for surgery on
the lower abdomen and pelvis. The usual position for surgery, called the dorsal recumbent position, is
flat on the back, but this would be impracticable for rectal surgery.
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Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 16: Postoperative Nursing Management
The recovery room nurse is admitting a patient from the OR following the patients successful
splenectomy. What is the first assessment that the nurse should perform on this newly admitted patient?
A) Heart rate and rhythm
B) Skin integrity
C) Core body temperature
D) Airway patency
Ans: D
Feedback:
The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent
hypoxemia and hypercapnia. Both can occur if the airway is obstructed and ventilation is reduced. This
assessment is followed by cardiovascular status and the condition of the surgical site. The core
temperature would be assessed after the airway, cardiovascular status, and wound (skin integrity).
An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal
cell carcinoma. The patients vital signs and level of consciousness stabilized, but the patient then
complains of severe nausea and begins to retch. What should the nurse do next?
A) Administer a dose of IV analgesic.
B) Apply a cool cloth to the patients forehead.
C) Offer the patient a small amount of ice chips.
D) Turn the patient completely to one side.
Ans: D
Feedback:
Turning the patient completely to one side allows collected fluid to escape from the side of the mouth if
the patient vomits. After turning the patient to the side, the nurse can offer a cool cloth to the patients
forehead. Ice chips can increase feelings of nausea. An analgesic is not administered for nausea and
vomiting.
The perioperative nurse is preparing to discharge a female patient home from day surgery performed under general
anesthetic. What instruction should the nurse give the patient prior to the patient leaving the hospital?
A) The patient should not drive herself home.
B) The patient should take an OTC sleeping pill for 2 nights.
C) The patient should attempt to eat a large meal at home to aid wound healing.
D) The patient should remain in bed for the first 48 hours postoperative.
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Ans: A
Feedback:
Although recovery time varies, depending on the type and extent of surgery and the patients overall
condition, instructions usually advise limited activity for 24 to 48 hours. Complete bedrest is
contraindicated in most cases, however. During this time, the patient should not drive a vehicle and
should eat only as tolerated. The nurse does not normally make OTC recommendations for hypnotics.
The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is
getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension
and consequent falls, what should the nurse have the patient do?
A) Sit in a chair for 10 minutes prior to ambulating.
B) Drink plenty of fluids to increase circulating blood volume.
C) Stand upright for 2 to 3 minutes prior to ambulating.
D) Perform range-of-motion exercises for each joint.
Ans: C
Feedback:
Older adults are at an increased risk for orthostatic hypotension secondary to age-related changes in
vascular tone. The patient should sit up and then stand for 2 to 3 minutes before ambulating to alleviate
orthostatic hypotension. The nurse should assess the patients ability to mobilize safely, but full
assessment of range of motion in all joints is not normally necessary. Sitting in a chair and increasing
fluid intake are insufficient to prevent orthostatic hypotension and consequent falls.
The perioperative nurse is providing care for a patient who is recovering on the postsurgical unit
following a transurethral prostate resection (TUPR). The patient is reluctant to ambulate, citing the need
to recover in bed. For what complication is the patient most at risk?
A) Atelectasis
B) Anemia
C) Dehydration
D) Peripheral edema
Ans: A
Feedback:
Atelectasis occurs when the postoperative patient fails to move, cough, and breathe deeply. With good
nursing care, this is an avoidable complication, but reduced mobility greatly increases the risk. Anemia
occurs rarely and usually in situations where the patient loses a significant amount of blood or continues
bleeding postoperatively. Fluid shifts postoperatively may result in dehydration and peripheral edema,
but the patient is most at risk for atelectasis.
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The nurse is caring for a patient on the medicalsurgical unit postoperative day 5. During each patient
assessment, the nurse evaluates the patient for infection. Which of the following would be most
indicative of infection?
A) Presence of an indwelling urinary catheter
B) Rectal temperature of 99.5F (37.5C)
C) Red, warm, tender incision
D) White blood cell (WBC) count of 8,000/mL
Ans: C
Feedback:
Redness, warmth, and tenderness in the incision area should lead the nurse to suspect a postoperative
infection. The presence of any invasive device predisposes a patient to infection, but by itself does not
indicate infection. An oral temperature of 99.5F may not signal infection in a postoperative patient
because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000/mL.
The nurse is preparing to change a patients abdominal dressing. The nurse recognizes the first step is to
provide the patient with information regarding the procedure. Which of the following explanations
should the nurse provide to the patient?
A) The dressing change is often painful, and we will be giving you pain medication prior to the
procedure so you do not have to worry.
B) During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you
can look at the incision and help with the procedure if you want to.
C) The dressing change should not be painful, but you can never be sure, and infection is always a
concern.
D) The best time for doing a dressing change is during lunch so we are not interrupted. I will provide
privacy, and it should not be painful.
Ans: B
Feedback:
When having dressings changed, the patient needs to be informed that the dressing change is a simple
procedure with little discomfort; privacy will be provided; and the patient is free to look at the incision
or even assist in the dressing change itself. If the patient decides to look at the incision, assurance is
given that the incision will shrink as it heals and that the redness will likely fade. Dressing changes
should not be painful, but giving pain medication prior to the procedure is always a good preventive
measure. Telling the patient that the dressing change should not be painful, but you can never be sure,
and infection is always a concern does not offer the patient any real information or options and serves
only to create fear. The best time for dressing changes is when it is most convenient for the patient;
nutrition is important so interrupting lunch is probably a poor choice.
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A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for
this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do?
A) Irrigate the Foley with 30 mL normal saline.
B) Notify the physician and continue to monitor the hourly urine output closely.
C) Decrease the IV fluid rate and massage the patients abdomen.
D) Have the patient sit in high-Fowlers position.
Ans: B
Feedback:
If the patient has an indwelling urinary catheter, hourly outputs are monitored and rates of less than 30
mL/hr are reported. The urine output should continue to be monitored hourly by the nurse. Irrigation
would not be warranted.
The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal
surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic
compression stocking. The nurse should explain that refusing to wear external pneumatic compression
stockings increases his risk of what postsurgical complication?
A) Sepsis
B) Infection
C) Pulmonary embolism
D) Hematoma
Ans: C
Feedback:
Patients who have surgery that limits mobility are at an increased risk for pulmonary embolism
secondary to deep vein thrombosis. The use of an external pneumatic compression stocking significantly
reduces the risk by increasing venous return to the heart and limiting blood stasis. The risk of infection
or sepsis would not be affected by an external pneumatic compression stocking. A hematoma or bruise
would not be affected by the external pneumatic compression stocking unless the stockings were placed
directly over the hematoma.
The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats
per minute. After 30 minutes, the patients blood pressure is 94/47 mm Hg, and the pulse is 110. The
nurse documents that the patients skin is cold, moist, and pale. Of what is the patient showing signs?
A) Hypothermia
B) Hypovolemic shock
C) Neurogenic shock
D) Malignant hyperthermia
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Ans: B
Feedback:
The patient is exhibiting symptoms of hypovolemic shock; therefore, the nurse should notify the patients
physician and anticipate orders for fluid and/or blood product replacement. Neurogenic shock does not
normally result in tachycardia and malignant hyperthermia would not present at this stage in the
operative experience. Hypothermia does not cause hypotension and tachycardia.
The PACU nurse is caring for a male patient who had a hernia repair. The patients blood pressure is now
164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure
was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following
surgery?
A) Dysrhythmias, blood loss, and hyperthermia
B) Electrolyte imbalances and neurologic changes
C) A parasympathetic reaction and low blood volumes
D) Pain, hypoxia, or bladder distention
Ans: D
Feedback:
Hypertension is common in the immediate postoperative period secondary to sympathetic nervous
system stimulation from pain, hypoxia, or bladder distention. Dysrhythmias, blood loss, hyperthermia,
electrolyte imbalances, and neurologic changes are not common postoperative reasons for hypertension.
A parasympathetic reaction and low blood volumes would cause hypotension.
The nurse is caring for a patient after abdominal surgery in the PACU. The patients blood pressure has
increased and the patient is restless. The patients oxygen saturation is 97%. What cause for this change
in status should the nurse first suspect?
A) The patient is hypothermic.
B) The patient is in shock.
C) The patient is in pain.
D) The patient is hypoxic.
Ans: C
Feedback:
An increase in blood pressure and restlessness are symptoms of pain. The patients oxygen saturation is
97%, so hypothermia, hypoxia, and shock are not likely causes of the patients restlessness.
The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a
knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is
cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the
packing and resuture the wound. You are aware that the wound will now heal by what means?
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A) Late intention
B) Second intention
C) Third intention
D) First intention
Ans: C
Feedback:
Third-intention healing or secondary suture is used for deep wounds that either had not been sutured
early or that had the suture break down and are resutured later, which is what has happened in this case.
Secondary suture brings the two opposing granulation surfaces back together; however, this usually
results in a deeper and wider scar. These wounds are also packed postoperatively with moist gauze and
covered with a dry, sterile dressing. Late intention is a term that sounds plausible, but is not used in
practice. Second intention is when the wound is left open and the wound is filled with granular tissue.
First intention wounds are wounds made aseptically with a minimum of tissue destruction.
The nurse is caring for an 82-year-old female patient in the PACU. The woman begins to awaken and
responds to her name, but is confused, restless, and agitated. What principle should guide the nurses
subsequent assessment?
A) Postoperative confusion in older adults is an indication of impaired oxygenation or possibly a
stroke during surgery.
B) Confusion, restlessness, and agitation are expected postoperative findings in older adults and they
will diminish in time.
C) Postoperative confusion is common in the older adult patent, but it could also indicate a significant
blood loss.
D) Confusion, restlessness, and agitation indicate an underlying cognitive deficit such as dementia.
Ans: C
Feedback:
Postoperative confusion is common in the older adult patient, but it could also indicate blood loss and
the potential for hypovolemic shock; it is a critical symptom for the nurse to identify. Despite being
common, it is not considered to be an expected finding. Postoperative confusion is an indication of an
oxygen problem or possibly a stroke during surgery, but blood loss is more likely. A new onset of
confusion, restlessness, and agitation does not necessarily suggest an underlying cognitive disorder.
An adult patient has just been admitted to the PACU following abdominal surgery. As the patient begins
to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale.
The nurse concerned the patient may be at risk for what?
A) Hemorrhage and shock
B) Aspiration
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C) Postoperative infection
D) Hypertension and dysrhythmias
Ans: A
Feedback:
The patient with a hemorrhage presents with hypotension; rapid, thready pulse; disorientation;
restlessness; oliguria; and cold, pale skin. Aspiration would manifest in airway disturbance.
Hypertension or dysrhythmias would be less likely to cause pallor and cool skin. An infection would not
be present at this early postoperative stage.
16. The nursing instructor is discussing postoperative care with a group of nursing students. A student nurse
asks, Why does the patient go to the PACU instead of just going straight up to the postsurgical unit?
What is the nursing instructors best response?
A) The PACU allows the patient to recover from anesthesia in a stimulating environment to facilitate
awakening and reorientation.
B) The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the
PACU until he or she is oriented, has stable vital signs, and is without complications.
C) Frequently, patients are placed in the medicalsurgical unit to recover, but hospitals are usually short
of beds, and the PACU is an excellent place to triage patients.
D) Patients remain in the PACU for a predetermined time because the surgeon will often need to
reinforce or alter the patients incision in the hours following surgery.
Ans: B
Feedback:
The PACU provides care for the patient while he or she recovers from the effects of anesthesia. The
patient must be oriented, have stable vital signs, and show no evidence of hemorrhage or other
complications. Patients will sometimes recover in the ICU, but this is considered an extension of the
PACU. The PACU does allow the patient to recover from anesthesia, but the environment is calm and
quiet as patients are initially disoriented and confused as they begin to awaken and reorient. Patients are
not usually placed in the medicalsurgical unit for recovery and, although hospitals are occasionally short
of beds, the PACU is not used for patient triage. Incisions are very rarely modified in the immediate
postoperative period.
The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the
nurse observes that the patients skin has become blue and dusky. The nurse looks, listens, and feels for
breathing, and determines the patient is not breathing. What is the priority intervention?
A) Check the patients oxygen saturation level, continue to monitor for apnea, and perform a focused
assessment.
B) Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw.
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C) Assess the arterial pulses, and place the patient in the Trendelenburg position.
D) Reintubate the patient.
Ans: B
Feedback:
When a nurse finds a patient who is not breathing, the priority intervention is to open the airway and
treat a possible hypopharyngeal obstruction. To treat the possible airway obstruction, the nurse tilts the
head back and then pushes forward on the angle of the lower jaw or performs the jaw thrust method to
open the airway. This is an emergency and requires the basic life support intervention of airway,
breathing, and circulation assessment. Arterial pulses should be checked only after airway and breathing
have been established. Reintubation and resuscitation would begin after rapidly ruling out a
hypopharyngeal obstruction.
18. The nurse is providing teaching about tissue repair and wound healing to a patient who has a leg ulcer.
Which of the following statements by the patient indicates that teaching has been effective?
A) Ill make sure to limit my intake of protein.
B) Ill make sure that the bandage is wrapped tightly.
C) My foot should feel cool or cold while my legs healing.
D) Ill eat plenty of fruits and vegetables.
Ans: D
Feedback:
Optimal nutritional status is important for wound healing; the patient should eat plenty of fruits and
vegetables and not reduce protein intake. To avoid impeding circulation to the area, the bandage should
be secure but not tight. If the patients foot feels cold, circulation is impaired, which inhibits wound
healing.
19. The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the
highest nursing priority?
A) Assessing for hemorrhage
B) Maintaining a patent airway
C) Managing the patients pain
D) Assessing vital signs every 30 minutes
Ans: B
Feedback:
The primary objective in the immediate postoperative period is to maintain ventilation and, thus, prevent
hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood).
Assessing for hemorrhage and assessing vital sign are also important, but constitute second and third
priorities. Pain management is important but only after the patient has been stabilized.
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The nurse is caring for a patient who is postoperative day 2 following a colon resection. While turning
him, wound dehiscence with evisceration occurs. What should be the nurses first response?
A) Return the patient to his previous position and call the physician.
B) Place saline-soaked sterile dressings on the wound.
C) Assess the patients blood pressure and pulse.
D) Pull the dehiscence closed using gloved hands.
Ans: B
Feedback:
The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying
and possible infection. Then the nurse should call the physician and take the patients vital signs. The
dehiscence needs to be surgically closed, so the nurse should never try to close it.
The PACU nurse is caring for a 45-year-old male patient who had a left lobectomy. The nurse is
assessing the patient frequently for airway patency and cardiovascular status. The nurse should know
that the most common cardiovascular complications seen in the PACU include what? Select all that
apply.
A) Hypotension
B) Hypervolemia
C) Heart murmurs
D) Dysrhythmias
E) Hypertension
Ans: A, D, E
Feedback:
The primary cardiovascular complications seen in the PACU include hypotension and shock,
hemorrhage, hypertension, and dysrhythmias. Heart murmurs are not adverse reactions to surgery.
Hypervolemia is not a common cardiovascular complication seen in the PACU, though fluid balance
must be vigilantly monitored.
A postoperative patient rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale
skin. The nurse suspects that the patient is experiencing a hemorrhage. What should be the nurses first
action?
A) Leave and promptly notify the physician.
B) Quickly attempt to determine the cause of hemorrhage.
C) Begin resuscitation.
D) Put the patient in the Trendelenberg position.
Ans: B
Feedback:
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Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic
measures. Resuscitation is not necessarily required and the nurse must not leave the patient. The
Trendelenberg position would be contraindicated.
The intraoperative nurse is transferring a patient from the OR to the PACU after replacement of the right
knee. The patient is a 73-year-old woman. The nurse should prioritize which of the following actions?
A) Keeping the patient sterile
B) Keeping the patient restrained
C) Keeping the patient warm
D) Keeping the patient hydrated
Ans: C
Feedback:
Special attention is given to keeping the patient warm because elderly patients are more susceptible to
hypothermia. It is all important for the nurse to pay attention to hydration, but hypovolemia does not
occur as quickly as hypothermia. The patient is never sterile and restraints are very rarely necessary.
24. A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the
patient to be discharged from the PACU? Select all that apply.
A) Absence of pain
B) Stable blood pressure
C) Ability to tolerate oral fluids
D) Sufficient oxygen saturation
E) Adequate respiratory function
Ans: B, D, E
Feedback:
A patient remains in the PACU until fully recovered from the anesthetic agent. Indicators of recovery
include stable blood pressure, adequate respiratory function, and adequate oxygen saturation level
compared with baseline. Patients can be released from PACU before resuming oral intake. Pain is often
present at discharge from the PACU and can be addressed in other inpatient settings.
The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of
the discharge instructions with the patient and her caregiver. What else should the nurse do before
discharging the patient from the facility? Select all that apply.
A) Provide all discharge instructions in writing.
B) Provide the nurses or surgeons contact information.
C) Give prescriptions to the patient.
D) Irrigate the patients incision and perform a sterile dressing change.
E) Administer a bolus dose of an opioid analgesic.
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Ans: A, B, C
Feedback:
Before discharging the patient, the nurse provides written instructions, prescriptions and the nurses or
surgeons telephone number. Administration of an opioid would necessitate further monitoring to ensure safety. A dressing
change would not normally be ordered on the day of surgery.
The nursing instructor is discussing the difference between ambulatory surgical centers and hospitalbased
surgical units. A student asks why some patients have surgery in the hospital and others are sent to
ambulatory surgery centers. What is the instructors best response?
A) Patients who go to ambulatory surgery centers are more independent than patients admitted to the
hospital.
B) Patients admitted to the hospital for surgery usually have multiple health needs.
C) In most cases, only emergency and trauma patients are admitted to the hospital.
D) Patients who have surgery in the hospital are those who need to have anesthesia administered.
Ans: B
Feedback:
Patients admitted to the clinical unit for postoperative care have multiple needs and stay for a short
period of time. Patients who have surgery in ambulatory centers do not necessarily have greater
independence. It is not true that only trauma and emergency surgeries are done in the hospital.
Ambulatory centers can administer anesthesia.
27. The nurse just received a postoperative patient from the PACU to the medicalsurgical unit. The patient is
an 84-year-old woman who had surgery for a left hip replacement. Which of the following concerns
should the nurse prioritize for this patient in the first few hours on the unit?
A) Beginning early ambulation
B) Maintaining clean dressings on the surgical site
C) Close monitoring of neurologic status
D) Resumption of normal oral intake
Ans: C
Feedback:
In the initial hours after admission to the clinical unit, adequate ventilation, hemodynamic stability,
incisional pain, surgical site integrity, nausea and vomiting, neurologic status, and spontaneous voiding
are primary concerns. A patient who has had total hip replacement does not ambulate during the first
few hours on the unit. Dressings are assessed, but may have some drainage on them. Oral intake will
take more time to resume.
28. The nurses aide notifies the nurse that a patient has decreased oxygen saturation levels. The nurse assesses
the patient and finds that he is tachypnic, has crackles on auscultation, and his sputum is frothy
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and pink. The nurse should suspect what complication?
A) Pulmonary embolism
B) Atelectasis
C) Laryngospasm
D) Flash pulmonary edema
Ans: D
Feedback:
Flash pulmonary edema occurs when protein and fluid accumulate in the alveoli unrelated to elevated
pulmonary artery occlusive pressure. Signs and symptoms include agitation; tachypnea; tachycardia;
decreased pulse oximetry readings; frothy, pink sputum; and crackles on auscultation. Laryngospasm
does not cause crackles or frothy, pink sputum. The patient with atelectasis has decreased breath sounds
over the affected area; the scenario does not indicate this. A pulmonary embolism does not cause this
symptomatology.
The nurse is performing the shift assessment of a postsurgical patient. The nurse finds his mental status,
level of consciousness, speech, and orientation are intact and at baseline, but the patient tells you he is
very anxious. What should the nurse do next?
A) Assess the patients oxygen levels.
B) Administer antianxiety medications.
C) Page the patients the physician.
D) Initiate a social work referral.
Ans: A
Feedback:
The nurse assesses the patients mental status and level of consciousness, speech, and orientation and
compares them with the preoperative baseline. Although a change in mental status or postoperative
restlessness may be related to anxiety, pain, or medications, it may also be a symptom of oxygen deficit
or hemorrhage. Antianxiety medications are not given until the cause of the anxiety is known. The
physician is notified only if the reason for the anxiety is serious or if an order for medication is needed.
A social work consult is inappropriate at this time.
The nurse is creating the plan of care for a patient who is status postsurgery for reduction of a femur
fracture. What is the most important short-term goal for this patient?
A) Relief of pain
B) Adequate respiratory function
C) Resumption of activities of daily living (ADLs)
D) Unimpaired wound healing
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Ans: B
Feedback:
Maintenance of the patients airway and breathing are imperative. Respiratory status is important because
pulmonary complications are among the most frequent and serious problems encountered by the surgical
patient. Wound healing and eventual resumption of ADLs would be later concerns. Pain management is
a high priority, but respiratory function is a more acute physiological need.
You are caring for a 71-year-old patient who is 4 days postoperative for bilateral inguinal hernias. The
patient has a history of congestive heart failure and peptic ulcer disease. The patient is highly reluctant to
ambulate and will not drink fluids except for hot tea with her meals. The nurses aide reports to you that
this patients vital signs are slightly elevated and that she has a nonproductive cough. When you assess
the patient, you auscultate crackles at the base of the lungs. What would you suspect is wrong with your
patient?
A) Pulmonary embolism
B) Hypervolemia
C) Hypostatic pulmonary congestion
D) Malignant hyperthermia
Ans: C
Feedback:
Hypostatic pulmonary congestion, caused by a weakened cardiovascular system that permits stagnation
of secretions at lung bases, may develop; this condition occurs most frequently in elderly patients who
are not mobilized effectively. The symptoms are often vague, with perhaps a slight elevation of
temperature, pulse, and respiratory rate, as well as a cough. Physical examination reveals dullness and
crackles at the base of the lungs. If the condition progresses, then the outcome may be fatal. A
pulmonary embolism does not have this presentation and hypervolemia is unlikely due to the patients
low fluid intake. Malignant hyperthermia occurs concurrent with the administration of anesthetic.
The nurse is admitting a patient to the medicalsurgical unit from the PACU. What should the nurse do to
help the patient clear secretions and help prevent pneumonia?
A) Encourage the patient to eat a balanced diet that is high in protein.
B) Encourage the patient to limit his activity for the first 72 hours.
C) Encourage the patient to take his medications as ordered.
D) Encourage the patient to use the incentive spirometer every 2 hours.
Ans: D
Feedback:
To clear secretions and prevent pneumonia, the nurse encourages the patient to turn frequently, take deep
breaths, cough, and use the incentive spirometer at least every 2 hours. These pulmonary exercises
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should begin as soon as the patient arrives on the clinical unit and continue until the patient is
discharged. A balanced, high protein diet; visiting family in the waiting room; or taking medications as
ordered would not help to clear secretions or prevent pneumonia.
A surgical patient has just been admitted to the unit from PACU with patient-controlled analgesia
(PCA). The nurse should know that the requirements for safe and effective use of PCA include what?
A) A clear understanding of the need to self-dose
B) An understanding of how to adjust the medication dosage
C) A caregiver who can administer the medication as ordered
D) An expectation of infrequent need for analgesia
Ans: A
Feedback:
The two requirements for PCA are an understanding of the need to self-dose and the physical ability to
self-dose. The patient does not adjust the dose and only the patient himself or herself should administer a
dose. PCAs are normally used for patients who are expected to have moderate to severe pain with a
regular need for analgesia.
A patient underwent an open bowel resection 2 days ago and the nurses most recent assessment of the
patients abdominal incision reveals that it is dehiscing. What factor should the nurse suspect may have
caused the dehiscence?
A) The patients surgical dressing was changed yesterday and today.
B) The patient has vomited three times in the past 12 hours.
C) The patient has begun voiding on the commode instead of a bedpan.
D) The patient used PCA until this morning.
Ans: B
Feedback:
Vomiting can produce tension on wounds, particularly of the torso. Dressing changes and light
mobilization are unlikely to cause dehiscence. The use of a PCA is not associated with wound
dehiscence.
The dressing surrounding a mastectomy patients Jackson-Pratt drain has scant drainage on it. The nurse
believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm
this suspicion?
A) Describe the appearance of the dressing in the electronic health record.
B) Photograph the patients abdomen for later comparison using a smartphone.
C) Trace the outline of the drainage on the dressing for future comparison.
D) Remove and weigh the dressing, reapply it, and then repeat in 8 hours.
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Ans: C
Feedback:
Spots of drainage on a dressing are outlined with a pen, and the date and time of the outline are recorded
on the dressing so that increased drainage can be easily seen. A dressing is never removed and then
reapplied. Photographs normally require informed consent, so they would not be used for this purpose.
Documentation is necessary, but does not confirm or rule out an increase in drainage.
The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days
postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn
how to change her dressing. What would indicate to the nurse the patients possible readiness to learn
how to change her dressing? Select all that apply.
A) The patient wants you to teach a family member to do dressing changes.
B) The patient expresses interest in the dressing change.
C) The patient is willing to look at the incision during a dressing change.
D) The patient expresses dislike of the surgical wound.
E) The patient assists in opening the packages of dressing material for the nurse.
Ans: B, C, E
Feedback:
While changing the dressing, the nurse has an opportunity to teach the patient how to care for the
incision and change the dressings at home. The nurse observes for indicators of the patients readiness to
learn, such as looking at the incision, expressing interest, or assisting in the dressing change. Expressing
dislike and wanting to delegate to a family member do not suggest readiness to learn.
The nursing instructor is talking with a group of medicalsurgical students about deep vein thrombosis
(DVT). A student asks what factors contribute to the formation of a DVT. What would be the instructors
best response?
A) There is a genetic link in the formation of deep vein thrombi.
B) Hypervolemia is often present in patients who go on to develop deep vein thrombi.
C) No known factors contribute to the formation of deep vein thrombi; they just occur.
D) Dehydration is a contributory factor to the formation of deep vein thrombi.
Ans: D
Feedback:
The stress response that is initiated by surgery inhibits the fibrinolytic system, resulting in blood
hypercoagulability. Dehydration, low cardiac output, blood pooling in the extremities, and bedrest add to
the risk of thrombosis formation. Hypervolemia is not a risk factor and there are no known genetic
factors.
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38. The home health nurse is caring for a postoperative patient who was discharged home on day 2 after
surgery. The nurse is performing the initial visit on the patients postoperatative day 2. During the visit,
the nurse will assess for wound infection. For most patients, what is the earliest postoperative day that a
wound infection becomes evident?
A) Day 9
B) Day 7
C) Day 5
D) Day 3
Ans: C
Feedback:
Wound infection may not be evident until at least postoperative day 5. This makes the other options
incorrect.
39. The nurse is caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The
patient is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the
patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired
psychomotor skills. What should the nurse suspect is the problem with the patient?
A) Postoperative delirium
B) Postoperative dementia
C) Senile dementia
D) Senile confusion
Ans: A
Feedback:
Postoperative delirium, characterized by confusion, perceptual and cognitive deficits, altered attention
levels, disturbed sleep patterns, and impaired psychomotor skills, is a significant problem for older
adults. Dementia does not have a sudden onset. Senile confusion is not a recognized health problem.
The surgeons preoperative assessment of a patient has identified that the patient is at a high risk for
venous thromboembolism. Once the patient is admitted to the postsurgical unit, what intervention should
the nurse prioritize to reduce the patients risk of developing this complication?
A) Maintain the head of the bed at 45 degrees or higher.
B) Encourage early ambulation.
C) Encourage oral fluid intake.
D) Perform passive range-of-motion exercises every 8 hours.
Ans: B
Feedback:
The benefits of early ambulation and leg exercises in preventing DVT cannot be overemphasized, and
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these activities are recommended for all patients, regardless of their risk. Increasing the head of the bed
is not effective. Ambulation is superior to passive range-of-motion exercises. Fluid intake is important,
but is less protective than early ambulation.
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UNIT 4 Gas Exchange and Respiratory Function
Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 17: Assessment of Respiratory Function
A patient is having her tonsils removed. The patient asks the nurse what function the tonsils normally serve. Which
of the following would be the most accurate response?
A) The tonsils separate your windpipe from your throat when you swallow.
B) The tonsils help to guard the body from invasion of organisms.
C) The tonsils make enzymes that you swallow and which aid with digestion.
D) The tonsils help with regulating the airflow down into your lungs
B) The tonsils help to guard the body from invasion of organisms.
The nurse is caring for a patient who has just returned to the unit after a colon resection. The patient is showing
signs of hypoxia. The nurse knows that this is probably caused by what?
A) Nitrogen narcosis
B) Infection
C) Impaired diffusion
D) Shunting
D) Shunting
The nurse is assessing a patient who frequently coughs after eating or drinking. How should the nurse best follow
up this assessment finding?
A) Obtain a sputum sample.
B) Perform a swallowing assessment.
C) Inspect the patients tongue and mouth.
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D) Assess the patients nutritional status.
B) Perform a swallowing assessment.
The ED nurse is assessing a patient complaining of dyspnea. The nurse auscultates the patients chest and hears
wheezing throughout the lung fields. What might this indicate?
A) The patient has a narrowed airway.
B) The patient has pneumonia.
C) The patient needs physiotherapy.
D) The patient has a hemothorax.
A) The patient has a narrowed airway.
The nurse is caring for a patient admitted with an acute exacerbation of chronic obstructive pulmonary disease.
During assessment, the nurse finds that the patient is experiencing increased dyspnea. What is the most accurate
measurement of the concentration of oxygen in the patients blood?
A) A capillary blood sample
B) Pulse oximetry
C) An arterial blood gas (ABG) study
D) A complete blood count (CBC)
C) An arterial blood gas (ABG) study
The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for
something to drink. Which criterion will determine when the nurse should allow the patient to drink fluids?
A) Presence of a cough and gag reflex
B) Absence of nausea
C) Ability to demonstrate deep inspiration
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D) Oxygen saturation of 92%
A) Presence of a cough and gag reflex
A patient with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air
inspired and expired with a normal breath?
A) Total lung capacity
B) Forced vital capacity
C) Tidal volume
D) Residual volume
C) Tidal volume
In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a patients
arterial oxygen saturation (SaO2). What procedure will best accomplish this?
A) Incentive spirometry
B) Arterial blood gas (ABG) measurement
C) Peak flow measurement
D) Pulse oximetry
D) Pulse oximetry
A patient asks the nurse why an infection in his upper respiratory system is affecting the clarity of his speech.
Which structure serves as the patients resonating chamber in speech?
A) Trachea
B) Pharynx
C) Paranasal sinuses
D) Larynx
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C) Paranasal sinuses
A patient with a decreased level of consciousness is in a recumbent position. How should the nurse best assess
the lung fields for a patient in this position?
A) Inform that physician that the patient is in a recumbent position and anticipate an order for a portable chest xray.
B) Turn the patient to enable assessment of all the patients lung fields.
C) Avoid turning the patient, and assess the accessible breath sounds from the anterior chest wall.
D) Obtain a pulse oximetry reading, and, if the reading is low, reposition the patient and auscultate breath sounds.
B) Turn the patient to enable assessment of all the patients lung fields.
A patient is undergoing testing to see if he has a pleural effusion. Which of the nurses respiratory assessment
findings would be most consistent with this diagnosis?
A) Increased tactile fremitus, egophony, and a dull sound upon percussion of the chest wall
B) Decreased tactile fremitus, wheezing, and a hyperresonant sound upon percussion of the chest wall
C) Lung fields dull to percussion, absent breath sounds, and a pleural friction rub
D) Normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion of the chest wall
C) Lung fields dull to percussion, absent breath sounds, and a pleural friction rub
The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside
table in a patients room. The nurse asks the patient when he produced the sputum specimen and he states that the
specimen is about 4 hours old. What action should the nurse take?
A) Immediately take the sputum specimen to the laboratory.
B) Discard the specimen and assist the patient in obtaining another specimen.
C) Refrigerate the sputum specimen and submit it once it is chilled.
D) Add a small amount of normal saline to moisten the specimen.
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B) Discard the specimen and assist the patient in obtaining another specimen.
The nurse is assessing a newly admitted medical patient and notes there is a depression in the lower portion of the
patients sternum. This patients health record should note the presence of what chest deformity?
A) A barrel chest
B) A funnel chest
C) A pigeon chest
D) Kyphoscoliosis
B) A funnel chest
The medical nurse who works on a pulmonology unit is aware that several respiratory conditions can affect lung
tissue compliance. The presence of what condition would lead to an increase in lung compliance?
A) Emphysema
B) Pulmonary fibrosis
C) Pleural effusion
D) Acute respiratory distress syndrome (ARDS)
A) Emphysema
A medical nurse has admitted a patient to the unit with a diagnosis of failure to thrive. The patient has developed a
fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that
there is a large quantity of it. The nurse notifies the patients physician because these symptoms are suggestive of
what?
A) Pneumothorax
B) Lung tumors
C) Infection
D) Pulmonary edema
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C) Infection
A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should
the nurse expect to assess on auscultation?
A) Expiratory wheezes
B) Inspiratory wheezes
C) Rhonchi
D) Crackles
D) Crackles
A patient has a diagnosis of multiple sclerosis. The nurse is aware that neuromuscular disorders such as multiple
sclerosis may lead to a decreased vital capacity. What does vital capacity measure?
A) The volume of air inhaled and exhaled with each breath
B) The volume of air in the lungs after a maximal inspiration
C) The maximal volume of air inhaled after normal expiration
D) The maximal volume of air exhaled from the point of maximal inspiration
D) The maximal volume of air exhaled from the point of maximal inspiration
While assessing an acutely ill patients respiratory rate, the nurse assesses four normal breaths followed by an
episode of apnea lasting 20 seconds. How should the nurse document this finding?
A) Eupnea
B) Apnea
C) Biots respiration
D) Cheyne-Stokes
C) Biots respiration
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The nurse is caring for an elderly patient in the PACU. The patient has had a bronchoscopy, and the nurse is
monitoring for complications related to the administration of lidocaine. For what complication related to the
administration of large doses of lidocaine in the elderly should the nurse assess?
A) Decreased urine output and hypertension
B) Headache and vision changes
C) Confusion and lethargy
D) Jaundice and elevated liver enzymes
C) Confusion and lethargy
While assessing a patient who has pneumonia, the nurse has the patient repeat the letter E while the nurses
auscultates. The nurse notes that the patients voice sounds are distorted and that the letter A is audible instead of
the letter E. How should this finding be documented?
A) Bronchophony
B) Egophony
C) Whispered pectoriloquy
D) Sonorous wheezes
B) Egophony
The clinic nurse is caring for a patient who has been diagnosed with emphysema and who has just had a
pulmonary function test (PFT) ordered. The patient asks, What exactly is this test for? What would be the nurses
best response?
A) A PFT measures how much air moves in and out of your lungs when you breathe.
B) A PFT measures how much energy you get from the oxygen you breathe.
C) A PFT measures how elastic your lungs are.
D) A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood.
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A) A PFT measures how much air moves in and out of your lungs when you breathe.
A patient is being treated for a pulmonary embolism and the medical nurse is aware that the patient suffered an
acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology?
A) Maintenance of constant osmotic pressure in the alveoli
B) Maintenance of muscle tone in the diaphragm
C) pH balance in the pulmonary veins and arteries
D) Adequate flow of blood through the pulmonary circulation.
D) Adequate flow of blood through the pulmonary circulation.
The nurse is performing a respiratory assessment of an adult patient and is attempting to distinguish between
vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these
normal breath sounds on what basis?
A) Their location over a specific area of the lung
B) The volume of the sounds
C) Whether they are heard on inspiration or expiration
D) Whether or not they are continuous breath sounds
A) Their location over a specific area of the lung
A patient has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed
excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function?
A) Acidbase balance
B) Perfusion
C) Diffusion
D) Ventilation
B) Perfusion
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A patient is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The
patient inquires about the normal function of pleural fluid. What should the nurse describe?
A) It allows for full expansion of the lungs within the thoracic cavity.
B) It prevents the lungs from collapsing within the thoracic cavity.
C) It limits lung expansion within the thoracic cavity.
D) It lubricates the movement of the thorax and lungs.
D) It lubricates the movement of the thorax and lungs.
The nurse is caring for a patient with a lower respiratory tract infection. When planning a focused respiratory
assessment, the nurse should know that this type of infection most often causes what?
A) Impaired gas exchange
B) Collapsed bronchial structures
C) Necrosis of the alveoli
D) Closed bronchial tree
A) Impaired gas exchange
The nurse is performing a respiratory assessment of a patient who has been experiencing episodes of hypoxia. The
nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas
exchange primarily depend?
A) An appropriate perfusiondiffusion ratio
B) An adequate ventilationperfusion ratio
C) Adequate diffusion of gas in shunted blood
D) Appropriate blood nitrogen concentration
B) An adequate ventilationperfusion ratio
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The nurse is caring for a patient with lung metastases who just underwent a mediastinotomy. What should be the
focus of the nurses postprocedure care?
A) Assisting with pulmonary function testing (PFT)
B) Maintaining the patients chest tube
C) Administering oral suction as needed
D) Performing chest physiotherapy
B) Maintaining the patients chest tube
The nurse is caring for a patient who has a pleural effusion and who underwent a thoracoscopic procedure earlier
in the morning. The nurse should prioritize assessment for which of the following?
A) Sputum production
B) Shortness of breath
C) Throat discomfort
D) Epistaxis
B) Shortness of breath
A gerontologic nurse is analyzing the data from a patients focused respiratory assessment. The nurse is aware that
the amount of respiratory dead space increases with age. What is the effect of this physiological change?
A) Increased diffusion of gases
B) Decreased diffusion capacity for oxygen
C) Decreased shunting of blood
D) Increased ventilation
B) Decreased diffusion capacity for oxygen
The nurse is assessing the respiratory status of a patient who is experiencing an exacerbation of her emphysema
symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate?
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A) Absence of breath sounds
B) Wheezing with discontinuous breath sounds
C) Faint breath sounds with prolonged expiration
D) Faint breath sounds with fine crackles
C) Faint breath sounds with prolonged expiration
The patient has just had an MRI ordered because a routine chest x-ray showed suspicious areas in the right lung.
The physician suspects bronchogenic carcinoma. An MRI would most likely be order to assess for what in this
patient?
A) Alveolar dysfunction
B) Forced vital capacity
C) Tidal volume
D) Chest wall invasion
D) Chest wall invasion
A sputum study has been ordered for a patient who has developed coarse chest crackles and a fever. At what time
should the nurse best collect the sample?
A) Immediately after a meal
B) First thing in the morning
C) At bedtime
D) After a period of exercise
B) First thing in the morning
The ED nurse is assessing the respiratory function of a teenage girl who presented with acute shortness of breath.
Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive what?
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A) Pleurisy
B) Emphysema
C) Asthma
D) Pneumonia
C) Asthma
The nurse is caring for a patient who has been scheduled for a bronchoscopy. How should the nurse prepare the
patient for this procedure?
A) Administer a bolus of IV fluids.
B) Arrange for the insertion of a peripherally inserted central catheter.
C) Administer nebulized bronchodilators every 2 hours until the test.
D) Withhold food and fluids for several hours before the test.
D) Withhold food and fluids for several hours before the test.
A nurse educator is reviewing the implications of the oxyhemoglobin dissociation curve with regard to the case of a
current patient. The patient currently has normal hemoglobin levels, but significantly decreased SaO2 and PaO2
levels. What is an implication of this physiological state?
A) The patients tissue demands may be met, but she will be unable to respond to physiological stressors.
B) The patients short-term oxygen needs will be met, but she will be unable to expel sufficient CO2.
C) The patient will experience tissue hypoxia with no sensation of shortness of breath or labored breathing.
D) The patient will experience respiratory alkalosis with no ability to compensate.
A) The patients tissue demands may be met, but she will be unable to respond to physiological stressors.
A medical patient rings her call bell and expresses alarm to the nurse, stating, Ive just coughed up this blood. That
cant be good, can it? How can the nurse best determine whether the source of the blood was the patients lungs?
A) Obtain a sample and test the pH of the blood, if possible.
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B) Try to see if the blood is frothy or mixed with mucus.
C) Perform oral suctioning to see if blood is obtained.
D) Swab the back of the patients throat to see if blood is present.
B) Try to see if the blood is frothy or mixed with mucus.
The nurse is completing a patients health history with regard to potential risk factors for lung disease. What
interview question addresses the most significant risk factor for respiratory diseases?
A) Have you ever been employed in a factory, smelter, or mill?
B) Does anyone in your family have any form of lung disease?
C) Do you currently smoke, or have you ever smoked?
D) Have you ever lived in an area that has high levels of air pollution?
C) Do you currently smoke, or have you ever smoked?
A patient on the medical unit has told the nurse that he is experiencing significant dyspnea, despite that he has not
recently performed any physical activity. What assessment question should the nurse ask the patient while
preparing to perform a physical assessment?
A) On a scale from 1 to 10, how bad would rate your shortness of breath?
B) When was the last time you ate or drank anything?
C) Are you feeling any nausea along with your shortness of breath?
D) Do you think that some medication might help you catch your breath?
A) On a scale from 1 to 10, how bad would rate your shortness of breath?
The nurse has assessed a patients family history for three generations. The presence of which respiratory disease
would justify this type of assessment?
A) Asthma
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B) Obstructive sleep apnea
C) Community-acquired pneumonia
D) Pulmonary edema
A) Asthma
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Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 18: Management of Patients With Upper Respiratory Tract Disorders
Which is the antibiotic of choice used to treat acute bacterial rhinosinusitis (ABRS)?
Amoxicillin
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which
instruction to the client and family?
"Family members should continue to talk to the client."
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of
2 to 12 days
Wound drains, inserted during the laryngectomy, stay in place until what criteria are met?
Drainage is <30 mL/day for 2 consecutive days.
The nurse is providing discharge instructions to a client who has nasal packing in place following nasal surgery.
Which discharge instructions would be most appropriate for the client?
Avoid sports activities for 6 weeks.
The nurse is providing discharge instructions for a client following laryngeal surgery. The nurse instructs the client
to avoid
swimming.
A patient is diagnosed as being in the early stage of laryngeal cancer of the glottis with only 1 vocal cord involved.
For what type of surgical intervention will the nurse plan to provide education?
Partial laryngectomy
A nurse takes the initial history of a patient who is being examined for cancer of the larynx. Select the sign that is
considered an early clinical indicator.
Hoarseness of more than 2 week's duration
A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the
clientts temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing
diagnosis is
Ineffective airway clearance related to excess mucus production
A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to
Seek medical help if he experiences inability to swallow
The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube.
Which of the following nursing actions is most important to complete every hour to ensure that the respiratory
system is not compromised?
Auscultate lung sounds.
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A client is being seen by the physician because of an unrelenting headache, facial tenderness, low-grade fever, and
dark yellow nasal discharge. The client reports seeming to develop sinus infections "all the time." Which factor may
predispose the client to sinusitis?
interference with sinus drainage
The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is
least likely?
"I was chewing ice chips all day long."
The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a lifethreatening situation?
Sudden restlessness
A client comes into the emergency department with epistaxis. What intervention should the nurse perform when
caring for a client with epistaxis?
Apply direct continuous pressure.
A client with acute viral rhinosinusitis is being seen in a clinic. The nurse is providing discharge instructions and
includes the following information:
Avoid air travel.
A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split
of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?
Partial laryngectomy
The nurse assesses a client who is bleeding profusely from the nose. The nurse documents this finding as which
condition?
Epistaxis
The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be
brought to the physiciants attention?
Hoarseness for 2 weeks
A client exhibits a sudden and complete loss of voice and is coughing. The nurse states
"Do not smoke and avoid being around others who are smoking."
Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy?
impaired verbal communication
A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible
complication of the infection by assessing for
Nuchal rigidity
A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and
was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the
pleurae, which surround the lungs, to prevent friction rub?
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20 mL or less
A 13-year-old soccer player presents to the emergency room with a fractured nose. The patientts mother is given
which of the following post-discharge instructions? Select all that apply.
Check for any unusual changes in breathing during the first 48 hours.
Observe for any clear drainage from either nostril.
Elevate the head of the bed for sleeping during the first week.
Restrict from sports activities for 6 weeks.
A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated
fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks?
Applying nasal packing
The nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been
put in place. Which intervention should the nurse include in the clientts care?
Apply an ice pack.
A patient has herpes simplex infection that developed after having the common cold. What medication does the
nurse anticipate will be administered for this infection?
An antiviral agent such as acyclovir
The nurse is caring for a client following a tonsillectomy and adenoidectomy. Two hours after the procedure, the
client begins to vomit large amounts of dark blood at frequent intervals and is tachycardic and febrile. After
notifying the surgeon, the nurse
obtains a light, mirror, gauze, and curved hemostats.
A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patientts family that:
A permanent tracheal stoma would be necessary.
A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring
for a client with epistaxis?
Apply direct continuous pressure.
Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer
require?
Emotional support
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged
adenoids?
Noisy breathing
An older male client with a history of chronic laryngitis reports a persistent hoarseness. What condition is the client
at risk to develop?
laryngeal cancer
The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing
plan of care?
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Develop an alternate method of communication.
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:
sit upright, leaning slightly forward.
The client is to receive cephalexin (Ancef) 500 mg in 50 mL of normal saline intravenous piggyback. The medication
is to infuse over 30 minutes. How many mL/hr would the nurse set the intravenous pump? Enter the correct number
ONLY.
100
The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical
equipment does the nurse anticipate to find in the clientts room?
A face mask
The nurse is caring for a client in the physiciants office with a potential sinus infection. The physician orders a
diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is
specifically ordered for this purpose?
Transillumination of the sinus
A homeless client with streptococcal pharyngitis is being seen in a clinic. The nurse is concerned that the client will
not continue treatment after leaving the clinic. Which of the following measures is the highest priority?
Administer one intramuscular injection of penicillin.
The nurse is caring for a client status post adenoidectomy. The nurse finds the client in severe respiratory distress
when entering the room. What does the nurse suspect?
Edema of the upper airway
The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete
in an effort to meet the clientts nutritional needs?
Initiate enteral feedings.
Most cases of acute pharyngitis are caused by which of the following?
Viral infection
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which
sign or symptom immediately?
Bleeding
Which is the priority nursing diagnosis for a client undergoing a laryngectomy?
Ineffective airway clearance
A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does
the nurse understand is the cause of acute pharyngitis?
Group A, beta-hemolytic streptococci
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Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 19: Management of Patients With Chest and Lower Respiratory Tract Disorders
A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which
intervention in the care plan?
Putting on an individually fitted mask when entering the client's room
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include
when planning this clientts care?
Encouraging increased fluid intake
Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for
tuberculosis?
"Because I had a previous reaction to the test, this time I need to get a chest X-ray."
A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the
nurse to implement with this client?
Developing a list of people with whom the client has had contact
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of
problems?
Hypercapnia, hypoventilation, and hypoxemia
During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his
understanding of relapse when he states that he must:
continue to take antibiotics for the entire 10 days.
Which interventions does a nurse implement for clients with empyema?
Encourage breathing exercises
A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse
expects the physician to document this fluid as
pleural effusion.
You are a clinic nurse caring for a client with acute tracheobronchitis. The client asks what may have caused the
infection. Which of the following responses from the nurse would be most accurate?
Chemical irritation
Which would be least likely to contribute to a case of hospital-acquired pneumonia?
A nurse washes her hands before beginning client care.
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A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the
following clinical manifestations correlate with a moderate pulmonary contusion?
Blood-tinged sputum
A client who works construction and has been demolishing an older building is diagnosed with pneumoconiosis.
This lung inflammation is most likely caused by exposure to:
asbestos
A client is being discharged following pelvic surgery. What would be included in the patient care instructions to
prevent the development of a pulmonary embolus?
Tense and relax muscles in the lower extremities
A client who underwent thoracic surgery to remove a lung tumor had a chest tube placed anteriorly. The surgical
team places this catheter to:
remove air from the pleural space.
In the prevention of occupational lung diseases, the nurse would direct preventive teaching to which high-risk
occupations? Select all that apply.
Rock quarry worker
Miner
A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included
in the plan of care?
"You must consume a diet rich in protein, such as chicken, fish, and beans."
The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to
prevent INH-associated peripheral neuropathy?
Vitamin B6
After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be
considered
Significant
The nurse is auscultating the patientts lung sounds to determine the presence of pulmonary edema. What
adventitious lung sounds are significant for pulmonary edema?
Crackles in the lung bases
A patient who wears contact lenses is to be placed on rifampin for tuberculosis therapy. What should the nurse tell
the patient?
"You should switch to wearing your glasses while taking this medication."
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A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects
that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for:
acute respiratory distress syndrome (ARDS)
On auscultation, which finding suggests a right pneumothorax?
Absence of breath sounds in the right thorax
A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary
embolism. Which findings suggest pulmonary embolism?
Chest pain and dyspnea
A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and
complains of acute chest pain. What action should the nurse take first?
Initiate oxygen therapy
A nurse observes a new environmental services employee enter the room of a client with severe acute respiratory
syndrome. Which action by the employee requires immediate intervention by the nurse
The employee enters the room wearing a gown, gloves, and a mask
Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the
suture line or chest dressing 2 hours after chest surgery?
Record the observation
Which type of lung cancer is the most prevalent among both men and women?
Adenocarcinoma
Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections?
Receiving vaccinations
What dietary recommendations should a nurse provide a client with a lung abscess?
diet rich in protein
Which is a true statement regarding severe acute respiratory syndrome (SARS)?
It is most contagious during the second week of illness
Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
Vitamin B6
The occupational nurse is completing routine assessments on the employees where you work. What might be
revealed by a chest radiograph for a client with occupational lung diseases?
Fibrotic changes in lungs
The nurse is caring for a client with tuberculosis. Why should the nurse always encourage a client with tuberculosis
to perform active range-of-motion (ROM) exercises three times a day?
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For maintaining muscle strength
The nurse is collaborating with a community group to develop plans to reduce the incidence of lung cancer in the
community. Which of the following would be most effective?
Classes at community centers to teach about smoking cessation strategies
A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse
implement for patients with empyema?
Encourage breathing exercises
The nurse is assessing a clientts potential for pulmonary emboli. What finding indicates possible deep vein
thrombosis
Localized calf tenderness
Which action should the nurse take first in caring for a client during an acute asthma attack?
Administer bronchodilator as ordered
A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing
assessments is significant in diagnosing this client with flail chest?
Paradoxical chest movement
A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left
lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most
common organism that causes community-acquired pneumonia?
Streptococcus pneumoniae
A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohnts
disease. What results would the nurse determine is not significant for holding the medication?
0 to 4 mm
A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which
nursing diagnosis has the highest priority?
Impaired gas exchange
An elderly client is diagnosed with pulmonary tuberculosis. Upset and tearful, he asks the nurse how long he must
be separated from his family. Which nursing diagnosis is most appropriate for this client?
Deficient knowledge (disease process and treatment regimen)
A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of
postoperative pneumonia in this client?
Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer
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A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD
testing is true?
A positive reaction indicates that the client has been exposed to the disease
A positive Mantoux test indicates that a client:
has produced an immune response
Resistance to a first-line antituberculotic agent in a client who has not received previous treatment is referred to as
primary drug resistance
You are assessing a clientts potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?
Pain in the calf
You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the
water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the
water-seal chamber is excessive?
See if there are leaks in the system
The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that
this client is at increased risk for which of the following?
Acute respiratory distress syndrome
You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory
failure?
Progressive loss of lung function associated with chronic disease
You are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to
prevent occupational lung disease in the employees of the company?
Fit all employees with protective masks
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is
clamped during transportation?
Tension pneumothorax
Which intervention does a nurse implement for clients with empyema?
Encourage breathing exercises
A nurse reading a chart notes that the client had a Mantoux skin test result with no induration and a 1-mm area of
ecchymosis. How does the nurse interpret this result?
Negative
The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the
client understands the information if the client correctly mentions which early sign of exacerbation?
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Shortness of breath
A client admitted to the hospital following a motor vehicle crash has suffered a flail chest. The nurse assesses the
client for what most common clinical manifestation of flail chest?
Paradoxical chest movement
The nurse is interpreting blood gases for a client with acute respiratory distress syndrome (ARDS). Which set of
blood gas values indicates respiratory acidosis?
pH 7.25, PaCO2 48, HCO3 24 (pH less than 7.35, PaCO2 48, HCO3 24 indicate respiratory acidosis; pH 7.87, PaCO2
38, HCO3 28 indicate metabolic alkalosis; pH 7.47, PaCO2 28, HCO3 30 indicate respiratory alkalosis; and pH 7.49,
PaCO2 34, HCO3 25 indicate respiratory alkalosis.)
After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be
considered:
Significant
The nurse is educating a patient who will be started on an antituberculosis medication regimen. The patient asks
the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient?
6 to 12 months
A nurse recognizes that a client with tuberculosis needs further teaching when the client states:
"The people I have contact with at work should be checked regularly."
A client is being evaluated for possible lung cancer. Which client statement most likely indicates lung cancer?
"My cough has changed from a dry cough to one with lots of sputum production."
A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. Which
nursing diagnosis takes priority with this client?
Ineffective breathing pattern related to tissue trauma
When interpreting the results of a Mantoux test, the nurse explains to the client that a reaction occurs when the
intradermal injection site shows
redness and induration
Which technique does the nurse suggest to a client with pleurisy while teaching about splinting the chest wall?
Turn onto the affected side
A client diagnosed with tuberculosis (TB) is taking medication for the treatment of TB. The nurse should instruct
the client that he will be safe from infecting others approximately how long after initiation of the chemotherapy
regimen?
Two to 3 weeks after initiation of bacteriocidal drugs
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A client presents to the ED reporting dyspnea on exertion and overall weakness. The clientts pulmonary arterial
pressure is 40/15 mm Hg. These symptoms indicate that the client may have which condition?
pulmonary arterial hypertension
The nurse is obtaining data from a client with a respiratory disorder. Which information would be considered a part
of the functional assessment and would assist in the diagnosis of an occupational lung disease?
Black-streaked sputum
During a community health fair, a nurse is teaching a group of seniors about promoting health and preventing
infection. Which intervention would best promote infection prevention for senior citizens who are at risk of
pneumococcal and influenza infections?
Receive vaccinations
The nurse is planning the care for a patient at risk of developing pulmonary embolism. What nursing interventions
should be included in the care plan? (Select all that apply.)
Encouraging a liberal fluid intake
Assisting the patient to do leg elevations above the level of the heart
Using elastic stockings, especially when decreased mobility would promote venous stasis
Applying a sequential compression device
A nurse is giving a speech addressing "Communicable Diseases of Winter" to a large group of volunteer women,
most of whom are older than 60 years. What preventive measures should the nurse recommend to these women,
who are at the risk of pneumococcal and influenza infections? Select all that apply.
vaccinations
hand antisepsis
A nurse is caring for a client with bronchogenic carcinoma. Which nursing diagnosis takes highest priority?
Ineffective airway clearance related to obstruction by a tumor or secretions
A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing
pneumonia?
A client with a nasogastric tube
A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and
shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse
notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the
nurse suspect?
Pneumothorax
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Influenza, an annual epidemic in the U.S., creates a significant increase in hospitalizations and an rise in the death
rates from pneumonia and cardiovascular disease. Besides death, what is the most serious complication of
influenza?
staphylococcal pneumonia
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Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 20: Management of Patients With Chronic Pulmonary Disease
A nurse is assisting with a subclavian vein central line insertion when the clientts oxygen saturation drops rapidly.
He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a
pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:
diminished or absent breath sounds on the affected side.
A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this
client maintain a patent airway and achieve maximal gas exchange, the nurse should:
instruct the client to drink at least 2 L of fluid daily.
A nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority?
Take ordered medications as scheduled.
Which statement describes emphysema?
A disease of the airways characterized by destruction of the walls of overdistended alveoli
A client is being seen in the emergency department for exacerbation of chronic obstructive pulmonary disease
(COPD). The first action of the nurse is to administer which of the following prescribed treatments?
Oxygen through nasal cannula at 2 L/minute
A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath and fatigue for 1
hour after awakening in the morning. Which of the following statements by the nurse would best help with the
clientts shortness of breath and fatigue?
"Delay self-care activities for 1 hour."
What is histamine, a mediator that supports the inflammatory process in asthma, secreted by?
Mast cells
The nurse should be alert for a complication of bronchiectasis that results from a combination of retained
secretions and obstruction that leads to the collapse of alveoli. This complication is known as
Atelectasis
A physician orders a beta2 adrenergic-agonist agent (bronchodilator) that is short-acting and administered only by
inhaler. What drug would the nurse know to administer to the client?
Albuterol
A junior-level nursing class has just finished learning about the management of clients with chronic pulmonary
diseases. They learned that a new definition of COPD leaves only one disorder within its classification. Which of the
following is that disorder?
Emphysema
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A commonly prescribed methylxanthine used as a bronchodilator is which of the following?
Theophylline
In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased
carbon dioxide tension in arterial blood, leading to which of the following acid-base imbalances?
Respiratory acidosis
Which of the following is accurate regarding status asthmaticus?
A severe asthma episode that is refractory to initial therapy
Which statement describes emphysema?
A disease of the airways characterized by destruction of the walls of overdistended alveoli
In which statements regarding medications taken by a client diagnosed with COPD do the drug name and the drug
category correctly match? Select all that apply.
Albuterol is a bronchodilator.
Ciprofloxacin is an antibiotic.
Prednisone is a corticosteroid.
Which statement is true about both lung transplant and bullectomy?
Both procedures improve the overall quality of life of a client with COPD.
A patient comes to the clinic for the third time in 2 months with chronic bronchitis. What clinical symptoms does
the nurse anticipate assessing for this patient?
Sputum and a productive cough
Upon assessment, the nurse suspects that a client with COPD may have bronchospasm. What manifestations
validate the nursets concern? Select all that apply.
Compromised gas exchange
Decreased airflow
Wheezes
The goal for oxygen therapy in COPD is to support tissue oxygenation, decrease the work of the cardiopulmonary
system, and maintain the resting partial arterial pressure of oxygen (PaO2) of at least
mm Hg and an arterial
oxygen saturation (SaO2) of at least %.
60 mm Hg; 90%
The classification of Stage III of COPD is defined as
severe COPD.
A client is diagnosed with a chronic respiratory disorder. After assessing the clientts knowledge of the disorder, the
nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?
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Anxiety
A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the
drug is producing a therapeutic effect?
Respiratory rate of 22 breaths/minute
A nurse consulting with a nutrition specialist knows itts important to consider a special diet for a client with chronic
obstructive pulmonary disease (COPD). Which diet is appropriate for this client?
High-protein
A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the clientts condition is
worsening when he:
uses the sternocleidomastoid muscles.
As status asthmaticus worsens, the nurse would expect which acid-base imbalance?
Respiratory acidosis
A nurse has established a nursing diagnosis of ineffective airway clearance. The datum that best supports this
diagnosis is that the client
Has wheezes in the right lung lobes
A client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client
reports sudden and unrelieved shortness of breath. Which of the following is the most important for the nurse to
assess?
Lung sounds
A client with chronic obstructive pulmonary disease (COPD) expresses a desire to quit smoking. The first
appropriate response from the nurse is:
"Have you tried to quit smoking before?"
The nurse has instructed the client to use a peak flow meter. The nurse evaluates client learning as satisfactory
when the client
Exhales hard and fast with a single blow
A young adult with cystic fibrosis is admitted to the hospital for an acute airway exacerbation. Aggressive
treatment is indicated. What is the first action by the nurse?
Collects sputum for culture and sensitivity
Which of the following factors contribute to the underlying pathophysiology of chronic obstructive pulmonary
disease (COPD)? Select all that apply.
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Mucus secretions block airways.
Overinflated alveoli impair gas exchange.
Inflamed airways obstruct airflow.
The nurse at the beginning of the evening shift receives a report at 1900 on the following patients. Which patient
would the nurse assess first?
An 86 year old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office
Asthma is cause by which type of response?
IgE-mediated
Which exposure accounts for most cases of COPD?
Exposure to tobacco smoke
A client with bronchiectasis is admitted to the nursing unit. The primary focus of nursing care for this client
includes
implementing measures to clear pulmonary secretions.
The nurse is reviewing pressurized metered-dose inhaler (pMDI) instructions with a client. Which statement by the
client indicates the need for further instruction?
"I can't use a spacer or holding chamber with the MDI."
The nurse is caring for a patient with status asthmaticus in the intensive care unit (ICU). What does the nurse
anticipate observing for the blood gas results related to hyperventilation for this patient?
Respiratory alkalosis
A client with asthma is prescribed a short acting beta-adrenergic (SABA) for quick relief. Which of the following is
the most likely drug to be prescribed?
Albuterol
The classification of Stage II of COPD is defined as
moderate COPD.
The classification of Stage IV of COPD is defined as
very severe COPD.
A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because
the client is extremely weak and cantt produce an effective cough, the nurse should monitor closely for:
atelectasis
For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes
adequate gas exchange?
Using a Venturi mask to deliver oxygen as ordered
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A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer?
An inhaled beta2-adrenergic agonist
A physician orders triamcinolone and salmeterol for a client with a history of asthma. What action should the nurse
take when administering these drugs?
Administer the salmeterol and then administer the triamcinolone.
Which medication is contraindicated in acute asthma exacerbations?
Cromolyn sodium
The classification of grade I COPD is defined as
mild COPD.
A client experiencing an asthmatic attack is prescribed methylprednisolone intravenously. What action should the
nurse take?
Assesses fasting blood glucose levels
A nurse is discussing asthma complications with a client and family. What complications should the nurse include
in the teaching? Select all that apply.
Atelectasis
Respiratory failure
Status asthmaticus
A nursing student is taking a pathophysiology examination. Which of the following factors would the student
correctly identify as contributing to the underlying pathophysiology of chronic obstructive pulmonary disease
(COPD)? Choose all that apply.
Inflamed airways that obstruct airflow
Mucus secretions that block airways
Overinflated alveoli that impair gas exchange
A nurse has just completed teaching with a client who has been prescribed a meter-dosed inhaler for the first time.
Which statement if made by the client would indicate to the nurse that further teaching and follow-up care is
necessary?
"I do not need to rinse my mouth with this type of inhaler."
A nursing student understands the importance of the psychosocial aspects of disease processes. When working
with a patient with COPD, the student would rank which of the following nursing diagnoses as the MOST important
when analyzing the psychosocial effects?
Ineffective coping related to anxiety
A nurse is teaching the client about use of the pictured item with a metered-dose inhaler (MDI). What instructions
should the nurse include in the teaching? Select all that apply.
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Take a slow, deep inhalation from the device.
The device may increase delivery of the MDI medication.
Activate the MDI once
Which of the following is the key underlying feature of asthma?
Inflammation
A client is being admitted to the medical-surgical unit for the treatment of an exacerbation of acute asthma. Which
medication is contraindicated in the treatment of asthma exacerbations?
Cromolyn sodium
Which measure may increase complications for a client with COPD?
Increased oxygen supply
The nurse is assigned to care for a patient with COPD with hypoxemia and hypercapnia. When planning care for
this patient, what does the nurse understand is the main goal of treatment?
Providing sufficient oxygen to improve oxygenation
A patient is being treated for status asthmaticus. What danger sign does the nurse observe that can indicate
impending respiratory failure?
Respiratory acidosis
A client with cystic fibrosis is admitted to the hospital with pneumonia. When should the nurse administer the
pancreatic enzymes that the client has been prescribed?
With meals
The nurse is instructing the patient with asthma in the use of a newly prescribed leukotriene receptor antagonist.
What should the nurse be sure to include in the education?
The patient should take the medication an hour before meals or 2 hours after a meal.
In which grade of COPD is the forced expiratory volume in 1 second (FEV1) greater than 80% predicted?
I
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UNIT 5 Cardiovascular and Circulatory Function
Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 21: Assessment of Cardiovascular Function
1. A patient is prescribed to have capillary blood glucose readings every four hours. What should the nurse include
when explaining capillaries to the patient?
1) It is a low-pressure vascular circuit.
2) Capillaries are the largest vessel within the arterial system.
3) The real work of the vascular system occurs at the capillary level.
4) They are flexible to adapt to changes in volume without large changes in pressure.
3) The real work of the vascular system occurs at the capillary level.
The real work of the vascular system is done at the capillary bed.
2. While auscultating a patientts heart rate the nurse hears scratching sounds. What is most likely causing this
sound?
1) Epicardium adhering to the heart surface
2) Low level of fluid in the pericardial cavity
3) Parietal pericardium adhering to the sternum
4) Endocardium adhering to the heart chambers
2) Low level of fluid in the pericardial cavity
Between the two layers of the heart is a pericardial cavity containing serous fluid that provides a lubricant that allows the
heart to beat without friction.
3. The nurse is reviewing the anatomy of the heart with a patient scheduled for cardiac surgery. Which patient
statement indicates additional teaching is required?
1) "Oxygenated blood returns to the left atrium through the pulmonary vein."
2) "The right atrium receives blood from the superior and inferior vena cava."
3) "Blood leaves the right ventricle and travels through the pulmonary vein to the lungs."
4) "Blood leaves the right ventricle and travels through the pulmonary artery to the lungs."
4) "Blood leaves the right ventricle and travels through the pulmonary artery to the lungs."
Deoxygenated blood is delivered to the pulmonary circuit through the pulmonary artery.
4. The nurse is preparing teaching about the coronary arteries for a group of patients scheduled for heart surgery.
Which information should the nurse include in this teaching?
1) The coronary arteries originate in the cusps of the aortic valve.
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2) The coronary arteries prevent the backflow of blood into the atria.
3) The coronary arteries respond to changes in pressure within the heart.
4) The coronary arteries prevent the backflow of blood into the ventricles.
1) The coronary arteries originate in the cusps of the aortic valve.
The left and right coronary arteries are the first arteries branching off of the aorta as it leaves the left ventricle and actually
originate in the cusps of the aortic valve.
5. The nurse notes that a patient has a low serum potassium level. Which phase of the cardiac action potential will
be most affected by this blood level?
1) Phase 0
2) Phase 1
3) Phase 3
4) Phase 4
3) Phase 3
In phase 3 final repolarization occurs, which is caused by the closing of the Ca++ channels and the rapid outflow of K+.
In phase 0 there is rapid depolarization caused by the opening of sodium (Na+) channels allowing rapid Na+ influx,
moving the membrane potential to +30.
In phase 1 Na+ influx decreases causing a slight movement toward negative of the membrane potential, producing an
initial repolarization.
In phase 4 there is a return to the resting membrane potential.
6. A patientts QRS complex is becoming increasingly wider. What is occurring within the heart muscle that is
reflected on this tracing?
1) The ventricles are repolarizing.
2) Atrial repolarization is occurring.
3) Ventricular depolarization is prolonged.
4) The atria depolarize and the impulse at the AV node is delayed.
3) Ventricular depolarization is prolonged.
The QRS complex corresponds to ventricular depolarization. If the complex is widening, then ventricular depolarization is
taking longer to complete.
7. A patient with a blood pressure of 88/50 mm Hg has a heart rate of 112 beats per minute. Which mechanism
should the nurse realize is occurring in this patient?
1) Positive chronotropic effect
2) Negative chronotropic effect
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3) Force of the mechanical contraction
4) Reaction to ventricular volume at the end of diastole
1) Positive chronotropic effect
Stimulus from the sympathetic nervous system initiated by information from baroreceptors in the aortic arch and the
carotids that are sensitive to changes in BP increase the HR through the release of norepinephrine. This is called a
positive chronotropic effect.
8. The nurse suspects that a patient is experiencing a release of norepinephrine from the adrenal medulla.
Which assessment finding did the nurse use to make this clinical decision?
1) Blood pressure 94/48 mm Hg 3) Heart rate 120 beats per minute
2) Heart rate 68 beats per minute 4) Blood pressure 180/100 mm Hg
3) Heart rate 120 beats per minute
Chemicals that can increase HR include norepinephrine released from the adrenal medulla.
9. The nurse is preparing to determine a patientts cardiac output. Which measurement should be used for preload?
1) Heart rate 3) Oxygen saturation
2) Blood pressure 4) Central venous pressure
4) Central venous pressure
Preload is reflected by measurements obtained through a centrally located IV line. For preload the central venous
pressure is used.
10. A patientts blood pressure is 174/98 mm Hg. Which aspect of cardiac output is most affected by this elevated
reading?
1) Preload 3) Afterload
2) Heart rate 4) Contractility
3) Afterload
Afterload is the resistance to flow the ventricle must overcome to open the semilunar valves and eject its contents. This is
related to BP in that hypertension on the right or left is implicated in the negative effects of increased afterload.
11. The nurse notes that a patient has bilateral lower extremity edema. For which health problem should the nurse
assess further?
1) Pericarditis 3) Lymph obstruction
2) Cardiac tamponade 4) Venous insufficiency
4) Venous insufficiency
Distended jugular veins are associated with pericarditis.
or cardiac tamponade.
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Unilateral extremity edema can indicate a lymphatic obstruction.
Bilateral lower extremity edema generally indicates venous insufficiency.
12. After palpating a patientts radial pulses, the nurse proceeds to palpate the brachial, carotid, femoral, popliteal,
and posterior tibial pulses. What condition caused the nurse to make this more thorough physical assessment?
1) Skin warm and dry 3) Edema of the left lower extremity
2) Various skin temperatures 4) Respiratory rate of 24 and labored
2) Various skin temperatures
Variations in temperature between different parts of the body may indicate vasoconstriction or vascular disease in the
affected extremities. A more extensive examination includes femoral, popliteal, and posterior tibial pulses.
13. The nurse is preparing to auscultate the heart sounds of a patient with mitral valve regurgitation. Which sound
should the nurse expect to hear?
1) Rub 3) Murmur
2) Click 4) Atrial gallop
3) Murmur
Murmurs are usually caused by turbulent flow through the valves. That turbulence can be caused by regurgitation of blood
through an incompetent valve.
14. A patient is being assessed for heart disease. For which laboratory test should the nurse instruct to avoid
eating and drinking fluids for 12 hours?
1) Lipid panel 3) C-reactive protein
2) Homocysteine 4) Partial thromboplastin time
1) Lipid panel
A lipid panel requires the patient to fast for approximately 8 to 12 hours prior to the test.
15. The nurse notes that a patient is scheduled for a brain natriuretic peptide level to be drawn. What patient
teaching should the nurse prepare for this patient?
1) Low-fat diet 3) Symptoms of a heart attack
2) Signs of heart failure 4) Lung versus heart problems
2) Signs of heart failure
Brain natriuretic peptide is released from overstretched ventricular tissue. Elevations are an indicator of heart failure.
16. A patient is scheduled for a transesophageal echocardiogram (TEE). What information should the nurse expect
to be provided from this test?
1) Cardiac filling pressures 3) Heart function during stress
2) Integrity of cardiac arteries 4) Presence of clots in the atria
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4) Presence of clots in the atria
Information about the presence of clots in the atrium, a risk factor for stroke, is more easily viewed through TEE.
17. A patient is recovering from a cardiac catheterization. For which finding should the nurse notify the health-care
provider?
1) Warm right foot 3) Discomfort lying flat for six hours
2) Urine output 250 mL/2 hours 4) Hematoma formation at puncture site
4) Hematoma formation at puncture site
The puncture site should be monitored for hematoma formation. This could cause occlusion of the femoral artery and
should be reported to the health-care provider.
18. An older patient is being evaluated for a cardiac click audible upon auscultation. Which age-related change
should the nurse realize might be causing this heart sound?
1) Hypertension 3) Atrial fibrillation
2) Valve stenosis 4) Congestive heart failure
2) Valve stenosis
A cardiac click is associated with valve stenosis.
19. The nurse notes that an older patientts point of maximum impulse is displaced to the left. What age- related
change should the nurse suspect as causing this assessment finding?
1) Valvular stenosis 3) Arterial wall narrowing
2) Left ventricular atrophy 4) Fibrosis of heart chambers
2) Left ventricular atrophy
Aging produces a number of physiological changes in the anatomy and physiology of the cardiovascular system. Physical
deconditioning can result in atrophy of the left ventricle, which would displace the point of maximum impulse.
20. The nurse is reviewing data collected during the assessment of an older patient. Which finding should the nurse
consider as being an age-related change of the cardiovascular system?
1) First heart sound louder 3) Heart rate 64 and regular
2) Friction rub auscultated 4) Blood pressure 168/96 mm Hg
4) Blood pressure 168/96 mm Hg
Hypertension is a common cardiovascular health issues related to aging.
Completion
Complete each statement.
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21. The nurse is preparing a teaching tool about the cardiac electrical conduction system. In which order should the
nurse explain the route of the action potential? (Enter the number of each step in the proper sequence; do not use
punctuation or spaces. Example: 1234)
1) Impulse travels to the bundle of His
2) Sinoatrial node fires in the right atrium
3) Impulse extends through Purkinje fibers
4) Impulse travels through bundle branches
5) Impulse travels to the atrioventricular node
6) Impulse spreads through atrial myocardium
2) Sinoatrial node fires in the right atrium
6) Impulse spreads through atrial myocardium
5) Impulse travels to the atrioventricular node
1) Impulse travels to the bundle of His
4) Impulse travels through bundle branches
3) Impulse extends through Purkinje fibers
The action potential begins in the sinoatrial node, which fires in the right atrium. Then the impulse spreads through the
atrial myocardium and travels to the atrioventricular node. It then travels to the bundle of His, through the bundle
branches, and extends through the Purkinje fibers.
22. The clinical trainer is reviewing the renin-angiotensin-aldosterone system with graduate nurses during
orientation to the telemetry unit. In which order should the trainer discuss this system? (Enter the number of each
step in the proper sequence; do not use punctuation or spaces. Example: 1234)
1) Sodium and water reabsorbed in the kidneys
2) Renin reacts with angiotensin to create angiotensin 1
3) Angiotensin I is converted to angiotensin II in the lungs
4) Kidneys release renin in response to a drop in blood pressure
5) Angiotensin II influences adrenal glands to release aldosterone
4) Kidneys release renin in response to a drop in blood pressure
2) Renin reacts with angiotensin to create angiotensin 1
3) Angiotensin I is converted to angiotensin II in the lungs
5) Angiotensin II influences adrenal glands to release aldosterone
1) Sodium and water reabsorbed in the kidneys
When the blood pressure drops, the kidneys respond by releasing the enzyme renin. Renin reacts with angiotensin to
create angiotensin I. Angiotensin I is then converted in the lungs to angiotensin II via angiotensin-converting enzyme.
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Angiotensin II acts on the adrenal glands to release aldosterone. The release of aldosterone promotes sodium and water
reabsorption in the kidneys, which increases circulating fluid volume.
23. A patient is prescribed a 12-lead electrocardiogram. In which order should the nurse apply the V leads? (Enter
the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234)
1) Midaxillary line
2) Between V2 and V4
3) Midclavicular line 5th intercostal space
4) 4th intercostal space left of the sternum
5) 4th intercostal space right of the sternum
6) Between V4 and V6 anterior axillary line
5) 4th intercostal space right of the sternum
4) 4th intercostal space left of the sternum
2) Between V2 and V4
3) Midclavicular line 5th intercostal space
6) Between V4 and V6 anterior axillary line
1) Midaxillary line
The chest positions for the V leads are: V1: 4th intercostal space, just to the right of the sternum; V2: 4th intercostal
space, just to the left of the sternum; V3: Between V4 and V2; V4: on the midclavicular line and 5th intercostal space; V5:
between V6 and V4 on the anterior axillary line; and V6: on the midaxillary line, horizontal with V4.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
24. The nurse is preparing content for a community health fair on risk factors for heart disease. What should the
nurse include as nonmodifiable risk factors? Select all that apply.
1) Age
2) Weight
3) Alcohol intake
4) Ethnic background
5) Parentst health history
1) Age
4) Ethnic background
5) Parents' health history
Weight and Alcohol intake are both modifiable risk factors where Age, ethnic background and parents health history are
not.
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25. Which information should the nurse include when documenting the findings of a patientts heart sounds?
Select all that apply.
1) Pitch
2) Clicks
3) Quality
4) Intensity
5) Location
1) Pitch
3) Quality
4) Intensity
5) Location
Clicks would be an abnormal finding, necessitating more thorough documentation.
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Brunner & Suddarth's Textbook of Medical Surgical Nursing 15th Edition
Chapter 22: Management of Patients With Arrhythmias and Conduction Problems
1. The nurse is caring for a patient who has had an ECG. The nurse notes that leads I, II, and III differ from one
another on the cardiac rhythm strip. How should the nurse best respond?
A) Recognize that the view of the electrical current changes in relation to the lead placement.
B) Recognize that the electrophysiological conduction of the heart differs with lead placement.
C) Inform the technician that the ECG equipment has malfunctioned.
D) Inform the physician that the patient is experiencing a new onset of dysrhythmia.
A) Recognize that the view of the electrical current changes in relation to the lead placement.
Feedback: Each lead offers a different reference point to view the electrical activity of the heart. The lead displays the
configuration of electrical activity of the heart. Differences between leads are not necessarily attributable to equipment
malfunction or dysrhythmias.
2. The nurse is analyzing a rhythm strip. What component of the ECG corresponds to the resting state of the
patients heart?
A) P wave
B) T wave
C) U wave
D) QRS complex
T-wave
T wave specifically represents ventricular muscle repolarization, or resting state.
3. The nursing educator is presenting a case study of an adult patient who has abnormal ventricular depolarization.
This pathologic change would be most evident in what component of the ECG?
A) P wave
B) T wave
C) QRS complex
D) U wave
QRS complex represents ventricular depolarization (ventricular contraction) the electrical activity of that ventricle.
4. An adult patient with third-degree AV block is admitted to the cardiac care unit and placed on continuous cardiac
monitoring. What rhythm characteristic will the ECG most likely show?
A) PP interval and RR interval are irregular.
B) PP interval is equal to RR interval.
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C) Fewer QRS complexes than P waves
D) PR interval is constant.
Fewer QRS complexes than P waves
Feedback: In third-degree AV block, no atrial impulse is conducted through the AV node into the ventricles. As a result,
there are impulses stimulating the atria and impulses stimulating the ventricles. Therefore, there are more P waves than
QRS complexes due to the difference in the natural pacemaker (nodes) rates of the heart. The other listed ECG changes
are not consistent with this diagnosis.
5. The nurse is writing a plan of care for a patient with a cardiac dysrhythmia. What would be the most appropriate
goal for the patient?
A) Maintain a resting heart rate below 70 bpm.
B) Maintain adequate control of chest pain.
C) Maintain adequate cardiac output.
D) Maintain normal cardiac structure.
Maintain adequate cardiac output.
Feedback: For patient safety, the most appropriate goal is to maintain cardiac output to prevent worsening complications
as a result of decreased cardiac output. A resting rate of less than 70 bpm is not appropriate for every patient. Chest pain
is more closely associated with acute coronary syndrome than with dysrhythmias. Nursing actions cannot normally
influence the physical structure of the heart
6. A patient has returned to the cardiac care unit after having a permanent pacemaker implantation. For which
potential complication should the nurse most closely assess this patient?
A) Chest pain
B) Bleeding at the implantation site
C) Malignant hyperthermia
D) Bradycardia
Bleeding at the implantation site
Feedback: Bleeding, hematomas, local infections, perforation of the myocardium, and tachycardia are complications of
pacemaker implantations. The nurse should monitor for chest pain and bradycardia, but bleeding is a more common
immediate complication. Malignant hyperthermia is unlikely because it is a response to anesthesia administration.
7. A patient the nurse is caring for has a permanent pacemaker implanted with the identification code beginning
with VVI. What does this indicate?
A) Ventricular paced, ventricular sensed, inhibited
B) Variable paced, ventricular sensed, inhibited
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C) Ventricular sensed, ventricular situated, implanted
D) Variable sensed, variable paced, inhibited
Ans: A Feedback: The identification of VVI indicates ventricular paced, ventricular sensed, inhibited. 8. The nurse is caring
for an adult patient who has gone into ventricular fibrillation. When assisting with defibrillating the patient, what must the
nurse do? A) Maintain firm contact between paddles and patient skin. B) Apply a layer of water as a conducting agent. C)
Call all clear once before discharging the defibrillator. D) Ensure the defibrillator is in the sync mode.*
Ans: A Feedback: When defibrillating an adult patient, the nurse should maintain good contact between the paddles and
the patients skin to prevent arcing, apply an appropriate conducting agent (not water) between the skin and the paddles,
and ensure the defibrillator is in the nonsync mode. Clear should be called three times before discharging the paddles.
9. A patient who is a candidate for an implantable cardioverter defibrillator (ICD) asks the nurse about the purpose
of this device. What would be the nurses best response?
A) To detect and treat dysrhythmias such as ventricular fibrillation and ventricular tachycardia
B) To detect and treat bradycardia, which is an excessively slow heart rate
C) To detect and treat atrial fibrillation, in which your heart beats too quickly and inefficiently
D) To shock your heart if you have a heart attack at home
Ans: A Feedback: The ICD is a device that detects and terminates life-threatening episodes of ventricular tachycardia and
ventricular fibrillation. It does not treat atrial fibrillation, MI, or bradycardia.
10. A nurse is providing health education to a patient scheduled for cryoablation therapy. The nurse should
describe what aspect of this treatment?
A) Peeling away the area of endocardium responsible for the dysrhythmia
B) Using electrical shocks directly to the endocarduim to eliminate the source of dysrhythmia
C) Using high-frequency sound waves to eliminate the source of dysrhythmia
D) Using a cooled probe to eliminate the source of dysrhythmia
Ans: D Feedback: Cryoablation therapy involves using a cooled probe to create a small scar on the endocardium to
eliminate the source of the dysrhythmias. Endocardium resection involves peeling away a specified area of the
endocardium. Electrical ablation involves using shocks to eliminate the area causing the dysrhythmias. Radio frequency
ablation uses high-frequency sound waves to destroy the area causing the dysrhythmias.
11. The nurse is caring for a patient who has just had an implantable cardioverter defibrillator (ICD) placed. What is
the priority area for the nurses assessment? A) Assessing the patients activity level B) Facilitating transthoracic
echocardiography C) Vigilant monitoring of the patients ECG D) Close monitoring of the patients peripheral
perfusion
Ans: C Feedback: After a permanent electronic device (pacemaker or ICD) is inserted, the patients heart rate and rhythm
are monitored by ECG. This is a priority over peripheral circulation and activity. Echocardiography is not indicated.
12. During a patients care conference, the team is discussing whether the patient is a candidate for cardiac
conduction surgery. What would be the most important criterion for a patient to have this surgery? A) Angina
pectoris not responsive to other treatments B) Decreased activity tolerance related to decreased cardiac output C)
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Atrial and ventricular tachycardias not responsive to other treatments D) Ventricular fibrillation not responsive to
other treatments
Ans: C Feedback: Cardiac conduction surgery is considered in patients who do not respond to medications and
antitachycardia pacing. Angina, reduced activity tolerance, and ventricular fibrillation are not criteria.
13. A nurse is caring for a patient who is exhibiting ventricular tachycardia (VT). Because the patient is pulseless,
the nurse should prepare for what intervention?
A) Defibrillation
B) ECG monitoring
C) Implantation of a cardioverter defibrillator
D) Angioplasty
Ans: A Feedback: Any type of VT in a patient who is unconscious and without a pulse is treated in the same manner as
ventricular fibrillation: Immediate defibrillation is the action of choice. ECG monitoring is appropriate, but this is an
assessment, not an intervention, and will not resolve the problem. An ICD and angioplasty do not address the
dysrhythmia.
14. A patient converts from normal sinus rhythm at 80 bpm to atrial fibrillation with a ventricular response at 166
bpm. Blood pressure is 162/74 mm Hg. Respiratory rate is 20 breaths per minute with normal chest expansion and
clear lungs bilaterally. IV heparin and Cardizem are given. The nurse caring for the patient understands that the
main goal of treatment is what?
A) Decrease SA node conduction
B) Control ventricular heart rate
C) Improve oxygenation
D) Maintain anticoagulation
Ans: B Feedback: Treatment for atrial fibrillation is to terminate the rhythm or to control ventricular rate. This is a priority
because it directly affects cardiac output. A rapid ventricular response reduces the time for ventricular filling, resulting in a
smaller stroke volume. Control of rhythm is the initial treatment of choice, followed by anticoagulation with heparin and
then Coumadin.
15. The nurse and the other members of the team are caring for a patient who converted to ventricular fibrillation
(VF). The patient was defibrillated unsuccessfully and the patient remains in VF. According to national standards,
the nurse should anticipate the administration of what medication?
A) Epinephrine 1 mg IV push
B) Lidocaine 100 mg IV push
C) Amiodarone 300 mg IV push
D) Sodium bicarbonate 1 amp IV push
Ans: A Feedback: Epinephrine should be administered as soon as possible after the first unsuccessful defibrillation and
then every 3 to 5 minutes. Antiarrhythmic medications such as amiodarone and licocaine are given if ventricular
dysrhythmia persists.
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16. The nurse is planning discharge teaching for a patient with a newly inserted permanent pacemaker. What is the
priority teaching point for this patient?
A) Start lifting the arm above the shoulder right away to prevent chest wall adhesion.
B) Avoid cooking with a microwave oven.
C) Avoid exposure to high-voltage electrical generators.
D) Avoid walking through store and library antitheft devices.
Ans: C Feedback: High-output electrical generators can reprogram pacemakers and should be avoided. Recent
pacemaker technology allows patients to safely use most household electronic appliances and devices (e.g., microwave
ovens). The affected arm should not be raised above the shoulder for 1 week following placement of the pacemaker.
Antitheft alarms may be triggered so patients should be taught to walk through them quickly and avoid standing in or near
these devices. These alarms generally do not interfere with pacemaker function.
17. A patient is brought to the ED and determined to be experiencing symptomatic sinus bradycardia. The nurse
caring for this patient is aware the medication of choice for treatment of this dysrhythmia is the administration of
atropine. What guidelines will the nurse follow when administering atropine? A) Administer atropine 0.5 mg as an IV
bolus every 3 to 5 minutes to a maximum of 3.0 mg. B) Administer atropine as a continuous infusion until
symptoms resolve. C) Administer atropine as a continuous infusion to a maximum of 30 mg in 24 hours. D)
Administer atropine 1.0 mg sublingually.
Ans: A Feedback: Atropine 0.5 mg given rapidly as an intravenous (IV) bolus every 3 to 5 minutes to a maximum total
dose of 3.0 mg is the medication of choice in treating symptomatic sinus bradycardia. By this guideline, the other listed
options are inappropriate.
18. An ECG has been ordered for a newly admitted patient. What should the nurse do prior to electrode placement?
A) Clean the skin with providone-iodine solution. B) Ensure that the area for electrode placement is dry. C) Apply
tincture of benzoin to the electrode sites and wait for it to become tacky. D) Gently abrade the skin by rubbing the
electrode sites with dry gauze or cloth.
Ans: D Feedback: An ECG is obtained by slightly abrading the skin with a clean dry gauze pad and placing electrodes on
the body at specific areas. The abrading of skin will enhance signal transmission. Disinfecting the skin is unnecessary and
conduction gel is used.
19. The nurse is caring for a patient who has just undergone catheter ablation therapy. The nurse in the step- down
unit should prioritize what assessment? A) Cardiac monitoring B) Monitoring the implanted device signal C) Pain
assessment D) Monitoring the patients level of consciousness (LOC)
Ans: A Feedback: Following catheter ablation therapy, the patient is closely monitored to ensure the dysrhythmia does not
reemerge. This is a priority over monitoring of LOC and pain, although these are valid and important assessments.
Ablation does not involve the implantation of a device.
20. The ED nurse is caring for a patient who has gone into cardiac arrest. During external defibrillation, what action
should the nurse perform? A) Place gel pads over the apex and posterior chest for better conduction. B) Ensure no
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one is touching the patient at the time shock is delivered. C) Continue to ventilate the patient via endotracheal tube
during the procedure. D) Allow at least 3 minutes between shocks.
Ans: B Feedback: In external defibrillation, both paddles may be placed on the front of the chest, which is the standard
paddle placement. Whether using pads, or paddles, the nurse must observe two safety measures. First, maintain good
contact between the pads or paddles and the patients skin to prevent leaking. Second, ensure that no one is in contact
with the patient or with anything that is touching the patient when the defibrillator is discharged, to minimize the chance
that electrical current will be conducted to anyone other than the patient. Ventilation should be stopped during
defibrillation.
21. A group of nurses are participating in orientation to a telemetry unit. What should the staff educator tell this
class about ST segments? A) They are the part of an ECG that reflects systole. B) They are the part of an ECG used
to calculate ventricular rate and rhythm. C) They are the part of an ECG that reflects the time from ventricular
depolarization through repolarization. D) They are the part of an ECG that represents early ventricular
repolarization.
Ans: D Feedback: ST segment is the part of an ECG that reflects the end of the QRS complex to the beginning of the T
wave. The part of an ECG that reflects repolarization of the ventricles is the T wave. The part of an ECG used to
calculate ventricular rate and rhythm is the RR interval. The part of an ECG that reflects the time from ventricular
depolarization through repolarization is the QT interval.
22. The nurse is providing care to a patient who has just undergone an electrophysiologic (EP) study. The patient
states that she is nervous about things going wrong during the procedure. What is the nurses best response? A)
This is basically a risk-free procedure. B) Thousands of patients undergo EP every year. C) Remember that this is a
step that will bring you closer to enjoying good health. D) The whole team will be monitoring you very closely for
the entire procedure.
Ans: D Feedback: Patients who are to undergo an EP study may be anxious about the procedure and its outcome. A
detailed discussion involving the patient, the family, and the electrophysiologist usually occurs to ensure that the patient
can give informed consent and to reduce the patients anxiety about the procedure. It is inaccurate to state that EP is riskfree and stating that it is common does not necessarily relieve the patients anxiety. Characterizing EP as a step toward
good health does not directly address the patients anxiety.
23. New nurses on the telemetry unit have been paired with preceptors. One new nurse asks her preceptor to
explain depolarization. What would be the best answer by the preceptor? A) Depolarization is the mechanical
contraction of the heart muscles. B) Depolarization is the electrical stimulation of the heart muscles. C)
Depolarization is the electrical relaxation of the heart muscles. D) Depolarization is the mechanical relaxation of the
heart muscles.
Ans: B Feedback: The electrical stimulation of the heart is called depolarization, and the mechanical contraction is called
systole. Electrical relaxation is called repolarization, and mechanical relaxation is called diastole.
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24. A cardiac care nurse is aware of factors that result in positive chronotropy. These factors would affect a
patients cardiac function in what way? A) Exacerbating an existing dysrhythmia B) Initiating a new dysrhythmia C)
Resolving ventricular tachycardia D) Increasing the heart rate
Ans: D Feedback: Stimulation of the sympathetic system increases heart rate. This phenomenon is known as positive
chronotropy. It does not influence dysrhythmias.
25. The nurse is caring for a patient with refractory atrial fibrillation who underwent the maze procedure several
months ago. The nurse reviews the result of the patients most recent cardiac imaging, which notes the presence of
scarring on the atria. How should the nurse best respond to this finding? A) Recognize that the procedure was
unsuccessful. B) Recognize this as a therapeutic goal of the procedure. C) Liaise with the care team in preparation
for repeating the maze procedure. D) Prepare the patient for pacemaker implantation.
Ans: B Feedback: The maze procedure is an open heart surgical procedure for refractory atrial fibrillation. Small
transmural incisions are made throughout the atria. The resulting formation of scar tissue prevents reentry conduction of
the electrical impulse. Consequently, scar formation would constitute a successful procedure. There is no indication for
repeating the procedure or implanting a pacemaker.
26. A patient is scheduled for catheter ablation therapy. When describing this procedure to the patients family, the
nurse should address what aspect of the treatment? A) Resetting of the hearts contractility B) Destruction of
specific cardiac cells C) Correction of structural cardiac abnormalities D) Clearance of partially occluded coronary
arteries
Ans: B Feedback: Catheter ablation destroys specific cells that are the cause or central conduction route of a
tachydysrhythmia. It does not reset the hearts contractility and it does not address structural or vascular abnormalities.
27. A patient has undergone diagnostic testing and received a diagnosis of sinus bradycardia attributable to sinus
node dysfunction. When planning this patients care, what nursing diagnosis is most appropriate? A) Acute pain B)
Risk for unilateral neglect C) Risk for activity intolerance D) Risk for fluid volume excess
Ans: C Feedback: Sinus bradycardia causes decreased cardiac output that is likely to cause activity intolerance. It does
not typically cause pain, fluid imbalances, or neglect of a unilateral nature.
28. The nurse is caring for a patient on telemetry. The patients ECG shows a shortened PR interval, slurring of the
initial QRS deflection, and prolonged QRS duration. What does this ECG show? A) Sinus bradycardia B) Myocardial
infarction C) Lupus-like syndrome D) Wolf-Parkinson-White (WPW) syndrome
Ans: D Feedback: In WPW syndrome there is a shortened PR interval, slurring (called a delta wave) of the initial QRS
deflection, and prolonged QRS duration. These characteristics are not typical of the other listed cardiac anomalies.
29. A patient is undergoing preoperative teaching before his cardiac surgery and the nurse is aware that a
temporary pacemaker will be placed later that day. What is the nurses responsibility in the care of the patients
pacemaker? A) Monitoring for pacemaker malfunction or battery failure B) Determining when it is appropriate to
remove the pacemaker C) Making necessary changes to the pacemaker settings D) Selecting alternatives to future
pacemaker use
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Ans: A Feedback: Monitoring for pacemaker malfunctioning and battery failure is a nursing responsibility. The other listed
actions are physician responsibilities.
30. The nurse caring for a patient whose sudden onset of sinus bradycardia is not responding adequately to
atropine. What might be the treatment of choice for this patient? A) Implanted pacemaker B) Trancutaneous
pacemaker C) ICD D) Asynchronous defibrillator
Ans: B Feedback: If a patient suddenly develops a bradycardia, is symptomatic but has a pulse, and is unresponsive to
atropine, emergency pacing may be started with transcutaneous pacing, which most defibrillators are now equipped to
perform. An implanted pacemaker is not a time-appropriate option. An asynchronous defibrillator or ICD would not provide
relief.
31. The nurse is caring for a patient who has had a dysrhythmic event. The nurse is aware of the need to assess for
signs of diminished cardiac output (CO). What change in status may signal to the nurse a decrease in cardiac
output? A) Increased blood pressure B) Bounding peripheral pulses C) Changes in level of consciousness D) Skin
flushing
Ans: C Feedback: The nurse conducts a physical assessment to confirm the data obtained from the history and to
observe for signs of diminished cardiac output (CO) during the dysrhythmic event, especially changes in level of
consciousness. Blood pressure tends to decrease with lowered CO and bounding peripheral pulses are inconsistent with
this problem. Pallor, not skin flushing, is expected.
32. Following cardiac resuscitation, a patient has been placed in a state of mild hypothermia before being
transferred to the cardiac intensive care unit. The nurses assessment reveals that the patient is experiencing
neuromuscular paralysis. How should the nurse best respond? A) Administer hypertonic IV solution. B) Administer
a bolus of warned normal saline. C) Reassess the patient in 15 minutes. D) Document this as an expected
assessment finding.
Ans: D Feedback: The nurse caring for a patient with hypothermia (passive or induced) needs to monitor for appropriate
level of cooling, sedation, and neuromuscular paralysis to prevent seizures; myoclonus; and shivering. Neuromuscular
paralysis is an expected finding and does not necessitate further interventions.
33. The nurse is caring for a patient who has had a biventricular pacemaker implanted. When planning the patients
care, the nurse should recognize what goal of this intervention? A) Resynchronization B) Defibrillation C)
Angioplasty D) Ablation
Ans: A Feedback: Biventricular (both ventricles) pacing, also called resynchronization therapy, may be used to treat
advanced heart failure that does not respond to medication. This type of pacing therapy is not called defibrillation,
angioplasty, or ablation therapy.
34. When planning the care of a patient with an implanted pacemaker, what assessment should the nurse prioritize?
A) Core body temperature B) Heart rate and rhythm C) Blood pressure D) Oxygen saturation level
Ans: B Feedback: For patients with pacemakers, close monitoring of the heart rate and rhythm is a priority, even though
each of the other listed vital signs must be assessed.
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35. The nurse is assessing a patient who had a pacemaker implanted 4 weeks ago. During the patients most recent
follow-up appointment, the nurse identifies data that suggest the patient may be socially isolated and depressed.
What nursing diagnosis is suggested by these data? A) Decisional conflict related to pacemaker implantation B)
Deficient knowledge related to pacemaker implantation C) Spiritual distress related to pacemaker implantation D)
Ineffective coping related to pacemaker implantation
Ans: D Feedback: Depression and isolation may be symptoms of ineffective coping with the implantation. These
psychosocial symptoms are not necessarily indicative of issues related to knowledge or decisions. Further data would be
needed to determine a spiritual component to the patients challenges.
36. The nurse is caring for a patient who is in the recovery room following the implantation of an ICD. The patient
has developed ventricular tachycardia (VT). What should the nurse assess and document? A) ECG to compare time
of onset of VT and onset of devices shock B) ECG so physician can see what type of dysrhythmia the patient has C)
Patients level of consciousness (LOC) at the time of the dysrhythmia D) Patients activity at time of dysrhythmia
Ans: A Feedback: If the patient has an ICD implanted and develops VT or ventricular fibrillation, the ECG should be
recorded to note the time between the onset of the dysrhythmia and the onset of the devices shock or antitachycardia
pacing. This is a priority over LOC or activity at the time of onset.
37. The staff educator is teaching a CPR class. Which of the following aspects of defibrillation should the educator
stress to the class? A) Apply the paddles directly to the patients skin. B) Use a conducting medium between the
paddles and the skin. C) Always use a petroleum-based gel between the paddles and the skin. D) Any available
liquid can be used between the paddles and the skin.
Ans: B Feedback: Use multifunction conductor pads or paddles with a conducting medium between the paddles and the
skin (the conducting medium is available as a sheet, gel, or paste). Do not use gels or pastes with poor electrical
conductivity.
38. During a CPR class, a participant asks about the difference between cardioversion and defibrillation. What
would be the instructors best response? A) Cardioversion is done on a beating heart; defibrillation is not. B) The
difference is the timing of the delivery of the electric current. C) Defibrillation is synchronized with the electrical
activity of the heart, but cardioversion is not. D) Cardioversion is always attempted before defibrillation because it
has fewer risks.
Ans: B Feedback: One major difference between cardioversion and defibrillation is the timing of the delivery of electrical
current. In cardioversion, the delivery of the electrical current is synchronized with the patients electrical events; in
defibrillation, the delivery of the current is immediate and unsynchronized. Both can be done on beating heart (i.e., in a
dysrhythmia). Cardioversion is not necessarily attempted first.
39. A patient is admitted to the cardiac care unit for an electrophysiology (EP) study. What goal should guide the
planning and execution of the patients care? A) Ablate the area causing the dysrhythmia. B) Freeze hypersensitive
cells. C) Diagnose the dysrhythmia. D) Determine the nursing plan of care.
Ans: C Feedback: A patient may undergo an EP study in which electrodes are placed inside the heart to obtain an
intracardiac ECG. This is used not only to diagnose the dysrhythmia but also to determine the most effective treatment
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plan. However, because an EP study is invasive, it is performed in the hospital and may require that the patient be
admitted.
40. A patient calls his cardiologists office and talks to the nurse. He is concerned because he feels he is being
defibrillated too often. The nurse tells the patient to come to the office to be evaluated because the nurse knows
that the most frequent complication of ICD therapy is what? A) Infection B) Failure to capture C) Premature battery
depletion D) Oversensing of dysrhythmias
Ans: D Feedback: Inappropriate delivery of ICD therapy, usually due to oversensing of atrial and sinus tachycardias with a
rapid ventricular rate response, is the most frequent complication of ICD. Infections, failure to capture, and premature
battery failure are less common.
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Brunner & Suddarthts Textbook of Medical Surgical Nursing 15th Edition
Chapter 23: Management of Patients With Coronary Vascular Disorders
A client in the emergency department complains of squeezing substernal pain that radiates to the left shoulder and
jaw. He also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do?
a) Complete the clientts registration information, perform an electrocardiogram, gain I.V. access, and take vital
signs.
b) Alert the cardiac catheterization team, administer oxygen, attach a cardiac monitor, and notify the physician.
c) Gain I.V. access, give sublingual nitroglycerin, and alert the cardiac catheterization team.
d) Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.
d
(Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.
Cardiac chest pain is caused by myocardial ischemia. Therefore the nurse should administer supplemental oxygen to
increase the myocardial oxygen supply, attach a cardiac monitor to help detect life-threatening arrhythmias, and take vital
signs to ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration
information may be delayed until the client is stabilized. Alerting the cardiac catheterization team or the physician before
completing the initial assessment is premature.)
Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI), a client reports
midsternal chest pain radiating down his left arm. The nurse notes that the client is restless and slightly
diaphoretic, and measures a temperature of 99.6° F (37.6° C); a heart rate of 102 beats/minute; regular, slightly
labored respirations at 26 breaths/minute; and a blood pressure of 150/90 mm Hg. Which nursing diagnosis takes
highest priority?
a) Decreased cardiac output
b) Risk for imbalanced body temperature
c) Acute pain
d) Anxiety
c
(Acute pain
The nursing diagnosis of Acute pain takes highest priority because it increases the client's pulse and blood pressure.
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During the acute phase of an MI, low-grade fever is an expected result of the body's response to myocardial tissue
necrosis. This makes Risk for imbalanced body temperature an incorrect answer. The client's blood pressure and heart
rate don't suggest a nursing diagnosis of Decreased cardiac output. Anxiety could be an appropriate nursing diagnosis,
but addressing Acute pain (the priority concern) may alleviate the client's anxiety.)
Which medication should a nurse have on hand when removing a sheath after cardiac catheterization?
a) Heparin
b) Adenosine (Adenocard)
c) Protamine sulfate
d) Atropine
d
(Atropine
Removing the sheath after cardiac catheterization may cause a vasovagal response, including bradycardia. The nurse
should have atropine on hand to increase the client's heart rate if this occurs. Heparin thins the blood; clients should stop
taking it before the sheath removal. Protamine sulfate is an antidote to heparin, but the nurse shouldn't administer it
during sheath removal. Adenosine treats tachyarrhythmias.)
Creatine kinase-MB isoenzyme (CK-MB) can increase as a result of:
a) skeletal muscle damage due to a recent fall.
b) I.M. injection.
c) myocardial necrosis.
d) cerebral bleeding.
c
(myocardial necrosis.
An increase in CK-MB is related to myocardial necrosis. An increase in total CK might occur for several reasons, including
brain injury, such as cerebral bleeding; skeletal muscle damage, which can result from I.M. injections or falls; muscular or
neuromuscular disease; vigorous exercise; trauma; or surgery.)
A patient presents to the ED complaining of anxiety and chest pain after shoveling heavy snow that morning. The
patient says that he has not taken nitroglycerin for months but did take three nitroglycerin tablets and although the
pain is less, "They did not work all that well. " The patient shows the nurse the nitroglycerin bottle and the
prescription was filled 12 months ago. The nurse anticipates which of the following physician orders?
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a) Serum electrolytes
b) Ativan 1 mg orally
c) Nitroglycerin SL
d) Chest x-ray
c
(Nitroglycerin SL
Nitroglycerin is volatile and is inactivated by heat, moisture, air, light, and time. Nitroglycerin should be renewed every 6
months to ensure full potency. The client's tablets were expired and the nurse should anticipate administering nitroglycerin
to assess if the chest pain subsides. The other choices may be ordered at a later time, but the priority is to relieve the
patient's chest pain.)
Patients who are taking beta-adrenergic blocking agents should be cautioned not to stop taking their medications
abruptly because which of the following may occur?
a) Worsening angina
b) Internal bleeding
c) Thrombocytopenia
d) Formation of blood clots
a
(Worsening angina
Patients taking beta blockers are cautioned not to stop taking them abruptly because angina may worsen and myocardial
infarction may develop. Beta blockers do not cause the formation of blood clots, internal bleeding, or thrombocytopenia.)
Upon discharge from the hospital, patients diagnosed with a myocardial infarction (MI) must be placed on all of the
following medications except:
a) Morphine IV
b) Angiotensin-converting enzyme (ACE) inhibitor
c) Aspirin
d) Statin
a
(Morphine IV
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Upon patient discharge, there needs to be documentation that the patient was discharged on a statin, an ACE or
angiotensin receptor blocking agent (ARB), and aspirin. Morphine IV is used for these patients to reduce pain and anxiety.
The patient would not be discharged with IV morphine.)
A client with chest pain doesntt respond to nitroglycerin. When hets admitted to the emergency department, the
health care team obtains an electrocardiogram and administers I.V. morphine. The physician also considers
administering alteplase (Activase). This thrombolytic agent must be administered how soon after onset of
myocardial infarction (MI) symptoms?
a) Within 5 to 7 days
b) Within 6 hours
c) Within 12 hours
d) Within 24 to 48 hours
b
(Within 6 hours
For the best chance of salvaging the client's myocardium, a thrombolytic agent must be administered within 6 hours after
onset of chest pain or other signs or symptoms of MI. Sudden death is most likely to occur within the first 24 hours after
an MI. Physicians initiate I.V. heparin therapy after administration of a thrombolytic agent; it usually continues for 5 to 7
days.)
A client is ordered a nitroglycerine transdermal patch for treatment of CAD and asks the nurse why the patch is
removed at bedtime. Which is the best response by the nurse?
a) "Contact dermatitis and skin irritations are common when the patch remains on all day."
b) "Removing the patch at night prevents drug tolerance while keeping the benefits."
c) "Nitroglycerine causes headaches, but removing the patch decreases the incidence."
d) "You do not need the effects of nitroglycerine while you sleep."
b
("Removing the patch at night prevents drug tolerance while keeping the benefits."
Tolerance to antiangina effects of nitrates can occur when taking these drugs for long periods of time. Therefore, to
prevent tolerance and maintain benefits, it is a common regime to remove transdermal patches at night. Common adverse
effects of nitroglycerine are headaches and contact dermatitis but not the reason for removing the patch at night. It is true
that while you rest, there is less demand on the heart but not the primary reason for removing the patch.)
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The nurse is reviewing the results of a total cholesterol level for a patient who has been taking simvastatin (Zocor).
What results display the effectiveness of the medication?
a) 250-275 mg/dL
b) 210-240 mg/dL
c) 160-190 mg/dL
d) 280-300 mg/dL
c
(160-190 mg/dL
Simvastatin (Zocor) is a statin frequently given as initial therapy for significantly elevated cholesterol and low-density
lipoprotein levels. Normal total cholesterol is less than 200 mg/dL.)
A client with severe angina pectoris and electrocardiogram changes is seen by a physician in the emergency
department. In terms of serum testing, itts most important for the physician to order cardiac:
a) troponin.
b) lactate dehydrogenase.
c) myoglobin.
d) creatine kinase.
a
(troponin.
This client exhibits signs of myocardial infarction (MI), and the most accurate serum determinant of an MI is troponin level.
Creatine kinase, lactate dehydrogenase and myoglobin tests can show evidence of muscle injury, but they're less specific
indicators of myocardial damage than troponin.)
A client with chest pain arrives in the emergency department and receives nitroglycerin, morphine (Duramorph),
oxygen, and aspirin. The physician diagnoses acute coronary syndrome. When the client arrives on the unit, his
vital signs are stable and he has no complaints of pain. The nurse reviews the physiciants orders. In addition to the
medications already given, which medication does the nurse expect the physician to order?
a) Nitroprusside (Nipride)
b) Furosemide (Lasix)
c) Carvedilol (Coreg)
d) Digoxin (Lanoxin)
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c
(Carvedilol (Coreg)
A client with suspected myocardial infarction should receive aspirin, nitroglycerin, morphine, and a beta-adrenergic blocker
such as carvedilol. Digoxin treats arrhythmias; there is no indication that the client is having arrhythmias. Furosemide is
used to treat signs of heart failure, which isn't indicated at this point. Nitroprusside increases blood pressure. This client
has stable vital signs and isn't hypotensive.)
In the treatment of coronary artery disease (CAD), medications are often ordered to control blood pressure in the
client. Which of the following is a primary purpose of using beta-adrenergic blockers in the nursing management of
CAD?
a) To decrease homocysteine levels
b) To dilate coronary arteries
c) To decrease workload of the heart
d) To prevent angiotensin II conversion
c
(To decrease workload of the heart
Beta-adrenergic blockers are used in the treatment of CAD to decrease the myocardial oxygen by reducing heart rate and
workload of the heart. Nitrates are used for vasodilation. Anti-lipid drugs (such as statins and Bvitamins) are used to
decrease homocysteine levels. ACE inhibitors inhibit the conversion of angiotensin.)
After 2-hour onset of acute chest pain, the client is brought to the emergency department for evaluation. Elevation
of which diagnostic findings would the nurse identify as suggestive of an acute myocardial infarction at this time?
a) WBC (white blood cell) count
b) Troponin I
c) C-reactive protein
d) Myoglobin
d
(Myoglobin
Myoglobin is a biomarker that rises in 2 to 3 hours after heart damage. Troponin is the gold standard for determining heart
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damage, but troponin I levels due not rise until 4 to 6 hours after MI. WBCs and C-reactive protein levels will rise but not
until about day 3.)
Which of the following medications is given to patients diagnosed with angina and is allergic to aspirin?
a) Diltiazem (Cardizem)
b) Felodipine (Plendil)
c) Amlodipine (Norvasc)
d) Clopidogrel (Plavix)
d
(Clopidogrel (Plavix)
Plavix or Ticlid is given to patients who are allergic to aspirin or given in addition to aspirin to patients at high risk for MI.
Norvasc, Cardizem, and Plendil are calcium channel blockers.)
A patientts elevated cholesterol levels are being managed with Lipitor, 40 mg daily. The nurse practitioner reviews
the patientts blood work every 6 months before renewing the prescription. The nurse explains to the patientts
daughter that this is necessary because of a major side effect of Lipitor that she is checking for. What is that sideeffect?
a) Hyperuricemia
b) Hyperglycemia
c) Gastrointestinal distress
d) Increased liver enzymes
d
(Increased liver enzymes
Myopathy and increased liver enzymes are significant side effects of the statins, HMG-CoA reductase inhibitors that are
used to affect lipoprotein metabolism.)
Heparin therapy is usually considered therapeutic when the patientts activated partial thromboplastin time (aPTT) is
how many times normal?
a) 2 to 2.5
b) .5 to 1
c) 2.5 to 3
d) .25 to .75
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a
(2 to 2.5
The amount of heparin administered is based on aPTT results, which should be obtained in follow-up to any alteration of
dosage. The patient's aPTT value would have to be greater than .5 to 1 times normal to be considered therapeutic. An
aPTT value that is 2.5 to 3 times normal would be too high to be considered therapeutic. The patient's aPTT value would
have to be greater than .25 to .75 times normal to be considered therapeutic.)
The nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease should be to:
a) educate the client about his symptoms.
b) decrease anxiety.
c) administer sublingual nitroglycerin.
d) enhance myocardial oxygenation.
d
(enhance myocardial oxygenation.
Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac
compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to
treat acute angina pectoris, but its administration isn't the first priority. Although educating the client and decreasing
anxiety are import in care delivery, neither is a priority when a client is compromised.)
A client with angina pectoris must learn how to reduce risk factors that exacerbate this condition. When developing
the clientts care plan, which expected outcome should a nurse include?
a) "Client will verbalize the intention to stop smoking."
b) "Client will verbalize an understanding of the need to call the physician if acute pain lasts more than 2 hours."
c) "Client will verbalize the intention to avoid exercise."
d) "Client will verbalize an understanding of the need to restrict dietary fat, fiber, and cholesterol."
a
("Client will verbalize the intention to stop smoking."
A client with angina pectoris should stop smoking at once because smoking increases the blood carboxyhemoglobin level;
this increase, in turn, reduces the heart's oxygen supply and may induce angina. The client must seek immediate medical
attention if chest pain doesn't subside after three nitroglycerin doses taken 5 minutes apart; serious myocardial damage or
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even sudden death may occur if chest pain persists for 2 hours. To improve coronary circulation and promote weight
management, the client should get regular daily exercise. The client should eat plenty of fiber, which may decrease serum
cholesterol and triglyceride levels and minimize hypertension, in turn reducing the risk for atherosclerosis (which plays a
role in angina).)
The nurse has been asked to explain the cause of angina pain to a patientts family. Choose the best statement. The
pain is due to:
a) A lack of oxygen in the heart muscle that causes the death of cells.
b) Complete closure of an artery.
c) Incomplete blockage of a major coronary artery.
d) A destroyed part of the heart muscle.
a
(A lack of oxygen in the heart muscle that causes the death of cells.
Impeded blood flow, due to blockage in a coronary artery, deprives the cardiac muscle cells of oxygen thus leading to a
condition known as ischemia.)
Which nursing actions would be of greatest importance in the management of a client preparing for angioplasty?
a) Withhold anticoagulant therapy.
b) Remove hair from skin insertion sites.
c) Inform client of diagnostic tests.
d) Assess distal pulses.
a
(Withhold anticoagulant therapy.
The nurse knows to withhold the anticoagulant therapy to decrease chance of hemorrhage during the procedure. The
nurse does inform the client of diagnostic test, will assess pulses, and prep the skin prior to the angioplasty, but this is not
the most important action to be taken.)
In providing nursing management to a client post-varicose vein surgery, the nurse would include which of the
following teaching measures? Select all that apply.
a) Cool compresses
b) Take warm showers in the morning.
c) Stand rather than sit.
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d) Elastic stockings
e) Exercise
f) Lower the extremities.
d, e
(Movement/exercise and use of elastic stocking aid in venous return. Cool compresses can cause vasoconstriction, which
can diminish arterial blood flow. Elevation of legs can be helpful in aiding venous return. Standing or sitting for prolonged
periods of time should be avoided. Showers in the morning can dilate blood vessels and contribute to venous congestion
and edema.)
A patient asks the nurse how long he will have to wait after taking nitroglycerin before experiencing pain relief.
What is the best answer by the nurse?
a) 3 minutes
b) 15 minutes
c) 60 minutes
d) 30 minutes
a
(3 minutes
Nitroglycerin may be given by several routes: sublingual tablet or spray, oral capsule, topical agent, and intravenous (IV)
administration. Sublingual nitroglycerin is generally placed under the tongue or in the cheek (buccal pouch) and ideally
alleviates the pain of ischemia within 3 minutes.)
A nurse is reevaluating a client receiving IV fibrinolytic therapy. Which of the following patient findings requires
immediate intervention by the nurse?
a) Minimal oozing of blood from the IV site
b) Altered level of consciousness
c) Chest pain: 2 of 10 (1-to-10 pain scale)
d) Presence of reperfusion dysrhythmias
b
(Altered level of consciousness
A patient receiving fibrinolytic therapy is at risk for complications associated with bleeding. Altered level of consciousness
may indicate hypoxia and intracranial bleeding and the infusion should be discontinued immediately. Minimal bleeding
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requires manual pressure. Reperfusion dysrhythmias are an expected finding. A chest pain score of 2 is low, and
indicates the patient's chest pain is subsiding, an expected outcome of this therapy.)
A 23-year-old female client has been diagnosed with Raynaudts disease. The nurse teaches the client which of the
following self-care strategies to minimize risks associated with this disease? Select all that apply.
a) Avoid over-the-counter decongestants and cold remedies.
b) Wear gloves to protect hands from injury when performing tasks.
c) Refrain from going outdoors in cold weather.
d) Limit activities that place stress on the ulnar nerve.
e) Do not smoke or stop smoking.
a, b, e
(The nurse instructs clients with Raynaud's disease to quit smoking, avoid over-the-counter decongestants, cold remedies,
and drugs for symptomatic relief of hay fever because of their vasoconstrictive qualities, protect hands and feet from
injury, and wear warm socks and mittens when going outdoors in the cold weather.)
While receiving a heparin infusion to treat deep vein thrombosis, a client reports that his gums bleed when he
brushes his teeth. What should the nurse do first?
a) Notify the physician.
b) Administer a coumarin derivative, as ordered, to counteract heparin.
c) Reassure the client that bleeding gums are a normal effect of heparin.
d) Stop the heparin infusion immediately.
a
(Notify the physician.
Because heparin can cause bleeding gums that may indicate excessive anticoagulation, the nurse should notify the
physician, who will evaluate the client's condition. The physician should order laboratory tests such as partial
thromboplastin time before concluding that the client's bleeding is significant. The ordered heparin dose may be
therapeutic rather than excessive, so the nurse shouldn't discontinue the heparin infusion unless the physician orders this
after evaluating the client. Protamine sulfate, not a coumarin derivative, is given to counteract heparin. Heparin doesn't
normally cause bleeding gums.)
A client is recovering from coronary artery bypass graft (CABG) surgery. The nurse knows that for several weeks
after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should
advise the client and his family to expect which common symptom that typically resolves spontaneously?
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a) Memory lapses
b) Ankle edema
c) Depression
d) Dizziness
c
(Depression
For the first few weeks after CABG surgery, clients commonly experience depression, fatigue, incisional chest discomfort,
dyspnea, and anorexia. Depression typically resolves without medical intervention. However, the nurse should advise
family members that symptoms of depression don't always resolve on their own. They should make sure they recognize
worsening symptoms of depression and know when to seek care. Ankle edema seldom follows CABG surgery and may
indicate right-sided heart failure. Because this condition is a sign of cardiac dysfunction, the client should report ankle
edema at once. Memory lapses reflect neurologic rather than cardiac dysfunction. Dizziness may result from decreased
cardiac output, an abnormal condition following CABG surgery. This symptom warrants immediate physician notification.)
A 65-year-old male client complains of pain and cramping in his thigh when climbing the stairs and numbness in
his legs after exertion. The nurse anticipates the physician will perform which of the following diagnostic tests right
in the office to determine PAD?
a) Ankle-brachial index
b) Exercise electrocardiography
c) Photoplethysmography
d) Electron beam computed tomography
a
(Ankle-brachial index
The client's symptoms indicate he may have peripheral artery disease (PAD). The ankle-brachial index is a simple,
noninvasive test used for its diagnosis. An exercise electrocardiography may be ordered for a client with possible CAD.
An EBCT is a radiologic test that produces x-rays of the coronary arteries using an electron beam. It is used to diagnose
for CAD. Clients with suspected venous insufficiency will undergo photoplethysmography, a diagnostic test that measures
light that is not absorbed by hemoglobin and consequently is reflected back to the machine.)
A patient diagnosed with a myocardial infarction (MI) has begun an active rehabilitation program. The nurse
recognizes an overall goal of rehabilitation for a patient who has had an MI includes which of the following?
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a) Returning the patient to work and a preillness lifestyle
b) Improvement of the quality of life
c) Prevention of another cardiac event
d) Limiting the effects and progression of atherosclerosis
b
(Improvement of the quality of life
Overall, cardiac rehabilitation is a complete program dedicated to extending and improving quality of life.)
A patient has had cardiac surgery and is being monitored in the intensive care unit (ICU). What complication should
the nurse monitor for that is associated with an alteration in preload?
a) Hypertension
b) Cardiac tamponade
c) Elevated central venous pressure
d) Hypothermia
b
(Cardiac tamponade
Preload alterations occur when too little blood volume returns to the heart as a result of persistent bleeding and
hypovolemia. Excessive postoperative bleeding can lead to decreased intravascular volume, hypotension, and low cardiac
output. Bleeding problems are common after cardiac surgery because of the effects of cardiopulmonary bypass, trauma
from the surgery, and anticoagulation. Preload can also decrease if there is a collection of fluid and blood in the
pericardium (cardiac tamponade), which impedes cardiac filling. Cardiac output is also altered if too much volume returns
to the heart, causing fluid overload.)
A nurse is caring for a client who had a three-vessel coronary bypass graft 4 days earlier. His cholesterol profile is
as follows: total cholesterol 265 mg/dl, low-density lipoprotein (LDL) 139 mg/dl, and high-density lipoprotein (HDL)
32 mg/dl. The client asks the nurse how to lower his cholesterol. The nurse should tell the client that:
a) his cholesterol is within the recommended guidelines and he doesntt need to lower it.
b) he should begin a running program, working up to 2 miles per day.
c) shetll ask the dietitian to talk with him about modifying his diet.
d) he should take his statin medication and not worry about his cholesterol.
c
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(she'll ask the dietitian to talk with him about modifying his diet.
A dietitian can help the client decrease the fat in his diet and make other beneficial dietary modifications. This client's total
cholesterol isn't within the recommended guidelines; it should be less than 200 mg/dl. LDL should be less than 79 mg/dl,
and HDL should be greater than 40 mg/dl. Although this client should take his statin medication, he should still be
concerned about his cholesterol level and make other lifestyle changes, such as dietary changes, to help lower it. The
client should increase his activity level, but he doesn't need to run 2 miles per day.)
The nurse is caring for a patient who was admitted to the telemetry unit with a diagnosis of rule/out acute MI. The
patientts chest pain began 3 hours ago. Which of the following laboratory tests would be most helpful in confirming
the diagnosis of a current MI?
a) Creatinine kinase-myoglobin (CK-MB) level
b) Troponin C level
c) Myoglobin level
d) CK-MM
a
(Creatinine kinase-myoglobin (CK-MB) level
Elevated CK-MB assessment by mass assay is an indicator of acute MI; the levels begin to increase within a few hours
and peak within 24 hours of an MI. If the area is reperfused (due to thrombotic therapy or PCI), it peaks earlier. CK-MM
(skeletal muscle) is not an indicator of cardiac muscle damage. There are three isomers of troponin: C, I, and T. Troponin
I and T are specific for cardiac muscle, and these biomarkers are currently recognized as reliable and critical markers of
myocardial injury. An increase in myoglobin is not very specific in indicating an acute cardiac event; however, negative
results are an excellent parameter for ruling out an acute MI.)
You are presenting a workshop at the senior citizens center about how the changes of aging predispose clients to
vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in
the older adult?
a) Raynaudts disease
b) Coronary thrombosis
c) Atherosclerosis
d) Arteriosclerosis
c
(Atherosclerosis
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Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. The disease correlates with
the aging process. The other choices may occur at any age.)
Understanding atherosclerosis, the nurse identifies which of the following to be both a risk factor for the
development of the disorder and an outcome?
a) Hypertension
b) Hyperlipidemia
c) Obesity
d) Glucose intolerance
a
(Hypertension
Increases in diastolic and systolic blood pressure are associated with an increased incidence of atherosclerosis, often an
inherited factor. Elevation of blood pressure results when the vessels cannot relax and impairs the ability of the artery to
dilate. Hyperlipidemia, diabetes, and obesity are all risk factors for atherosclerosis but do not result from the disorder.)
A nurse completed a physical exam for an insurance company. The nurse noted a cluster of abnormalities that she
knew was considered a major risk factor for coronary artery disease. Choose that condition.
a) Metabolic syndrome
b) Diabetes mellitus
c) Hypolipidemia
d) Congestive heart failure
a
(Metabolic syndrome
Metabolic syndrome includes three of six conditions that are recognized as a major risk factor for CAD. Insulin resistance
is part of the syndrome but the patient may not yet have diabetes.)
A client, who has undergone a percutaneous transluminal coronary angioplasty (PTCA), has received discharge
instructions. Which statement by the client would indicate the need for further teaching by the nurse?
a) "I should expect bruising at the catheter site for up to 3 weeks."
b) "I should expect a low-grade fever and swelling at the site for the next week."
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c) "I should avoid taking a tub bath until my catheter site heals."
d) "I should avoid prolonged sitting."
b
("I should expect a low-grade fever and swelling at the site for the next week."
Fever and swelling at the site are signs of infection and should be reported to the physician. Showers should be taken
until the insertion site is healed. Prolonged sitting can result in thrombosis formation. Bruising at the insertion site is
common and may take from 1 to 3 weeks to resolve.)
A nurse is teaching about risk factors that increase the probability of heart disease to a community group. Which of
the following risk factors will the nurse include? Choose all that apply.
a) African-American descent
b) Family history of coronary heart disease
c) Elevated C-reactive protein
d) Body mass index (BMI) of 23
e) Age greater than 45 years for men
a, b, c, e
(Risk factors for coronary heart disease (CHD) include family history of CHD, age older than 45 years for men and 65
years for women, African-American race, BMI of 25 or greater, and elevated C-reactive protein.)
Which condition most commonly results in coronary artery disease (CAD)?
a) Renal failure
b) Myocardial infarction
c) Diabetes mellitus
d) Atherosclerosis
d
(Atherosclerosis
Atherosclerosis (plaque formation), is the leading cause of CAD. Diabetes mellitus is a risk factor for CAD, but it isn't the
most common cause. Myocardial infarction is a common result of CAD. Renal failure doesn't cause CAD, but the two
conditions are related.)
The nurse at a community health fair is discussing the risk factors for heart failure. The nurse recognizes that the
client at the highest risk for heart failure is the client:
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A. With hypertension who also has chronic renal insufficiency.
B. Who has coronary artery disease (CAD) and pulmonary hypertension.
C. Who has atherosclerosis and experienced a myocardial infarction 5 years ago.
D. With diabetes mellitus who also has hypertension and aortic valve regurgitation.
D
(Risk factors for heart failure include hypertension, renal insufficiency, CAD, pulmonary hypertension, atherosclerosis, MI,
diabetes mellitus, and valvular disorders. The client with diabetes mellitus, hypertension, and aortic valve regurgitation has
more risk factors than the other clients.)
The nurse is preparing to administer digoxin to a client with heart failure. Which of the following findings would
require follow-up before administering the medication?
A. Serum potassium level, 3.2 mEq/L
B. Serum sodium level, 135 mEq/L
C. Blood pressure, 118/72 mm Hg
D. Pulse, 62
A
(The nurse should notify the primary health care provider for a client receiving digoxin who has a serum potassium level
of 3.2 mEq/L as hypokalemia can induce digitalis toxicity. The serum sodium level, blood pressure, and pulse are all
within the expected range and do not require follow up at this time.)
The nurse is caring for a client who recently experienced a myocardial infarction. The client states "If I had just
called the doctor when I first started feeling bad, this would not have happened." The nurse understands that the
client is experiencing:
A. Denial
B. Anger
C. Bargaining
D. Acceptance
C
(The client's statement reflects the bargaining stage of the disease/grief process. Denial would be indicated by refusing to
believe the diagnosis. Anger would be indicated with a statement reflecting that emotion. Acceptance is the stage where
the client takes control of the diagnosis and care required.)
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The nurse is reviewing new prescriptions for a client with heart failure who has developed pulmonary edema. Which
of the following prescriptions should the nurse clarify?
A. 0.9% sodium chloride IV at 125 mL/hr
B. Serum electrolyte and creatinine levels daily
C. Maintain the head of the bed above 45 degrees
D. Mechanical ventilation with positive-end expiratory pressure
A
(IV fluids should be administered sparingly in clients with pulmonary edema. Clients with pulmonary edema are expected
to have prescriptions for maintaining the head of the bed above 45 degrees, serum electrolyte and creatinine level
measurements daily, and mechanical ventilation with PEEP if breathing becomes compromised.)
The charge nurse is observing a newly hired nurse perform client care tasks. It would require intervention by the
charge nurse if the newly hired nurse is observed:
A. Initiating continuous arterial oxygen saturation monitoring for a client with heart failure.
B. Initiating the administration of IV nitroprusside for a client experiencing pulmonary edema.
C. Requesting to discontinue the administraton of intravenous furosemide for a client with heart failure who has
had clear lung sounds and a negative fluid balance for the past 2 days.
D. Requesting the removal of an indwelling urinary catheter that was inserted 3 days ago for a client who is
receiving intravenous furosemide for the management of pulmonary edema.
D
(Clients receiving intravenous furosemide require strict I/O monitoring with the use of an indwelling catheter until the
clien's pulmonary edema has subsided. Clients with heart failure should receivie continuous arterial oxygen saturation
monitoring, and intravenous furosemide can be ransitioned to oral when the client's lung sounds have improved. Clients
with pulmonary edema should receive IV nitrprusside for symptom relief as long as the client is not hypotensive.)
The nurse is caring for a client with a new diagnosis of heart failure. The client is concerned because the clientts
spouse lives in a long-term care facility and cannot assist with medical decisions or care. The nurse should:
A. Talk to the client about the clientts advanced directive wishes at this time.
B. Ask the facility ethics committee to make decisions for the clientts health care needs.
C. Initiate a referral for a social worker to transfer the client to the same long-term care facility.
D. Arrange for a client advocate to travel to the long-term care facility and assess the spousets abilities to
participate in the clientts care.
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A
(Nurses are responsible for explaining and clarifying advance directives for clients who express concern for medical care
decisions. Ethics committees do not make decisions for clients, they provide additional research and guidance to the
parties involved. The client is not exhibiting any needs that require placement in a long-term care facility at this time. A
client advocate would not travel to another facility to assess the spouse's ability to participate in the client's medical care.)
The nurse is assessing an older adult client. The nurse understands that the client is at increased risk for
developing pulmonary edema because the client:
A. Is over the age of 75.
B. Has impaired renal function.
C. Has a serum sodium level of 140 mEq/L.
D. Has chronic obstructive pulmonary disease (COPD).
B
(Pulmonary edema is an acute event that results from left ventricular failure. It can occur following acute MI or as an
exacerbation of chronic HF. Pulmonary edema can also develop slowly, especially when it is caused by noncardiac
disorders such as renal failure and other conditions that cause fluid overload. Being over the age of 75 and having COPD
has no impact on the development of pulmonary edema. A serum sodium level of 140 mEq/L is within the expected range
and also has no impact on the development of pulmonary edema.)
The nurse is caring for a client with acute decompensated heart failure. Which of the following actions should the
nurse take? Refer to the clientts medical record below for more information.
Vital Signs
P 108
R 26
BP 164/92 mm Hg
SpO2 87% Room Air
T 98.6º F
Pain 6/10 thoracic
Nursets Notes:
Client has a productive cough that is frothy and is short of breath. Moist crackles auscultated throughout the lung
fields.
A. Place the client in the left lateral positon.
B. Request a prescription for intravenous furosemide.
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C. Request a prescription for intravenous fluid resuscitation.
D. Administer prescribed morphine for reports of chest pain.
B
(The client is experiencing pulmonary edema and the nurse should request a prescription for intravenous furosemide,
place the client in the semi or high-fowler's position, initiate strict I/O with a reduction of circulating fluid volume, and
morphine should be avoided as it may induce respiratory depression, further complicating the pathophysiology of
pulmonary edema.)
The nurse is caring for a client who had coronary artery bypass graft (CABG) surgery 6 hours ago and has
produced 200 mL of chest tube drainage over the past 3 hours. Which of the following actions should the nurse
take?
A. Document the clientts chest tube output and continue to monitor the client.
B. Notify the clientts physician and suggest a further assessment of the potential for hemorrhage.
C. Increase the infusion rate of the clientts IV fluid to replace the fluids lost through the chest tube drainge.
D. Clamp the clientts chest tube in preparation for removal and reinsertion of a new tube.
A
(Nursing management includes accurate measurement of chest tube drainage, which should not exceed 150 mL per hour
immediately following a CABG surgery. 200 mL over 3 hours does not exceed this amount, and thus, the nurse should
continue to monitor the client. This amount of drainage does not indicate hemorrhage, nor does it require fluid
replacement. Chest tubes should not be clamped, and this client does not require an additonal or new tube at this time.)
The nurse is caring for a patient who has been diagnosed with an elevated cholesterol level. The nurse is
aware that plaque on the inner lumen of arteries is composed chiefly of what?
A) Lipids and fibrous tissue
B) White blood cells
C) Lipoproteins
D) High-density cholesterol
Ans: A
Feedback:
As T-lymphocytes and monocytes infiltrate to ingest lipids on the arterial wall and then die, a fibrous
tissue develops. This causes plaques to form on the inner lumen of arterial walls. These plaques do not
consist of white cells, lipoproteins, or high-density cholesterol.
A patient presents to the walk-in clinic complaining of intermittent chest pain on exertion, which is
eventually attributed to angina. The nurse should inform the patient that angina is most often attributable
to what cause?
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A) Decreased cardiac output
B) Decreased cardiac contractility
C) Infarction of the myocardium
D) Coronary arteriosclerosis
Ans: D
Feedback:
In most cases, angina pectoris is due to arteriosclerosis. The disease is not a result of impaired cardiac
output or contractility. Infarction may result from untreated angina, but it is not a cause of the disease.
The nurse is caring for an adult patient who had symptoms of unstable angina upon admission to the
hospital. What nursing diagnosis underlies the discomfort associated with angina?
A) Ineffective breathing pattern related to decreased cardiac output
B) Anxiety related to fear of death
C) Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)
D) Impaired skin integrity related to CAD
Ans: C
Feedback:
Ineffective cardiopulmonary tissue perfusion directly results in the symptoms of discomfort associated
with angina. Anxiety and ineffective breathing may result from angina chest pain, but they are not the
causes. Skin integrity is not impaired by the effects of angina.
The triage nurse in the ED assesses a 66-year-old male patient who presents to the ED with complaints
of midsternal chest pain that has lasted for the last 5 hours. If the patients symptoms are due to an MI,
what will have happened to the myocardium?
A) It may have developed an increased area of infarction during the time without treatment.
B) It will probably not have more damage than if he came in immediately.
C) It may be responsive to restoration of the area of dead cells with proper treatment.
D) It has been irreparably damaged, so immediate treatment is no longer necessary.
Ans: A
Feedback:
When the patient experiences lack of oxygen to myocardium cells during an MI, the sooner treatment is
initiated, the more likely the treatment will prevent or minimize myocardial tissue necrosis. Delays in
treatment equate with increased myocardial damage. Despite the length of time the symptoms have been present,
treatment needs to be initiated immediately to minimize further damage. Dead cells cannot be
restored by any means.
Family members bring a patient to the ED with pale cool skin, sudden midsternal chest pain unrelieved
with rest, and a history of CAD. How should the nurse best interpret these initial data?
A) The symptoms indicate angina and should be treated as such.
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B) The symptoms indicate a pulmonary etiology rather than a cardiac etiology.
C) The symptoms indicate an acute coronary episode and should be treated as such.
D) Treatment should be determined pending the results of an exercise stress test.
Ans: C
Feedback:
Angina and MI have similar symptoms and are considered the same process, but are on different points
along a continuum. That the patients symptoms are unrelieved by rest suggests an acute coronary
episode rather than angina. Pale cool skin and sudden onset are inconsistent with a pulmonary etiology.
Treatment should be initiated immediately regardless of diagnosis.
An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows
that the vessel most commonly used as source for a CABG is what?
A) Brachial artery
B) Brachial vein
C) Femoral artery
D) Greater saphenous vein
Ans: D
Feedback:
The greater saphenous vein is the most commonly used graft site for CABG. The right and left internal
mammary arteries, radial arteries, and gastroepiploic artery are other graft sites used, though not as
frequently. The femoral artery, brachial artery, and brachial vein are never harvested.
A patient with an occluded coronary artery is admitted and has an emergency percutaneous transluminal
coronary angioplasty (PTCA). The patient is admitted to the cardiac critical care unit after the PTCA.
For what complication should the nurse most closely monitor the patient?
A) Hyperlipidemia
B) Bleeding at insertion site
C) Left ventricular hypertrophy
D) Congestive heart failure
Ans: B
Complications of PTCA may include bleeding at the insertion site, abrupt closure of the artery, arterial
thrombosis, and perforation of the artery. Complications do not include hyperlipidemia, left ventricular
hypertrophy, or congestive heart failure; each of these problems takes an extended time to develop and
none is emergent.
The nurse is caring for a patient who is scheduled for cardiac surgery. What should the nurse include in
preoperative care?
A) With the patient, clarify the surgical procedure that will be performed.
B) Withhold the patients scheduled medications for at least 12 hours preoperatively.
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C) Inform the patient that health teaching will begin as soon as possible after surgery.
D) Avoid discussing the patients fears as not to exacerbate them.
Ans: A
Feedback:
Preoperatively, it is necessary to evaluate the patients understanding of the surgical procedure, informed
consent, and adherence to treatment protocols. Teaching would begin on admission or even prior to
admission. The physician would write orders to alter the patients medication regimen if necessary; this
will vary from patient to patient. Fears should be addressed directly and empathically
The OR nurse is explaining to a patient that cardiac surgery requires the absence of blood from the
surgical field. At the same time, it is imperative to maintain perfusion of body organs and tissues. What
technique for achieving these simultaneous goals should the nurse describe?
A) Coronary artery bypass graft (CABG)
B) Percutaneous transluminal coronary angioplasty (PTCA)
C) Atherectomy
D) Cardiopulmonary bypass
Ans: D
Feedback:
Cardiopulmonary bypass is often used to circulate and oxygenate blood mechanically while bypassing
the heart and lungs. PTCA, atherectomy, and CABG are all surgical procedures, none of which achieves the two goals
listed.
The nurse has just admitted a 66-year-old patient for cardiac surgery. The patient tearfully admits to the
nurse that she is afraid of dying while undergoing the surgery. What is the nurses best response?
A) Explore the factors underlying the patients anxiety.
B) Teach the patient guided imagery techniques.
C) Obtain an order for a PRN benzodiazepine.
D) Describe the procedure in greater detail.
Ans: A
Feedback:
An assessment of anxiety levels is required in the patient to assist the patient in identifying fears and
developing coping mechanisms for those fears. The nurse must further assess and explore the patients
anxiety before providing interventions such as education or medications.
A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should
inform the patient about what potential adverse effects?
A) Nervousness or paresthesia
B) Throbbing headache or dizziness
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C) Drowsiness or blurred vision
D) Tinnitus or diplopia
Ans: B
Feedback:
Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy.
Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a
result of nitroglycerin therapy.
The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk
factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled
and some that cannot. What risk factors would the nurse list that can be controlled or modified?
A) Gender, obesity, family history, and smoking
B) Inactivity, stress, gender, and smoking
C) Obesity, inactivity, diet, and smoking
D) Stress, family history, and obesity
Ans: C
Feedback:
The risk factors for CAD that can be controlled or modified include obesity, inactivity, diet, stress, and
smoking. Gender and family history are risk factors that cannot be controlled.
A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his
left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI).
What nursing assessment activity is a priority on admission to the CCU?
A) Begin ECG monitoring.
B) Obtain information about family history of heart disease.
C) Auscultate lung fields.
D) Determine if the patient smokes.
Ans: A
Feedback:
The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be
obtained within 10 minutes from the time a patient reports pain or arrives in the ED. By monitoring
serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and
monitored; life-threatening arrhythmias are the leading cause of death in the first hours after an MI.
Obtaining information about family history of heart disease and whether the patient smokes are not
immediate priorities in the acute phase of MI. Data may be obtained from family members later. Lung
fields are auscultated after oxygenation and pain control needs are met.
The public health nurse is participating in a health fair and interviews a patient with a history of
hypertension, who is currently smoking one pack of cigarettes per day. She denies any of the most
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common manifestations of CAD. Based on these data, the nurse would expect the focuses of CAD
treatment most likely to be which of the following?
A) Drug therapy and smoking cessation
B) Diet and drug therapy
C) Diet therapy only
D) Diet therapy and smoking cessation
Ans: D
Feedback:
Due to the absence of symptoms, dietary therapy would likely be selected as the first-line treatment for
possible CAD. Drug therapy would be determined based on a number of considerations and diagnostics
findings, but would not be directly indicated. Smoking cessation is always indicated, regardless of the
presence or absence of symptoms.
The nurse is working with a patient who had an MI and is now active in rehabilitation. The nurse should
teach this patient to cease activity if which of the following occurs?
A) The patient experiences chest pain, palpitations, or dyspnea.
B) The patient experiences a noticeable increase in heart rate during activity.
C) The patients oxygen saturation level drops below 96%.
D) The patients respiratory rate exceeds 30 breaths/min.
Ans: A
Feedback:
Any activity or exercise that causes dyspnea and chest pain should be stopped in the patient with CAD.
Heart rate must not exceed the target rate, but an increase above resting rate is expected and is
therapeutic. In most patients, a respiratory rate that exceeds 30 breaths/min is not problematic. Similarly,
oxygen saturation slightly below 96% does not necessitate cessation of activity.
A patient with cardiovascular disease is being treated with amlodipine (Norvasc), a calcium channel
blocking agent. The therapeutic effects of calcium channel blockers include which of the following?
A) Reducing the hearts workload by decreasing heart rate and myocardial contraction
B) Preventing platelet aggregation and subsequent thrombosis
C) Reducing myocardial oxygen consumption by blocking adrenergic stimulation to the heart
D) Increasing the efficiency of myocardial oxygen consumption, thus decreasing ischemia and
relieving pain
Ans: A
Feedback:
Calcium channel blocking agents decrease sinoatrial node automaticity and atrioventricular node
conduction, resulting in a slower heart rate and a decrease in the strength of the heart muscle contraction.
These effects decrease the workload of the heart. Antiplatelet and anticoagulation medications are
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administered to prevent platelet aggregation and subsequent thrombosis, which impedes blood flow. Beta-blockers reduce
myocardial consumption by blocking beta-adrenergic sympathetic stimulation to
the heart. The result is reduced myocardial contractility (force of contraction) to balance the
myocardium oxygen needs and supply. Nitrates reduce myocardial oxygen consumption, which
decreases ischemia and relieves pain by dilating the veins and, in higher doses, the arteries.
The nurse is providing care for a patient with high cholesterol and triglyceride values. In teaching the
patient about therapeutic lifestyle changes such as diet and exercise, the nurse realizes that the desired
goal for cholesterol levels is which of the following?
A) High HDL values and high triglyceride values
B) Absence of detectable total cholesterol levels
C) Elevated blood lipids, fasting glucose less than 100
D) Low LDL values and high HDL values
Ans: D
Feedback:
The desired goal for cholesterol readings is for a patient to have low LDL and high HDL values. LDL
exerts a harmful effect on the coronary vasculature because the small LDL particles can be easily
transported into the vessel lining. In contrast, HDL promotes the use of total cholesterol by transporting
LDL to the liver, where it is excreted. Elevated triglycerides are also a major risk factor for cardiovascular disease. A goal
is also to keep triglyceride levels less than 150 mg/dL. All individuals possess detectable levels of total cholesterol.
When discussing angina pectoris secondary to atherosclerotic disease with a patient, the patient asks
why he tends to experience chest pain when he exerts himself. The nurse should describe which of the
following phenomena?
A) Exercise increases the hearts oxygen demands.
B) Exercise causes vasoconstriction of the coronary arteries.
C) Exercise shunts blood flow from the heart to the mesenteric area.
D) Exercise increases the metabolism of cardiac medications.
Ans: A
Feedback:
Physical exertion increases the myocardial oxygen demand. If the patient has arteriosclerosis of the
coronary arteries, then blood supply is diminished to the myocardium. Exercise does not cause
vasoconstriction or interfere with drug metabolism. Exercise does not shunt blood flow away from the
heart.
The nurse is caring for a patient who is believed to have just experienced an MI. The nurse notes
changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that
ischemia is occurring?
A) P wave inversion
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B) T wave inversion
C) Q wave changes with no change in ST or T wave
D) P wave enlargement
Ans: B
Feedback:
T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves
occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an
old MI.
An adult patient is admitted to the ED with chest pain. The patient states that he had developed
unrelieved chest pain that was present for approximately 20 minutes before coming to the hospital. To
minimize cardiac damage, the nurse should expect to administer which of the following interventions?
A) Thrombolytics, oxygen administration, and nonsteroidal anti-inflammatories
B) Morphine sulphate, oxygen, and bed rest
C) Oxygen and beta-adrenergic blockers
D) Bed rest, albuterol nebulizer treatments, and oxygen
Ans: B
Feedback:
The patient with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin,
and morphine. Morphine sulphate reduces preload and decreases workload of the heart, along with
increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the
best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated.
Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the
heart rate.
The nurse is assessing a patient who was admitted to the critical care unit 3 hours ago following cardiac
surgery. The nurses most recent assessment reveals that the patients left pedal pulses are not palpable
and that the right pedal pulses are rated at +2. What is the nurses best response?
A) Document this expected assessment finding during the initial postoperative period.
B) Reposition the patient with his left leg in a dependent position.
C) Inform the patients physician of this assessment finding.
D) Administer an ordered dose of subcutaneous heparin.
Ans: C
Feedback:
If a pulse is absent in any extremity, the cause may be prior catheterization of that extremity, chronic
peripheral vascular disease, or a thromboembolic obstruction. The nurse immediately reports newly
identified absence of any pulse.
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In preparation for cardiac surgery, a patient was taught about measures to prevent venous
thromboembolism. What statement indicates that the patient clearly understood this education?
A) Ill try to stay in bed for the first few days to allow myself to heal.
B) Ill make sure that I dont cross my legs when Im resting in bed.
C) Ill keep pillows under my knees to help my blood circulate better.
D) Ill put on those compression stockings if I get pain in my calves.
Ans: B
Feedback:
To prevent venous thromboembolism, patients should avoid crossing the legs. Activity is generally
begun as soon as possible and pillows should not be placed under the popliteal space. Compression
stockings are often used to prevent venous thromboembolism, but they would not be applied when
symptoms emerge.
An ED nurse is assessing an adult woman for a suspected MI. When planning the assessment, the nurse
should be cognizant of what signs and symptoms of MI that are particularly common in female patients?
Select all that apply.
A) Shortness of breath
B) Chest pain
C) Anxiety
D) Numbness
E) Weakness
Ans: D, E
Feedback:
Although these symptoms are not wholly absent in men, many women have been found to have atypical
symptoms of MI, including indigestion, nausea, palpitations, and numbness. Shortness of breath, chest
pain, and anxiety are common symptoms of MI among patients of all ages and genders.
When assessing a patient diagnosed with angina pectoris it is most important for the nurse to gather what
information?
A) The patients activities limitations and level of consciousness after the attacks
B) The patients symptoms and the activities that precipitate attacks
C) The patients understanding of the pathology of angina
D) The patients coping strategies surrounding the attacks
Ans: B
Feedback:
The nurse must gather information about the patients symptoms and activities, especially those that
precede and precipitate attacks of angina pectoris. The patients coping, understanding of the disease, and
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status following attacks are all important to know, but causative factors are a primary focus of the
assessment interview.
You are writing a care plan for a patient who has been diagnosed with angina pectoris. The patient
describes herself as being distressed and shocked by her new diagnosis. What nursing diagnosis is most
clearly suggested by the womans statement?
A) Spiritual distress related to change in health status
B) Acute confusion related to prognosis for recovery
C) Anxiety related to cardiac symptoms
D) Deficient knowledge related to treatment of angina pectoris
Ans: C
Feedback:
Although further assessment is warranted, it is not unlikely that the patient is experiencing anxiety. In
patients with CAD, this often relates to the threat of sudden death. There is no evidence of confusion
(i.e., delirium or dementia) and there may or may not be a spiritual element to her concerns. Similarly, it
is not clear that a lack of knowledge or information is the root of her anxiety.
The nurse is caring for patient who tells the nurse that he has an angina attack beginning. What is the
nurses most appropriate initial action?
A) Have the patient sit down and put his head between his knees.
B) Have the patient perform pursed-lip breathing.
C) Have the patient stand still and bend over at the waist.
D) Place the patient on bed rest in a semi-Fowlers position.
Ans: D
Feedback:
When a patient experiences angina, the patient is directed to stop all activities and sit or rest in bed in a
semi-Fowlers position to reduce the oxygen requirements of the ischemic myocardium. Pursed-lip
breathing and standing will not reduce workload to the same extent. No need to have the patient put his
head between his legs because cerebral perfusion is not lacking.
A patient presents to the ED in distress and complaining of crushing chest pain. What is the nurses
priority for assessment?
A) Prompt initiation of an ECG
B) Auscultation of the patients point of maximal impulse (PMI)
C) Rapid assessment of the patients peripheral pulses
D) Palpation of the patients cardiac apex
Ans: A
Feedback:
The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be
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obtained within 10 minutes from the time a patient reports pain or arrives in the ED. Each of the other
listed assessments is valid, but ECG monitoring is the most time dependent priority.
The ED nurse is caring for a patient with a suspected MI. What drug should the nurse anticipate
administering to this patient?
A) Oxycodone
B) Warfarin
C) Morphine
D) Acetaminophen
Ans: C
Feedback:
The patient with suspected MI is given aspirin, nitroglycerin, morphine, an IV beta- blocker, and other
medications, as indicated, while the diagnosis is being confirmed. Tylenol, warfarin, and oxycodone are
not typically used.
The nurse is assessing a patient with acute coronary syndrome (ACS). The nurse includes a careful
history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are
suggestive of ACS? Select all that apply.
A) Dyspnea
B) Unusual fatigue
C) Hypotension
D) Syncope
E) Peripheral cyanosis
Ans: A, B, D
Feedback:
Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or
discomfort, difficulty breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis).
Each symptom must be evaluated with regard to time, duration, and the factors that
precipitate the symptom and relieve it, and in comparison with previous symptoms. Hypotension and
peripheral cyanosis are not typically associated with ACS.
The nurse is creating a plan of care for a patient with acute coronary syndrome. What nursing action
should be included in the patients care plan?
A) Facilitate daily arterial blood gas (ABG) sampling.
B) Administer supplementary oxygen, as needed.
C) Have patient maintain supine positioning when in bed.
D) Perform chest physiotherapy, as indicated.
Ans: B
Feedback:
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Oxygen should be administered along with medication therapy to assist with symptom relief.
Administration of oxygen raises the circulating level of oxygen to reduce pain associated with low levels
of myocardial oxygen. Physical rest in bed with the head of the bed elevated or in a supportive chair
helps decrease chest discomfort and dyspnea. ABGs are diagnostic, not therapeutic, and they are rarely
needed on a daily basis. Chest physiotherapy is not used in the treatment of ACS.
The nurse is participating in the care conference for a patient with ACS. What goal should guide the care
teams selection of assessments, interventions, and treatments?
A) Maximizing cardiac output while minimizing heart rate
B) Decreasing energy expenditure of the myocardium
C) Balancing myocardial oxygen supply with demand
D) Increasing the size of the myocardial muscle
Ans: C
Balancing myocardial oxygen supply with demand (e.g., as evidenced by the relief of chest pain) is the
top priority in the care of the patient with ACS. Treatment is not aimed directly at minimizing heart rate
because some patients experience bradycardia. Increasing the size of the myocardium is never a goal.
Reducing the myocardiums energy expenditure is often beneficial, but this must be balanced with
productivity.
The nurse working on the coronary care unit is caring for a patient with ACS. How can the nurse best
meet the patients psychosocial needs?
A) Reinforce the fact that treatment will be successful.
B) Facilitate a referral to a chaplain or spiritual leader.
C) Increase the patients participation in rehabilitation activities.
D) Directly address the patients anxieties and fears.
Ans: D
Feedback:
Alleviating anxiety and decreasing fear are important nursing functions that reduce the sympathetic
stress response. Referrals to spiritual care may or may not be appropriate, and this does not relieve the
nurse of responsibility for addressing the patients psychosocial needs. Treatment is not always
successful, and false hope should never be fostered. Participation in rehabilitation may alleviate anxiety
for some patients, but it may exacerbate it for others.
The nurse is caring for a patient who has undergone percutaneous transluminal coronary angioplasty
(PTCA). What is the major indicator of success for this procedure?
A) Increase in the size of the arterys lumen
B) Decrease in arterial blood flow in relation to venous flow
C) Increase in the patients resting heart rate
D) Increase in the patients level of consciousness (LOC)
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Ans: A
Feedback:
PTCA is used to open blocked coronary vessels and resolve ischemia. The procedure may result in
beneficial changes to the patients LOC or heart rate, but these are not the overarching goals of PTCA.
Increased arterial flow is the focus of the procedures.
A nurse has taken on the care of a patient who had a coronary artery stent placed yesterday. When
reviewing the patients daily medication administration record, the nurse should anticipate administering
what drug?
A) Ibuprofen
B) Clopidogrel
C) Dipyridamole
D) Acetaminophe
Ans: B
Feedback:
Because of the risk of thrombus formation within the stent, the patient receives antiplatelet medications,
usually aspirin and clopidogrel. Ibuprofen and acetaminophen are not antiplatelet drugs. Dipyridamole is
not the drug of choice following stent placement.
A nurse is working with a patient who has been scheduled for a percutaneous coronary intervention
(PCI) later in the week. What anticipatory guidance should the nurse provide to the patient?
A) He will remain on bed rest for 48 to 72 hours after the procedure.
B) He will be given vitamin K infusions to prevent bleeding following PCI.
C) A sheath will be placed over the insertion site after the procedure is finished.
D) The procedure will likely be repeated in 6 to 8 weeks to ensure success.
Ans: C
Feedback:
A sheath is placed over the PCI access site and kept in place until adequate coagulation is achieved.
Patients resume activity a few hours after PCI and repeated treatments may or may not be necessary.
Anticoagulants, not vitamin K, are administered during PCI.
Preoperative education is an important part of the nursing care of patients having coronary artery
revascularization. When explaining the pre- and postoperative regimens, the nurse would be sure to
include education about which subject?
A) Symptoms of hypovolemia
B) Symptoms of low blood pressure
C) Complications requiring graft removal
D) Intubation and mechanical ventilation
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Ans: D
Feedback:
Most patients remain intubated and on mechanical ventilation for several hours after surgery. It is
important that patients realize that this will prevent them from talking, and the nurse should reassure
them that the staff will be able to assist them with other means of communication. Teaching would
generally not include symptoms of low blood pressure or hypovolemia, as these are not applicable to
most patients. Teaching would also generally not include rare complications that would require graft
removal.
A patient in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention
(PCI) access site in her femoral region. What is the nurses most appropriate action?
A) Call for assistance and initiate cardiopulmonary resuscitation.
B) Reposition the patients leg in a nondependent position.
C) Promptly remove the femoral sheath.
D) Call for help and apply pressure to the access site.
Ans: D
Feedback:
The femoral sheath produces pressure on the access site. Pressure will temporarily reduce bleeding and
allow for subsequent interventions. Removing the sheath would exacerbate bleeding and repositioning would not halt it.
CPR is not indicated unless there is evidence of respiratory or cardiac arrest.
The nurse providing care for a patient post PTCA knows to monitor the patient closely. For what
complications should the nurse monitor the patient? Select all that apply.
A) Abrupt closure of the coronary artery
B) Venous insufficiency
C) Bleeding at the insertion site
D) Retroperitoneal bleeding
E) Arterial occlusion
Ans: A, C, D, E
Feedback:
Complications after the procedure may include abrupt closure of the coronary artery and vascular
complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial
occlusion, as well as acute renal failure. Venous insufficiency is not a postprocedure complication of a
PTCA.
A patient who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours
and the nurse has confirmed the patency of the urinary catheter. What is the nurses most appropriate
action?
A) Document the patients low urine output and monitor closely for the next several hours.
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B) Contact the dietitian and suggest the need for increased oral fluid intake.
C) Contact the patients physician and suggest assessment of fluid balance and renal function.
D) Increase the infusion rate of the patients IV fluid to prompt an increase in renal function.
Ans: C
Feedback:
Nursing management includes accurate measurement of urine output. An output of less than 1 mL/kg/h may indicate
hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may
be indicated, but is beyond the independent scope of the dietitian or nurse.
A patient is recovering in the hospital from cardiac surgery. The nurse has identified the diagnosis of
risk for ineffective airway clearance related to pulmonary secretions. What intervention best addresses
this risk?
A) Administration of bronchodilators by nebulizer
B) Administration of inhaled corticosteroids by metered dose inhaler (MDI)
C) Patients consistent performance of deep breathing and coughing exercises
D) Patients active participation in the cardiac rehabilitation program
Ans: C
Feedback:
Clearance of pulmonary secretions is accomplished by frequent repositioning of the patient, suctioning,
and chest physical therapy, as well as educating and encouraging the patient to breathe deeply and
cough. Medications are not normally used to achieve this goal. Rehabilitation is important, but will not
necessarily aid the mobilization of respiratory secretions.
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Brunner & Suddarth's Textbook of Medical Surgical Nursing 15th Edition
Chapter 24: Management of Patients With Structural, Infectious, and Inflammatory Cardiac
Disorders
1. A patient with mitral stenosis exhibits new symptoms of a dysrhythmia. Based on the pathophysiology
of this disease process, the nurse would expect the patient to exhibit what heart rhythm?
A) Ventricular fibrillation (VF)
B) Ventricular tachycardia (VT)
C) Atrial fibrillation
D) Sinus bradycardia
Ans: C
Feedback:
In patients with mitral valve stenosis, the pulse is weak and often irregular because of atrial fibrillation. Bradycardia, VF,
and VT are not characteristic of this valvular disorder.
2. A patient who has undergone a valve replacement with a mechanical valve prosthesis is due to be
discharged home. During discharge teaching, the nurse should discuss the importance of antibiotic
prophylaxis prior to which of the following?
A) Exposure to immunocompromised individuals
B) Future hospital admissions
C) Dental procedures
D) Live vaccinations
Ans: C
Feedback:
Following mechanical valve replacement, antibiotic prophylaxis is necessary before dental procedures
involving manipulation of gingival tissue, the periapical area of the teeth or perforation of the oral
mucosa (not including routine anesthetic injections, placement of orthodontic brackets, or loss of
deciduous teeth). There are no current recommendations around antibiotic prophylaxis prior to
vaccination, future hospital admissions, or exposure to people who are immunosuppressed.
3. A patient with hypertrophic cardiomyopathy (HCM) has been admitted to the medical unit. During the
nurses admission interview, the patient states that she takes over-the-counter water pills on a regular
basis. How should the nurse best respond to the fact that the patient has been taking diuretics?
A) Encourage the patient to drink at least 2 liters of fluid daily.
B) Increase the patients oral sodium intake.
C) Inform the care provider because diuretics are contraindicated.
D) Ensure that the patients fluid balance is monitored vigilantly.
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Ans: C
Feedback:
Diuretics are contraindicated in patients with HCM, so the primary care provider should be made aware. Adjusting the
patients sodium or fluid intake or fluid monitoring does not address this important contraindication.
4. The critical care nurse is caring for a patient who is receiving cyclosporine postoperative heart
transplant. The patient asks the nurse to remind him what this medication is for. How should the nurse
best respond?
A) Azathioprine decreases the risk of thrombus formation.
B) Azathioprine ensures adequate cardiac output.
C) Azathioprine increases the number of white blood cells.
D) Azathioprine minimizes rejection of the transplant.
Ans: D
Feedback:
After heart transplant, patients are constantly balancing the risk of rejection with the risk of infection. Most commonly,
patients receive cyclosporine or tacrolimus (FK506, Prograf), azathioprine (Imuran), or mycophenolate mofetil (CellCept),
and corticosteroids (prednisone) to minimize rejection. Cyclosporine does not prevent thrombus formation, enhance
cardiac output, or increase white cell counts.
5. A patient with a history rheumatic heart disease knows that she is at risk for bacterial endocarditis when
undergoing invasive procedures. Prior to a scheduled cystoscopy, the nurse should ensure that the patient
knows the importance of taking which of the following drugs?
A) Enoxaparin (Lovenox)
B) Metoprolol (Lopressor)
C) Azathioprine (Imuran)
D) Amoxicillin (Amoxil)
Ans: D
Feedback:
Although rare, bacterial endocarditis may be life-threatening. A key strategy is primary prevention in
high-risk patients (i.e., those with rheumatic heart disease, mitral valve prolapse, or prosthetic heart
valves). Antibiotic prophylaxis is recommended for high-risk patients immediately before and
sometimes after certain procedures. Amoxicillin is the drug of choice. None of the other listed drugs is
an antibiotic.
6. A patient with pericarditis has just been admitted to the CCU. The nurse planning the patients care
should prioritize what nursing diagnosis?
A) Anxiety related to pericarditis
B) Acute pain related to pericarditis
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C) Ineffective tissue perfusion related to pericarditis
D) Ineffective breathing pattern related to pericarditis
Ans: B
Feedback:
The most characteristic symptom of pericarditis is chest pain, although pain also may be located beneath
the clavicle, in the neck, or in the left trapezius (scapula) region. The pain or discomfort usually remains
fairly constant, but it may worsen with deep inspiration and when lying down or turning. Anxiety is
highly plausible and should be addressed, but chest pain is a nearly certain accompaniment to the
disease. Breathing and tissue perfusion are likely to be at risk, but pain is certain, especially in the early
stages of treatment.
7. A patient newly admitted to the telemetry unit is experiencing progressive fatigue, hemoptysis, and
dyspnea. Diagnostic testing has revealed that these signs and symptoms are attributable to pulmonary
venous hypertension. What valvular disorder should the nurse anticipate being diagnosed in this patient?
A) Aortic regurgitation
B) Mitral stenosis
C) Mitral valve prolapse
D) Aortic stenosis
Ans: B
Feedback:
The first symptom of mitral stenosis is often dyspnea on exertion as a result of pulmonary venous
hypertension. Symptoms usually develop after the valve opening is reduced by one-third to one-half its
usual size. Patients are likely to show progressive fatigue as a result of low cardiac output. The enlarged
left atrium may create pressure on the left bronchial tree, resulting in a dry cough or wheezing. Patients
may expectorate blood (i.e., hemoptysis) or experience palpitations, orthopnea, paroxysmal nocturnal
dyspnea (PND), and repeated respiratory infections. Pulmonary venous hypertension is not typically
caused by aortic regurgitation, mitral valve prolapse, or aortic stenosis.
8. The nurse is caring for a patient with mitral stenosis who is scheduled for a balloon valvuloplasty. The
patient tells the nurse that he is unsure why the surgeon did not opt to replace his damaged valve rather
than repairing it. What is an advantage of valvuloplasty that the nurse should cite?
A) The procedure can be performed on an outpatient basis in a physicians office.
B) Repaired valves tend to function longer than replaced valves.
C) The procedure is not associated with a risk for infection.
D) Lower doses of antirejection drugs are required than with valve replacement.
Ans: B
Feedback:
In general, valves that undergo valvuloplasty function longer than prosthetic valve replacements and
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patients do not require continuous anticoagulation. Valvuloplasty carries a risk of infection, like all
surgical procedures, and it is not performed in a physicians office. Antirejection drugs are unnecessary
because foreign tissue is not introduced.
9. The nurse is reviewing the echocardiography results of a patient who has just been diagnosed with
dilated cardiomyopathy (DCM). What changes in heart structure characterize DCM?
A) Dilated ventricles with atrophy of the ventricles
B) Dilated ventricles without hypertrophy of the ventricles
C) Dilation and hypertrophy of all four heart chambers
D) Dilation of the atria and hypertrophy of the ventricles
Ans: B
Feedback:
DCM is characterized by significant dilation of the ventricles without significant concomitant
hypertrophy and systolic dysfunction. The ventricles do not atrophy in patients with DCM.
10. A patient has been admitted to the medical unit with signs and symptoms suggestive of endocarditis. The
physicians choice of antibiotics would be primarily based on what diagnostic test?
A) Echocardiography
B) Blood cultures
C) Cardiac aspiration
D) Complete blood count
Ans: B
Feedback:
To help determine the causative organisms and the most effective antibiotic treatment for the patient, blood cultures are
taken. A CBC can help establish the degree and stage of infection, but not the causative microorganism.
Echocardiography cannot indicate the microorganisms causing the infection. Cardiac aspiration is not a diagnostic test.
11. A community health nurse is presenting an educational event and is addressing several health problems,
including rheumatic heart disease. What should the nurse describe as the most effective way to prevent
rheumatic heart disease?
A) Recognizing and promptly treating streptococcal infections
B) Prophylactic use of calcium channel blockers in high-risk populations
C) Adhering closely to the recommended child immunization schedule
D) Smoking cessation
Ans: A
Feedback:
Group A streptococcus can cause rheumatic heart fever, resulting in rheumatic endocarditis. Being
aware of signs and symptoms of streptococcal infections, identifying them quickly, and treating them
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promptly, are the best preventative techniques for rheumatic endocarditis. Smoking cessation,
immunizations, and calcium channel blockers will not prevent rheumatic heart disease.
12. A patient with mitral valve prolapse is admitted for a scheduled bronchoscopy to investigate recent
hemoptysis. The physician has ordered gentamicin to be taken before the procedure. What is the
rationale for this?
A) To prevent bacterial endocarditis
B) To prevent hospital-acquired pneumonia
C) To minimize the need for antibiotic use during the procedure
D) To decrease the need for surgical asepsis
Ans: A
Feedback:
Antibiotic prophylaxis is recommended for high-risk patients immediately before and sometimes after
the following invasive procedures, such as bronchoscopy. Gentamicin would not be given to prevent
pneumonia, to avoid antibiotic use during the procedure, or to decrease the need for surgical asepsis.
13. The nurse is admitting a patient with complaints of dyspnea on exertion and fatigue. The patients ECG
shows dysrhythmias that are sometimes associated with left ventricular hypertrophy. What diagnostic
tool would be most helpful in diagnosing cardiomyopathy?
A) Cardiac catheterization
B) Arterial blood gases
C) Echocardiogram
D) Exercise stress test
Ans: C
Feedback:
The echocardiogram is one of the most helpful diagnostic tools because the structure and function of the
ventricles can be observed easily. The ECG is also important, and can demonstrate dysrhythmias and
changes consistent with left ventricular hypertrophy. Cardiac catheterization specifically addresses
coronary artery function and arterial blood gases evaluate gas exchange and acid balance. Stress testing
is not normally used to differentiate cardiomyopathy from other cardiac pathologies.
14. The nurse is preparing a patient for cardiac surgery. During the procedure, the patients heart will be
removed and a donor heart implanted at the vena cava and pulmonary veins. What procedure will this
patient undergo?
A) Orthotopic transplant
B) Xenograft
C) Heterotropic transplant
D) Homograft
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Ans: A
Feedback:
Orthotopic transplantation is the most common surgical procedure for cardiac transplantation. The
recipients heart is removed, and the donor heart is implanted at the vena cava and pulmonary veins. Some surgeons still
prefer to remove the recipients heart, leaving a portion of the recipients atria (with
the vena cava and pulmonary veins) in place. Homografts, or allografts (i.e., human valves), are obtained
from cadaver tissue donations and are used for aortic and pulmonic valve replacement. Xenografts and
heterotropic transplantation are not terms used to describe heart transplantation.
15. A patient is undergoing diagnostic testing for mitral stenosis. What statement by the patient during the
nurses interview is most suggestive of this valvular disorder?
A) I get chest pain from time to time, but it usually resolves when I rest.
B) Sometimes when Im resting, I can feel my heart skip a beat.
C) Whenever I do any form of exercise I get terribly short of breath.
D) My feet and ankles have gotten terribly puffy the last few weeks.
Ans: C
Feedback:
The first symptom of mitral stenosis is often breathing difficulty (dyspnea) on exertion as a result of
pulmonary venous hypertension. Patients with mitral stenosis are likely to show progressive fatigue as a
result of low cardiac output. Palpitations occur in some patients, but dyspnea is a characteristic early
symptom. Peripheral edema and chest pain are atypical.
16. The nurse is caring for a patient who is scheduled to undergo mechanical valve replacement. Patient
education should include which of the following
A) Use of patient-controlled analgesia
B) Long-term anticoagulant therapy
C) Steroid therapy
D) Use of IV diuretic
Ans: B
Feedback:
Mechanical valves necessitate long-term use of required anticoagulants. Diuretics and steroids are not
indicated and patient-controlled analgesia may or may be not be used in the immediate postoperative
period.
17. The staff educator is presenting a workshop on valvular disorders. When discussing the pathophysiology
of aortic regurgitation the educator points out the need to emphasize that aortic regurgitation causes
what?
A) Cardiac tamponade
B) Left ventricular hypertrophy
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C) Right-sided heart failure
D) Ventricular insufficiency
Ans: B
Feedback:
Aortic regurgitation eventually causes left ventricular hypertrophy. In aortic regurgitation, blood from
the aorta returns to the left ventricle during diastole in addition to the blood normally delivered by the
left atrium. The left ventricle dilates, trying to accommodate the increased volume of blood. Aortic
regurgitation does not cause cardiac tamponade, right-sided heart failure, or ventricular insufficiency.
18. The nurse is creating a plan of care for a patient with a cardiomyopathy. What priority goal should
underlie most of the assessments and interventions that are selected for this patient?
A) Absence of complications
B) Adherence to the self-care program
C) Improved cardiac output
D) Increased activity tolerance
Ans: C
Feedback:
The priority nursing diagnosis of a patient with cardiomyopathy would include improved or maintained
cardiac output. Regardless of the category and cause, cardiomyopathy may lead to severe heart failure,
lethal dysrhythmias, and death. The pathophysiology of all cardiomyopathies is a series of progressive
events that culminate in impaired cardiac output. Absence of complications, adherence to the self-care
program, and increased activity tolerance should be included in the care plan, but they do not have the
priority of improved cardiac output.
19. An older adult patient has been diagnosed with aortic regurgitation. What change in blood flow should
the nurse expect to see on this patients echocardiogram?
A) Blood to flow back from the aorta to the left ventricle
B) Obstruction of blood flow from the left ventricle
C) Blood to flow back from the left atrium to the left ventricle
D) Obstruction of blood from the left atrium to left ventricle
Ans: A
Feedback:
Aortic regurgitation occurs when the aortic valve does not completely close, and blood flows back to the
left ventricle from the aorta during diastole. Aortic regurgitation does not cause obstruction of blood
flow from the left ventricle, blood to flow back from the left atrium to the left ventricle, or obstruction of
blood from the left atrium to left ventricle.
20. A patient who has undergone valve replacement surgery is being prepared for discharge home. Because
the patient will be discharged with a prescription for warfarin (Coumadin), the nurse should educate the
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patient about which of the following?
A) The need for regularly scheduled testing of the patients International Normalized Ratio (INR)
B) The need to learn to sleep in a semi-Fowlers position for the first 6 to 8 weeks to prevent emboli
C) The need to avoid foods that contain vitamin K
D) The need to take enteric-coated ASA on a daily basis
Ans: A
Feedback:
Patients who take warfarin (Coumadin) after valve replacement have individualized target INRs; usually
between 2 and 3.5 for mitral valve replacement and 1.8 and 2.2 for aortic valve replacement. Natural
sources of vitamin K do not normally need to be avoided and ASA is not indicated. Sleeping upright is
unnecessary.
21. A nurse is planning discharge health education for a patient who will soon undergo placement of a
mechanical valve prosthesis. What aspect of health education should the nurse prioritize in anticipation
of discharge?
A) The need for long-term antibiotics
B) The need for 7 to 10 days of bed rest
C) Strategies for preventing atherosclerosis
D) Strategies for infection prevention
Ans: D
Feedback:
Patients with a mechanical valve prosthesis (including annuloplasty rings and other prosthetic materials
used in valvuloplasty) require education to prevent infective endocarditis. Despite these infections risks, antibiotics are not
used long term. Activity management is important, but extended bed rest is
unnecessary. Valve replacement does not create a heightened risk for atherosclerosis.
22. A patient with mitral valve stenosis is receiving health education at an outpatient clinic. To minimize the
patients symptoms, the nurse should teach the patient to do which of the following?
A) Eat a high-protein, low-carbohydrate diet.
B) Avoid activities that cause an increased heart rate.
C) Avoid large crowds and public events.
D) Perform deep breathing and coughing exercises.
Ans: B
Feedback:
Patients with mitral stenosis are advised to avoid strenuous activities, competitive sports, and pregnancy, all of which
increase heart rate. Infection prevention is important, but avoiding crowds is not usually
necessary. Deep breathing and coughing are not likely to prevent exacerbations of symptoms and
increased protein intake is not necessary.
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23. A patient is admitted to the critical care unit (CCU) with a diagnosis of cardiomyopathy. When
reviewing the patients most recent laboratory results, the nurse should prioritize assessment of which of
the following?
A) Sodium
B) AST, ALT, and bilirubin
C) White blood cell differential
D) BUN
Ans: A
Feedback:
Sodium is the major electrolyte involved with cardiomyopathy. Cardiomyopathy often leads to heart
failure which develops, in part, from fluid overload. Fluid overload is often associated with elevated
sodium levels. Consequently, sodium levels are followed more closely than other important laboratory
values, including BUN, leukocytes, and liver function tests.
24. A patient has been admitted with an aortic valve stenosis and has been scheduled for a balloon
valvuloplasty in the cardiac catheterization lab later today. During the admission assessment, the patient
tells the nurse he has thoracolumbar scoliosis and is concerned about lying down for any extended
period of time. What is a priority action for the nurse?
A) Arrange for an alternative bed.
B) Measure the degree of the curvature.
C) Notify the surgeon immediately.
D) Note the scoliosis on the intake assessment.
Ans: C
Feedback:
Most often used for mitral and aortic valve stenosis, balloon valvuloplasty is contraindicated for patients
with left atrial or ventricular thrombus, severe aortic root dilation, significant mitral valve regurgitation,
thoracolumbar scoliosis, rotation of the great vessels, and other cardiac conditions that require open
heart surgery. Therefore notifying the physician would be the priority over further physical assessment. An alternative bed
would be unnecessary and documentation is not a sufficient response.
25. A patient is a candidate for percutaneous balloon valvuloplasty, but is concerned about how this
procedure will affect her busy work schedule. What guidance should the nurse provide to the patient?
A) Patients generally stay in the hospital for 6 to 8 days.
B) Patients are kept in the hospital until they are independent with all aspects of their care.
C) Patients need to stay in the hospital until they regain normal heart function for their age.
D) Patients usually remain at the hospital for 24 to 48 hours.
Ans: D
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Feedback:
After undergoing percutaneous balloon valvuloplasty, the patient usually remains in the hospital for 24
to 48 hours. Prediagnosis levels of heart function are not always attainable and the patient does not need
to be wholly independent prior to discharge.
26. A patient has been diagnosed with a valvular disorder. The patient tells the nurse that he has read about
numerous treatment options, including valvuloplasty. What should the nurse teach the patient about
valvuloplasty?
A) For some patients, valvuloplasty can be done in a cardiac catheterization laboratory.
B) Valvuloplasty is a dangerous procedure, but it has excellent potential if it goes well.
C) Valvuloplasty is open heart surgery, but this is very safe these days and normally requires only an
overnight hospital stay.
D) Its prudent to get a second opinion before deciding to have valvuloplasty.
Ans: A
Feedback:
Some valvuloplasty procedures do not require general anesthesia or cardiopulmonary bypass and can be
performed in a cardiac catheterization laboratory or hybrid room. Open heart surgery is not required and
the procedure does not carry exceptional risks that would designate it as being dangerous. Normally
there is no need for the nurse to advocate for a second opinion.
27. The patient has just returned to the floor after balloon valvuloplasty of the aortic valve and the nurse is
planning appropriate assessments. The nurse should know that complications following this procedure
include what? Select all that apply.
A) Emboli
B) Mitral valve damage
C) Ventricular dysrhythmia
D) Atrial-septal defect
E) Plaque formation
Ans: A, B, C
Feedback:
Possible complications include aortic regurgitation, emboli, ventricular perforation, rupture of the aortic
valve annulus, ventricular dysrhythmia, mitral valve damage, and bleeding from the catheter insertion
sites. Atrial-septal defect and plaque formation are not complications of a balloon valvuloplasty.
28. The nurse is caring for a patient with right ventricular hypertrophy and consequently decreased right
ventricular function. What valvular disorder may have contributed to this patients diagnosis?
A) Mitral valve regurgitation
B) Aortic stenosis
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C) Aortic regurgitation
D) Mitral valve stenosis
Ans: D
Feedback:
Because no valve protects the pulmonary veins from the backward flow of blood from the atrium, the
pulmonary circulation becomes congested. As a result, the right ventricle must contract against an
abnormally high pulmonary arterial pressure and is subjected to excessive strain. Eventually, the right
ventricle fails. None of the other listed valvular disorders has this pathophysiological effect.
29. The cardiac nurse is caring for a patient who has been diagnosed with dilated cardiomyopathy (DCM).
Echocardiography is likely to reveal what pathophysiological finding?
A) Decreased ejection fraction
B) Decreased heart rate
C) Ventricular hypertrophy
D) Mitral valve regurgitation
Ans: A
Feedback:
DCM is distinguished by significant dilation of the ventricles without simultaneous hypertrophy. The
ventricles have elevated systolic and diastolic volumes, but a decreased ejection fraction. Bradycardia
and mitral valve regurgitation do not typically occur in patients with DCM.
30. A 17-year-old boy is being treated in the ICU after going into cardiac arrest during a football practice. Diagnostic
testing reveals cardiomyopathy as the cause of the arrest. What type of cardiomyopathy is
particularly common among young people who appear otherwise healthy?
A) Dilated cardiomyopathy (DCM).
B) Arrhythmogenic right ventricular cardiomyopathy (ARVC)
C) Hypertrophic cardiomyopathy (HCM)
D) Restrictive or constrictive cardiomyopathy (RCM)
Ans: C
Feedback:
With HCM, cardiac arrest (i.e., sudden cardiac death) may be the initial manifestation in young people,
including athletes. DCM, ARVC, and RCM are not typically present in younger adults who appear
otherwise healthy.
31. The nurse is teaching a patient diagnosed with aortic stenosis appropriate strategies for attempting to
relieve the symptom of angina without drugs. What should the nurse teach the patient?
A) To eat a small meal before taking nitroglycerin
B) To drink a glass of milk before taking nitroglycerin
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C) To engage in 15 minutes of light exercise before taking nitroglycerin
D) To rest and relax before taking nitroglycerin
Ans: D
Feedback:
The venous dilation that results from nitroglycerin decreases blood return to the heart, thus decreasing
cardiac output and increasing the risk of syncope and decreased coronary artery blood flow. The nurse
teaches the patient about the importance of attempting to relieve the symptoms of angina with rest and
relaxation before taking nitroglycerin and to anticipate the potential adverse effects. Exercising, eating, and drinking are
not recommended prior to using nitroglycerin.
32. A patient has been living with dilated cardiomyopathy for several years but has experienced worsening
symptoms despite aggressive medical management. The nurse should anticipate what potential
treatment?
A) Heart transplantation
B) Balloon valvuloplasty
C) Cardiac catheterization
D) Stent placement
Ans: A
Feedback:
When heart failure progresses and medical treatment is no longer effective, surgical intervention,
including heart transplantation, is considered. Valvuloplasty, stent placement, and cardiac catheterization
will not address the pathophysiology of cardiomyopathy.
33. A patient has undergone a successful heart transplant and has been discharged home with a medication
regimen that includes cyclosporine and tacrolimus. In light of this patients medication regimen, what
nursing diagnosis should be prioritized?
A) Risk for injury
B) Risk for infection
C) Risk for peripheral neurovascular dysfunction
D) Risk for unstable blood glucose
Ans: B
Feedback:
Immunosuppressants decrease the bodys ability to resist infections, and a satisfactory balance must be
achieved between suppressing rejection and avoiding infection. These drugs do not create a heightened
risk of injury, neurovascular dysfunction, or unstable blood glucose levels.
34. The nurse is caring for a patient with acute pericarditis. What nursing management should be instituted
to minimize complications?
A) The nurse keeps the patient isolated to prevent nosocomial infections.
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B) The nurse encourages coughing and deep breathing.
C) The nurse helps the patient with activities until the pain and fever subside.
D) The nurse encourages increased fluid intake until the infection resolves.
Ans: C
Feedback:
To minimize complications, the nurse helps the patient with activity restrictions until the pain and fever
subside. As the patients condition improves, the nurse encourages gradual increases of activity. Actions
to minimize complications of acute pericarditis do not include keeping the patient isolated. Due to pain, coughing and
deep breathing are not normally encouraged. An increase in fluid intake is not always necessary.
35. A patient who has recently recovered from a systemic viral infection is undergoing diagnostic testing for
myocarditis. Which of the nurses assessment findings is most consistent with myocarditis?
A) Sudden changes in level of consciousness (LOC)
B) Peripheral edema and pulmonary edema
C) Pleuritic chest pain
D) Flulike symptoms
Ans: D
Feedback:
The most common symptoms of myocarditis are flulike. Chest pain, edema, and changes in LOC are not
characteristic of myocarditis.
36. The nurse on the hospitals infection control committee is looking into two cases of hospital-acquired
infective endocarditis among a specific classification of patients. What classification of patients would
be at greatest risk for hospital-acquired endocarditis?
A) Hemodialysis patient
B) Patients on immunoglobulins
C) Patients who undergo intermittent urinary catheterization
D) Children under the age of 12
Ans: A
Feedback:
Hospital-acquired infective endocarditis occurs most often in patients with debilitating disease or
indwelling catheters and in patients who are receiving hemodialysis or prolonged IV fluid or antibiotic
therapy. Patients taking immunosuppressive medications or corticosteroids are more susceptible to
fungal endocarditis. Patients on immunoglobulins, those who need in and out catheterization, and
children are not at increased risk for nosocomial infective endocarditis.
37. The nurse is caring for a recent immigrant who has been diagnosed with mitral valve regurgitation. The
nurse should know that in developing countries the most common cause of mitral valve regurgitation is
what?
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A) A decrease in gamma globulins
B) An insect bite
C) Rheumatic heart disease and its sequelae
D) Sepsis and its sequelae
Ans: C
Feedback:
The most common cause of mitral valve regurgitation in developing countries is rheumatic heart disease
and its sequelae.
38. Most individuals who have mitral valve prolapse never have any symptoms, although this is not the case
for every patient. What symptoms might a patient have with mitral valve prolapse? Select all that apply.
A) Anxiety
B) Fatigue
C) Shoulder pain
D) Tachypnea
E) Palpitations
Ans: A, B, E
Feedback:
Most people who have mitral valve prolapse never have symptoms. A few have symptoms of fatigue, shortness of breath,
lightheadedness, dizziness, syncope, palpitations, chest pain, and anxiety. Hyperpnea and shoulder pain are not
characteristic symptoms of mitral valve prolapse.
39. A cardiac surgery patients new onset of signs and symptoms is suggestive of cardiac tamponade. As a
member of the interdisciplinary team, what is the nurses most appropriate action?
A) Prepare to assist with pericardiocentesis.
B) Reposition the patient into a prone position.
C) Administer a dose of metoprolol.
D) Administer a bolus of normal saline.
Ans: A
Feedback:
Cardiac tamponade requires immediate pericardiocentesis. Beta-blockers and fluid boluses will not
relieve the pressure on the heart and prone positioning would likely exacerbate symptoms.
40. The nurse is auscultating the breath sounds of a patient with pericarditis. What finding is most consistent
with this diagnosis?
A) Wheezes
B) Friction rub
C) Fine crackles
D) Coarse crackles
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Ans: B
Feedback:
A pericardial friction rub is diagnostic of pericarditis. Crackles are associated with pulmonary edema
and fluid accumulation, whereas wheezes signal airway constriction; neither of these occurs with
pericarditis.
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Brunner & Suddarth's Textbook of Medical Surgical Nursing 15th Edition
Chapter 25: Management of Patients With Complications From Heart Disease
The nurse notes that a patient has developed a cough productive for mucoid sputum, is short of breath, has
cyanotic hands, and has noisy, moistsounding, rapid breathing. These symptoms and signs are suggestive of what
health problem?
Pericarditis
Cardiomyopathy
Pulmonary edema
Right ventricular hypertrophy
Pericarditis
Cardiomyopathy
Pulmonary edema***
Right ventricular hypertrophy
Feedback: As a result of decreased cerebral oxygenation, the patient with pulmonary edema becomes increasingly
restless and anxious. Along with a sudden onset of breathlessness and a sense of suffocation, the patient's hands
become cold and moist, the nail beds become cyanotic (bluish), and the skin turns ashen (gray). The pulse is weak and
rapid, and the neck veins are distended. Incessant coughing may occur, producing increasing quantities of foamy sputum.
Pericarditis, ventricular hypertrophy, and cardiomyopathy do not involve wet breath sounds or mucus production.
The nurse is assessing an older adult patient with numerous health problems. What assessment datum indicates an
increase in the patientts risk for heart failure (HF)?
The patient takes Lasix (furosemide) 20 mg/day.
The patientts potassium level is 4.7 mEq/L.
The patient is an African American man.
The patientts age is greater than 65.
The patient takes Lasix (furosemide) 20 mg/day.
The patient's potassium level is 4.7 mEq/L.
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The patient is an African American man.
The patient's age is greater than 65.*****
Feedback: HF is the most common reason for hospitalization of people older than 65 years of age and is the second most
common reason for visits to a physician's office. A potassium level of 4.7 mEq/L is within reference range and does not
indicate an increased risk for HF. The fact that the patient takes Lasix 20 mg/day does not indicate an increased risk for
HF, although this drug is often used in the treatment of HF. The patient being an African American man does not indicate
an increased risk for HF.
The triage nurse in the ED is assessing a patient with chronic HF who has presented with worsening symptoms. In
reviewing the patientts medical history, what is a potential primary cause of the patientts heart failure?
Endocarditis
Pleural effusion
Atherosclerosis
Atrialseptal defect
Endocarditis
Pleural effusion
Atherosclerosis***
Atrialseptal defect
Feedback: Atherosclerosis of the coronary arteries is the primary cause of HF. Pleural effusion, endocarditis, and an
atrialseptal defect are not health problems that contribute to the etiology of HF.
Which assessment would be most appropriate for a patient who is receiving a loop diuretic for HF?
Monitor liver function studies
Monitor for hypotension
Assess the patientts vitamin D intake
Assess the patient for hyperkalemia
Monitor liver function studies
Monitor for hypotension***
Assess the patient's vitamin D intake
Assess the patient for hyperkalemia
Feedback: Diuretic therapy increases urine output and decreases blood volume, which places the patient at risk of
hypotension. Patients are at risk of losing potassium with loop diuretic therapy and need to continue with potassium in
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their diet; hypokalemia is a consequent risk. Liver function is rarely compromised by diuretic therapy and vitamin D intake
is not relevant.
The nurse is assessing a patient who is known to have rightsided HF. What assessment finding is most consistent
with this patientts diagnosis?
Pulmonary edema
Distended neck veins
Dry cough
Orthopnea
Pulmonary edema
Distended neck veins***
Dry cough
Orthopnea
Feedback: Rightsided HF may manifest by distended neck veins, dependent edema, hepatomegaly, weight gain, ascites,
anorexia, nausea, nocturia, and weakness. The other answers do not apply.
The nurse is caring for an adult patient with HF who is prescribed digoxin. When assessing the patient for adverse
effects, the nurse should assess for which of the following signs and symptoms?
Confusion and bradycardia
Uncontrolled diuresis and tachycardia
Numbness and tingling in the extremities
Chest pain and shortness of breath
Confusion and bradycardia****
Uncontrolled diuresis and tachycardia
Numbness and tingling in the extremities
Chest pain and shortness of breath
Feedback: A key concern associated with digitalis therapy is digitalis toxicity. Symptoms include anorexia, nausea, visual
disturbances, confusion, and bradycardia. The other listed signs and symptoms are not characteristic of digitalis toxicity.
A nurse in the CCU is caring for a patient with HF who has developed an intracardiac thrombus. This creates a high
risk for what sequela?
Stroke
Myocardial infarction (MI)
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Hemorrhage
Peripheral edema
Stroke***
Myocardial infarction (MI)
Hemorrhage
Peripheral edema
Feedback: Intracardiac thrombi can become lodged in the cerebral vasculature, causing stroke. There is no direct risk of
MI, hemorrhage, or peripheral edema.
The nurse is caring for a 68yearold patient the nurse suspects has digoxin toxicity. In addition to physical
assessment, the nurse should collect what assessment datum?
Skin turgor
Potassium level
White blood cell count
Peripheral pulses
Skin turgor
Potassium level***
White blood cell count
Peripheral pulses
Feedback: The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of
hypokalemia and digoxin toxicity may occur. Skin turgor, white cell levels, and peripheral pulses are not normally affected
in cases of digitalis toxicity.
The triage nurse in the ED is performing a rapid assessment of a man with complaints of severe chest pain and
shortness of breath. The patient is diaphoretic, pale, and weak. When the patient collapses, what should the nurse
do first?
Check for a carotid pulse.
Apply supplemental oxygen.
Give two full breaths.
Gently shake and shout, "Are you OK?"
Check for a carotid pulse.
Apply supplemental oxygen.
Give two full breaths.
Gently shake and shout, "Are you OK?"***
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Feedback: Assessing responsiveness is the first step in basic life support. Opening the airway and checking for
respirations should occur next. If breathing is absent, two breaths should be given, usually accompanied by
supplementary oxygen. Circulation is checked by palpating the carotid artery.
A patient presents to the ED complaining of increasing shortness of breath. The nurse assessing the patient notes
a history of leftsided HF. The patient is agitated and occasionally coughing up pinktinged, foamy sputum. The
nurse should recognize the signs and symptoms of what health problem?
Rightsided heart failure
Acute pulmonary edema
Pneumonia
Cardiogenic shock
Rightsided heart failure
Acute pulmonary edema****
Pneumonia
Cardiogenic shock
Feedback: Because of decreased contractility and increased fluid volume and pressure in patients with HF, fluid may be
driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema and signs and symptoms described.
In rightsided heart failure, the patient exhibits hepatomegaly, jugular vein distention, and peripheral edema. In pneumonia,
the patient would have a temperature spike, and sputum that varies in color. Cardiogenic shock would show signs of
hypotension and tachycardia.
A patient admitted to the medical unit with HF is exhibiting signs and symptoms of pulmonary edema. The nurse is
aware that positioning will promote circulation. How should the nurse best position the patient?
In a high Fowlerts position
On the left sidelying position
In a flat, supine position
In the Trendelenburg position
In a high Fowler's position****
On the left sidelying position
In a flat, supine position
In the Trendelenburg position
Feedback: Proper positioning can help reduce venous return to the heart. The patient is positioned upright. If the patient is
unable to sit with the lower extremities dependent, the patient may be placed in an upright position in bed. The supine
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position and Trendelenburg positions will not reduce venous return, lower the output of the right ventricle, or decrease
lung congestion. Similarly, sidelying does not promote circulation.
The nurse has entered a patientts room and found the patient unresponsive and not breathing. What is the nursets
next appropriate action?
Palpate the patientts carotid pulse.
Illuminate the patientts call light.
Begin performing chest compressions.
Palpate the patient's carotid pulse.
Illuminate the patient's call light.
Begin performing chest compressions.
Activate the Emergency Response System (ERS).***
Feedback: After checking for responsiveness and breathing, the nurse should activate the ERS. Assessment of carotid
pulse should follow and chest compressions may be indicated. Illuminating the call light is an insufficient response.
The nurse is providing discharge education to a patient diagnosed with HF. What should the nurse teach this
patient to do to assess her fluid balance in the home setting?
Monitor her blood pressure daily
Assess her radial pulses daily
Monitor her weight daily
Monitor her bowel movements
Monitor her blood pressure daily
Assess her radial pulses daily
Monitor her weight daily***
Monitor her bowel movements
Feedback: To assess fluid balance at home, the patient should monitor daily weights at the same time every day.
Assessing radial pulses and monitoring the blood pressure may be done, but these measurements do not provide
information about fluid balance. Bowel function is not indicative of fluid balance.
The nurse is caring for an 84yearold man who has just returned from the OR after inguinal hernia repair. The OR
report indicates that the patient received large volumes of IV fluids during surgery and the nurse recognizes that
the patient is at risk for leftsided heart failure. What signs and symptoms would indicate leftsided heart failure?
Jugular vein distention
Right upper quadrant pain
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Bibasilar fine crackles
Dependent edema
Jugular vein distention
Right upper quadrant pain
Bibasilar fine crackles****
Dependent edema
Feedback: Bibasilar fine crackles are a sign of alveolar fluid, a sequela of left ventricular fluid, or pressure overload.
Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by rightsided heart
failure, usually a chronic condition.
A patient with HF is placed on a lowsodium diet. Which statement by the patient indicates that the nursets
nutritional teaching plan has been effective?
"I will have a ham and cheese sandwich for lunch."
"I will have a baked potato with broiled chicken for dinner."
"I will have a tossed salad with cheese and croutons for lunch."
"I will have chicken noodle soup with crackers and an apple for lunch."
"I will have a ham and cheese sandwich for lunch."
"I will have a baked potato with broiled chicken for dinner."****
"I will have a tossed salad with cheese and croutons for lunch."
"I will have chicken noodle soup with crackers and an apple for lunch."
Feedback: The patient's choice of a baked potato with broiled chicken indicates that the teaching plan has been effective.
Potatoes and chicken are relatively low in sodium. Ham, cheese, and soup are often high in sodium.
The nursets comprehensive assessment of a patient who has HF includes evaluation of the patientts hepatojugular
reflux. What action should the nurse perform during this assessment?
Elevate the patientts head to 90 degrees.
Press the right upper abdomen.
Press above the patientts symphysis pubis.
Lay the patient flat in bed.
Elevate the patient's head to 90 degrees.
Press the right upper abdomen.*****
Press above the patient's symphysis pubis.
Lay the patient flat in bed.
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Feedback: Hepatojugular reflux, a sign of rightsided heart failure, is assessed with the head of the bed at a 45degree
angle. As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the
internal jugular vein. If the internal jugular vein becomes distended, a patient has positive hepatojugular reflux.
The nurse overseeing care in the ICU reviews the shift report on four patients. The nurse recognizes which patient
to be at greatest risk for the development of cardiogenic shock?
The patient admitted with acute renal failure
The patient admitted following an MI
The patient admitted with malignant hypertension
The patient admitted following a stroke
The patient admitted with acute renal failure
The patient admitted following an MI***
The patient admitted with malignant hypertension
The patient admitted following a stroke
Feedback: Cardiogenic shock may occur following an MI when a large area of the myocardium becomes ischemic,
necrotic, and hypokinetic. It also can occur as a result of endstage heart failure, cardiac tamponade, pulmonary embolism,
cardiomyopathy, and dysrhythmias. While patients with acute renal failure are at risk for dysrhythmias and patients
experiencing a stroke are at risk for thrombus formation, the patient admitted following an MI is at the greatest risk for
development of cardiogenic shock when compared with the other listed diagnoses.
When assessing the patient with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus
is characterized by what assessment finding?
A diastolic blood pressure that is lower during exhalation
A diastolic blood pressure that is higher during inhalation
A systolic blood pressure that is higher during exhalation
A systolic blood pressure that is lower during inhalation
A diastolic blood pressure that is lower during exhalation
A diastolic blood pressure that is higher during inhalation
A systolic blood pressure that is higher during exhalation
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A systolic blood pressure that is lower during inhalation****
Feedback: Systolic blood pressure that is markedly lower during inhalation is called pulsus paradoxus. The difference in
systolic pressure between the point that is heard during exhalation and the point that is heard during inhalation is
measured. Pulsus paradoxus exceeding 10 mm Hg is abnormal.
The cardiac monitor alarm alerts the critical care nurse that the patient is showing no cardiac rhythm on the
monitor. The nursets rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation,
how will the nurse describe this initial absence of cardiac rhythm?
Pulseless electrical activity (PEA)
Ventricular fibrillation
Ventricular tachycardia
Asystole
Pulseless electrical activity (PEA)
Ventricular fibrillation
Ventricular tachycardia
Asystole***
Feedback: Cardiac arrest occurs when the heart ceases to produce an effective pulse and circulate blood. It may be
caused by a cardiac electrical event such as ventricular fibrillation, ventricular tachycardia, profound bradycardia, or when
there is no heart rhythm at all (asystole). Cardiac arrest may also occur when electrical activity is present, but there is
ineffective cardiac contraction or circulating volume, which is PEA. Asystole is the only condition that involves the absolute
absence of a heart rhythm.
The nurse is reviewing a newly admitted patientts electronic health record, which notes a history of orthopnea?
What nursing action is most clearly indicated?
Teach the patient deep breathing and coughing exercises.
Administer supplemental oxygen at all times.
Limit the patientts activity level.
Avoid positioning the patient supine.
Teach the patient deep breathing and coughing exercises.
Administer supplemental oxygen at all times.
Limit the patient's activity level.
Avoid positioning the patient supine.****
Feedback: Orthopnea is defined as difficulty breathing while lying flat. This is a possible complication of HF and,
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consequently, the nurse should avoid positioning the patient supine. Oxygen supplementation may or may not be
necessary and activity does not always need to be curtailed. Deep breathing and coughing exercises do not directly
address this symptom.
The nurse is planning the care of a patient with HF. The nurse should identify what overall goals of this patientts
care?
Improve functional status
Prevent endocarditis.
Extend survival.
Limit physical activity.
Relieve patient symptoms.
Improve functional status****
Prevent endocarditis.
Extend survival.****
Limit physical activity.
Relieve patient symptoms.***
Feedback: The overall goals of management of HF are to relieve the patient's symptoms, to improve functional status and
quality of life, and to extend survival. Activity limitations should be accommodated, but reducing activity is not a goal.
Endocarditis is not a common complication of HF and preventing it is not a major goal of care.
A patient with HF has met with his primary care provider and begun treatment with an angiotensinconverting
enzyme (ACE) inhibitor. When the patient begins treatment, the nurse should prioritize what assessment?
Blood pressure
Level of consciousness (LOC)
Assessment for nausea
Oxygen saturation
Blood pressure****
Level of consciousness (LOC)
Assessment for nausea
Oxygen saturation
Feedback: Patients receiving ACE inhibitors are monitored for hypotension, hyperkalemia (increased potassium in the
blood), and alterations in renal function. ACE inhibitors do not typically cause alterations in LOC. Oxygen saturation must
be monitored in patients with HF, but this is not particular to ACE inhibitor therapy. ACE inhibitors do not normally cause
nausea.
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The nurse is reviewing the medication administration record of a patient diagnosed with systolic HF. What
medication should the nurse anticipate administering to this patient?
A betaadrenergic blocker
An antiplatelet aggregator
A calcium channel blocker
A nonsteroidal antiinflammatory drug (NSAID)
A betaadrenergic blocker***
An antiplatelet aggregator
A calcium channel blocker
A nonsteroidal antiinflammatory drug (NSAID)
Feedback: Several medications are routinely prescribed for systolic HF, including ACE inhibitors, betablockers, diuretics,
and digitalis. Calcium channel blockers, antiplatelet aggregators, and NSAIDs are not commonly prescribed.
The nurse is caring for a patient with systolic HF whose previous adverse reactions preclude the safe use of ACE
inhibitors. The nurse should anticipate that the prescriber may choose what combination of drugs?
Loop diuretic and antiplatelet aggregator
Loop diuretic and calcium channel blocker
Combination of hydralazine and isosorbide dinitrate
Combination of digoxin and normal saline
Loop diuretic and antiplatelet aggregator
Loop diuretic and calcium channel blocker
Combination of hydralazine and isosorbide dinitrate***
Combination of digoxin and normal saline
Feedback: A combination of hydralazine and isosorbide dinitrate may be an alternative for patients who cannot take ACE
inhibitors. Antiplatelet aggregators, calcium channel blockers, and normal saline are not typically prescribed.
A patient with a diagnosis of HF is started on a betablocker. What is the nursets priority role during gradual
increases in the patientts dose?
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Educating the patient that symptom relief may not occur for several weeks
Stressing that symptom relief may take up to 4 months to occur
Making adjustments to each dayts dose based on the blood pressure trends
Educating the patient about the potential changes in LOC that may result from the drug
Educating the patient that symptom relief may not occur for several weeks***
Stressing that symptom relief may take up to 4 months to occur
Making adjustments to each day's dose based on the blood pressure trends
Educating the patient about the potential changes in LOC that may result from the drug
Feedback: An important nursing role during titration is educating the patient about the potential worsening of symptoms
during the early phase of treatment and stressing that improvement may take several weeks. Relief does not take 4
months, however. The nurse monitors blood pressure, but changes are not made based on shortterm assessment results.
Betablockers rarely affect LOC.
The nurse is performing a physical assessment on a patient suspected of having HF. The presence of what sound
would signal the possibility of impending HF?
An S3 heart sound
Pleural friction rub
Faint breath sounds
A heart murmur
An S3 heart sound***
Pleural friction rub
Faint breath sounds
A heart murmur
Feedback: The heart is auscultated for an S3 heart sound, a sign that the heart is beginning to fail and that increased
blood volume fills the ventricle with each beat. HF does not normally cause a pleural friction rub or murmurs. Changes in
breath sounds occur, such as the emergence of crackles or wheezes, but faint breath sounds are less characteristic of
HF.
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An older adult patient with HF is being discharged home on an ACE inhibitor and a loop diuretic. The patientts most
recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per
minute, and blood pressure of 94/59 mm Hg. When planning this patientts subsequent care, what nursing diagnosis
should be identified?
Risk for ineffective tissue perfusion related to dysrhythmia
Risk for fluid volume excess related to medication regimen
Risk for ineffective breathing pattern related to hypoxia
Risk for falls related to hypotension
Risk for ineffective tissue perfusion related to dysrhythmia
Risk for fluid volume excess related to medication regimen
Risk for ineffective breathing pattern related to hypoxia
Risk for falls related to hypotension*****
Feedback: The combination of low BP, diuretic use, and ACE inhibitor use constitute a risk for falls. There is no evidence,
or heightened risk, of dysrhythmia. The patient's medications create a risk for fluid deficit, not fluid excess. Hypoxia is a
risk for all patients with HF, but this is not in evidence for this patient at this time.
The nurse is performing an initial assessment of a client diagnosed with HF. The nurse also assesses the patientts
sensorium and LOC. Why is the assessment of the patientts sensorium and LOC important in patients with HF?
HF ultimately affects oxygen transportation to the brain.
Patients with HF are susceptible to overstimulation of the sympathetic nervous system.
Decreased LOC causes an exacerbation of the signs and symptoms of HF.
The most significant adverse effect of medications used for HF treatment is altered LOC.
HF ultimately affects oxygen transportation to the brain.****
Patients with HF are susceptible to overstimulation of the sympathetic nervous system.
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Decreased LOC causes an exacerbation of the signs and symptoms of HF.
The most significant adverse effect of medications used for HF treatment is altered LOC.
Feedback: As the volume of blood ejected by the heart decreases, so does the amount of oxygen transported to the
brain. Sympathetic stimulation is not a primary concern in patients with HF, although it is a possibility. HF affects LOC but
the reverse is not usually true. Medications used to treat HF carry many adverse effects, but the most common and
significant effects are cardiovascular.
Cardiopulmonary resuscitation has been initiated on a patient who was found unresponsive. When performing
chest compressions, the nurse should do which of the following?
Perform at least 100 chest compressions per minute.
Pause to allow a colleague to provide a breath every 10 compressions.
Pause chest compressions to allow for vital signs monitoring every 4 to 5 minutes.
Perform highquality chest compressions as rapidly as possible.
Perform at least 100 chest compressions per minute.***
Pause to allow a colleague to provide a breath every 10 compressions.
Pause chest compressions to allow for vital signs monitoring every 4 to 5 minutes.
Perform highquality chest compressions as rapidly as possible.
Feedback: During CPR, the chest is compressed 2 inches at a rate of at least 100 compressions per minute. This rate is
the resuscitator's goal; the aim is not to give compressions as rapidly as possible. Compressions are not stopped after 10
compressions to allow for a breath or for full vital signs monitoring.
The nurse is providing patient education prior to a patientts discharge home after treatment for HF. The nurse gives
the patient a home care checklist as part of the discharge teaching. What should be included on this checklist?
Know how to recognize and prevent orthostatic hypotension.
Weigh yourself weekly at a consistent time of day.
Measure everything you eat and drink until otherwise instructed.
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Limit physical activity to only those tasks that are absolutely necessary.
Know how to recognize and prevent orthostatic hypotension.****
Weigh yourself weekly at a consistent time of day.
Measure everything you eat and drink until otherwise instructed.
Limit physical activity to only those tasks that are absolutely necessary.
Feedback: Patients with HF should be aware of the risks of orthostatic hypotension. Weight should be measured daily;
detailed documentation of all forms of intake is not usually required. Activity should be gradually increased within the
parameters of safety and comfort.
The nurse is educating an 80yearold patient diagnosed with HF about his medication regimen. What should the
nurse to teach this patient about the use of oral diuretics?
Avoid drinking fluids for 2 hours after taking the diuretic.
Take the diuretic in the morning to avoid interfering with sleep.
Avoid taking the medication within 2 hours consuming dairy products.
Take the diuretic only on days when experiencing shortness of breath.
Avoid drinking fluids for 2 hours after taking the diuretic
.
Take the diuretic in the morning to avoid interfering with sleep.****
Avoid taking the medication within 2 hours consuming dairy products.
Take the diuretic only on days when experiencing shortness of breath.
Feedback: Oral diuretics should be administered early in the morning so that diuresis does not interfere with the patient's
nighttime rest. Discussing the timing of medication administration is especially important for elderly patients who may have
urinary urgency or incontinence. The nurse would not teach the patient about the timing of fluid intake. Fluid intake does
not need to be adjusted and dairy products are not contraindicated.
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The nurse is addressing exercise and physical activity during discharge education with a patient diagnosed with
HF. What should the nurse teach this patient about exercise?
"Do not exercise unsupervised."
"Eventually aim to work up to 30 minutes of exercise each day."
"Slow down if you get dizzy or short of breath."
"Start your exercise program with highimpact activities."
"Do not exercise unsupervised."
"Eventually aim to work up to 30 minutes of exercise each day."******
"Slow down if you get dizzy or short of breath."
"Start your exercise program with highimpact activities."
Feedback: Eventually, a total of 30 minutes of physical activity every day should be encouraged. Supervision is not
necessarily required and the emergence of symptoms should prompt the patient to stop exercising, not simply to slow the
pace. Lowimpact activities should be prioritized.
The nurse is creating a care plan for a patient diagnosed with HF. When addressing the problem of anxiety, what
interventions should the nurse include in the care plan? Select all that apply.
Facilitate the presence of friends and family whenever possible.
Teach the patient about the harmful effects of anxiety on cardiac function.
Provide supplemental oxygen, as needed.
Provide validation of the patientts expressions of anxiety.
Administer benzodiazepines two to three times daily.
Facilitate the presence of friends and family whenever possible.*****
Teach the patient about the harmful effects of anxiety on cardiac function.
Provide supplemental oxygen, as needed.***
Provide validation of the patient's expressions of anxiety.*****
Administer benzodiazepines two to three times daily.
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Feedback: The nurse should empathically validate the patient's sensations of anxiety. The presence of friends and family
are frequently beneficial and oxygen supplementation promotes comfort. Antianxiety medications may be necessary for
some patients, but alternative methods of relief should be prioritized. As well, medications are administered on a PRN
basis. Teaching the patient about the potential harms of anxiety is likely to exacerbate, not relieve, the problem.
The critical care nurse is caring for a patient who is in cardiogenic shock. What assessments must the nurse
perform on this patient? Select all that apply.
Platelet level
Fluid status
Cardiac rhythm
Action of medications
Sputum volume
Platelet level
Fluid status***
Cardiac rhythm****
Action of medications***
Sputum volume
Feedback: The critical care nurse must carefully assess the patient in cardiogenic shock, observe the cardiac rhythm,
monitor hemodynamic parameters, monitor fluid status, and adjust medications and therapies based on the assessment
data. Platelet levels and sputum production are not major assessment parameters in a patient who is experiencing
cardiogenic shock.
A cardiovascular patient with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of
dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE.
What is the nursets best action?
Rapidly assess the patientts cardiopulmonary status.
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Arrange for an ECG.
Increase the height of the patientts bed.
Manage the patientts anxiety.
Rapidly assess the patient's cardiopulmonary status.****
Arrange for an ECG.
Increase the height of the patient's bed.
Manage the patient's anxiety.
Feedback: Patient management in the event of a PE begins with cardiopulmonary assessment and intervention. This is a
priority over ECG monitoring, management of anxiety, or repositioning of the patient, even though each of these actions
may be appropriate and necessary.
The nurse is caring for a patient who has developed obvious signs of pulmonary edema. What is the priority
nursing action?
Lay the patient flat.
Notify the family of the patientts critical state.
Stay with the patient.
Update the physician.
Lay the patient flat.
Notify the family of the patient's critical state.
Stay with the patient.****
Update the physician.
Feedback: Because the patient has an unstable condition, the nurse must remain with the patient. The physician must be
updated promptly, but the patient should not be left alone in order for this to happen. Supine positioning is unlikely to
relieve dyspnea. The family should be informed, but this is not the priority action.
A cardiac patientts resistance to left ventricular filling has caused blood to back up into the patientts circulatory
system. What health problem is likely to result?
Acute pulmonary edema
Rightsided HF
Right ventricular hypertrophy
Leftsided HF
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Acute pulmonary edema****
Rightsided HF
Right ventricular hypertrophy
Leftsided HF
Feedback: With increased resistance to left ventricular filling, blood backs up into the pulmonary circulation. The patient
quickly develops pulmonary edema from the blood volume overload in the lungs. When the blood backs up into the
pulmonary circulation, rightsided HF, leftsided HF, and right ventricular hypertrophy do not directly occur.
A patient who is at high risk for developing intracardiac thrombi has been placed on longterm anticoagulation.
What aspect of the patientts health history creates a heightened risk of intracardiac thrombi?
Atrial fibrillation
Infective endocarditis
Recurrent pneumonia
Recent surgery
Atrial fibrillation***
Infective endocarditis
Recurrent pneumonia
Recent surgery
Feedback: Intracardiac thrombi are especially common in patients with atrial fibrillation, because the atria do not contract
forcefully and blood flows slowly and turbulently, increasing the likelihood of thrombus formation. Endocarditis, pneumonia,
and recent surgery do not normally cause an increased risk for intracardiac thrombi formation.
Diagnostic imaging reveals that the quantity of fluid in a clientts pericardial sac is dangerously increased. The
nurse should collaborate with the other members of the care team to prevent the development of what
complication?
Pulmonary edema
Pericardiocentesis
Cardiac tamponade
Pericarditis
Pulmonary edema
Pericardiocentesis
Cardiac tamponade***
Pericarditis
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Feedback: An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the heart,
eventually causing cardiac tamponade. Pericardiocentesis is the treatment for this complication. Pericarditis and
pulmonary edema do not result from this pathophysiological process.
The nurse is caring for a patient with severe left ventricular dysfunction who has been identified as being at risk for
sudden cardiac death. What medical intervention can be performed that may extend the survival of the patient?
Insertion of an implantable cardioverter defibrillator
Insertion of an implantable pacemaker
Administration of a calcium channel blocker
Administration of a betablocker
Insertion of an implantable cardioverter defibrillator**
Insertion of an implantable pacemaker
Administration of a calcium channel blocker
Administration of a betablocker
Feedback: In patients with severe left ventricular dysfunction and the possibility of lifethreatening dysrhythmias, placement
of an implantable cardioverter defibrillator (ICD) can prevent sudden cardiac death and extend survival. A pacemaker, a
calcium channel blocker, and a betablocker are not medical interventions that may extend the survival of the patient with
left ventricular dysfunction.
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Brunner & Suddarth's Textbook of Medical Surgical Nursing 15th Edition
Chapter 26: Assessment and Management of Patients With Vascular Disorders and Problems of
Peripheral Circulation
A nursing instructor is discussing the diagnosis of intermittent claudication with students. To determine if the
students understand the pathophysiology of the disease, the instructor asks, "What percentage of the arterial
lumen must be obstructed before intermittent claudication is experienced?"
a) 40
b) 20
c) 50
d) 30
C
(Explanation: pg 824
Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent
claudication is experienced.)
Which of the following terms refers to a muscular, cramplike pain in the extremities consistently reproduced with
the same degree of exercise and relieved by rest?
a) Intermittent claudication
b) Aneurysm
c) Ischemia
d) Bruit
A
(Correct response: Intermittent claudication
Explanation: Page 823
Intermittent claudication is a sign of peripheral arterial insufficiency. An aneurysm is a localized sac of an artery wall
formed at a weak point in the vessel. A bruit is the sound produced by turbulent blood flow through an irregular, tortuous,
stenotic, or dilated vessel. Ischemia is a term used to denote deficient blood supply.)
The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal
vein in the foot is which of the following?
a) Lymphoscintigraphy
b) Air plethysmography
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c) Contrast phlebography
d) Lymphangiography
C
(Contrast phlebography
Correct
Explanation: Page 827
Also known as venography, contrast phlebography involves injecting a radiopaque contrast agent into the venous system.
If a thrombus exists, the x-ray image reveals an unfilled segment of vein in an otherwise completely filled vein. Air
plethysmography quantifies venous reflux and calf muscle pump ejection. In lymphangiography, contrast media are
injected into the lymph system. In a lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system.
(less).)
A nurse is teaching a patient newly diagnosed with arterial insufficiency. Which of the following terms should the
nurse use to refer to leg pain that occurs when the patient is walking?
a) Intermittent claudication
b) Thromboangiitis obliterans
c) Dyspnea
d) Orthopnea
A
(Intermittent claudication
Explanation: , p. 824
Intermittent claudication is leg pain that is brought on by exercise and relieved by rest. Dyspnea is the patient's subjective
statement of difficulty breathing. Orthopnea is the inability of the patient to breathe except in the upright (sitting) position.
Thromboangiitis obliterans is a peripheral vascular disease also known as Buerger's disease.)
The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine
causes which of the following?
a) Diuresis
b) Vasospasm
c) Slowed heart rate
d) Depression of the cough reflex
B
(Vasospasm
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Correct
Explanation: Page 831
Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. Tobacco smoke also
impairs transport and cellular use of oxygen and increases blood viscosity. Patients with arterial insufficiency who smoke
or chew tobacco must be fully informed of the effects of nicotine on circulation and be encouraged to stop.)
A nurse and physician are preparing to visit a hospitalized client with perepheral arterial disease. As you approach
the clientts room, the physician asks if the client has reported any intermittent claudication. The client has reported
this symptom. The nurse explains to the physician which of the following details?
a) The client can walk about 50 feet before getting pain in the right lower leg.
b) The client experiences shortness of breath after walking about 50 feet.
c) The clientts fingers tingle when left in one position for too long.
d) The clientts legs awaken him during the night with itching.
A
(The client can walk about 50 feet before getting pain in the right lower leg.
Correct
Explanation: pp. 823-824
Intermittent claudication is caused by the inability of the arterial system to provide adequate blood flow to the tissues
when increased demands are made for oxygen and nutrients during exercise. Pain is then experienced. When the client
rests and decreases demands, the pain subsides. The client can then walk the same distance and repeat the process.)
A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is
appropriate for the nurse to give the client for promoting circulation to the extremities?
a) Keep the extremities elevated slightly.
b) Massage the calf muscles if pain occurs.
c) Use a heating pad to promote warmth.
d) Participate in a regular walking program.
D
(Correct response: Participate in a regular walking program.
Explanation: p. 831
Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking
program to help develop collateral circulation. They should be advised to rest if pain develops and to resume activity when
pain subsides. Extremities should be kept in a dependent position to promote circulation; elevation of the extremities will
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decrease circulation. Heating pads should not be used by anyone with impaired circulation to avoid burns. Massaging the
calf muscles will not decrease pain. Intermittent claudication subsides with rest.)
A nurse is developing a nursing care plan for a client with peripheral arterial disease. Which of the following will be
the priority nursing diagnosis?
a) Ineffective peripheral tissue perfusion
b) Impaired tissue integrity
c) Ineffective self-health management
d) Ineffective thermoregulation
A
(Ineffective peripheral tissue perfusion
Correct
Explanation: Page 832
The goal is to increase arterial blood supply to the extremities; the priority nursing diagnosis is Ineffective peripheral tissue
perfusion related to compromised circulation.)
A community health nurse teaches a group of seniors about modifiable risk factors that contribute to the
development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which
of the following statements?
a) "The older I get the higher my risk for peripheral arterial disease gets."
b) "Since my family is from Italy, I have a higher risk of developing peripheral arterial disease."
c) "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels."
d) "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."
D
("I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."
Correct
Explanation: P828
The use of tobacco products may be one of the most important risk factors in the development of atherosclerotic lesions.
Nicotine in tobacco decreases blood flow to the extremities and increases heart rate and blood pressure by stimulating the
sympathetic nervous system. This causes vasoconstriction, thereby decreasing arterial blood flow. It also increases the
risk of clot formation by increasing the aggregation of platelets.)
Choice Multiple question - Select all answer choices that apply.
Which of the following is accurate regarding the effects of nicotine and tobacco smoke on the body? Select all that
apply.
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a) Decreases blood viscosity
b) Causes vasospasm
c) Impairs transport and cellular use of oxygen
d) Reduces circulation to the extremities
e) Increases blood viscosity
B, C, D, E
(• Impairs transport and cellular use of oxygen
Reduces circulation to the extremities
Increases blood viscosity
Causes vasospasm
Correct
Explanation: Page 828
Nicotine from tobacco products causes vasospasm and can dramatically reduce circulation to the extremities. Tobacco
smoke also impairs transport and cellular use of oxygen and increases blood viscosity.)
Choice Multiple question - Select all answer choices that apply.
Which of the following are complications of percutaneous transluminal balloon angioplasty (PTA)? Select all that
apply.
a) Embolization
b) Bleeding
c) Dissection of the vessel
d) Hematoma
e) Stent migration
A, B, C, D, E
(• Hematoma
Embolization
Dissection of the vessel
Bleeding
Stent migration
Explanation: Page 830
Complications from PTA include hematoma, embolization dissection of the vessel, bleeding, intimal damage (dissection),
and stent migration.)
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Pentoxifylline (Trental) is a medication used for which of the following?
a) Elevated triglycerides
b) Claudication
c) Thromboemboli
d) Hypertension
B
(Claudication
Explanation: Page 837
Trental and Pletal are the only medications specifically indicated for the treatment of claudication. Thromboemboli,
hypertension, and elevated triglycerides are not indications of Trental.)
A home health nurse is teaching a client with peripheral arterial disease ways to improve circulation to the lower
extremities. The nurse encourages which of the following in teaching?
a) Keeping the legs in a neutral or dependent position
b) Elevation of the legs above the heart
c) Application of ace wraps from the toe to below the knees
d) Use of antiembolytic stockings
A
(Keeping the legs in a neutral or dependent position
Correct
Explanation: p. 831
Keeping the legs in a neutral or dependent position assists in delivery of arterial blood from the heart to the lower
extremities. All the other choices will aid in venous return, but will hinder arterial supply to the lower extremities.)
The nurse performing an assessment on a patient who has arterial insufficiency of the legs and an ulcer on the left
great toe would expect to find which of the following characteristics?
a) Aching, cramping pain
b) Diminished or absent pulses
c) Pulses are present, may be difficult to palpate
d) Superficial ulcer
B
(Diminished or absent pulses
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Explanation:p824
Occlusive arterial disease impairs blood flow and can reduce or obliterate palpable pulsations in the extremities. A
diminished or absent pulse is a characteristic of arterial insufficiency.)
Which of the following is the most effective intervention for preventing progression of vascular disease?
a) Avoid trauma
b) Use neutral soaps
c) Wear sturdy shoes
d) Risk factor modification
D
(Risk factor modification
Explanation:
Risk factor modification is the most effective intervention for preventing progression of vascular disease. Measures to
prevent tissue loss and amputation are a high priority. Patients are taught to avoid trauma; wear sturdy, well-fitting shoes
or slippers; and use pH neutral soaps and body lotions.)
A nurse is providing education about maintaining tissue integrity to a client with peripheral arterial disease. Which
of the following statements by the client indicates a need for clarification?
a) "I can use lambts wool between my toes if necessary."
b) "Shoes made of synthetic material are best for my feet."
c) "I should apply powder daily because my feet perspire."
d) "It is important to apply sunscreen to the top of my feet when wearing sandals."
B
("Shoes made of synthetic material are best for my feet."
Correct
Explanation: pg835
The client should wear leather shoes with an extra-depth toebox. Synthetic shoes do not allow air to circulate.)
Which of the following diagnostic tests are used to quantify venous reflux and calf muscle pump ejection?
a) Lymphangiography
b) Air plethysmography
c) Contrast phlebography
d) Lymphoscintigraphy
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B
(Air plethysmography
Explanation: p. 827
Air plethysmography is used to quantify venous reflux and calf muscle pump action. Contrast phlebography involves
injecting a radiopaque contrast agent into the venous system. Lymphoscintigraphy is done when a radioactively labeled
colloid is injected subcutaneously in the second interdigital space. The extremity is then exercised to facilitate the uptake
of the colloid by the lymphatic system, and serial images are obtained at present intervals. Lymphoangiography provides a
way of detecting lymph node involvement resulting from metastatic carcinoma, lymphoma, or infection in sites that are
otherwise inaccessible to the examiner except by surgery.)
A client is diagnosed with peripheral arterial disease. Review of the clientts chart shows an ankle-brachial index
(ABI) on the right of 0.45. This indicates that the right foot has which of the following?
a) Tissue loss to that foot
b) Moderate to severe arterial insufficiency
c) Very mild arterial insufficiency
d) No arterial insufficiency
B
(Moderate to severe arterial insufficiency
Correct
Explanation: Moderate to severe arterial insufficiency
Correct
Explanation: p826
Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to
moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have
severe ischemia and an ABI of 0.25 or less.
Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to
moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have
severe ischemia and an ABI of 0.25 or less.)
In a patient with a bypass graft, the distal outflow vessel must be at least what percentage patent for the graft to
remain patent?
a) 30
b) 50
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c) 40
d) 20
B
(50
Correct
Explanation: Page 837
The distal outflow vessel must be at least 50% patent for the graft to remain patent.)
A patient in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and
hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this
statement, which priority assessment should the nurse complete?
a) Assess for unilateral swelling and tenderness of either leg.
b) Ask about any skin color changes that occur in response to cold.
c) Attempt to palpate the dorsalis pedis and posterior tibial pulses.
d) Check for the presence of tortuous veins bilaterally on the legs.
C
(Attempt to palpate the dorsalis pedis and posterior tibial pulses.
Explanation: Page 824
Intermittent claudication is a sign of peripheral arterial insufficiency. The nurse should assess for other clinical
manifestations of peripheral arterial disease in a patient who describes intermittent claudication. A thorough assessment of
the patient's skin color and temperature and the character of the peripheral pulses are important in the diagnosis of
arterial disorders.)
The nurse completes discharge teaching for a patient following a femoral-to-popliteal bypass graft. What response
by the patient would indicate teaching was effective?
a) "I can now stop taking my Lipitor because my leg is fixed."
b) "I can stop the exercises that were started in the hospital once I return home."
c) "I will call if I develop any coldness, numbness, tingling, or pain in the surgical leg."
d) "It will important for me to sit at the kitchen table to promote better breathing."
C
("I will call if I develop any coldness, numbness, tingling, or pain in the surgical leg."
Correct
Explanation: Page 838
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The nurse ensures that the patient has the knowledge and ability to assess for any postoperative complications such as
infection, occlusion of the artery or graft, and decreased blood flow. Coldness, numbness, tingling, and pain are signs of
peripheral arterial occlusion, and immediate intervention is required.)
A client with peripheral arterial disease asks the nurse about using a heating pad to warm the feet. The nursets best
response is which of the following?
a) "A heating pad to your feet is a good idea because it increases the metabolic rate."
b) "It is better to soak your feet in hot water as long as the water temperature is below 110 degrees F."
c) "It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet."
d) "A heating pad to your feet is fine as long as the temperature stays below 105 degrees F
C
("It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet."
Explanation: p. 831
It is safer to apply a heating pad to the abdomen, causing a reflex vasodilation in the extremities. Heat may be applied
directly to ischemic extremities; however, the temperature of the heating source must not exceed body temperature.
Excess heat may increase the metabolic rate of the extremities and increase the need for oxygen beyond that provided by
the reduced arterial flow through the diseased artery.)
A nurse is caring for a client following an arterial vascular bypass graft in the leg. Over the next 24 hours, what
should the nurse plan to assess?
a) Color of the leg every 4 hours
b) Peripheral pulses every 15 minutes following surgery
c) Blood pressure every 2 hours
d) Ankle-arm indices every 12 hours
B
(Peripheral pulses every 15 minutes following surgery.)
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this
procedure may cause which harmless temporary change?
a) Purplish stools
b) Bluish urine
c) Redness of the upper part of the feet
d) Coldness of the soles
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b
(Bluish urine
Lymphangiography may turn the urine blue temporarily; it doesn't alter stool color. For several months after the procedure,
the upper part of the feet may appear blue, not red. Lymphangiography doesn't affect the soles.)
A nurse is caring for a client following an arterial vascular bypass graft in the leg. Over the next 24 hours, what
should the nurse plan to assess?
a) Blood pressure every 2 hours
b) Ankle-arm indices every 12 hours
c) Peripheral pulses every 15 minutes following surgery
d) Color of the leg every 4 hours
c) Peripheral pulses every 15 minutes following surgery
The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses,
Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are
checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at
progressively longer intervals if the patient's status remains stable.
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein
thrombosis (DVT) by:
a) forcing blood into the deep venous system.
b) providing warmth to the extremity.
c) encouraging ambulation to prevent pooling of blood.
d) elevating the extremity to prevent pooling of blood.
a) forcing blood into the deep venous system.
Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool.
Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings.
Antiembolism stockings could possibly provide warmth, but this factor isn't how they prevent DVT. Elevating the extremity
decreases edema but doesn't prevent DVT.
The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse
include in the education of the patient during ambulation?
a) "Walk to the point of pain, rest until the pain subsides, then resume ambulation."
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b) "If you feel pain during the walk, keep walking until the end of the hallway is reached."
c) "As soon as you feel pain, we will go back and elevate your legs."
d) "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room."
a) "Walk to the point of pain, rest until the pain subsides, then resume ambulation."
The nurse instructs the patient to walk to the point of pain, rest until the pain subsides, and then resume walking so that
endurance can be increased as collateral circulation develops. Pain can serve as a guide in determining the appropriate
amount of exercise.
The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the
nurse understand that therapeutic benefits will begin?
a) Within 12 hours
b) Within the first 24 hours
c) In 3 to 5 days
d) In 2 days
c) In 3 to 5 days
Oral anticoagulants, such as warfarin, are monitored by the PT or the INR. Because the full anticoagulant effect of
warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has
been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0) (Holbrook et al., 2012).
The nurse performing an assessment on a patient who has arterial insufficiency of the legs and an ulcer on the left
great toe would expect to find which of the following characteristics?
a) Diminished or absent pulses
b) Aching, cramping pain
c) Pulses are present, may be difficult to palpate
d) Superficial ulcer
a) Diminished or absent pulses
Occlusive arterial disease impairs blood flow and can reduce or obliterate palpable pulsations in the extremities. A
diminished or absent pulse is a characteristic of arterial insufficiency.
A patient is having an angiography to detect the presence of an aneurysm. After the contrast is administered by the
interventionist, the patient begins to complain of nausea and difficulty breathing. What medication is a priority to
administer at this time?
a) Cimetidine (Tagamet)
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b) Metoprolol (Lopressor)
c) Hydrocortisone (Solu-Cortef)
d) Epinephrine
d) Epinephrine
Infrequently, a patient may have an immediate or delayed allergic reaction to the iodine contained in the contrast agent
used in angiography. Manifestations include dyspnea, nausea and vomiting, sweating, tachycardia, and numbness of the
extremities. Any such reaction must be reported to the interventionalist at once; treatment may include the administration
of epinephrine, antihistamines, or corticosteroids.
A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin
on the lower legs, the nurse notes edema, brown pigmentation in the gater area, pedal pulses, and a few irregularly
shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with
peripheral circulation. Which of the following does the nurse suspect?
a) Neither venous nor arterial insufficiency
b) Venous insufficiency
c) Arterial insufficiency
d) Trauma
b) Venous insufficiency
Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gater area, and a reddish blue
color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the
anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and
circular shape with a pale to black ulcer base.
A community health nurse teaches a group of seniors about modifiable risk factors that contribute to the
development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which
of the following statements?
a) "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels."
b) "Since my family is from Italy, I have a higher risk of developing peripheral arterial disease."
c) "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."
d) "The older I get the higher my risk for peripheral arterial disease gets."
c) "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."
The use of tobacco products may be one of the most important risk factors in the development of atherosclerotic lesions.
Nicotine in tobacco decreases blood flow to the extremities and increases heart rate and blood pressure by stimulating the
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sympathetic nervous system. This causes vasoconstriction, thereby decreasing arterial blood flow. It also increases the
risk of clot formation by increasing the aggregation of platelets.
Aortic dissection may be mistaken for which of the following disease processes?
a) Stroke
b) Angina
c) Pneumothorax
d) Myocardial infarction (MI)
d) Myocardial infarction (MI)
Aortic dissection may be mistaken for an acute MI, which could confuse the clinical picture and initial treatment. Aortic
dissection is not mistaken for stroke, pneumothorax, or angina.
When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial
thromboplastin time (aPTT) is within the therapeutic range of:
a) 2.5 to 3.0 times the baseline control.
b) 1.5 to 2.5 times the baseline control.
c) 4.5 times the baseline control.
d) 3.5 times the baseline control.
b) 1.5 to 2.5 times the baseline control.
A normal PTT level is 21 to 35 seconds. A reading of more than 100 seconds indicates a significant risk of hemorrhage.
A nurse is changing a dressing on an arterial suture site. The site is red, with foul-smelling drainage. Based on
these symptoms, the nurse is aware to monitor for which type of aneurysm?
a) Saccular
b) False
c) Anastomotic
d) Dissecting
c) Anastomotic
An anastomotic aneurysm occurs as a result of infection at arterial suture or graft sites. Dissection results from a rupture
in the intimal layer, resulting in bleeding between the intimal and medial layers of the arterial wall. Saccular aneurysms
collect blood in the weakened outpouching. In a false aneurysm, the mass is actually a pulsating hematoma.
A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms
of aneurysm rupture and thus looks for which of the following?
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a) Higher than normal blood pressure and falling hematocrit
b) Constant, intense headache and falling blood pressure
c) Slow heart rate and high blood pressure
d) Constant, intense back pain and falling blood pressure
d) Constant, intense back pain and falling blood pressure
Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and
decreasing hematocrit.
Which sign or symptom suggests that a clientts abdominal aortic aneurysm is extending?
a) Increased abdominal and back pain
b) Elevated blood pressure and rapid respirations
c) Decreased pulse rate and blood pressure
d) Retrosternal back pain radiating to the left arm
a) Increased abdominal and back pain
Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing
more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate
myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be
affected.
A client is diagnosed with peripheral arterial disease. Review of the clientts chart shows an ankle-brachial index
(ABI) on the right of 0.45. This indicates that the right foot has which of the following?
a) No arterial insufficiency
b) Very mild arterial insufficiency
c) Tissue loss to that foot
d) Moderate to severe arterial insufficiency
d) Moderate to severe arterial insufficiency
Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to
moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have
severe ischemia and an ABI of 0.25 or less.
The most common site of aneurysm formation is in the:
a) aortic arch, around the ascending and descending aorta.
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b) descending aorta, beyond the subclavian arteries.
c) ascending aorta, around the aortic arch.
d) abdominal aorta, just below the renal arteries.
d) abdominal aorta, just below the renal arteries.
About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debakey type I aneurysms).
Debakey type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debakey type
III aneurysms occur in the descending aorta, beyond the subclavian arteries.
A home health nurse is teaching a client with peripheral arterial disease ways to improve circulation to the lower
extremities. The nurse encourages which of the following in teaching?
a) Keeping the legs in a neutral or dependent position
b) Use of antiembolytic stockings
c) Elevation of the legs above the heart
d) Application of ace wraps from the toe to below the knees
a) Keeping the legs in a neutral or dependent position
Keeping the legs in a neutral or dependent position assists in delivery of arterial blood from the heart to the lower
extremities. All the other choices will aid in venous return, but will hinder arterial supply to the lower extremities.
A patient is being discharged home with a venous stasis ulcer on the right lower leg. Which topic will the nurse
include in patient teaching prior to discharge?
a) Application of graduated compression stockings
b) Methods of keeping the wound area dry
c) Adequate carbohydrate intake
d) Prophylactic antibiotic therapy
a) Application of graduated compression stockings
Graduated compression stockings usually are prescribed for patients with venous insufficiency. The amount of pressure
gradient is determined by the amount and severity of venous disease. Graduated compression stockings are designed to
apply 100% of the prescribed pressure gradient at the ankle and pressure that decreases as the stocking approaches the
thigh, reducing the caliber of the superficial veins in the leg and increasing flow in the deep veins. These stockings may
be knee high, thigh high, or pantyhose.
The nurse is assessing a patient with suspected acute venous insufficiency. What clinical manifestations would
indicate this condition to the nurse? (Select all that apply.)
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a) Sharp pain that may be relieved by the elevation of the extremity
b) Full superficial veins
c) Initial absence of edema
d) Cool and cyanotic skin
e) Brisk capillary refill of the toes
a) Sharp pain that may be relieved by the elevation of the extremity
b) Full superficial veins
d) Cool and cyanotic skin
Postthrombotic syndrome is characterized by chronic venous stasis, resulting in edema, altered pigmentation, pain, and
stasis dermatitis. The patient may notice the symptoms less in the morning and more in the evening. Obstruction or poor
calf muscle pumping in addition to valvular reflux must be present for the development of severe postthrombotic syndrome
and stasis ulcers. Superficial veins may be dilated.
A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is
accurate?
a) Sclerotherapy is used to cure varicose veins.
b) The severity of discomfort isntt related to the size of varicosities.
c) Primary varicose veins are caused by deep vein thrombosis (DVT) and inflammation.
d) Varicose veins are more common in men than in women.
b) The severity of discomfort isn't related to the size of varicosities.
Clients with varicose veins commonly complain of aching, heaviness, itching, moderate swelling, and unsightly
appearance of the legs. However, the severity of discomfort is hard to assess and seems unrelated to the size of
varicosities. Varicose veins are more common in women than in men. Primary varicose veins typically result from a
congenital or familial predisposition that makes the vein wall less elastic; secondary varicosities occur when trauma,
obstruction, DVT, or inflammation damages valves. Sclerotherapy, in which a sclerosing agent is injected into a vein, is
used to treat varicose veins; it doesn't cure them.
Vasodilation or vasoconstriction produced by an external cause will interfere with a nursets accurate assessment
of a client with peripheral vascular disease (PVD). Therefore, the nurse should:
a) match the room temperature to the clientts body temperature.
b) maintain room temperature at 78° F (25.6° C).
c) keep the client uncovered.
d) keep the client warm.
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d) keep the client warm.
The nurse should keep the client covered and expose only the portion of the client's body that she's assessing. The nurse
should also keep the client warm by maintaining his room temperature between 68° F and 74° F (20° and 23.3° C).
Extreme temperatures aren't good for clients with PVD. The valves in their arteries and veins are already insufficient, and
exposing them to vast changes in temperature could affect assessment findings. Keeping the client uncovered would
cause him to become chilled. Matching the room temperature to the client's body temperature is inappropriate.
A client with no known history of peripheral vascular disease comes to the emergency department complaining of
sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled,
cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should:
a) place a heating pad around the affected calf.
b) keep the affected leg level or slightly dependent.
c) shave the affected leg in anticipation of surgery.
d) elevate the affected leg as high as possible.
b) keep the affected leg level or slightly dependent.
While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg
level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a
heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg.
Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or
nicks.
Which of the following observations regarding ulcer formation on the patientts lower extremity indicates that the
ulcer is a result of venous insufficiency?
a) Is deep, involving the joint space
b) Base is pale to black
c) Border of the ulcer is irregular
d) Is very painful to the patient, even though superficial
c) Border of the ulcer is irregular
The border of an ulcer caused by arterial insufficiency is circular. Superficial venous insufficiency ulcers cause minimal
pain. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color. Venous insufficiency ulcers are
usually superficial.
While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do
first?
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a) Monitor the partial thromboplastin time (PTT).
b) Prepare to administer protamine sulfate.
c) Decrease the heparin infusion rate.
d) Start an I.V. infusion of dextrose 5% in water (D5W).
b) Prepare to administer protamine sulfate.
Frank hematuria indicates excessive anticoagulation and bleeding — and heparin overdose. The nurse should discontinue
the heparin infusion immediately and prepare to administer protamine sulfate, the antidote for heparin. Decreasing the
heparin infusion rate wouldn't prevent further bleeding. Although the nurse should continue to monitor PTT, this action
should occur later. An I.V. infusion of D5W may be administered, but only after protamine has been given.
The most important factor regulating the caliber of blood vessels, which determines resistance to flow, is:
a) Hormonal secretion.
b) Independent arterial wall activity.
c) The influence of circulating chemicals.
d) The sympathetic nervous system.
d) The sympathetic nervous system.
Stimulation of the sympathetic nervous system causes vasoconstriction thus regulating blood flow. Norepinephrine is the
responsible neurotransmitter.
A client complains of leg pain brought on by walking several blocks — a symptom that first arose several weeks
earlier. The clientts history includes diabetes mellitus and a two-pack-per-day cigarette habit for the past 42 years.
The physician diagnoses intermittent claudication and orders pentoxifylline (Trental), 400 mg three times daily with
meals. Which instruction concerning long-term care should the nurse provide?
a) "Reduce your level of exercise."
b) "Consider cutting down on your smoking."
c) "See the physician if complications occur."
d) "Practice meticulous foot care."
d) "Practice meticulous foot care."
Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them
susceptible to injury and poor healing. Therefore, meticulous foot care is essential. The nurse should teach the client to
bathe his feet in warm water and dry them thoroughly, cut the toenails straight across, wear well-fitting shoes, and avoid
taking medications without the approval of a physician. Because nicotine is a vasoconstrictor, this client should stop
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smoking, not just consider cutting down. Daily walking is beneficial to clients with intermittent claudication. To evaluate the
effectiveness of the therapeutic regimen, this client should see the physician regularly, not just when complications occur.
Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals
deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect:
a) left calf circumference 1" (2.5 cm) larger than the right.
b) a decrease in the left pedal pulse.
c) loss of hair on the lower portion of the left leg.
d) pallor and coolness of the left foot.
a) left calf circumference 1" (2.5 cm) larger than the right.
Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the
opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow,
which doesn't occur in DVT.
A patient with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which of the
following is the most likely cause?
a) The patient is experiencing normal sensations associated with this condition.
b) The aneurysm has become obstructed.
c) The aneurysm may be preparing to rupture.
d) The patient is experiencing inflammation of the aneurysm.
c) The aneurysm may be preparing to rupture.
Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Abdominal
pain is often localized in the middle or lower abdomen to the left of the midline. Low back pain may be present because of
pressure of the aneurysm on the lumbar nerves. Indications of a rupturing abdominal aortic aneurysm include constant,
intense back pain; falling blood pressure; and decreasing hematocrit. Rupture into the peritoneal cavity is rapidly fatal. A
retroperitoneal rupture of an aneurysm may result in hematomas in the scrotum, perineum, flank, or penis.
A health care provider wants a cross-sectional image of the abdomen to evaluate the degree of stenosis in a
patientts left common iliac artery. The nurse knows to prepare the patient for which of the following?
a) Computed tomography angiography (CTA)
b) Magnetic resonance angiography (MRA)
c) Doppler ultrasound
d) Angiography
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a) Computed tomography angiography (CTA)
A CTA is used to visualize arteries and veins and help assess for stenosis and occlusion.
A nurse should be prepared to manage complications following abdominal aortic aneurysm resection. Which
complication is most common?
a) Renal failure
b) Enteric fistula
c) Graft occlusion
d) Hemorrhage and shock
a) Renal failure
Renal failure commonly occurs if clamping time is prolonged, cutting off the blood supply to the kidneys. Hemorrhage and
shock are the most common complications before abdominal aortic aneurysm resection, and they occur if the aneurysm
leaks or ruptures. Graft occlusion and enteric fistula formation are rare complications of abdominal aortic aneurysm repair.
A nurse is providing education about maintaining tissue integrity to a client with peripheral arterial disease. Which
of the following statements by the client indicates a need for clarification?
a) "It is important to apply sunscreen to the top of my feet when wearing sandals."
b) "I can use lambts wool between my toes if necessary."
c) "I should apply powder daily because my feet perspire."
d) "Shoes made of synthetic material are best for my feet."
d) "Shoes made of synthetic material are best for my feet."
The client should wear leather shoes with an extra-depth toebox. Synthetic shoes do not allow air to circulate.
Which of the following is a characteristic of an arterial ulcer?
a) Brawny edema
b) Border regular and well demarcated
c) Ankle-brachial index (ABI) > 0.90
d) Edema may be severe
b) Border regular and well demarcated
Characteristics of an arterial ulcer include a border that is regular and demarcated. Brawny edema, ABI > 0.90, and
edema that may be severe are characteristics of a venous ulcer.
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The nurse is educating a patient with chronic venous insufficiency about prevention of complications related to the
disorder. What should the nurse include in the information given to the patient? (Select all that apply.)
a) Sleep with the foot of the bed elevated about 6 inches.
b) Sit as much as possible to rest the valves in the legs.
c) Avoid constricting garments.
d) Sit on the side of the bed and dangle the feet.
e) Elevate the legs above the heart level for 30 minutes every 2 hours.
a) Sleep with the foot of the bed elevated about 6 inches.
c) Avoid constricting garments.
e) Elevate the legs above the heart level for 30 minutes every 2 hours.
Elevating the legs decreases edema, promotes venous return, and provides symptomatic relief. The legs should be
elevated frequently throughout the day (at least 15 to 20 minutes four times daily). At night, the patient should sleep with
the foot of the bed elevated about 15 cm (6 inches). Prolonged sitting or standing in one position is detrimental; walking
should be encouraged. When sitting, the patient should avoid placing pressure on the popliteal spaces, as occurs when
crossing the legs or sitting with the legs dangling over the side of the bed. Constricting garments, especially socks that
are too tight at the top or that leave marks on the skin, should be avoided.
To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a
45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals:
a) a 30-second filling time for the veins.
b) no rubor for 10 seconds after the maneuver.
c) dependent pallor.
d) elevational rubor.
c) dependent pallor.
If arterial insufficiency is present, elevation of the limb would yield a pallor from the lack of circulation. Rubor and
increased venous filling time would suggest venous problems secondary to venous trapping and incompetent valves.
A client with peripheral arterial disease asks the nurse about using a heating pad to warm the feet. The nursets best
response is which of the following?
a) "It is better to soak your feet in hot water as long as the water temperature is below 110 degrees F."
b) "A heating pad to your feet is a good idea because it increases the metabolic rate."
c) "A heating pad to your feet is fine as long as the temperature stays below 105 degrees F."
d) "It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet."
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d) "It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet."
It is safer to apply a heating pad to the abdomen, causing a reflex vasodilation in the extremities. Heat may be applied
directly to ischemic extremities; however, the temperature of the heating source must not exceed body temperature.
Excess heat may increase the metabolic rate of the extremities and increase the need for oxygen beyond that provided by
the reduced arterial flow through the diseased artery.
The nurse is taking a health history of a new patient. The patient reports experiencing pain in his left lower leg and
foot when walking. This pain is relieved with rest. The nurse notes that the left lower leg is slightly edematous and
is hairless. When planning this patientts subsequent care, the nurse should most likely address what health
problem?
A)
Coronary artery disease (CAD)
B)
Intermittent claudication
C)
Arterial embolus
D)
Raynaudts disease
Ans: Intermittent claudication
Feedback:
A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and
relieved by rest is experienced by patients with peripheral arterial insufficiency. Referred to as intermittent claudication,
this pain is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of
increased demands for nutrients and oxygen during exercise. The nurse would not suspect the patient has CAD, arterial
embolus, or Raynaud's disease; none of these health problems produce this cluster of signs and symptoms.
While assessing a patient the nurse notes that the patientts ankle-brachial index (ABI) of the right leg is 0.40. How
should the nurse best respond to this assessment finding?
A)
Assess the patientts use of over-the-counter dietary supplements.
B)
Implement interventions relevant to arterial narrowing.
C)
Encourage the patient to increase intake of foods high in vitamin K.
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D)
Adjust the patientts activity level to accommodate decreased coronary output.
Ans: Implement interventions relevant to arterial narrowing.
Feedback:
ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of less than 1.0 indicates possible claudication
of the peripheral arteries. It does not indicate inadequate coronary output. There is no direct indication for changes in
vitamin K intake and OTC medications are not likely causative.
The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease
(PAD). What assessment finding is most consistent with this diagnosis?
A)
Numbness and tingling in the distal extremities
B)
Unequal peripheral pulses between extremities
C)
Visible clubbing of the fingers and toes
D)
Reddened extremities with muscle atrophy
Ans: Unequal peripheral pulses between extremities
Feedback:
PAD assessment may manifest as unequal pulses between extremities, with the affected leg cooler and paler than the
unaffected leg. Intermittent claudication is far more common than sensations of numbness and tingling. Clubbing and
muscle atrophy are not associated with PAD.
The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission
assessment that the patient takes oral contraceptives. Consequently, the nursets postoperative plan of care should
include what intervention?
A)
Early ambulation and leg exercises
B)
Cessation of the oral contraceptives until 3 weeks postoperative
C)
Doppler ultrasound of peripheral circulation twice daily
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D)
Dependent positioning of the patientts extremities when at rest
Ans: Early ambulation and leg exercises
Feedback:
Oral contraceptive use increases blood coagulability; with bed rest, the patient may be at increased risk of developing
deep vein thrombosis. Leg exercises and early ambulation are among the interventions that address this risk. Assessment
of peripheral circulation is important, but Doppler ultrasound may not be necessary to obtain these data. Dependent
positioning increases the risk of venous thromboembolism (VTE). Contraceptives are not normally discontinued to address
the risk of VTE in the short term.
A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse
include in the plan?
A)
Avoiding tight-fitting socks.
B)
Limit activity whenever possible.
C)
Sleep with legs in a dependent position.
D)
Avoid the use of pressure stockings.
Ans: Avoiding tight-fitting socks.
Feedback:
Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles; maintaining activities, such
as walking, sleeping with legs elevated, and using pressure stockings. Not included in the teaching plan for venous
insufficiency would be reducing activity, sleeping with legs dependent, and avoiding pressure stockings. Each of these
actions exacerbates venous insufficiency.
The nurse is caring for a patient with a large venous leg ulcer. What intervention should the nurse implement to
promote healing and prevent infection?
A)
Provide a high-calorie, high-protein diet.
B)
Apply a clean occlusive dressing once daily and whenever soiled.
C)
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Irrigate the wound with hydrogen peroxide once daily.
D)
Apply an antibiotic ointment on the surrounding skin with each dressing change.
Ans: Provide a high-calorie, high-protein diet.
Feedback:
Wound healing is highly dependent on adequate nutrition. The diet should be sufficiently high in calories and protein.
Antibiotic ointments are not normally used on the skin surrounding a leg ulcer and occlusive dressings can exacerbate
impaired blood flow. Hydrogen peroxide is not normally used because it can damage granulation tissue.
The nurse is caring for a patient who returned from the tropics a few weeks ago and who sought care with signs
and symptoms of lymphedema. The nursets plan of care should prioritize what nursing diagnosis?
A)
Risk for infection related to lymphedema
B)
Disturbed body image related to lymphedema
C)
Ineffective health maintenance related to lymphedema
D)
Risk for deficient fluid volume related to lymphedema
Ans: Risk for infection related to lymphedema
Feedback:
Lymphedema, which is caused by accumulation of lymph in the tissues, constitutes a significant risk for infection. The
patient's body image is likely to be disturbed, and the nurse should address this, but infection is a more significant threat
to the patient's physiological well-being. Lymphedema is unrelated to ineffective health maintenance and deficient fluid
volume is not a significant risk.
An occupational health nurse is providing an educational event and has been asked by an administrative worker
about the risk of varicose veins. What should the nurse suggest as a proactive preventative measure for varicose
veins?
A)
Sit with crossed legs for a few minutes each hour to promote relaxation.
B)
Walk for several minutes every hour to promote circulation.
C)
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Elevate the legs when tired.
D)
Wear snug-fitting ankle socks to decrease edema.
Ans: Walk for several minutes every hour to promote circulation.
Feedback:
A proactive approach to preventing varicose veins would be to walk for several minutes every hour to promote circulation.
Sitting with crossed legs may promote relaxation, but it is contraindicated for patients with, or at risk for, varicose veins.
Elevating the legs only helps blood passively return to the heart and does not help maintain the competency of the valves
in the veins. Wearing tight ankle socks is contraindicated for patients with, or at risk for, varicose veins; socks that are
below the muscles of the calf do not promote venous return, the socks simply capture the blood and promote venous
stasis.
A patient comes to the walk-in clinic with complaints of pain in his foot following stepping on a roofing nail 4 days
ago. The patient has a visible red streak running up his foot and ankle. What health problem should the nurse
suspect?
A)
Cellulitis
B)
Local inflammation
C)
Elephantiasis
D)
Lymphangitis
Ans: Lymphangitis
Feedback:
Lymphangitis is an acute inflammation of the lymphatic channels. It arises most commonly from a focus of infection in an
extremity. Usually, the infectious organism is hemolytic streptococcus. The characteristic red streaks that extend up the
arm or the leg from an infected wound outline the course of the lymphatic vessels as they drain. Cellulitis is caused by
bacteria, which cause a generalized edema in the subcutaneous tissues surrounding the affected area. Local inflammation
would not present with red streaks in the lymphatic channels. Elephantiasis is transmitted by mosquitoes that carry
parasitic worm larvae; the parasites obstruct the lymphatic channels and results in gross enlargement of the limbs.
The triage nurse in the ED is assessing a patient who has presented with complaint of pain and swelling in her right
lower leg. The patientts pain became much worse last night and appeared along with fever, chills, and sweating.
The patient states, "I hit my leg on the car door 4 or 5 days ago and it has been sore ever since." The patient has a
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history of chronic venous insufficiency. What intervention should the nurse anticipate for this patient?
A)
Platelet transfusion to treat thrombocytopenia
B)
Warfarin to treat arterial insufficiency
C)
Antibiotics to treat cellulitis
D)
Heparin IV to treat VTE
Ans: Antibiotics to treat cellulitis
Feedback:
Cellulitis is the most common infectious cause of limb swelling. The signs and symptoms include acute onset of swelling,
localized redness, and pain; it is frequently associated with systemic signs of fever, chills, and sweating. The patient may
be able to identify a trauma that accounts for the source of infection. Thrombocytopenia is a loss or decrease in platelets
and increases a patient's risk of bleeding; this problem would not cause these symptoms. Arterial insufficiency would
present with ongoing pain related to activity. This patient does not have signs and symptoms of VTE.
A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral
arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures
to prevent what complication?
A)
Aoritis
B)
Deep vein thrombosis
C)
Thoracic aortic aneurysm
D)
Raynaudts disease
Ans: Deep vein thrombosis
Feedback:
Although the exact cause of venous thrombosis remains unclear, three factors, known as Virchow's triad, are believed to
play a significant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation.
In this woman's case, she has venous stasis from immobility, vessel wall injury from PAD, and altered blood coagulation
from HF. The cause of aoritis is unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk
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factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD, or
mobility issues. Raynaud's disease is a disorder that involves spasms of blood vessels and, again, no direct connection to
HF, PAD, or mobility issues.
A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing his health
history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and
does not exercise. What would be the priority health education for this patient?
A)
The lack of exercise, which is the main cause of PAD.
B)
The likelihood that heavy alcohol intake is a significant risk factor for PAD.
C)
Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD.
D)
Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD.
Ans: Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD.
Feedback:
Tobacco is powerful vasoconstrictor; its use with PAD is highly detrimental, and patients are strongly advised to stop
using tobacco. Sedentary lifestyle is also a risk factor, but smoking is likely a more significant risk factor that the nurse
should address. Alcohol use is less likely to cause PAD, although it carries numerous health risks.
A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the nursing
diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. What is the
most appropriate intervention for this diagnosis?
A)
Elevate his legs and arms above his heart when resting.
B)
Encourage the patient to engage in a moderate amount of exercise.
C)
Encourage extended periods of sitting or standing.
D)
Discourage walking in order to limit pain.
Ans: Encourage the patient to engage in a moderate amount of exercise.
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Feedback:
The nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation requires interventions that
focus on improving circulation. Encouraging the patient to engage in a moderate amount of exercise serves to improve
circulation. Elevating his legs and arms above his heart when resting would be passive and fails to promote circulation.
Encouraging long periods of sitting or standing would further compromise circulation. The nurse should encourage, not
discourage, walking to increase circulation and decrease pain.
The nurse is caring for a 72-year-old patient who is in cardiac rehabilitation following heart surgery. The patient has
been walking on a regular basis for about a week and walks for 15 minutes 3 times a day. The patient states that he
is having a cramp-like pain in the legs every time he walks and that the pain gets "better when I rest." The patientts
care plan should address what problem?
A)
Decreased mobility related to VTE
B)
Acute pain related to intermittent claudication
C)
Decreased mobility related to venous insufficiency
D)
Acute pain related to vasculitis
Ans: Acute pain related to intermittent claudication
Feedback:
Intermittent claudication presents as a muscular, cramp-type pain in the extremities consistently reproduced with the same
degree of exercise or activity and relieved by rest. Patients with peripheral arterial insufficiency often complain of
intermittent claudication due to a lack of oxygen to muscle tissue. Venous insufficiency presents as a disorder of venous
blood reflux and does not present with cramp-type pain with exercise. Vasculitis is an inflammation of the blood vessels
and presents with weakness, fever, and fatigue, but does not present with cramp-type pain with exercise. The pain
associated with VTE does not have this clinical presentation.
A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac rehabilitation following an MI.
The nursets plan of care calls for the patient to walk for 10 minutes 3 times a day. The patient questions the
relationship between walking and heart function. How should the nurse best reply?
A)
"The arteries in your legs constrict when you walk and allow the blood to move faster and with more pressure on
the tissue."
B)
Walking increases your heart rate and blood pressure. Therefore your heart is under less stress."
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C)
"Walking helps your heart adjust to your new arteries and helps build your self-esteem."
D)
"When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which
allows more blood to return to your heart."
Ans: "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which
allows more blood to return to your heart."
Feedback:
Veins, unlike arteries, are equipped with valves that allow blood to move against the force of gravity. The legs have oneway bicuspid valves that prevent blood from seeping backward as it moves forward by the muscles in our legs pressing
on the veins as we walk and increasing venous return. Leg arteries do constrict when walking, which allows the blood to
move faster and with more pressure on the tissue, but the greater concern is increasing the flow of venous blood to the
heart. Walking increases, not decreases, the heart' pumping ability, which increases heart rate and blood pressure and
the hearts ability to manage stress. Walking does help the heart adjust to new arteries and may enhance self-esteem, but
the patient had an MI—there are no "new arteries."
The nurse is caring for a patient who is admitted to the medical unit for the treatment of a venous ulcer in the area
of her lateral malleolus that has been unresponsive to treatment. What is the nurse most likely to find during an
assessment of this patientts wound?
A)
Hemorrhage
B)
Heavy exudate
C)
Deep wound bed
D)
Pale-colored wound bed
Ans: Heavy exudate
Feedback:
Venous ulcerations in the area of the medial or lateral malleolus (gaiter area) are typically large, superficial, and highly
exudative. Venous hypertension causes extravasation of blood, which discolors the area of the wound bed. Bleeding is
not normally present.
The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein thrombophlebitis (DVT). Which
laboratory value would most clearly indicate that the patientts warfarin is at therapeutic levels?
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A)
Partial thromboplastin time (PTT) within normal reference range
B)
Prothrombin time (PT) eight to ten times the control
C)
International normalized ratio (INR) between 2 and 3
D)
Hematocrit of 32%
Ans: International normalized ratio (INR) between 2 and 3
Feedback:
The INR is most often used to determine if warfarin is at a therapeutic level; an INR of 2 to 3 is considered therapeutic.
Warfarin is also considered to be at therapeutic levels when the client's PT is 1.5 to 2 times the control. Higher values
indicate increased risk of bleeding and hemorrhage, whereas lower values indicate increased risk of blood clot formation.
Heparin, not warfarin, prolongs PTT. Hematocrit does not provide information on the effectiveness of warfarin; however, a
falling hematocrit in a client taking warfarin may be a sign of hemorrhage.
The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks several
blocks. The patient has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. The
physician diagnoses intermittent claudication. The nurse should provide what instruction about long-term care to
the client?
A)
"Be sure to practice meticulous foot care."
B)
"Consider cutting down on your smoking."
C)
"Reduce your activity level to accommodate your limitations."
D)
"Try to make sure you eat enough protein."
Ans: "Be sure to practice meticulous foot care."
Feedback:
The patient with peripheral vascular disease or diabetes should receive education or reinforcement about skin and foot
care. Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them
susceptible to injury and poor healing; therefore, meticulous foot care is essential. The patient should stop smoking—not
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just cut down—because nicotine is a vasoconstrictor. Daily walking benefits the patient with intermittent claudication.
Increased protein intake will not alleviate the patient's symptoms.
A patient who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which
assessments should the nurse perform during the first postoperative day?
A)
Assess pulse of affected extremity every 15 minutes at first.
B)
Palpate the affected leg for pain during every assessment.
C)
Assess the patient for signs and symptoms of compartment syndrome every 2 hours.
D)
Perform Doppler evaluation once daily.
Ans: Assess pulse of affected extremity every 15 minutes at first.
Feedback:
The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses,
Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are
checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at
progressively longer intervals if the patient's status remains stable. Doppler evaluations should be performed every 2
hours. Pain is regularly assessed, but palpation is not the preferred method of performing this assessment. Compartment
syndrome results from the placement of a cast, not from vascular surgery.
You are caring for a patient who is diagnosed with Raynaudts phenomenon. The nurse should plan interventions to
address what nursing diagnosis?
A)
Chronic pain
B)
Ineffective tissue perfusion
C)
Impaired skin integrity
D)
Risk for injury
Ans: Ineffective tissue perfusion
Feedback:
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Raynaud's phenomenon is a form of intermittent arteriolar vasoconstriction resulting in inadequate tissue perfusion. This
results in coldness, pain, and pallor of the fingertips or toes. Pain is typically intermittent and acute, not chronic, and skin
integrity is rarely at risk. In most cases, the patient is not at a high risk for injury.
A patient presents to the clinic complaining of the inability to grasp objects with her right hand. The patientts right
arm is cool and has a difference in blood pressure of more than 20 mm Hg compared with her left arm. The nurse
should expect that the primary care provider may diagnose the woman with what health problem?
A)
Lymphedema
B)
Raynaudts phenomenon
C)
Upper extremity arterial occlusive disease
D)
Upper extremity VTE
Ans: Upper extremity arterial occlusive disease
Feedback:
The patient with upper extremity arterial occlusive disease typically complains of arm fatigue and pain with exercise
(forearm claudication) and inability to hold or grasp objects (e.g., combing hair, placing objects on shelves above the
head) and, occasionally, difficulty driving. Assessment findings include coolness and pallor of the affected extremity,
decreased capillary refill, and a difference in arm blood pressures of more than 20 mm Hg. These symptoms are not
closely associated with Raynaud's or lymphedema. The upper extremities are rare sites for VTE.
A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-yearold resident. During inspection of the residentts feet, the nurse notes that she appears to have early evidence of
gangrene on one of her great toes. The nurse knows that gangrene in the elderly is often the first sign of what?
A)
Chronic venous insufficiency
B)
Raynaudts phenomenon
C)
VTE
D)
PAD
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Ans: PAD
Feedback:
In elderly people, symptoms of PAD may be more pronounced than in younger people. In elderly patients who are
inactive, gangrene may be the first sign of disease. Venous insufficiency does not normally manifest with gangrene.
Similarly, VTE and Raynaud's phenomenon do not cause the ischemia that underlies gangrene.
The prevention of VTE is an important part of the nursing care of high-risk patients. When providing patient
teaching for these high-risk patients, the nurse should advise lifestyle changes, including which of the following?
Select all that apply.
A)
High-protein diet
B)
Weight loss
C)
Regular exercise
D)
Smoking cessation
E)
Calcium and vitamin D supplementation
Ans: Weight loss, Regular exercise, Smoking cessation
Feedback:
Patients at risk for VTE should be advised to make lifestyle changes, as appropriate, which may include weight loss,
smoking cessation, and regular exercise. Increased protein intake and supplementation with vitamin D and calcium do not
address the main risk factors for VTE.
The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a comorbidity of renal
insufficiency. How will this patientts renal status affect heparin therapy?
A)
Heparin is contraindicated in the treatment of this patient.
B)
Heparin may be administered subcutaneously, but not IV.
C)
Lower doses of heparin are required for this patient.
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D)
Coumadin will be substituted for heparin.
Ans: Lower doses of heparin are required for this patient.
Feedback:
If renal insufficiency exists, lower doses of heparin are required. Coumadin cannot be safely and effectively used as a
substitute and there is no contraindication for IV administration.
The nurse is assessing a woman who is pregnant at 27 weekst gestation. The patient is concerned about the recent
emergence of varicose veins on the backs of her calves. What is the nursets best response?
A)
Facilitate a referral to a vascular surgeon.
B)
Assess the patientts ankle-brachial index (ABI) and perform Doppler ultrasound testing.
C)
Encourage the patient to increase her activity level.
D)
Teach the patient that circulatory changes during pregnancy frequently cause varicose veins.
Ans: Teach the patient that circulatory changes during pregnancy frequently cause varicose veins.
Feedback:
Pregnancy may cause varicosities because of hormonal effects related to decreased venous outflow, increased pressure
by the gravid uterus, and increased blood volume. In most cases, no intervention or referral is necessary. This finding is
not an indication for ABI assessment and increased activity will not likely resolve the problem.
Graduated compression stockings have been prescribed to treat a patientts venous insufficiency. What education
should the nurse prioritize when introducing this intervention to the patient?
A)
The need to take anticoagulants concurrent with using compression stockings
B)
The need to wear the stockings on a "one day on, one day off" schedule
C)
The importance of wearing the stockings around the clock to ensure maximum benefit
D)
The importance of ensuring the stockings are applied evenly with no pressure points
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Ans: The importance of ensuring the stockings are applied evenly with no pressure points
Feedback:
Any type of stocking can inadvertently become a tourniquet if applied incorrectly (i.e., rolled tightly at the top). In such
instances, the stockings produce rather than prevent stasis. For ambulatory patients, graduated compression stockings
are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning. They are used
daily, not on alternating days. Anticoagulants are not always indicated in patients who are using compression stockings.
The nurse caring for a patient with a leg ulcer has finished assessing the patient and is developing a problem list
prior to writing a plan of care. What major nursing diagnosis might the care plan include?
A)
Risk for disuse syndrome
B)
Ineffective health maintenance
C)
Sedentary lifestyle
D)
Imbalanced nutrition: less than body requirements
Ans: Imbalanced nutrition: less than body requirements
Feedback:
Major nursing diagnoses for the patient with leg ulcers may include imbalanced nutrition: less than body requirements,
related to increased need for nutrients that promote wound healing. Risk for disuse syndrome is a state in which an
individual is at risk for deterioration of body systems owing to prescribed or unavoidable musculoskeletal inactivity. A leg
ulcer will affect activity, but rarely to this degree. Leg ulcers are not necessarily a consequence of ineffective health
maintenance or sedentary lifestyle.
How should the nurse best position a patient who has leg ulcers that are venous in origin?
A)
Keep the patientts legs flat and straight.
B)
Keep the patientts knees bent to 45-degree angle and supported with pillows.
C)
Elevate the patientts lower extremities.
D)
Dangle the patientts legs over the side of the bed.
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Ans: Elevate the patient's lower extremities.
Feedback:
Positioning of the legs depends on whether the ulcer is of arterial or venous origin. With venous insufficiency, dependent
edema can be avoided by elevating the lower extremities. Dangling the patient's legs and applying pillows may further
compromise venous return.
A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best
prevent skin breakdown in the patientts lower extremities?
A)
Ensure that the patientts heels are protected and supported.
B)
Closely monitor the patientts serum albumin and prealbumin levels.
C)
Perform gentle massage of the patientts lower legs, as tolerated.
D)
Perform passive range-of-motion exercises once per shift.
Ans: Ensure that the patient's heels are protected and supported.
Feedback:
If the patient is on bed rest, it is important to relieve pressure on the heels to prevent pressure ulcerations, since the heels
are among the most vulnerable body regions. Monitoring blood work does not directly prevent skin breakdown, even
though albumin is related to wound healing. Massage is not normally indicated and may exacerbate skin breakdown.
Passive range- of-motion exercises do not directly reduce the risk of skin breakdown.
The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The
nursets assessment should include which of the following components? Select all that apply.
A)
Location and type of pain
B)
Apical heart rate
C)
Bilateral comparison of peripheral pulses
D)
Comparison of temperature in the patientts legs
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E)
Identification of mobility limitations
Ans: Location and type of pain, Bilateral comparison of peripheral pulses, Comparison of temperature in the patient's legs,
Identification of mobility limitations
Feedback:
A careful nursing history and assessment are important. The extent and type of pain are carefully assessed, as are the
appearance and temperature of the skin of both legs. The quality of all peripheral pulses is assessed, and the pulses in
both legs are compared. Any limitation of mobility and activity that results from vascular insufficiency is identified. Not
likely is there any direct indication for assessment of apical heart rate, although peripheral pulses must be assessed.
A nurse on a medical unit is caring for a patient who has been diagnosed with lymphangitis. When reviewing this
patientts medication administration record, the nurse should anticipate which of the following?
A)
Coumadin (warfarin)
B)
Lasix (furosemide)
C)
An antibiotic
D)
An antiplatelet aggregator
Ans: An antibiotic
Feedback:
Lymphangitis is an acute inflammation of the lymphatic channels caused by an infectious process. Antibiotics are always a
component of treatment. Diuretics are of nominal use. Anticoagulants and antiplatelet aggregators are not indicated in this
form of infection.
A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On
inspection, the nurse observes that the patientts left leg is visibly swollen and reddened. What is the nursets most
appropriate action?
A)
Administer a PRN dose of subcutaneous heparin.
B)
Inform the physician that the patient has signs and symptoms of VTE.
C)
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Mobilize the patient promptly to dislodge any thrombi in the patientts lower leg.
D)
Massage the patientts lower leg to temporarily restore venous return.
Ans: Inform the physician that the patient has signs and symptoms of VTE.
Feedback:
VTE requires prompt medical follow-up. Heparin will not dissolve an established clot. Massaging the patient's leg and
mobilizing the patient would be contraindicated because they would dislodge the clot, possibly resulting in a pulmonary
embolism.
A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What
assessment finding would signal an impending rupture of the patientts aneurysm?
A)
Sudden increase in blood pressure and a decrease in heart rate
B)
Cessation of pulsating in an aneurysm that has previously been pulsating visibly
C)
Sudden onset of severe back or abdominal pain
D)
New onset of hemoptysis
Ans: Sudden onset of severe back or abdominal pain
Feedback:
Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Impending
rupture is not typically signaled by increased blood pressure, bradycardia, cessation of pulsing, or hemoptysis.
A nurse is reviewing the physiological factors that affect a patientts cardiovascular health and tissue oxygenation.
What is the systemic arteriovenous oxygen difference?
A)
The average amount of oxygen removed by each organ in the body
B)
The amount of oxygen removed from the blood by the heart
C)
The amount of oxygen returning to the lungs via the pulmonary artery
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D)
The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood
Ans: The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood
Feedback:
The average amount of oxygen removed collectively by all of the body tissues is about 25%. This means that the blood in
the vena cava contains about 25% less oxygen than aortic blood. This is known as the systemic arteriovenous oxygen
difference. The other answers do not apply.
The nurse is evaluating a patientts diagnosis of arterial insufficiency with reference to the adequacy of the patientts
blood flow. On what physiological variables does adequate blood flow depend? Select all that apply.
A)
Efficiency of heart as a pump
B)
Adequacy of circulating blood volume
C)
Ratio of platelets to red blood cells
D)
Size of red blood cells
E)
Patency and responsiveness of the blood vessels
Ans: Efficiency of heart as a pump, Adequacy of circulating blood volume, Patency and responsiveness of the blood
vessels
Feedback:
Adequate blood flow depends on the efficiency of the heart as a pump, the patency and responsiveness of the blood
vessels, and the adequacy of circulating blood volume. Adequacy of blood flow does not primarily depend on the size of
red cells or their ratio to the number of platelets.
A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patientts left
foot. How should the nurse proceed with assessment?
A)
Have the primary care provider order a CT.
B)
Apply a tourniquet for 3 to 5 minutes and then reassess.
C)
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Elevate the extremity and attempt to palpate the pulses.
D)
Use Doppler ultrasound to identify the pulses.
Ans: Use Doppler ultrasound to identify the pulses.
Feedback:
When pulses cannot be reliably palpated, a hand-held continuous wave (CW) Doppler ultrasound device may be used to
hear (insonate) the blood flow in vessels. CT is not normally warranted and the application of a tourniquet poses health
risks and will not aid assessment. Elevating the extremity would make palpation more difficult.
A medical nurse has admitted four patients over the course of a 12-hour shift. For which patient would assessment
of ankle-brachial index (ABI) be most clearly warranted?
A)
A patient who has peripheral edema secondary to chronic heart failure
B)
An older adult patient who has a diagnosis of unstable angina
C)
A patient with poorly controlled type 1 diabetes who is a smoker
D)
A patient who has community-acquired pneumonia and a history of COPD
Ans: A patient with poorly controlled type 1 diabetes who is a smoker
Feedback:
Nurses should perform a baseline ABI on any patient with decreased pulses or any patient 50 years of age or older with a
history of diabetes or smoking. The other answers do not apply.
An older adult patient has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future
ulcers. What should the nurse include in this plan?
A)
Use of supplementary oxygen to aid tissue oxygenation
B)
Daily use of normal saline compresses on the lower limbs
C)
Daily administration of prophylactic antibiotics
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D)
A high-protein diet that is rich in vitamins
Ans: A high-protein diet that is rich in vitamins
Feedback:
A diet that is high in protein, vitamins C and A, iron, and zinc is encouraged to promote healing and prevent future ulcers.
Prophylactic antibiotics and saline compresses are not used to prevent ulcers. Oxygen supplementation does not prevent
ulcer formation.
A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his problems first
began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma, the nurse should
suspect that the patient has a history of what health problem?
A)
Raynaudts phenomenon
B)
CAD
C)
Arterial insufficiency
D)
Varicose veins
Ans: Arterial insufficiency
Feedback:
Arterial insufficiency may result in gangrene of the toe (digital gangrene), which usually is caused by trauma. The toe is
stubbed and then turns black. Raynaud's, CAD and varicose veins are not the usual causes of digital gangrene in the
elderly.
When assessing venous disease in a patientts lower extremities, the nurse knows that what test will most likely be
ordered?
A)
Duplex ultrasonography
B)
Echocardiography
C)
Positron emission tomography (PET)
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D)
Radiography
Ans: Duplex ultrasonography
Feedback:
Duplex ultrasound may be used to determine the level and extent of venous disease as well as its chronicity. Radiographs(xrays), PET scanning, and echocardiography are never used for this purpose as they do not allow visualization of blood
flow.
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Brunner & Suddarth's Textbook of Medical Surgical Nursing 15th Edition
Chapter 27: Assessment and Management of Patients With Hypertension
An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. The
nurses health education should include which of the following?
A) Increasing fluids to avoid extracellular volume depletion from the diuretic effect of the beta- blocker
B) Maintaining a diet high in dairy to increase protein necessary to prevent organ damage
C) Use of strategies to prevent falls stemming from postural hypotension
D) Limiting exercise to avoid injury that can be caused by increased intracranial pressure
Ans: C
Feedback: Elderly people have impaired cardiovascular reflexes and are more sensitive to postural hypotension. The
nurse teaches patients to change positions slowly when moving from lying or sitting positions to a standing position, and
counsels elderly patients to use supportive devices as necessary to prevent falls that could result from dizziness. Lifestyle
changes, such as regular physical activity/exercise, and a diet rich in fruits, vegetables, and low-fat dairy products, is
strongly recommended. Increasing fluids in elderly patients may be contraindicated due to cardiovascular disease.
Increased intracranial pressure is not a risk and activity should not normally be limited.
A patient with primary hypertension comes to the clinic complaining of a gradual onset of blurry vision and
decreased visual acuity over the past several weeks. The nurse is aware that these symptoms could be indicative of
what?
A) Retinal blood vessel damage
B) Glaucoma
C) Cranial nerve damage
D) Hypertensive emergency
Ans: A
Feedback: Blurred vision, spots in front of the eyes, and diminished visual acuity can mean retinal blood vessel damage
indicative of damage elsewhere in the vascular system as a result of hypertension. Glaucoma and cranial nerve damage
do not normally cause these symptoms. A hypertensive emergency would have a more rapid onset.
A nurse is performing blood pressure screenings at a local health fair. While obtaining subjective assessment data
from a patient with hypertension, the nurse learns that the patient has a family history of hypertension and she
herself has high cholesterol and lipid levels. The patient says she smokes one pack of cigarettes daily and drinks
about a pack of beer every day. The nurse notes what nonmodifiable risk factor for hypertension?
A) Hyperlipidemia
B) Excessive alcohol intake
C) A family history of hypertension
D) Closer adherence to medical regimen
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Ans: C
Feedback: Unlike cholesterol levels, alcohol intake and adherence to treatment, family history is not modifiable.
The staff educator is teaching ED nurses about hypertensive crisis. The nurse educator should explain that
hypertensive urgency differs from hypertensive emergency in what way?
A) The BP is always higher in a hypertensive emergency.
B) Vigilant hemodynamic monitoring is required during treatment of hypertensive emergencies.
C) Hypertensive urgency is treated with rest and benzodiazepines to lower BP.
D) Hypertensive emergencies are associated with evidence of target organ damage.
Ans: D
Feedback: Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an
intensive care setting because of the serious target organ damage that may occur. Blood pressures are extremely
elevated in both urgency and emergencies, but there is no evidence of target organ damage in hypertensive urgency.
Extremely close hemodynamic monitoring of the patients BP is required in both situations. The medications of choice in
hypertensive emergencies are those with an immediate effect, such as IV vasodilators. Oral doses of fast-acting agents,
such as beta-adrenergic blocking agents, angiotensin-converting enzyme inhibitors, or alpha-agonists, are recommended
for the treatment of hypertensive urgencies.
A group of student nurses are practicing taking blood pressure. A 56-year-old male student has a blood pressure
reading of 146/96 mm Hg. Upon hearing the reading, he exclaims, My pressure has never been this high. Do you
think my doctor will prescribe medication to reduce it? Which of the following responses by the nursing instructor
would be best?
A) Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination.
B) We will need to reevaluate your blood pressure because your age places you at high risk for hypertension.
C) A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure
reassessed several times before a diagnosis can be made.
D) You have no need to worry. Your pressure is probably elevated because you are being tested.
Ans: C
Feedback: Hypertension is confirmed by two or more readings with systolic pressure of at least 140 mm Hg and diastolic
pressure of at least 90 mm Hg. An age of 56 does not constitute a risk factor in and of itself. The nurse should not tell the
student that there is no need to worry.
A 40-year-old male newly diagnosed with hypertension is discussing risk factors with the nurse. The nurse talks
about lifestyle changes with the patient and advises that the patient should avoid tobacco use. What is the primary
rationale behind that advice to the patient?
A) Quitting smoking will cause the patients hypertension to resolve.
B) Tobacco use increases the patients concurrent risk of heart disease.
C) Tobacco use is associated with a sedentary lifestyle.
D) Tobacco use causes ventricular hypertrophy.
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Ans: B
Feedback: Smoking increases the risk for heart disease, for which a patient with hypertension is already at an increased
risk. Quitting will not necessarily cause hypertension to resolve and smoking does not directly cause ventricular
hypertrophy. The association with a sedentary lifestyle is true, but this is not the main rationale for the nurses advice; the
association with heart disease is more salient.
A patient has been prescribed anti-hypertensives. After assessment and analysis, the nurse has identified a nursing
diagnosis of risk for ineffective health maintenance related to nonadherence to therapeutic regimen. When planning
this patients care, what desired outcome should the nurse identify?
A) Patient takes medication as prescribed and reports any adverse effects.
B) Patients BP remains consistently below 140/90 mm Hg.
C) Patient denies signs and symptoms of hypertensive urgency.
D) Patient is able to describe modifiable risk factors for hypertension.
Ans: A
Feedback: The most appropriate expected outcome for a patient who is given the nursing diagnosis of risk for ineffective
health maintenance is that he or she takes the medication as prescribed. The other listed goals are valid aspects of care,
but none directly relates to the patients role in his or her treatment regimen.
The nurse is providing care for a patient with a new diagnosis of hypertension. How can the nurse best promote the
patients adherence to the prescribed therapeutic regimen?
A) Screen the patient for visual disturbances regularly.
B) Have the patient participate in monitoring his or her own BP.
C) Emphasize the dire health outcomes associated with inadequate BP control.
D) Encourage the patient to lose weight and exercise regularly.
Ans: B
Feedback: Adherence to the therapeutic regimen increases when patients actively participate in self-care, including selfmonitoring of BP and diet. Dire warnings may motivate some patients, but for many patients this is not an appropriate or
effective strategy. Screening for vision changes and promoting healthy lifestyle are appropriate nursing actions, but do not
necessarily promote adherence to a therapeutic regimen.
A patient newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is
prolonged. The nurse explains that a patient with prolonged, uncontrolled hypertension is at risk for developing
what health problem?
A) Renal failure
B) Right ventricular hypertrophy
C) Glaucoma
D) Anemia
Ans: A
Feedback: When uncontrolled hypertension is prolonged, it can result in renal failure, myocardial infarction, stroke,
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impaired vision, left ventricular hypertrophy, and cardiac failure. Glaucoma and anemia are not directly associated with
hypertension.
A patient with primary hypertension complains of dizziness with ambulation. The patient is currently on an alphaadrenergic blocker and the nurse assesses characteristic signs and symptoms of postural hypotension. When
teaching this patient about risks associated with postural hypotension, what should the nurse emphasize?
A) Rising slowly from a lying or sitting position
B) Increasing fluids to maintain BP
C) Stopping medication if dizziness persists
D) Taking medication first thing in the morning
Ans: A
Feedback: Patients who experience postural hypotension should be taught to rise slowly from a lying or sitting position
and use a cane or walker if necessary for safety. It is not necessary to teach these patients about increasing fluids or
taking medication in the morning (this would increase the effects of dizziness). Patient should not be taught to stop the
medication if dizziness persists because this is unsafe and beyond the nurses scope of practice.
The nurse is planning the care of a patient who has been diagnosed with hypertension, but who otherwise enjoys
good health. When assessing the response to an antihypertensive drug regimen, what blood pressure would be the
goal of treatment?
A) 156/96 mm Hg or lower
B) 140/90 mm Hg or lower
C) Average of 2 BP readings of 150/80 mm Hg
D) 120/80 mm Hg or lower
Ans: B
Feedback: The goal of antihypertensive drug therapy is a BP of 140/90 mm Hg or lower. A pressure of 130/80 mm Hg is
the goal for patients with diabetes or chronic kidney disease.
A patient in a hypertensive emergency is admitted to the ICU. The nurse anticipates that the patient will be treated
with IV vasodilators, and that the primary goal of treatment is what?
A) Lower the BP to reduce onset of neurologic symptoms, such as headache and vision changes.
B) Decrease the BP to a normal level based on the patients age.
C) Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment.
D) Reduce the BP to 120/75 mm Hg as quickly as possible.
Ans: C
Feedback: Initially, the treatment goal in hypertensive emergencies is to reduce the mean arterial pressure by 25% in the
first hour of treatment, with further reduction over the next 24 hours. Lowering the BP too fast may cause hypotension in a
patient whose body has adjusted to hypertension and could cause a stroke, MI, or visual changes. Neurologic symptoms
should be addressed, but this is not the primary focus of treatment planning.
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The nursing lab instructor is teaching student nurses how to take blood pressure. To ensure accurate
measurement, the lab instructor would teach the students to avoid which of the following actions?
A) Measuring the BP after the patient has been seated quietly for more than 5 minutes
B) Taking the BP at least 10 minutes after nicotine or coffee ingestion
C) Using a cuff with a bladder that encircles at least 80% of the limb
D) Using a bare forearm supported at heart level on a firm surface
Ans: B
Feedback: Blood pressures should be taken with the patient seated with arm bare, supported, and at heart level. The
patient should not have smoked tobacco or taken caffeine in the 30 minutes preceding the measurement. The patient
should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb
being measured and have a width of at least 40% of limb circumference. Using a cuff that is too large results in a lower
BP and a cuff that is too small will give a higher BP measurement.
A nurse is teaching an adult female patient about the risk factors for hypertension. What should the nurse explain
as risk factors for primary hypertension?
A) Obesity and high intake of sodium and saturated fat
B) Diabetes and use of oral contraceptives
C) Metabolic syndrome and smoking
D) Renal disease and coarctation of the aorta
Ans: A
Feedback: Obesity, stress, high intake of sodium or saturated fat, and family history are all risk factors for primary
hypertension. Diabetes and oral contraceptives are risk factors for secondary hypertension. Metabolic syndrome, renal
disease, and coarctation of the aorta are causes of secondary hypertension.
The nurse is caring for an older adult with a diagnosis of hypertension who is being treated with a diuretic and betablocker. Which of the following should the nurse integrate into the management of this clients hypertension?
A) Ensure that the patient receives a larger initial dose of antihypertensive medication due to impaired absorption.
B) Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion.
C) Recognize that an older adult is less likely to adhere to his or her medication regimen than a younger patient.
D) Carefully assess for weight loss because of impaired kidney function resulting from normal aging.
Ans: B
Feedback: Elderly people have impaired cardiovascular reflexes and thus are more sensitive to extracellular volume
depletion caused by diuretics. The nurse needs to assess hydration status, low BP, and postural hypotension carefully.
Older adults may have impaired absorption, but they do not need a higher initial dose of an antihypertensive than a
younger person. Adherence to treatment is not necessarily linked to age. Kidney function and absorption decline with age;
less, rather than more antihypertensive medication is prescribed. Weight gain is not necessarily indicative of kidney
function decline.
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A patient with secondary hypertension has come into the clinic for a routine check-up. The nurse is aware that the
difference between primary hypertension and secondary hypertension is which of the following?
A) Secondary hypertension has a specific cause.
B) Secondary hypertension has a more gradual onset than primary hypertension.
C) Secondary hypertension does not cause target organ damage.
D) Secondary hypertension does not normally respond to antihypertensive drug therapy.
Ans: A
Feedback: Secondary hypertension has a specific identified cause. A cause could include narrowing of the renal arteries,
renal parenchymal disease, hyperaldosteronism, certain medications, pregnancy, and coarctation of the aorta. Secondary
hypertension does respond to antihypertensive drug therapy and can cause target organ damage if left untreated.
The nurse is assessing a patient new to the clinic. Records brought to the clinic with the patient show the patient
has hypertension and that her current BP readings approximate the readings from when she was first diagnosed.
What contributing factor should the nurse first explore in an effort to identify the cause of the clients inadequate BP
control?
A) Progressive target organ damage
B) Possibility of medication interactions
C) Lack of adherence to prescribed drug therapy
D) Possible heavy alcohol use or use of recreational drugs
Ans: C
Feedback: Deviation from the therapeutic program is a significant problem for people with hypertension and other chronic
conditions requiring lifetime management. An estimated 50% of patients discontinue their medications within 1 year of
beginning to take them. Consequently, this is a more likely problem than substance use, organ damage, or adverse drug
interactions.
A patient has come to the clinic for a follow-up assessment that will include a BP reading. To ensure an accurate
reading, the nurse should confirm that the patient has done which of the following?
A) Tried to rest quietly for 5 minutes before the reading is taken
B) Refrained from smoking for at least 8 hours
C) Drunk adequate fluids during the day prior
D) Avoided drinking coffee for 12 hours before the visit
Ans: A
Feedback: Prior to the nurse assessing the patients BP, the patient should try to rest quietly for 5 minutes. The forearm
should be positioned at heart level. Caffeine products and cigarette smoking should be avoided for at least 30 minutes
prior to the visit. Recent fluid intake is not normally relevant.
The nurse is providing care for a patient with a diagnosis of hypertension. The nurse should consequently assess
the patient for signs and symptoms of which other health problem?
A) Migraines
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B) Atrial-septal defect
C) Atherosclerosis
D) Thrombocytopenia
Ans: C
Feedback: Hypertension is both a sign and a risk factor for atherosclerotic heart disease. It is not associated with
structural cardiac defects, low platelet levels, or migraines.
The nurse is developing a nursing care plan for a patient who is being treated for hypertension. What is a
measurable patient outcome that the nurse should include?
A) Patient will reduce Na+ intake to no more than 2.4 g daily.
B) Patient will have a stable BUN and serum creatinine levels.
C) Patient will abstain from fat intake and reduce calorie intake.
D) Patient will maintain a normal body weight.
Ans: A
Feedback: Dietary sodium intake of no more than 2.4 g sodium is recommended as a dietary lifestyle modification to
prevent and manage hypertension. Giving a specific amount of allowable sodium intake makes this a measurable goal.
None of the other listed goals is quantifiable and measurable.
A patient with newly diagnosed hypertension has come to the clinic for a follow-up visit. The patient asks the nurse
why she has to come in so often. What would be the nurses best response?
A) We do this so you dontt suffer a stroke.
B) We do this to determine how your blood pressure changes throughout the day.
C) We do this to see how often you should change your medication dose.
D) We do this to make sure your health is stable. Well then monitor it at routinely scheduled intervals.
Ans: D
Feedback: When hypertension is initially detected, nursing assessment involves carefully monitoring the BP at frequent
intervals and then at routinely scheduled intervals. The reference to stroke is frightening and does not capture the overall
rationale for the monitoring regimen. Changes throughout the day are not a clinical priority for most patients. The patient
must not change his or her medication doses unilaterally.
The hospital nurse cares for many patients who have hypertension. What nursing diagnosis is most common
among patients who are being treated for this health problem?
A) Deficient knowledge regarding the lifestyle modifications for management of hypertension
B) Noncompliance with therapeutic regimen related to adverse effects of prescribed therapy
C) Deficient knowledge regarding BP monitoring
D) Noncompliance with treatment regimen related to medication costs
Ans: B
Feedback: Deviation from the therapeutic program is a significant problem for people with hypertension and other chronic
conditions requiring lifetime management. For many patients, this is related to adverse effects of medications. Medication
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cost is relevant for many patients, but adverse effects are thought to be a more significant barrier. Many patients are
aware of necessary lifestyle modification, but do not adhere to them. Most patients are aware of the need to monitor their
BP.
The nurse is teaching a patient about some of the health consequences of uncontrolled hypertension. What health
problems should the nurse describe? Select all that apply.
A) Transient ischemic attacks
B) Cerebrovascular accident
C) Retinal hemorrhage
D) Venous insufficiency
E) Right ventricular hypertrophy
Ans: A, B, C
Feedback: Potential complications of hypertension include the following: left ventricular hypertrophy; MI; heart failure;
transient ischemic attacks (TIAs); cerebrovascular accident; renal insufficiency and failure; and retinal hemorrhage.
Venous insufficiency and right ventricular hypertrophy are not potential complications of uncontrolled hypertension.
The nurse is collaborating with the dietitian and a patient with hypertension to plan dietary modifications. These
modifications should include which of the following?
A) Reduced intake of protein and carbohydrates
B) Increased intake of calcium and vitamin D
C) Reduced intake of fat and sodium
D) Increased intake of potassium, vitamin B12 and vitamin D
Ans: C
Feedback: Lifestyle modifications usually include restricting sodium and fat intake, increasing intake of fruits and
vegetables, and implementing regular physical activity. There is no need to increase calcium, potassium, and vitamin
intake. Calorie restriction may be required for some patients, but a specific reduction in protein and carbohydrates is not
normally indicated.
The critical care nurse is caring for a patient just admitted in a hypertensive emergency. The nurse should
anticipate the administration of what medication?
A) Warfarin (Coumadin)
B) Furosemide (Lasix)
C) Sodium nitroprusside (Nitropress)
D) Ramipril (Altace)
Ans: C
Feedback: The medications of choice in hypertensive emergencies are those that have an immediate effect. IV
vasodilators, including sodium nitroprusside (Nitropress), nicardipine hydrochloride (Cardene), clevidipine (Cleviprex),
fenoldopam mesylate (Corlopam), enalaprilat, and nitroglycerin, have immediate actions that are short lived (minutes to 4
hours), and they are therefore used for initial treatment. Ramipril is administered orally and would not meet the patients
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immediate need for BP management. Diuretics, such as Lasix, are not used as initial treatments and there is no indication
for anticoagulants such as Coumadin.
A patient in hypertensive emergency is being cared for in the ICU. The patient has become hypovolemic secondary
to natriuresis. What is the nurses most appropriate action?
A) Add sodium to the patients IV fluid, as ordered.
B) Administer a vasoconstrictor, as ordered.
C) Promptly cease antihypertensive therapy.
D) Administer normal saline IV, as ordered.
Ans: D Feedback: If there is volume depletion secondary to natriuresis caused by the elevated BP, then volume
replacement with normal saline can prevent large, sudden drops in BP when antihypertensive medications are
administered. Sodium administration, cessation of antihypertensive therapy, and administration of vasoconstrictors are not
normally indicated.
27. During an adult patients last two office visits, the nurse obtained BP readings of 122/84 mm Hg and 130/88 mm
Hg, respectively. How would this patients BP be categorized?
A) Normal
B) Prehypertensive
C) Stage 1 hypertensive
D) Stage 2 hypertensive
Ans: B
Feedback: Prehypertension is defined systolic BP of 120 to 139 mm Hg or diastolic BP of 80 to 89 mm Hg.
A patient comes to the walk-in clinic complaining of frequent headaches. While assessing the patients vital signs,
the nurse notes the BP is 161/101 mm Hg. According to JNC 7, how would this patients BP be defined if a similar
reading were obtained at a subsequent office visit?
A) High normal
B) Normal
C) Stage 1 hypertensive
D) Stage 2 hypertensive
Ans: D
Feedback: JNC 7 defines stage 2 hypertension as a reading 160/100 mm Hg.
A patient has been diagnosed as being prehypertensive. What should the nurse encourage this patient to do to aid
in preventing a progression to a hypertensive state?
A) Avoid excessive potassium intake.
B) Exercise on a regular basis.
C) Eat less protein and more vegetables.
D) Limit morning activity.
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Ans: B
Feedback: To prevent or delay progression to hypertension and reduce risk, JNC 7 urged health care providers to
encourage people with blood pressures in the prehypertension category to begin lifestyle modifications, such as nutritional
changes and exercise. There is no need for patients to limit their activity in the morning or to avoid potassium and protein
intake.
The nurse is screening a number of adults for hypertension. What range of blood pressure is considered normal?
A) Less than 140/90 mm Hg
B) Less than 130/90 mm Hg
C) Less than 129/89 mm Hg
D) Less than 120/80 mm Hg
Ans: D
Feedback: JNC 7 defines a blood pressure of less than 120/80 mm Hg as normal, 120 to 129/80 to 89 mm Hg as
prehypertension, and 140/90 mm Hg or higher as hypertension.
A community health nurse teaching a group of adults about preventing and treating hypertension. The nurse
should encourage these participants to collaborate with their primary care providers and regularly monitor which of
the following?
A) Heart rate
B) Sodium levels
C) Potassium levels
D) Blood lipid levels
Ans: D
Feedback: Hypertension often accompanies other risk factors for atherosclerotic heart disease, such as dyslipidemia
(abnormal blood fat levels), obesity, diabetes, metabolic syndrome, and a sedentary lifestyle. Individuals with hypertension
need to monitor their sodium intake, but hypernatremia is not a risk factor for hypertension. In many patients, heart rate
does not correlate closely with BP. Potassium levels do not normally relate to BP.
A community health nurse is planning an educational campaign addressing hypertension. The nurse should
anticipate that the incidence and prevalence of hypertension are likely to be highest among members of what ethnic
group?
A) Pacific Islanders
B) African Americans
C) Asian-Americans
D) Hispanics
Ans: D
Feedback: The prevalence of uncontrolled hypertension varies by ethnicity, with Hispanics and African Americans having
the highest prevalence at approximately 63% and 57%, respectively.
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The home health nurse is caring for a patient who has a comorbidity of hypertension. What assessment question
most directly addresses the possibility of worsening hypertension?
A) Are you eating less salt in your diet?
B) How is your energy level these days?
C) Do you ever get chest pain when you exercise?
D) Do you ever see spots in front of your eyes?
Ans: D
Feedback: To identify complications or worsening hypertension, the patient is questioned about blurred vision, spots in
front of the eyes, and diminished visual acuity. The heart, nervous system, and kidneys are also carefully assessed, but
angina pain and decreased energy are not normally suggestive of worsening hypertension. Sodium limitation is a
beneficial lifestyle modification, but nonadherence to this is not necessarily a sign of worsening symptoms.
A student nurse is taking care of an elderly patient with hypertension during a clinical experience. The instructor
asks the student about the relationships between BP and age. What would be the best answer by the student?
A) Because of reduced smooth muscle tone in blood vessels, blood pressure tends to go down with age, not up.
B) Decreases in the strength of arteries and the presence of venous insufficiency cause hypertension in the elderly.
C) Structural and functional changes in the cardiovascular system that occur with age contribute to increases in
blood pressure.
D) The neurologic system of older adults is less efficient at monitoring and regulating blood pressure.
Ans: C
Feedback: Structural and functional changes in the heart and blood vessels contribute to increases in BP that occur with
aging. Venous insufficiency does not cause hypertension, however. Increased BP is not primarily a result of neurologic
changes.
A 55-year-old patient comes to the clinic for a routine check-up. The patients BP is 159/100 mm Hg and the
physician diagnoses hypertension after referring to previous readings. The patient asks why it is important to treat
hypertension. What would be the nurses best response?
A) Hypertension can cause you to develop dangerous blood clots in your legs that can migrate to your lungs.
B) Hypertension puts you at increased risk of type 1 diabetes and cancer in your age group.
C) Hypertension is the leading cause of death in people your age.
D) Hypertension greatly increases your risk of stroke and heart disease.
Ans: D
Feedback: Hypertension, particularly elevated systolic BP, increases the risk of death, stroke, and heart failure in people
older than 50 years. Hypertension is not a direct precursor to pulmonary emboli, and it does not put older adults at
increased risk of type 1 diabetes or cancer. It is not the leading cause of death in people 55 years of age.
The nurse is reviewing the medication administration record of a patient who takes a variety of medications for the
treatment of hypertension. What potential therapeutic benefits of anti-hypertensives should the nurse identify?
Select all that apply.
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A) Increased venous return
B) Decreased peripheral resistance
C) Decreased blood volume
D) Decreased strength and rate of myocardial contractions
E) Decreased blood viscosity
Ans: B, C, D
Feedback: The medications used for treating hypertension decrease peripheral resistance, blood volume, or the strength
and rate of myocardial contraction. Antihypertensive medications do not increase venous return or decrease blood
viscosity.
A newly diagnosed patient with hypertension is prescribed Diuril, a thiazide diuretic. What patient education should
the nurse provide to this patient?
A) Eat a banana every day because Diuril causes moderate hyperkalemia.
B) Take over-the-counter potassium pills because Diuril causes your kidneys to lose potassium.
C) Diuril can cause low blood pressure and dizziness, especially when you get up suddenly.
D) Diuril increases sodium levels in your blood, so cut down on your salt.
Ans: C
Feedback: Thiazide diuretics can cause postural hypotension, which may be potentiated by alcohol, barbiturates, opioids,
or hot weather. Diuril does not cause either moderate hyperkalemia or severe hypokalemia and it does not result in
hypernatremia.
A patient in hypertensive urgency is admitted to the hospital. The nurse should be aware of what goal of treatment
for a patient in hypertensive urgency?
A) Normalizing BP within 2 hours
B) Obtaining a BP of less than 110/70 mm Hg within 36 hours
C) Obtaining a BP of less than 120/80 mm Hg within 36 hours
D) Normalizing BP within 24 to 48 hours
Ans: D
Feedback: In cases of hypertensive urgency, oral agents can be administered with the goal of normalizing BP within 24 to
48 hours. For patients with this health problem, a BP of 120/80 mm Hg may be unrealistic.
A patients medication regimen for the treatment of hypertension includes hydrochlorothiazide. Following
administration of this medication, the nurse should anticipate what effect?
A) Drowsiness or lethargy
B) Increased urine output
C) Decreased heart rate D) Mild agitation
Ans: B
Feedback: Thiazide diuretics lower BP by reducing circulating blood volume; this results in a short-term increase in urine
output. These drugs do not cause bradycardia, agitation, or drowsiness.
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A patients recently elevated BP has prompted the primary care provider to prescribe furosemide (Lasix). The nurse
should closely monitor which of the following?
A) The clients oxygen saturation level
B) The patients red blood cells, hematocrit, and hemoglobin
C) The patients level of consciousness
D) The patients potassium level
Ans: D
Feedback: Loop diuretics can cause potassium depletion. They do not normally affect level of consciousness,
erythrocytes, or oxygen saturation.
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UNIT 6 Hematologic Function
Brunner & Suddarth's Textbook of Medical Surgical Nursing 15th Edition
Chapter 28: Assessment of Hematologic Function and Treatment Modalities
A patient with a hematologic disorder asks the nurse how the body forms blood cells. The nurse should describe a
process that takes place where?
A) In the spleen
B) In the kidneys
C) In the bone marrow
D) In the liver
C) In the bone marrow
Bone marrow is the primary site for hematopoiesis. The liver and spleen may be involved during embryonic development
or when marrow is destroyed. The kidneys release erythropoietin, which stimulates the marrow to increase production of
red blood cells (RBCs). However, blood cells are not primarily formed in the spleen, kidneys, or liver.
A man suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary
hemostasis is activated. What occurs in primary hemostasis?
A) Severed blood vessels constrict.
B) Thromboplastin is released.
C) Prothrombin is converted to thrombin.
D) Fibrin is lysed.
A) Severed blood vessels constrict
Primary hemostasis involves the severed vessel constricting and platelets collecting at the injury site. Secondary
hemostasis occurs when thromboplastin is released, prothrombin converts to thrombin, and fibrin is lysed.
A patient has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the patients consequent
increase in RBC production, the nurse knows that the patient may need to increase her daily intake of what
substance?
A) Vitamin E
B) Vitamin D
C) Iron
D) Magnesium
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C) Iron
To replace blood loss, the rate of red cell production increases. Iron is incorporated into hemoglobin. Vitamins E and D
and magnesium do not need to be increased when RBC production is increased.
The nurse is planning the care of a patient with a nutritional deficit and a diagnosis of megaloblastic anemia. The
nurse should recognize that this patients health problem is due to what?
A) Production of inadequate quantities of RBCs
B) Premature release of immature RBCs
C) Injury to the RBCs in circulation
D) Abnormalities in the structure and function RBCs
D) Abnormalities in the structure and function RBCs
Vitamin B12 and folic acid deficiencies are characterized by the production of abnormally large erythrocytes called
megaloblasts. Because these cells are abnormal, many are sequestered (trapped) while still in the bone marrow, and their
rate of release is decreased. Some of these cells actually die in the marrow before they can be released into the
circulation. This results in megaloblastic anemia. This pathologic process does not involve inadequate production,
premature release, or injury to existing RBCs.
A nurse is caring for a patient who undergoing preliminary testing for a hematologic disorder. What sign or
symptom most likely suggests a potential hematologic disorder?
A) Sudden change in LOC
B) Recurrent infections
C) Anaphylaxis
D) Severe fatigue
D) Severe fatigue
The most common indicator of hematologic disease is extreme fatigue. This is more common than changes in LOC,
infections, or anaphylaxis.
The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood
cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is
the most appropriate initial action for the nurse to take?
A) Notify the physician
B) Stop the transfusion immediately
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C) Remove the patients IV access
D) Assess the patients chest sounds and vital sounds
B) Stop the transfusion immediately
Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions.
The nurse should discontinue the transfusion immediately, monitor the patients vital signs, and notify the physician. The
blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion
reaction or a bacterial infection is suspected. The patients IV access should not be removed.
The nurse is describing the role of plasminogen in the clotting cascade. Where in the body is plasminogen present?
A) Myocardial muscle tissue
B) All body fluids
C) Cerebral tissue
D) Venous and arterial vessel walls
B) All body fluids
Plasminogen, which is present in all body fluids, circulates with fibrinogen. Plasminogen is found in body fluids, not tissue.
The nurse is caring for a patient who has developed scar tissue in many of the areas that normally produce blood
cells. What organs can become active in blood cell production by the process of extramedullary hematopoiesis?
A) Spleen and kidneys
B) Kidneys and pancreas
C) Pancreas and liver
D) Liver and spleen
D) Liver and spleen
In adults with disease that causes marrow destruction, fibrosis, or scarring, the liver and spleen can also resume
production of blood cells by a process known as extramedullary hematopoiesis. The kidneys and pancreas do not produce
blood cells for the body.
Through the process of hematopoiesis, stem cells differentiate into either myeloid or lymphoid stem cells. Into what
do myeloid stem cells further differentiate? Select all that apply.
A) Leukocytes
B) Natural killer cells
C) Cytokines
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D) Platelets
E) Erythrocytes
A,D,E) Leukocytes, Platelets, Erythrocytes
Myeloid stem cells differentiate into three broad cell types: erythrocytes, leukocytes, and platelets. Natural killer cells and
cytokines do not originate as myeloid stem cells.
A patient wound has begun to heal and the blood clot which formed is no longer necessary. When a blood clot is no
longer needed, the fibrinogen and fibrin will be digested by which of the following?
A) Plasminogen
B) Thrombin
C) Prothrombin
D) Plasmin
D) Plasmin
The substance plasminogen is required to lyse (break down) the fibrin. Plasminogen, which is present in all body fluids,
circulates with fibrinogen and is therefore incorporated into the fibrin clot as it forms. When the clot is no longer needed
(e.g., after an injured blood vessel has healed), the plasminogen is activated to form plasmin. Plasmin digests the
fibrinogen and fibrin. Prothrombin is converted to thrombin, which in turn catalyzes the conversion of fibrinogen to fibrin so
a clot can form.
A patient undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the
primary advantage of autologous transfusions?
A) Safe transfusion for patients with a history of transfusion reactions
B) Prevention of viral infections from another persons blood
C) Avoidance of complications in patients with alloantibodies
D) Prevention of alloimmunization
B) Prevention of viral infections from another persons blood
The primary advantage of autologous transfusions is the prevention of viral infections from another persons blood. Other
secondary advantages include safe transfusion for patients with a history of transfusion reactions, prevention of
alloimmunization, and avoidance of complications in patients with alloantibodies.
A patient has been diagnosed with a lymphoid stem cell defect. This patient has the potential for a problem
involving which of the following?
A) Plasma cells
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B) Neutrophils
C) Red blood cells
D) Platelets
A) Plasma cells
A defect in a myeloid stem cell can cause problems with erythrocyte, leukocyte, and platelet production. In contrast, a
defect in the lymphoid stem cell can cause problems with T or B lymphocytes, plasma cells (a more differentiated form of
B lymphocyte), or natural killer (NK) cells.
The nurse is describing normal RBC physiology to a patient who has a diagnosis of anemia. The nurse should
explain that the RBCs consist primarily of which of the following?
A) Plasminogen
B) Hemoglobin
C) Hematocrit
D) Fibrin
B) Hemoglobin
Mature erythrocytes consist primarily of hemoglobin, which contains iron and makes up 95% of the cell mass. RBCs are
not made of fibrin or plasminogen. Hematocrit is a measure of RBC volume in whole blood.
The nurse educating a patient with anemia is describing the process of RBC production. When the patients kidneys
sense a low level of oxygen in circulating blood, what physiologic response is initiated?
A) Increased stem cell synthesis
B) Decreased respiratory rate
C) Arterial vasoconstriction
D) Increased production of erythropoietin
D) Increased production of erythropoietin
If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (i.e., anemia),
erythropoietin levels increase. The body does not compensate with vasoconstriction, decreased respiration, or increased
stem cell activity.
An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a
complete blood count, what diagnostic assessment should the nurse anticipate?
A) Stool for occult blood
B) Bone marrow biopsy
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C) Lumbar puncture
D) Urinalysis
A) Stool for occult blood
Iron deficiency in the adult generally indicates blood loss (e.g., from bleeding in the GI tract or heavy menstrual flow).
Bleeding in the GI tract can be preliminarily identified by testing stool for the presence of blood. A bone marrow biopsy
would not be undertaken for the sole purpose of investigating an iron deficiency. Lumbar puncture and urinalysis would
not be clinically relevant.
A patient is being treated for the effects of a longstanding vitamin B12 deficiency. What aspect of the patients
health history would most likely predispose her to this deficiency?
A) The patient has irregular menstrual periods.
B) The patient is a vegan.
C) The patient donated blood 60 days ago.
D) The patient frequently smokes marijuana.
B) The patient is a vegan
Because vitamin B12 is found only in foods of animal origin, strict vegetarians may ingest little vitamin B12. Irregular
menstrual periods, marijuana use, and blood donation would not precipitate a vitamin B12 deficiency.
The nurses review of a patients most recent blood work reveals a significant increase in the number of band cells.
The nurses subsequent assessment should focus on which of the following?
A) Respiratory function
B) Evidence of decreased tissue perfusion
C) Signs and symptoms of infection
D) Recent changes in activity tolerance
C) Signs and symptoms of infection
Ordinarily, band cells account for only a small percentage of circulating granulocytes, although their percentage can
increase greatly under conditions in which neutrophil production increases, such as infection. This finding is not
suggestive of problems with oxygenation and subsequent activity intolerance.
A nurse is educating a patient about the role of B lymphocytes. The nurses description will include which of the
following physiologic processes?
A) Stem cell differentiation
B) Cytokine production
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C) Phagocytosis
D) Antibody production
D) Antibody production
B lymphocytes are capable of differentiating into plasma cells. Plasma cells, in turn, produce antibodies. Cytokines are
produced by NK cells. Stem cell differentiation greatly precedes B lymphocyte production.
A patients most recent blood work reveals low levels of albumin. This assessment finding should suggest the
possibility of what nursing diagnosis?
A) Risk for imbalanced fluid volume related to low albumin
B) Risk for infection related to low albumin
C) Ineffective tissue perfusion related to low albumin
D) Impaired skin integrity related to low albumin
A) Risk for imbalanced fluid volume related to low albumin
Albumin is particularly important for the maintenance of fluid balance within the vascular system. Deficiencies nearly
always manifest as fluid imbalances. Tissue oxygenation and skin integrity are not normally affected. Low albumin does
not constitute a risk for infection.
An individual has accidentally cut his hand, immediately initiating the process of hemostasis. Following
vasoconstriction, what event in the process of hemostasis will take place?
A) Fibrin will be activated at the bleeding site.
B) Platelets will aggregate at the injury site.
C) Thromboplastin will form a clot.
D) Prothrombin will be converted to thrombin.
B) Platelets will aggregate at the injury site
Following vasoconstriction, circulating platelets aggregate at the site and adhere to the vessel and to one another, forming
an unstable hemostatic plug. Events involved in the clotting cascade take place subsequent to this initial platelet action.
The nurse is providing care for an older adult who has a hematologic disorder. What age-related change in
hematologic function should the nurse integrate into care planning?
A) Bone marrow in older adults produces a smaller proportion of healthy, functional blood cells.
B) Older adults are less able to increase blood cell production when demand suddenly increases.
C) Stem cells in older adults eventually lose their ability to differentiate.
D) The ratio of plasma to erythrocytes and lymphocytes increases with age.
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B) Older adults are less able to increase blood cell production when demand suddenly increases.
Due to a variety of factors, when an older person needs more blood cells, the bone marrow may not be able to increase
production of these cells adequately. Stem cell activity continues throughout the lifespan, although at a somewhat
decreased rate. The proportion of functional cells does not greatly decrease and the relative volume of plasma does not
change significantly.
A clients health history reveals daily consumption of two to three bottles of wine. The nurse should plan
assessments and interventions in light of the patients increased risk for what hematologic disorder?
A) Leukemia
B) Anemia
C) Thrombocytopenia
D) Lymphoma
B) Anemia
Heavy alcohol use is associated with numerous health problems, including anemia. Leukemia and lymphoma are not
associated with alcohol use; RBC levels are typically affected more than platelet levels
A patients diagnosis of atrial fibrillation has prompted the primary care provider to prescribe warfarin (Coumadin),
an anticoagulant. When assessing the therapeutic response to this medication, what is the nurses most appropriate
action?
A) Assess for signs of myelosuppression.
B) Review the patients platelet level.
C) Assess the patients capillary refill time.
D) Review the patients international normalized ratio (INR).
D) Review the patients international normalized ratio (INR)
The INR and aPTT serve as useful screening tools for evaluating a patients clotting ability and to monitor the therapeutic
effectiveness of anticoagulant medications. The patients platelet level is not normally used as a short-term indicator of
anticoagulation effectiveness. Assessing the patient for signs of myelosuppression and capillary refill time does not
address the effectiveness of anticoagulants.
A patient has been scheduled for a bone marrow biopsy and admits to the nurse that she is worried about the pain
involved with the procedure. What patient education is most accurate?
A) Youll be given painkillers before the test, so there wont likely be any pain?
B) Youll feel some pain when the needle enters your skin, but none when the needle enters the bone because of the
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absence of nerves in bone.
C) Most people feel some brief, sharp pain when the needle enters the bone.
D) Ill be there with you, and Ill try to help you keep your mind off the pain.
C) Most people feel some brief, sharp pain when the needle enters the bone.
Patients typically feel a pressure sensation as the needle is advanced into position. The actual aspiration always causes
sharp, but brief pain, resulting from the suction exerted as the marrow is aspirated into the syringe; the patient should be
warned about this. Stating, Ill try to help you keep your mind off the pain may increase the patients fears of pain, because
this does not help the patient know what to expect.
A patient is scheduled for a splenectomy. During discharge education, what teaching point should the nurse
prioritize?
b
A) The importance of adhering to prescribed immunosuppressant therapy
B) The need to report any signs or symptoms of infection promptly
C) The need to ensure adequate folic acid, iron, and vitamin B12 intake
D) The importance of limiting activity postoperatively to prevent hemorrhage
B) The need to report any signs or symptoms of infection promptly
After splenectomy, the patient is instructed to seek prompt medical attention if even relatively minor symptoms of infection
occur. Often, patients with high platelet counts have even higher counts after splenectomy, which can predispose them to
serious thrombotic or hemorrhagic problems. However, this increase is usually transient and therefore often does not
warrant additional treatment. Dietary modifications are not normally necessary and immunosuppressants would be strongly
contraindicated.
The nurses brief review of a patients electronic health record indicates that the patient regularly undergoes
therapeutic phlebotomy. Which of the following rationales for this procedure is most plausible?
A) The patient may chronically produce excess red blood cells.
B) The patient may frequently experience a low relative plasma volume.
C) The patient may have impaired stem cell function.
D) The patient may previously have undergone bone marrow biopsy
The patient may chronically produce excess red blood cells
Persistently elevated hematocrit is an indication for therapeutic phlebotomy. It is not used to address excess or deficient
plasma volume and is not related to stem cell function. Bone marrow biopsy is not an indication for therapeutic
phlebotomy
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A nurse has participated in organizing a blood donation drive at a local community center. Which of the following
individuals would most likely be disallowed from donating blood?
A) A man who is 81 years of age
B) A woman whose blood pressure is 88/51 mm Hg
C) A man who donated blood 4 months ago
D) A woman who has type 1 diabetes
B) A woman whose blood pressure is 88/51 mm Hg
For potential blood donors, systolic arterial BP should be 90 to 180 mm Hg, and the diastolic pressure should be 50 to
100 mm Hg. There is no absolute upper age limit. Donation 4 months ago does not preclude safe repeat donation and
diabetes is not a contraindication.
A nurse at a blood donation clinic has completed the collection of blood from a woman. The woman states that she
feels lightheaded and she appears visibly pale. What is the nurses most appropriate action?
A) Help her into a sitting position with her head lowered below her knees
B) Administer supplementary oxygen by nasal prongs
C) Obtain a full set of vital signs
D) Inform a physician or other primary care provider
A) Help her into a sitting position with her head lowered below her knees
A donor who appears pale or complains of faintness should immediately lie down or sit with the head lowered below the
knees. He or she should be observed for another 30 minutes. There is no immediate need for a physicians care.
Supplementary oxygen may be beneficial, but may take too much time to facilitate before a syncopal episode.
Repositioning must precede assessment of vital signs.
A patients low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should
the nurse perform?
A) Have the patient identify his or her blood type in writing.
B) Ensure that the patient has granted verbal consent for transfusion.
C) Assess the patients vital signs to establish baselines.
D) Facilitate insertion of a central venous catheter.
C) Assess the patients vital signs to establish baselines
Prior to a transfusion, the nurse must take the patients temperature, pulse, respiration, and BP to establish a baseline.
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Written consent is required and the patients blood type is determined by type and cross match, not by the patients selfdeclaration. Peripheral venous access is sufficient for blood transfusion.
A patient on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate
and the nurse notes that the infusion began 4 hours ago. What is the nurses most appropriate action?
A) Apply an icepack to the blood that remains to be infused.
B) Discontinue the remainder of the PRBC transfusion and inform the physician.
C) Disconnect the bag of PRBCs, cool for 30 minutes and then administer.
D) Administer the remaining PRBCs by the IV direct (IV push) route.
B) Discontinue the remainder of the PRBC transfusion and inform the physician.
Because of the risk of infection, a PRBC transfusion should not exceed 4 hours. Remaining blood should not be
transfused, even if it is cooled. Blood is not administered by the IV direct route.
Two units of PRBCs have been ordered for a patient who has experienced a GI bleed. The patient is highly reluctant
to receive a transfusion, stating, Im terrified of getting AIDS from a blood transfusion.How can the nurse best
address the patients concerns?
D) The chances of contracting AIDS from a blood transfusion in the United States are exceedingly low.
The patient can be reassured about the very low possibility of contracting HIV from the transfusion. However, it is not an
absolute impossibility. Antiretroviral medications are not introduced into donated blood. The blood supply is constantly
dynamic, due to the brief life of donated blood.
A patient is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What
was the etiology of this patients adverse reaction?
A) Antibodies to donor leukocytes remained in the blood.
B) The donor blood was incompatible with that of the patient.
C) The patient had a sensitivity reaction to a plasma protein in the blood.
D) The blood was infused too quickly and overwhelmed the patients circulatory system.
B) The donor blood was incompatible with that of the patient
An acute hemolytic reaction occurs when the donor blood is incompatible with that of the recipient. In the case of a febrile
nonhemolytic reaction, antibodies to donor leukocytes remain in the unit of blood or blood component. An allergic reaction
is a sensitivity reaction to a plasma protein within the blood component. Hypervolemia does not cause an acute hemolytic
reaction.
An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute
hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion
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reaction?
A) Ensure that blood components are never infused at a rate greater than 125 mL/hr.
B) Administer prophylactic antihistamines prior to all blood transfusions.
C) Establish baseline vital signs for all patients receiving transfusions.
D) Be vigilant in identifying the patient and the blood component.
D) Be vigilant in identifying the patient and the blood component
The most common causes of acute hemolytic reaction are errors in blood component labeling and patient identification
that result in the administration of an ABO-incompatible transfusion. Actions to address these causes are necessary in all
health care settings. Prophylactic antihistamines are not normally administered, and would not prevent acute hemolytic
reactions. Similarly, baseline vital signs and slow administration will not prevent this reaction
A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurses rapid
assessment reveals bilateral lung crackles and elevated BP. What is the nurses most appropriate action?
A) Slow the infusion rate and monitor the patient closely.
B) Discontinue the transfusion and begin resuscitation.
C) Pause the transfusion and administer a 250 mL bolus of normal saline.
D) Discontinue the transfusion and administer a beta-blocker, as ordered.
A) Slow the infusion rate and monitor the patient closely.
The patient is showing early signs of hypervolemia; the nurse should slow the infusion rate and assess the patient closely
for any signs of exacerbation. At this stage, discontinuing the transfusion is not necessary. A bolus would worsen the
patients fluid overload.
A patient lives with a diagnosis of sickle cell anemia and receives frequent blood transfusions. The nurse should
recognize the patients consequent risk of what complication of treatment?
A) Hypovolemia
B) Vitamin B12 deficiency
C) Thrombocytopenia
D) Iron overload
D) Iron overload
Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload.
These individuals are not at risk for hypovolemia and there is no consequent risk for low platelet or vitamin B12 levels.
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A patient is receiving the first of two ordered units of PRBCs. Shortly after the initiation of the transfusion, the
patient complains of chills and experiences a sharp increase in temperature.
What is the nurses priority action?
A) Position the patient in high Fowlers.
B) Discontinue the transfusion.
C) Auscultate the patients lungs.
D) Obtain a blood specimen from the patient.
B) Discontinue the transfusion
Stopping the transfusion is the first step in any suspected transfusion reaction. This must precede other assessments and
interventions, including repositioning, chest auscultation, and collecting specimens.
Fresh-frozen plasma (FFP) has been ordered for a hospital patient. Prior to administration of this blood product, the
nurse should prioritize what patient education?
A) Infection risks associated with FFP administration
B) Physiologic functions of plasma
C) Signs and symptoms of a transfusion reaction
D) Strategies for managing transfusion-associated anxiety
C) Signs and symptoms of a transfusion reaction
Patients should be educated about signs and symptoms of transfusion reactions prior to administration of any blood
product. In most cases, this is priority over education relating to infection. Anxiety may be an issue for some patients, but
transfusion reactions are a possibility for all patients. Teaching about the functions of plasma is not likely a high priority.
The nurse is preparing to administer a unit of platelets to an adult patient. When administering this blood product,
which of the following actions should the nurse perform?
A) Administer the platelets as rapidly as the patient can tolerate.
B) Establish IV access as soon as the platelets arrive from the blood bank.
C) Ensure that the patient has a patent central venous catheter.
D) Aspirate 10 to 15 mL of blood from the patients IV immediately following the transfusion.
A) Administer the platelets as rapidly as the patient can tolerate.
The nurse should infuse each unit of platelets as fast as patient can tolerate to diminish platelet clumping during
administration. IV access should be established prior to obtaining the platelets from the blood bank. A central line is
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appropriate for administration, but peripheral IV access (22-gauge or larger) is sufficient. There is no need to aspirate after
the transfusion.
Which of the following circumstances would most clearly warrant autologous blood donation?
A) The patient has type-O blood.
B) The patient has sickle cell disease or a thalassemia.
C) The patient has elective surgery pending.
D) The patient has hepatitis C.
C) The patient has elective surgery pending
Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high. Type-O
blood, hepatitis, sickle cell disease, and thalassemia are not clear indications for autologous donation.
A patients electronic health record states that the patient receives regular transfusions of factor IX. The nurse
would be justified in suspecting that this patient has what diagnosis?
A) Leukemia
B) Hemophilia
C) Hypoproliferative anemia
D) Hodgkins lymphoma
B) Hemophilia
Administration of clotting factors is used to treat diseases where these factors are absent or insufficient; hemophilia is
among the most common of these diseases. Factor IX is not used in the treatment of leukemia, lymphoma, or anemia.
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Brunner & Suddarth's Textbook of Medical Surgical Nursing 15th Edition
Chapter 29:Management of Patients With Nonmalignant Hematologic Disorders
1. A nurse is caring for a patient who has sickle cell anemia and the nurses assessment reveals the
possibility of substance abuse. What is the nurses most appropriate action?
A) Encourage the patient to rely on complementary and alternative therapies.
B) Encourage the patient to seek care from a single provider for pain relief.
C) Teach the patient to accept chronic pain as an inevitable aspect of the disease.
D) Limit the reporting of emergency department visits to the primary health care provider.
Ans: B
Feedback:
The patient should be encouraged to use a single primary health care provider to address health care concerns.
Emergency department visits should be reported to the primary health care provider to achieve optimal management of
the disease. It would inappropriate to teach the patient to simply accept his or her pain. Complementary therapies are
usually insufficient to fully address pain in sickle cell disease.
2. A patient newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission
assessment, the patient asks the nurse to explain the disease. What should the nurse explain to this patient?
A) There could be an attack on the platelets by antibodies.
B) There could be decreased production of platelets.
C) There could be impaired communication between platelets.
D) There could be an autoimmune process causing platelet malfunction.
Ans: B
Feedback:
Thrombocytopenia can result from a decreased platelet production, increased platelet destruction, or increased
consumption of platelets. Impaired platelet communication, antibodies, and autoimmune processes are not typical
pathologies.
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3. A critical care nurse is caring for a patient with autoimmune hemolytic anemia. The patient is not
responding to conservative treatments, and his condition is now becoming life threatening. The nurse is aware that
a treatment option in this case may include what?
A) Hepatectomy
B) Vitamin K administration
C) Platelet transfusion
D) Splenectomy
Ans: D
Feedback:
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A splenectomy may be the course of treatment if autoimmune hemolytic anemia does not respond to conservative
treatment. Vitamin K administration is treatment for vitamin K deficiency and does not resolve anemia. Platelet transfusion
may be the course of treatment for some bleeding disorders. Hepatectomy would not help the patient.
4. A nurse is providing education to a patient with iron deficiency anemia who has been prescribed iron
supplements. What should the nurse include in health education?
A) Take the iron with dairy products to enhance absorption.
B) Increase the intake of vitamin E to enhance absorption.
C) Iron will cause the stools to darken in color.
D) Limit foods high in fiber due to the risk for diarrhea.
Ans: C
Feedback:
The nurse will inform the patient that iron will cause the stools to become dark in color. Iron should be taken on an empty
stomach, as its absorption is affected by food, especially dairy products. Patients should be instructed to increase their
intake of vitamin C to enhance iron absorption. Foods high in fiber should be consumed to minimize problems with
constipation, a common side effect associated with iron therapy.
5. The nurse is assessing a new patient with complaints of overwhelming fatigue and a sore tongue that is
visibly smooth and beefy red. This patient is demonstrating signs and symptoms associated with what form of what
hematologic disorder?
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 641
A) Sickle cell anemia
B) Hemophilia
C) Megaloblastic anemia
D) Thrombocytopenia
Ans: C
Feedback:
A red, smooth, sore tongue is a symptom associated with megaloblastic anemia. Sickle cell disease, hemophilia, and
thrombocytopenia do not have symptoms involving the tongue.
6. A patient with renal failure has decreased erythropoietin production. Upon analysis of the patients
complete blood count, the nurse will expect which of the following results?
A) An increased hemoglobin and decreased hematocrit
B) A decreased hemoglobin and hematocrit
C) A decreased mean corpuscular volume (MCV) and red cell distribution width (RDW)
D) An increased MCV and RDW
Ans: B
Feedback:
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The decreased production of erythropoietin will result in a decreased hemoglobin and hematocrit. The patient will have
normal MCV and RDW because the erythrocytes are normal in appearance.
7. A patient comes to the clinic complaining of fatigue and the health interview is suggestive of pica.
Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse suspect that
the patient will be diagnosed?
A) Iron deficiency anemia
B) Pernicious anemia
C) Sickle cell anemia
D) Hemolytic anemia
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 642
Ans: A
Feedback:
A low serum iron level, a low ferritin level, and symptoms of pica are associated with iron deficiency anemia. TIBC may
also be elevated. None of the other anemias are associated with pica.
8. A patient comes into the clinic complaining of fatigue. Blood work shows an increased bilirubin
concentration and an increased reticulocyte count. What would the nurse suspect the patient has?
A) A hypoproliferative anemia
B) A leukemia
C) Thrombocytopenia
D) A hemolytic anemia
Ans: D
Feedback:
In hemolytic anemias, premature destruction of erythrocytes results in the liberation of hemoglobin from the erythrocytes
into the plasma; the released hemoglobin is converted in large part to bilirubin, and therefore the bilirubin concentration
rises. The increased erythrocyte destruction leads to tissue hypoxia, which in turn stimulates erythropoietin production.
This increased production is reflected in an increased reticulocyte count as the bone marrow responds to the loss of
erythrocytes. Hypoproliferative anemias, leukemia, and thrombocytopenia lack this pathology and presentation.
9. A nurse is caring for a patient with severe anemia. The patient is tachycardic and complains of dizziness
and exertional dyspnea. The nurse knows that in an effort to deliver more blood to hypoxic tissue, the workload on
the heart is increased. What signs and symptoms might develop if this patient goes into heart failure?
A) Peripheral edema
B) Nausea and vomiting
C) Migraine
D) Fever
Ans: A
Feedback:
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Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 643
Cardiac status should be carefully assessed in patients with anemia. When the hemoglobin level is low, the heart attempts
to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tissue. This increased cardiac
workload can result in such symptoms as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional
dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver
(hepatomegaly), and by peripheral edema. Nausea, migraine, and fever are not associated with heart failure.
10. A patient is admitted to the hospital with pernicious anemia. The nurse should prepare to administer
which of the following medications?
A) Folic acid
B) Vitamin B12
C) Lactulose
D) Magnesium sulfate
Ans: B
Feedback:
Pernicious anemia is characterized by vitamin B12 deficiency. Magnesium sulfate, lactulose, and folic acid do not address
the pathology of this type of anemia.
11. A patients blood work reveals a platelet level of 17,000/mm3. When inspecting the patients integumentary
system, what finding would be most consistent with this platelet level?
A) Dermatitis
B) Petechiae
C) Urticaria
D) Alopecia
Ans: B
Feedback:
When the platelet count drops to less than 20,000/mm3, petechiae can appear. Low platelet levels do not normally result
in dermatitis, urticaria (hives), or alopecia (hair loss).
12. A nurse is admitting a patient with immune thrombocytopenic purpura to the unit. In completing the
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 644
admission assessment, the nurse must be alert for what medications that potentially alter platelet function? Select
all that apply.
A) Antihypertensives
B) Penicillins
C) Sulfa-containing medications
D) Aspirin-based drugs
E) NSAIDs
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Ans: C, D, E
Feedback:
The nurse must be alert for sulfa-containing medications and others that alter platelet function (e.g., aspirin-based or other
NSAIDs). Antihypertensive drugs and the penicillins do not alter platelet function.
13. A patient, 25 years of age, comes to the emergency department complaining of excessive bleeding from
a cut sustained when cleaning a knife. Blood work shows a prolonged PT but a vitamin K deficiency is ruled out.
When assessing the patient, areas of ecchymosis are noted on other areas of the body. Which of the following is
the most plausible cause of the patients signs and symptoms?
A) Lymphoma
B) Leukemia
C) Hemophilia
D) Hepatic dysfunction
Ans: D
Feedback:
Prolongation of the PT, unless it is caused by vitamin K deficiency, may indicate severe hepatic dysfunction. The majority
of hemophiliacs are diagnosed as children. The scenario does not describe signs or symptoms of lymphoma or leukemia.
14. A patient with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal
varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse
expect the care team to order for this patient?
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 645
A) Packed red blood cells (PRBCs)
B) Vitamin K
C) Oral anticoagulants
D) Heparin infusion
Ans: A
Feedback:
Patients with liver dysfunction may have life-threatening hemorrhage from peptic ulcers or esophageal varices. In these
cases, replacement with fresh frozen plasma, PRBCs, and platelets is usually required. Vitamin K may be ordered once
the bleeding is stopped, but that is not what is needed to stop the bleeding of the varices. Anticoagulants would
exacerbate the patients bleeding.
15. The nurse on the pediatric unit is caring for a 10-year-old boy with a diagnosis of hemophilia. The nurse
knows that a priority nursing diagnosis for a patient with hemophilia is what?
A) Hypothermia
B) Diarrhea
C) Ineffective coping
D) Imbalanced nutrition: Less than body requirements
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Ans: C
Feedback:
Most patients with hemophilia are diagnosed as children. They often require assistance in coping with the condition
because it is chronic, places restrictions on their lives, and is an inherited disorder that can be passed to future
generations. Children with hemophilia are not at risk of hypothermia, diarrhea, or imbalanced nutrition.
16. A group of nurses are learning about the high incidence and prevalence of anemia among different
populations. Which of the following individuals is most likely to have anemia?
A) A 50-year-old African-American woman who is going through menopause
B) An 81-year-old woman who has chronic heart failure
C) A 48-year-old man who travels extensively and has a high-stress job
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 646
D) A 13-year-old girl who has just experienced menarche
Ans: B
Feedback:
The incidence and prevalence of anemia are exceptionally high among older adults, and the risk of anemia is
compounded by the presence of heart disease. None of the other listed individuals exhibits high-risk factors for anemia,
though exceptionally heavy menstrual flow can result in anemia.
17. An adult patient has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely
to apply to this patients health status?
A) Risk for deficient fluid volume related to impaired erythropoiesis
B) Risk for infection related to tissue hypoxia
C) Acute pain related to uncontrolled hemolysis
D) Fatigue related to decreased oxygen-carrying capacity
Ans: D
Feedback:
Fatigue is the major assessment finding common to all forms of anemia. Anemia does not normally result in acute pain or
fluid deficit. The patient may have an increased risk of infection due to impaired immune function, but fatigue is more
likely.
18. A patient has been living with a diagnosis of anemia for several years and has experienced recent declines in
her hemoglobin levels despite active treatment. What assessment finding would signal complications of anemia?
A) Venous ulcers and visual disturbances
B) Fever and signs of hyperkalemia
C) Epistaxis and gastroesophageal reflux
D) Ascites and peripheral edema
Ans: D
Feedback:
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Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 647
A significant complication of anemia is heart failure from chronic diminished blood volume and the hearts compensatory
effort to increase cardiac output. Patients with anemia should be assessed for signs and symptoms of heart failure,
including ascites and peripheral edema. None of the other listed signs and symptoms is characteristic of heart failure.
19. A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron- deficiency
anemia in recent weeks. When providing the patient with nutritional guidelines and meal suggestions, what foods
would be most likely to increase the womans iron stores?
A) Salmon accompanied by whole milk
B) Mixed vegetables and brown rice
C) Beef liver accompanied by orange juice
D) Yogurt, almonds, and whole grain oats
Ans: C
Feedback:
Food sources high in iron include organ meats, other meats, beans (e.g., black, pinto, and garbanzo), leafy green
vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the
absorption of iron. All of the listed foods are nutritious, but liver and orange juice are most likely to be of benefit.
20. A patient with poorly controlled diabetes has developed end-stage renal failure and consequent anemia.
When reviewing this patients treatment plan, the nurse should anticipate the use of what drug?
A) Magnesium sulfate
B) Epoetin alfa
C) Low-molecular weight heparin
D) Vitamin K
Ans: B
Feedback:
The availability of recombinant erythropoietin (epoetin alfa [Epogen, Procrit], darbepoetin alfa [Aranesp]) has dramatically
altered the management of anemia in end-stage renal disease. Heparin, vitamin K, and magnesium are not indicated in
the treatment of renal failure or the consequent anemia.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 648
21. A nurse is planning the care of a patient with a diagnosis of sickle cell disease who has been admitted for
the treatment of an acute vaso-occlusive crisis. What nursing diagnosis should the nurse prioritize in the patients
plan of care?
A) Risk for disuse syndrome related to ineffective peripheral circulation
B) Functional urinary incontinence related to urethral occlusion
C) Ineffective tissue perfusion related to thrombosis
D) Ineffective thermoregulation related to hypothalamic dysfunction
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Ans: C
Feedback:
There are multiple potential complications of sickle cell disease and sickle cell crises. Central among these, however, is
the risk of thrombosis and consequent lack of tissue perfusion. Sickle cell crises are not normally accompanied by
impaired thermoregulation or genitourinary complications. Risk for disuse syndrome is not associated with the effects of
acute vaso-occlusive crisis.
22. A patient is being treated on the medical unit for a sickle cell crisis. The nurses most recent assessment
reveals an oral temperature of 100.5F and a new onset of fine crackles on lung auscultation. What is the nurses
most appropriate action?
A) Apply supplementary oxygen by nasal cannula.
B) Administer bronchodilators by nebulizer.
C) Liaise with the respiratory therapist and consider high-flow oxygen.
D) Inform the primary care provider that the patient may have an infection.
Ans: D
Feedback:
Patients with sickle cell disease are highly susceptible to infection,thus any early signs of infection should be reported
promptly. There is no evidence of respiratory distress, so oxygen therapy and bronchodilators are not indicated.
23. The medical nurse is aware that patients with sickle cell anemia benefit from understanding what
situations can precipitate a sickle cell crisis. When teaching a patient with sickle cell anemia about strategies to
prevent crises, what measures should the nurse recommend?
A) Using prophylactic antibiotics and performing meticulous hygiene
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 649
B) Maximizing physical activity and taking OTC iron supplements
C) Limiting psychosocial stress and eating a high-protein diet
D) Avoiding cold temperatures and ensuring sufficient hydration
Ans: D
Feedback:
Keeping warm and providing adequate hydration can be effective in diminishing the occurrence and severity of attacks.
Hygiene, antibiotics, and high protein intake do not prevent crises. Maximizing activity may exacerbate pain and be
unrealistic.
24. A patient with a documented history of glucose-6-phosphate dehydrogenase deficiency has presented to
the emergency department with signs and symptoms including pallor, jaundice, and malaise. Which of the nurses
assessment questions relates most directly to this patients hematologic disorder?
A) When did you last have a blood transfusion?
B) What medications have taken recently?
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C) Have you been under significant stress lately?
D) Have you suffered any recent injuries?
Ans: B
Feedback:
Exacerbations of glucose-6-phosphate dehydrogenase deficiency are nearly always precipitated by medications. Blood
transfusions, stress, and injury are less common triggers.
25. A patients electronic health record notes that he has previously undergone treatment for secondary
polycythemia. How should this aspect of the patients history guide the nurses subsequent assessment?
A) The nurse should assess for recent blood donation.
B) The nurse should assess for evidence of lung disease.
C) The nurse should assess for a history of venous thromboembolism.
D) The nurse should assess the patient for impaired renal function.
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 650
Ans: B
Feedback:
Any reduction in oxygenation, such as lung disease, can cause secondary polycythemia. Blood donation does not
precipitate this problem and impaired renal function typically causes anemia, not polycythemia. A history of VTE is not a
likely contributor.
26. A patients absolute neutrophil count (ANC) is 440/mm3. But the nurses assessment reveals no apparent
signs or symptoms of infection. What action should the nurse prioritize when providing care for this patient?
A) Meticulous hand hygiene
B) Timely administration of antibiotics
C) Provision of a nutrient-dense diet
D) Maintaining a sterile care environment
Ans: A
Feedback:
Providing care for a patient with neutropenia requires that the nurse adhere closely to standard precautions and infection
control procedures. Hand hygiene is central to such efforts. Prophylactic antibiotics are rarely used and it is not possible
to provide a sterile environment for care. Nutrition is highly beneficial, but hand hygiene is the central aspect of care.
27. A nurse is providing discharge education to a patient who has recently been diagnosed with a bleeding
disorder. What topic should the nurse prioritize when teaching this patient?
A) Avoiding buses, subways, and other crowded, public sites
B) Avoiding activities that carry a risk for injury
C) Keeping immunizations current
D) Avoiding foods high in vitamin K
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Ans: B
Feedback:
Patients with bleeding disorders need to understand the importance of avoiding activities that increase
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 651
the risk of bleeding, such as contact sports. Immunizations involve injections and may be contraindicated for some
patients. Patients with bleeding disorders do not need to normally avoid crowds. Foods high in vitamin K may beneficial,
not detrimental.
28. A nurse is a long-term care facility is admitting a new resident who has a bleeding disorder. When
planning this residents care, the nurse should include which of the following?
A) Housing the resident in a private room
B) Implementing a passive ROM program to compensate for activity limitation
C) Implementing of a plan for fall prevention
D) Providing the patient with a high-fiber diet
Ans: C
Feedback:
To prevent bleeding episodes, the nurse should ensure that an older adult with a bleeding disorder does not suffer a fall.
Activity limitation is not necessarily required, however. A private room is not necessary and there is no reason to increase
fiber intake.
29. The results of a patients most recent blood work and physical assessment are suggestive of immune
thrombocytopenic purpura (ITP). This patient should undergo testing for which of the following potential causes?
Select all that apply.
A) Hepatitis
B) Acute renal failure
C) HIV
D) Malignant melanoma
E) Cholecystitis
Ans: A, C
Feedback:
Viral illnesses have the potential to cause ITP. Renal failure, malignancies, and gall bladder inflammation are not typical
causes of ITP.
30. A patient with a recent diagnosis of ITP has asked the nurse why the care team has not chosen to
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 652
administer platelets, stating, I have low platelets, so why not give me a transfusion of exactly what Im missing?
How should the nurse best respond?
A) Transfused platelets usually arent beneficial because theyre rapidly destroyed in the body.
B) A platelet transfusion often blunts your bodys own production of platelets even further.
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C) Finding a matching donor for a platelet transfusion is exceedingly difficult.
D) A very small percentage of the platelets in a transfusion are actually functional.
Ans: A
Feedback:
Despite extremely low platelet counts, platelet transfusions are usually avoided. Transfusions tend to be ineffective not
because the platelets are nonfunctional but because the patients antiplatelet antibodies bind with the transfused platelets,
causing them to be destroyed. Matching the patients blood type is not usually necessary for a platelet transfusion. Platelet
transfusions do not exacerbate low platelet production.
31. A client with several chronic health problems has been newly diagnosed with a qualitative platelet defect. What
component of the patients previous medication regimen may have contributed to the development of this disorder?
A) Calcium carbonate
B) Vitamin B12
C) Aspirin
D) Vitamin D
Ans: C
Feedback:
Aspirin may induce a platelet disorder. Even small amounts of aspirin reduce normal platelet aggregation, and the
prolonged bleeding time lasts for several days after aspirin ingestion. Calcium, vitamin D, and vitamin B12 do not have the
potential to induce a platelet defect.
32. A young man with a diagnosis of hemophilia A has been brought to emergency department after
suffering a workplace accident resulting in bleeding. Rapid assessment has revealed the source of the patients
bleeding and established that his vital signs are stable. What should be the nurses next action?
A) Position the patient in a prone position to minimize bleeding.
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 653
B) Establish IV access for the administration of vitamin K.
C) Prepare for the administration of factor VIII.
D) Administer a normal saline bolus to increase circulatory volume.
Ans: C
Feedback:
Injuries in patients with hemophilia necessitate prompt administration of clotting factors. Vitamin K is not a treatment
modality and a prone position will not be appropriate for all types and locations of wounds. A normal saline bolus is not
indicated.
33. A nurse is planning the care of a patient who has a diagnosis of hemophilia A. When addressing the
nursing diagnosis of Acute Pain Related to Joint Hemorrhage, what principle should guide the nurses choice of
interventions?
A) Gabapentin (Neurontin) is effective because of the neuropathic nature of the patients pain.
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B) Opioids partially inhibit the patients synthesis of clotting factors.
C) Opioids may cause vasodilation and exacerbate bleeding.
D) NSAIDs are contraindicated due to the risk for bleeding.
Ans: D
Feedback:
NSAIDs may be contraindicated in patients with hemophilia due to the associated risk of bleeding. Opioids do not have a
similar effect and they do not inhibit platelet synthesis. The pain associated with hemophilia is not neuropathic.
34. A night nurse is reviewing the next days medication administration record (MAR) of a patient who has
hemophilia. The nurse notes that the MAR specifies both oral and subcutaneous options for the administration of a
PRN antiemetic. What is the nurses best action?
A) Ensure that the day nurse knows not to give the antiemetic.
B) Contact the prescriber to have the subcutaneous option discontinued.
C) Reassess the patients need for antiemetics.
D) Remove the subcutaneous route from the patients MAR.
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 654
Ans: B
Feedback:
Injections must be avoided in patients with hemophilia. Consequently, the nurse should ensure that the prescriber makes
the necessary change. The nurse cannot independently make a change to a patients MAR in most cases. Facilitating the
necessary change is preferable to deferring to the day nurse.
35. A patient with Von Willebrand disease (vWD) has experienced recent changes in bowel function that
suggest the need for a screening colonoscopy. What intervention should be performed in anticipation of this
procedure?
A) The patient should not undergo the normal bowel cleansing protocol prior to the procedure.
B) The patient should receive a unit of fresh-frozen plasma 48 hours before the procedure.
C) The patient should be admitted to the surgical unit on the day before the procedure.
D) The patient should be given necessary clotting factors before the procedure.
Ans: D
Feedback:
A goal of treating vWD is to replace the deficient protein (e.g., vWF or factor VIII) prior to an invasive procedure to
prevent subsequent bleeding. Bowel cleansing is not contraindicated and FFP does not reduce the patients risk of
bleeding. There may or may not be a need for preprocedure hospital admission.
36. A patients low prothrombin time (PT) was attributed to a vitamin K deficiency and the patients PT normalized
after administration of vitamin K. When performing discharge education in an effort to prevent recurrence, what
should the nurse emphasize?
A) The need for adequate nutrition
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B) The need to avoid NSAIDs
C) The need for constant access to factor concentrate
D) The need for meticulous hygiene
Ans: A
Feedback:
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 655
Vitamin K deficiency is often the result of a nutritional deficit. NSAIDs do not influence vitamin K synthesis and clotting
factors are not necessary to treat or prevent a vitamin K deficiency. Hygiene is not related to the onset or prevention of
vitamin K deficiency.
37. A patient with a history of atrial fibrillation has contacted the clinic saying that she has accidentally
overdosed on her prescribed warfarin (Coumadin). The nurse should recognize the possible need for what
antidote?
A) IVIG
B) Factor X
C) Vitamin K
D) Factor VIII
Ans: C
Feedback:
Vitamin K is administered as an antidote for warfarin toxicity.
38. An intensive care nurse is aware of the need to identify patients who may be at risk of developing
disseminated intravascular coagulation (DIC). Which of the following ICU patients most likely faces the highest risk
of DIC?
A) A patient with extensive burns
B) A patient who has a diagnosis of acute respiratory distress syndrome
C) A patient who suffered multiple trauma in a workplace accident
D) A patient who is being treated for septic shock
Ans: D
Feedback:
Sepsis is a common cause of DIC. A wide variety of acute illnesses can precipitate DIC, but sepsis is specifically
identified as a cause.
39. A patient is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for
Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this
diagnosis are being met?
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 656
A) Assess for edema.
B) Assess skin integrity frequently.
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C) Assess the patients level of consciousness frequently.
D) Closely monitor intake and output.
Ans: D
Feedback:
The patient with DIC is at a high risk of deficient fluid volume. The nurse can best gauge the effectiveness of care by
closely monitoring the patients intake and output. Each of the other assessments is a necessary element of care, but
none addresses fluid balance as directly as close monitoring of intake and output.
40. A patient with a pulmonary embolism is being treated with a heparin infusion. What diagnostic finding
suggests to the nurse that treatment is effective?
A) The patients PT is within reference ranges.
B) Arterial blood sampling tests positive for the presence of factor XIII.
C) The patients platelet level is below 100,000/mm3.
D) The patients activated partial thromboplastin time (aPTT) is 1.5 to 2.5 times the control value.
Ans: D
Feedback:
The therapeutic effect of heparin is monitored by serial measurements of the aPTT; the dose is adjusted to maintain the
range at 1.5 to 2.5 times the laboratory control. Heparin dosing is not determined on the basis of platelet levels, the
presence or absence of clotting factors, or PT levels.
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Brunner & Suddarth's Textbook of Medical Surgical Nursing 15th Edition
Chapter 30: Management of Patients With Hematologic Neoplasms
Which nursing intervention is most appropriate for a client with multiple myeloma?
A) Restricting fluid intake
B) Preventing bone injury
C) Monitoring respiratory status
D) Balancing rest and activity
B
(Preventing bone injury
When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and
infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate
interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the
client well hydrated — not restrict his fluid intake.)
A client is undergoing tests for multiple myeloma. Diagnostic study findings in multiple myeloma include:
A) Serum calcium level of 7.5 mg/dl
B) Serum creatinine level 0.5 mg/dl
C) Bence Jones protein in the urine
D) Serum protein level 5.8 g/dl
C
(Bence Jones protein in the urine
Presence of Bence Jones protein in the urine almost always confirms multiple myeloma; however, the absence of the
protein doesn't rule out the disease. Serum creatinine level may be increased (above 1.2 mg/dl in men and 0.9 mg/dl in
women). Serum calcium levels are above 10.2 mg/dl in multiple myeloma because calcium is lost from the bone and
reabsorbed in the serum. The serum protein level is increased in multiple myeloma, not decreased.)
A nurse is assessing a client with multiple myeloma. The nurse should keep in mind that clients with multiple
myeloma are at risk for:
A) Hypoxemia.
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B) Pathologic bone fractures.
C) Chronic liver failure.
D) Acute heart failure.
B
(Pathologic bone fractures.
Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis and osteolytic
lesions. Also, clients are at risk for renal failure secondary to myeloma proteins by causing renal tubular obstruction. Liver
failure and heart failure aren't usually sequelae of multiple myeloma. Hypoxemia isn't usually related to multiple myeloma.)
A client with leukemia is being discharged from the hospital to hospice care. Which statement by the client
indicates the client has not achieved the goal for the nursing diagnosis Spiritual Distress?
A) "I do not understand why this happened to me."
B) "I know I am going to die. I want to say good-bye to my family."
C) "I am going to call my clergy to pray with me."
D) "I have resources within myself that I can depend on."
A
("I do not understand why this happened to me."
The statement "I do not understand why this happened to me" indicates that the client is not accepting of the
consequences of his health problems and impending death. The other statements indicate the client has plans that would
result in spiritual well-being or harmony.)
Following bone marrow aspiration of a 19-year-old client, analysis reveals more than 20% immature blast cells.
Platelet counts are 9000/mm3. What nursing interventions should the nurse employ for the care of this client? Select
all answers that apply.
A) Administer prescribed docusate (Colace) daily.
B) Recommend taking ibuprofen for mild aches and pains.
C) Apply pressure to venipuncture sites for 1 to 2 minutes.
D) Assess for mental state changes.
E) Discuss the withholding of oral contraceptives.
A, D
(Administer prescribed docusate (Colace) daily.
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Assess for mental state changes.
The client has leukemia with immature blast cells and an extremely low platelet count. The client is at increased risk for
bleeding. Interventions that would address bleeding include assessing for mental status changes (because bleeding could
occur in the brain) and administering stool softeners to prevent constipation (which would increase the risk of bleeding
from the rectum). Oral contraceptives would be administered to induce amenorrhea. Ibuprofen would be avoided because
this medication inhibits platelet function. The nurse is to apply pressure to venipuncture sites for 5 minutes.)
Your client has just been prescribed oral iron. Why would you advise this client to avoid taking their medication
with coffee, tea, eggs, or milk?
A) Untoward reactions may occur.
B) Coffee, tea, eggs, and milk interact with oral iron.
C) Grand mal seizures may result.
D) Absorption of iron will decrease.
D
(Absorption of iron will decrease.
When a client takes the drug with coffee, tea, eggs, or milk, absorption of oral iron decreases. The use of meperidine or
Demerol when treating pain in clients with sickle cell crisis may result in grand mal seizures. Antacids, tetracyclines, and
vitamin C interact with oral iron.)
The nurse is assisting the client with multiple myeloma to ambulate. What is the most important nursing diagnosis
to help prevent fractures in this client?
A) Safety
B) Adequate nutrition
C) Adequate hydration
D) Increased mobility
A (Safety)
A patient with a diagnosis of immune thrombocytopenic purpura (ITP) is currently receiving IVIG for the treatment
of her health condition. The nurse who is providing this patientts care is aware that ITP is a consequence of:
A) Platelet destruction and impaired platelet production resulting from an autoimmune process
B) Impaired liver function and the sequestering of platelets by hepatocytes
C) Hemolysis of platelets in individuals who lack immunity to the Epstein-Barr virus
D) Inappropriate platelet aggregation on the walls of the great vessels
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A
(Platelet destruction and impaired platelet production resulting from an autoimmune process
Although the precise cause of ITP remains unknown, the platelet count is decreased by a combination of autoantibodymediated platelet destruction and impaired platelet production secondary to autoantibody effects on the megakaryocyte.
Viruses, impaired liver function, and inappropriate platelet aggregation are not dimensions of the etiology of ITP.)
A 71-year-old woman with a history of rheumatoid arthritis and chronic heart failure has been admitted to the
hospital for the treatment of a suspected upper gastrointestinal bleed. When performing an assessment of this
patient, which of the following questions most directly addresses a likely cause of the womants bleeding disorder?
A) "Did either of your parents or siblings have problems with bleeding?"
B) "How closely do you tend to monitor your blood pressure when youtre at home?"
C) "Has your doctor prescribed a water pill for your heart failure?"
D) "Do you ever take aspirin to treat the pain of your arthritis?"
D
("Do you ever take aspirin to treat the pain of your arthritis?"
An important functional platelet disorder is that induced by aspirin. Even small amounts of aspirin reduce normal platelet
aggregation, and the prolonged bleeding time lasts for several days after aspirin ingestion. Diuretics, hypertension, and
family history are not central parameters in the assessment of a bleeding disorder.)
Which of the following is the only curative treatment for chronic myeloid leukemia (CML)?
A) Idarubicin
B) Cytarabine
C) Allogeneic stem cell transplant
D) Imatinib
C
(Allogeneic stem cell transplant
Allogeneic stem cell transplantation remains the only curative treatment for CML. The efficacy of Imatinib as first-line
treatment and the treatment-related mortality of stem cell transplant limits use of transplant to patients with high risk or
relapsed disease, or in those patients who did not respond to therapy with TKI. Cytarabine and idarubicin are part of
induction therapy for acute myeloid leukemia (AML).)
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Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in
a client with leukemia?
A) Apply prolonged pressure to needle sites or other sources of external bleeding.
B) Monitor temperature at least once per shift.
C) Eliminate direct contact with others who are infectious.
D) Implement neutropenic precautions.
A
(Apply prolonged pressure to needle sites or other sources of external bleeding.
For a client with leukemia, the nurse should apply prolonged pressure to needle sites or other sources of external
bleeding. Reduced platelet production results in a delayed clotting process and increases the potential for hemorrhage.
Implementing neutropenic precautions and eliminating direct contact with others are interventions to address the risk for
infection.)
Which term refers to a form of white blood cell involved in immune response?
A) Spherocyte
B) Thrombocyte
C) Lymphocyte
D) Granulocyte
C
(Lymphocyte
Both B and T lymphocytes respond to exposure to antigens. Granulocytes include basophils, neutrophils, and eosinophils.
A spherocyte is a red blood cell without central pallor, seen with hemolysis. A thrombocyte is a platelet.)
Which term is used to refer to a primitive cell that is capable of self-replication and differentiation?
A) Reticulocyte
B) Spherocyte
C) Band cell
D) Stem cell
D
(Stem cell
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Stem cells may differentiate into myeloid or lymphoid stem cells. A band cell is a slightly immature neutrophil. A
spherocyte is a red blood cell without central pallor. A reticulocyte is a slightly immature red blood cell.)
A client has completed induction therapy and has diarrhea and severe mucositis. What is the appropriate nursing
goal?
A) Address issues of negative body image.
B) Administer pain medication.
C) Place the client in reverse isolation.
D) Maintain nutrition.
D
(Maintain nutrition.
Maintaining nutrition is the most important goal after induction therapy because the client experiences severe diarrhea and
can easily become nutritionally deficient and develop fluid and electrolyte imbalance. The client is most likely not in pain at
this point, and this is an intervention, not a goal.)
A client presents with peripheral neuropathy and hypothesia of the feet. What is the best nursing intervention?
- Assess for signs of injury.
- Keep the feet cool.
- Elevate the clientts legs.
- Encourage ambulation.
Assess for signs of injury.
A client with hypothesia of the feet will have decreased sensation and numbness. The nurse should assess for signs of
injury. If the client is injured, he or she will not be able to feel it; this could lead to the development of infection.
Ambulation will not help the client, and elevating the legs may make the problem worse, as blood flow to the feet would
be decreased. Keeping the feet cold will also decrease blood flow.
A client with AML has pale mucous membranes and bruises on the legs. What is the primary nursing intervention?
A) Assess the clientts hemoglobin and platelets.
B) Assess the clientts pulse and blood pressure.
C) Check the clientts history.
D) Assess the clientts skin.
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A
(Assess the client's hemoglobin and platelets.
Clients with AML may develop pallor from anemia and a tendency to bleed because of a low platelet count. Assessing the
client's hemoglobin and platelets will help to determine whether this is the cause of the symptoms. This would be the
priority above assessing pulses, blood pressure, history, or skin.)
A client with leukemia has developed a cough and increased fatigue. What is the primary nursing intervention?
A) Medicate the client to relieve pain.
B) Place a cooling blanket on the client.
C) Evaluate the client for potential infection.
D) Administer an antitussive.
C
(Evaluate the client for potential infection.
The client with leukemia has a lack of mature and normal granulocytes to fight infection. For this reason, the client is
susceptible to infection. The primary nursing intervention is to evaluate for potential infection if the client has a cough and
increased fatigue. Administering an antitussive would not be appropriate before determining the cause of the cough. A
cooling blanket would not be needed if the client does not have a fever. Medicating the client to relieve pain would come
after the assessment phase.)
The nurse is assessing several clients. Which client does the nurse determine is most likely to have Hodgkin
lymphoma?
A) The client with painful lymph nodes under the arm.
B) The client with enlarged lymph nodes in the neck.
C) The client with painful lymph nodes in the groin.
D) The client with a painful sore throat.
B
(The client with enlarged lymph nodes in the neck.
Lymph node enlargement in Hodgkin lymphoma is not painful. The client with enlarged lymph nodes in the neck is most
likely to have Hodgkin lymphoma if the enlarged nodes are painless. Sore throat is not a sign for this disorder.)
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A patient with acute myeloid leukemia (AML) is having hematopoietic stem cell transplantation (HSCT) with
radiation therapy. In which complication do the donorts lymphocytes recognize the patientts body as foreign and
set up reactions to attack the foreign host?
A) Acute respiratory distress syndrome
B) Graft-versus-host disease
C) Remission
D) Bone marrow depression
B
(Graft-versus-host disease
Patients who undergo HSCT have a significant risk of infection, graft-versus host disease (in which the donor's
lymphocytes [graft] recognize the patient's body as "foreign" and set up reactions to attack the foreign host), and other
complications.)
The nurse practitioner suspects that a patient has multiple myeloma based on his major presenting symptom and
the analysis of his laboratory results. Select the classic symptom for this disease.
A) Severe thrombocytopenia
B) Bone pain in the back of the ribs
C) Gradual muscle paralysis
D) Debilitating fatigue
B
(Bone pain in the back of the ribs
Although patients can have asymptomatic bone involvement, the most common presenting symptom of multiple myeloma
is bone pain, usually in the back or ribs. Unlike arthritic pain, the bone pain associated with myeloma increases with
movement and decreases with rest; patients may report that they have less pain on awakening but the pain intensity
increases during the day.)
A nurse is caring for a client with multiple myeloma. Which laboratory value is the nurse most likely to see?
A) Hypermagnesemia
B) Hypernatremia
C) Hyperkalemia
D) Hypercalcemia
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D
(Hypercalcemia
Calcium is released when bone is destroyed, causing hypercalcemia. Multiple myeloma doesn't affect potassium, sodium,
or magnesium levels.)
Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia?
A) Provide a clear liquid, low-sodium diet.
B) Put on a mask, gown, and gloves when entering the clientts room.
C) Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing.
D) Have the client use a soft toothbrush and electric razor, avoid using enemas, and watch for signs of bleeding.
C
(Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing.
Neutropenia occurs when the absolute neutrophil count falls below 1,000/mm3, reflecting a severe risk of infection. The
nurse should provide a low-bacterial diet, which means eliminating fresh fruits and vegetables, avoiding invasive
procedures such as enemas, and practicing frequent hand washing. Using a soft toothbrush, avoiding straight-edged
razors and enemas, and monitoring for bleeding are precautions for clients with thrombocytopenia. Putting on a mask,
gown, and gloves when entering the client's room are reverse isolation measures. A neutropenic client doesn't need a
clear liquid diet or sodium restrictions.)
The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor.
Why?
A) The client is at risk for spontaneous and uncontrolled bleeding.
B) Trauma and microabrasions may contribute to anemia.
C) Fragile tissues and altered clotting mechanisms may result in hemorrhage.
D) The client is at risk for infection from microorganisms.
B
(Trauma and microabrasions may contribute to anemia.
In a client with leukemia who is at risk for hemorrhage, the nurse handles the client gently when assisting and encourages
the client to use electric razors. Trauma and microabrasions from razors may contribute to anemia from bleeding. Fragile
tissues and altered clotting mechanisms may result in hemorrhage even after minor trauma. Therefore, the nurse inspects
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the skin for signs of bruising and petechiae and reports melena, hematuria, or epistaxis (nosebleeds). The risks for
spontaneous and uncontrolled bleeding or infection from microorganisms are not addressed by the use of electric razors.)
The nursing instructor is talking with their clinical group about coagulopathies. How should the instructor define
coagulopathies?
A) Coagulopathies are bleeding disorders that are characterized by a deficiency of globulins in the plasma.
B) Coagulopathies are bleeding disorders that involve platelets or clotting factors.
C) Coagulopathies are bleeding disorders that are characterized by abnormalities in the numbers and types of red
blood cells in the body.
D) Coagulopathies are bleeding disorders that involve the destruction of stem cells in the bone marrow.
B
(Coagulopathies are bleeding disorders that involve platelets or clotting factors.
Coagulopathies are bleeding disorders that involve platelets or clotting factors. Coagulopathies do not involve the numbers
and types of red blood cells. They are not characterized by a deficiency of globulins in the plasma and they do not involve
the destruction of stem cells in the bone marrow.)
A 63-year-old woman has been diagnosed with polycythemia vera (PV) after undergoing a series of diagnostic tests.
When the womants nurse is providing health education, what subject should the nurse prioritize?
A) Maintenance of long-term vascular access device
B) Lifestyle modifications and techniques for preventing thromboembolism
C) Strategies for managing activity
D) Nutritional modifications necessary for maintaining a low-iron diet
B
(Lifestyle modifications and techniques for preventing thromboembolism
The increased blood volume and viscosity that are the hallmarks of PV create a significant risk of thromboembolism. A
vascular access device is not necessary for the treatment of PV, and a low-iron diet does not resolve the disease.
Patients may experience fatigue, but this risk is superseded by that of thromboembolism.)
A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been
having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the
fracture. What does the nurse suspect may be occurring based on these symptoms?
A) Multiple myeloma
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B) Leukemia
C) Hemolytic anemia
D) Polycythemia vera
A
(Multiple myeloma
The first symptom usually is vague pain in the pelvis, spine, or ribs. As the disease progresses, the pain becomes more
severe and localized. The pain intensifies with activity and is relieved by rest. When tumors replace bone marrow,
pathologic fractures develop. Hemolytic anemia does not result in pathologic fractures nor does polycythemia vera or
leukemia.)
Which statement indicates the client understands teaching about induction therapy for leukemia?
A) "I will start slowly with medication treatment."
B) "I will need to come every week for treatment."
C) "I know I can never be cured."
D) "I will be in the hospital for several weeks."
D
("I will be in the hospital for several weeks."
Induction therapy involves high doses of several medications and the client is usually admitted to the hospital for several
weeks. The treatment is started quickly and the goal is to cure or put the disease into remission.)
What assessment findingbest indicates that the client has recovered from induction therapy?
A) Absence of bone pain
B) No evidence of edema
C) Vital signs within normal ranges
D) Neutrophil and platelet counts within normal limits
D
(Neutrophil and platelet counts within normal limits
Recovery from induction therapy is indicated when the neutrophil and platelet counts have returned to normal and any
infection has resolved. Stable vital signs, lack of edema, and absence of pain are not indicative of recovery from induction
therapy.)
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The nurse is interacting with a family that has been caring for a client with cancer for several months. What are the
best interventions to assist in relieving caregiver stress in this family? Select all that apply.
A) Suggest the family go to church more often.
B) Suggest support for household maintenance.
C) Suggest the prescription of antianxiety medications.
D) Educate the family about medications and side effects.
E) Allow family members to express feelings.
B, D, E
(- Suggest support for household maintenance.
- Educate the family about medications and side effects.
- Allow family members to express feelings.)
The nurse is performing an assessment on a patient with acute myeloid leukemia (AML) and observes multiple
areas of ecchymosis and petechiae. What laboratory study should the nurse be concerned about?
A) Platelet count of 9,000/mm3
B) WBC count of 4,200 cells/mcL
C) Hematocrit of 38%
D) Creatinine level of 1.0 mg/dL
A
(Platelet count of 9,000/mm3
Complications of AML include bleeding and infection, which are the major causes of death. The risk of bleeding correlates
with the level and duration of platelet deficiency (thrombocytopenia). The low platelet count can cause ecchymoses
(bruises) and petechiae. Major hemorrhages also may develop when the platelet count drops to less than 10,000/mm3.)
A nurse has established for a client the nursing diagnosis of risk for infection. Which of the following interventions
would the nurse include in the plan of care for this client? Select all answers that apply.
A) Assess skin and mucus membranes every shift.
B) Provide oral hygiene once daily.
C) Encourage the client to take deep breaths every 4 hours while awake.
D) Place fresh flowers on a shelf on the opposite wall from the client.
E) Auscultate lung sounds every shift and prn.
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A, C, E
(- Assess skin and mucus membranes every shift.
- Encourage the client to take deep breaths every 4 hours while awake.
- Auscultate lung sounds every shift and prn.)
The client was admitted to the Emergency Department after an accident with a chain saw. The client is exhibiting
signs and symptoms of acute hypovolemic anemia from severe blood loss. What signs and symptoms would the
nurse assess for?
A) Reduced urine output
B) Malabsorption disorders
C) Fatigue
D) Postural hypotension
A
(Reduced urine output
Acute hypovolemic anemia from severe blood loss is evidenced by the signs and symptoms of hypovolemic shock, which
include reduced urine output. The symptoms of chronic hypovolemic anemia include fatigue and postural hypotension.
Clients with malabsorption disorders are at great risk of iron deficiency anemia.)
The nurse is currently planning the care of a patient with multiple myeloma who is experiencing bone destruction.
When reviewing the patientts most recent blood work, what value would the nurse pay particular attention to?
A) Hypercalcemia
B) Elevated red blood cell (RBC) count
C) Hyperproteinemia
D) Elevated serum viscosity
A
(Hypercalcemia
Hypercalcemia may occur when bone destruction occurs due to the disease process. Elevated serum viscosity occurs
because plasma cells excrete excess immunoglobulin. RBC count will be decreased. Hyperproteinemia would not be
present.)
A 50-year-old woman was recently diagnosed with non-Hodgkints lymphoma (NHL) and has begun a treatment
regimen that includes simultaneous radiation therapy and chemotherapy. The combination of severe symptoms
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and aggressive therapy has necessitated admission to the hospital. When providing care for this patient, which of
the following actions should the nurse implement?
A) Applying standard precautions conscientiously to reduce the patientts risk of infection
B) Monitoring the patientts bowel pattern and facilitating a high-fiber diet
C) Encouraging frequent mobilization and independence in activities of daily living
D) Providing meticulous skin care and turning the patient at least once every 2 hours
A
(Applying standard precautions conscientiously to reduce the patient's risk of infection
Treatment for NHL creates a significant risk of infection, a threat that must be minimized when planning and implementing
nursing care. This is a priority over ADLs in the short term. The patient does not have a significantly increased risk of skin
breakdown or constipation, although the nurse would assess for each problem.)
Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets?
A) Anemia
B) Thrombocytopenia
C) Pancytopenia
D) Leukopenia
C
(Pancytopenia
Pancytopenia may be congenital or acquired. Anemia refers to decreased red cell mass. Leukopenia refers to a less-thannormal amount of WBCs in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.)
A client who is being treated for AML has bruises on both legs. What is the nursets most appropriate action?
A) Ask the client whether they have recently fallen.
B) Keep the client on bed rest.
C) Evaluate the clientts INR.
D) Evaluate the clientts platelet count.
D
(Evaluate the client's platelet count.
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Complications of AML include bleeding. The risk of bleeding correlates with the level and duration of platelet deficiency.
Major hemorrhages may develop when the platelet count drops to less than 10,000/mm3. The bleeding is usually
unrelated to falling. Keeping the client on bed rest will not prevent bleeding when the client has a low platelet count.
Assessment for other areas of bleeding is also a priority intervention.)
A patient with AML is having aggressive chemotherapy to attempt to achieve remission. The patient is aware that
hospitalization will be necessary for several weeks. What type of therapy will the nurse explain that the patient will
receive?
A) Standard therapy
B) Supportive therapy
C) Antimicrobial therapy
D) Induction therapy
D
(Induction therapy
Despite advances in understanding of the biology of AML, substantive advances in treatment response rates and survival
rates have not occurred for decades, with the exception of advances made in treating APL (see later discussion). Even for
patients with subtypes that have not benefited from advances in treatment, cure is still possible. The overall objective of
treatment is to achieve complete remission, in which there is no evidence of residual leukemia in the bone marrow.
Attempts are made to achieve remission by the aggressive administration of chemotherapy, called induction therapy,
which usually requires hospitalization for several weeks.)
A patient with polycythemia vera is complaining of severe itching. What triggers does the nurse know can cause
this distressing symptom? (Select all that apply.)
A) Aspirin
B) Allergic reaction to the red blood cell increase
C) Alcohol consumption
D) Exposure to water of any temperature
E) Temperature change
C, D, E
(- Alcohol consumption
- Exposure to water of any temperature
- Temperature change
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Pruritus is very common, occurring in up to 70% of patients with polycythemia vera (Saini, Patnaik & Tefferi, 2010) and is
one of the most distressing symptoms of this disease. It is triggered by contact with temperature change, alcohol
consumption, or, more typically, exposure to water of any temperature but seems to be worse with exposure to hot water.)
Clinical assessment of a patient with AML includes observing for signs of infection, the major cause of death for
AML. The nurse should assess for indicators of:
A) Thrombocytopenia.
B) Splenomegaly.
C) Bone marrow expansion.
D) Neutropenia.
B
(Splenomegaly.
Acute myeloid leukemia starts inside the bone marrow and prevents the formation of white blood cells. A bone marrow
analysis that shows greater than 30% of immature blast cells is indicative of an AML diagnosis.)
A nurse assesses a patient who has been diagnosed with DIC. Which of the following indicators are consistent with
this diagnosis? Select all that apply.
A) Capillary fill time <3 seconds
B) Increased breath sounds
C) Cyanosis in the extremities
D) Polyuria
E) Increased blood urea nitrogen (BUN) and creatinine
F) Dyspnea and hypoxia
C, E, F
(- Increased blood urea nitrogen (BUN) and creatinine
- Dyspnea and hypoxia
- Cyanosis in the extremities
Urine output would be decreased in DIC, and capillary fill time would be more than 3 seconds; breath sounds would be
decreased. Refer to Table 20-4 in the text.)
1. An oncology nurse is providing health education for a patient who has recently been diagnosed with leukemia.
What should the nurse explain about commonalities between all of the different subtypes of leukemia?
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A) The different leukemias all involve unregulated proliferation of white blood cells.
B) The different leukemias all have unregulated proliferation of red blood cells and decreased bone marrow
function.
C) The different leukemias all result in a decrease in the production of white blood cells.
D) The different leukemias all involve the development of cancer in the lymphatic system.
A) The different leukemias all involve unregulated proliferation of white blood cells.
Leukemia commonly involves unregulated proliferation of white blood cells. Decreased production of red blood cells is
associated with anemias. Decreased production of white blood cells is associated with leukopenia. The leukemias are not
characterized by their involvement with the lymphatic system.
2. A nurse is caring for a patient who has a diagnosis of acute leukemia. What assessment most directly addresses
the most common cause of death among patients with leukemia?
A) Monitoring for infection
B) Monitoring nutritional status
C) Monitor electrolyte levels
D) Monitoring liver function
A) Monitoring for infection
In patients with acute leukemia, death typically occurs from infection or bleeding. Compromised nutrition, electrolyte
imbalances, and impaired liver function are all plausible, but none is among the most common causes of death in this
patient population.
3. An oncology nurse is caring for a patient with multiple myeloma who is experiencing bone destruction. When
reviewing the patientts most recent blood tests, the nurse should anticipate what imbalance?
A) Hypercalcemia
B) Hyperproteinemia
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C) Elevated serum viscosity
D) Elevated RBC count
A) Hypercalcemia
Hypercalcemia may result when bone destruction occurs due to the disease process. Elevated serum viscosity occurs
because plasma cells excrete excess immunoglobulin. RBC count will be decreased. Hyperproteinemia would not be
present.
4. A nurse is planning the care of a patient who has been admitted to the medical unit with a diagnosis of multiple
myeloma. In the patientts care plan, the nurse has identified a diagnosis of Risk for Injury. What pathophysiologic
effect of multiple myeloma most contributes to this risk?
A) Labyrinthitis
B) Left ventricular hypertrophy
C) Decreased bone density
D) Hypercoagulation
C) Decreased bone density
Clients with multiple myeloma are at risk for pathologic bone fractures secondary to diffuse osteoporosis and osteolytic
lesions. Labyrinthitis is uncharacteristic, and patients do not normally experience hypercoagulation or cardiac hypertrophy.
5. A patient with advanced leukemia is responding poorly to treatment. The nurse finds the patient tearful and trying
to express his feelings, but he is clearly having difficulty. What is the nursets most appropriate action?
A) Tell him that you will give him privacy and leave the room.
B) Offer to call pastoral care.
C) Ask if he would like you to sit with him while he collects his thoughts.
D) Tell him that you can understand how hets feeling.
C) Ask if he would like you to sit with him while he collects his thoughts.
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Providing emotional support and discussing the uncertain future are crucial. Leaving is incorrect because leaving the
patient doesn't show acceptance of his feelings. Offering to call pastoral care may be helpful for some patients but should
be done after the nurse has spent time with the patient. Telling the patient that you understand how he's feeling is
inappropriate because it doesn't help him express his feelings.
6. A nursing student is caring for a patient with acute myeloid leukemia who is preparing to undergo induction
therapy. In preparing a plan of care for this patient, the student should assign the highest priority to which nursing
diagnoses?
A) Activity Intolerance
B) Risk for Infection
C) Acute Confusion
D) Risk for Spiritual Distress
B) Risk for Infection
Induction therapy places the patient at risk for infection, thus this is the priority nursing diagnosis. During the time of
induction therapy, the patient is very ill, with bacterial, fungal, and occasional viral infections; bleeding and severe
mucositis, which causes diarrhea; and marked decline in the ability to maintain adequate nutrition. Supportive care
consists of administering blood products and promptly treating infections. Immobility, confusion, and spiritual distress are
possible, but infection is the patient's most acute physiologic threat.
7. A 77-year-old male is admitted to a unit with a suspected diagnosis of acute myeloid leukemia (AML). When
planning this patientts care, the nurse should be aware of what epidemiologic fact?
A) Early diagnosis is associated with good outcomes.
B) Five-year survival for older adults is approximately 50%.
C) Five-year survival for patients over 75 years old is less than 2%.
D) Survival rates are wholly dependent on the patientts pre-illness level of health.
C) Five-year survival for patients over 75 years old is less than 2%.
he 5-year survival rate for patients with AML who are 50 years of age or younger is 43%; it drops to 19% for those
between 50 and 64 years, and drops to1.6% for those older than 75 years. Early diagnosis is beneficial, but is
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nonetheless not associated with good outcomes or high survival rates. Preillness health is significant, but not the most
important variable.
8. A 35-year-old male is admitted to the hospital complaining of severe headaches, vomiting, and testicular pain.
His blood work shows reduced numbers of platelets, leukocytes, and erythrocytes, with a high proportion of
immature cells. The nurse caring for this patient suspects a diagnosis of what?
A) AML
B) CML
C) MDS
D) ALL
D) ALL
In acute lymphocytic leukemia (ALL), manifestations of leukemic cell infiltration into other organs are more common than
with other forms of leukemia, and include pain from an enlarged liver or spleen, as well as bone pain. The central nervous
system is frequently a site for leukemic cells; thus, patients may exhibit headache and vomiting because of meningeal
involvement. Other extranodal sites include the testes and breasts. This particular presentation is not closely associated
with acute myeloid leukemia (AML), chronic myeloid leukemia (CML), or myelodysplastic syndromes (MDS)
9. A patient with leukemia has developed stomatitis and is experiencing a nutritional deficit. An oral anesthetic has
consequently been prescribed. What health education should the nurse provide to the patient?
A) Chew with care to avoid inadvertently biting the tongue.
B) Use the oral anesthetic 1 hour prior to meal time.
C) Brush teeth before and after eating.
D) Swallow slowly and deliberately.
A) Chew with care to avoid inadvertently biting the tongue.
If oral anesthetics are used, the patient must be warned to chew with extreme care to avoid inadvertently biting the
tongue or buccal mucosa. An oral anesthetic would be metabolized by the time the patient eats if it is used 1 hour prior to
meals. There is no specific need to warn the patient about brushing teeth or swallowing slowly because an oral anesthetic
has been used.
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10. A patient diagnosed with acute myelogenous leukemia has just been admitted to the oncology unit. When
writing this patientts care plan, what potential complication should the nurse address?
A) Pancreatitis
B) Hemorrhage
C) Arteritis
D) Liver dysfunction
B) Hemorrhage
Pancreatitis, arteritis, and liver dysfunction are generally not complications of leukemia. However, the patient faces a high
risk of hemorrhage.
11. An emergency department nurse is triaging a 77-year-old man who presents with uncharacteristic fatigue as
well as back and rib pain. The patient denies any recent injuries. The nurse should recognize the need for this
patient to be assessed for what health problem?
A) Hodgkin disease
B) Non-Hodgkin lymphoma
C) Multiple myeloma
D) Acute thrombocythemia
C) Multiple myeloma
Back pain, which is often a presenting symptom in multiple myeloma, should be closely investigated in older patients. The
lymphomas and bleeding disorders do not typically present with the primary symptom of back pain or rib pain.
12. A home health nurse is caring for a patient with multiple myeloma. Which of the following interventions should
the nurse prioritize when addressing the patientts severe bone pain?
A) Implementing distraction techniques
B) Educating the patient about the effective use of hot and cold packs
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C) Teaching the patient to use NSAIDs effectively
D) Helping the patient manage the opioid analgesic regime
D) Helping the patient manage the opioid analgesic regime
For severe pain resulting from multiple myeloma, opioids are likely necessary. NSAIDs would likely be ineffective and are
associated with significant adverse effects. Hot and cold packs as well as distraction would be insufficient for severe pain.
13. A nurse is caring for a patient with Hodgkin lymphoma at the oncology clinic. The nurse should be aware of
what main goal of care?
A) Cure of the disease
B) Enhancing quality of life
C) Controlling symptoms
D) Palliation
A) Cure of the disease
The goal in the treatment of Hodgkin lymphoma is cure. Palliation is thus not normally necessary. Quality of life and
symptom control are vital, but the overarching goal is the cure the disease.
14. A patient with non-Hodgkints lymphoma is receiving information from the oncology nurse. The patient asks the
nurse why she should stop drinking and smoking and stay out of the sun. What would be the nursets best
response?
A) Everyone should do these things because theytre health promotion activities that apply to everyone.
B) You dontt want to develop a second cancer, do you?
C) You need to do this just to be on the safe side.
D) Itts important to reduce other factors that increase the risk of second cancers.
D) It's important to reduce other factors that increase the risk of second cancers.
The nurse should encourage patients to reduce other factors that increase the risk of developing second cancers, such as
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use of tobacco and alcohol and exposure to environmental carcinogens and excessive sunlight. The other options do not
answer the patient's question, and also make light of the patient's question.
15. An adult patient has presented to the health clinic with a complaint of a firm, painless cervical lymph node. The
patient denies any recent infectious diseases. What is the nursets most appropriate response to the patientts
complaint?
A) Call 911.
B) Promptly refer the patient for medical assessment.
C) Facilitate a radiograph of the patientts neck and have the results forwarded to the patientts primary care
provider.
D) Encourage the patient to track the size of the lymph node and seek care in 1 week.
B) Promptly refer the patient for medical assessment
Hodgkin lymphoma usually begins as an enlargement of one or more lymph nodes on one side of the neck. The individual
nodes are painless and firm but not hard. Prompt medical assessment is necessary if a patient has this presentation.
However, there is no acute need to call 911. Delaying care for 1 week could have serious consequences and x-rays are
not among the common diagnostic tests.
16. A nurse practitioner is assessing a patient who has a fever, malaise, and a white blood cell count that is
elevated. Which of the following principles should guide the nursets management of the patientts care?
A) There is a need for the patient to be assessed for lymphoma.
B) Infection is the most likely cause of the patientts change in health status.
C) The patient is exhibiting signs and symptoms of leukemia.
D) The patient should undergo diagnostic testing for multiple myeloma
B) Infection is the most likely cause of the patient's change in health status.
Leukocytosis is most often the result of infection. It is only considered pathologic (and suggestive of leukemia) if it is
persistent and extreme. Multiple myeloma and lymphoma are not likely causes of this constellation of symptoms.
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17. Diagnostic testing has resulted in a diagnosis of acute myeloid leukemia (AML) in an adult patient who is
otherwise healthy. The patient and the care team have collaborated and the patient will soon begin induction
therapy. The nurse should prepare the patient for which of the following?
A) Daily treatment with targeted therapy medications
B) Radiation therapy on a daily basis
C) Hematopoietic stem cell transplantation
D) An aggressive course of chemotherapy
D) An aggressive course of chemotherapy
Attempts are made to achieve remission of AML by the aggressive administration of chemotherapy, called induction
therapy, which usually requires hospitalization for several weeks. Induction therapy is not synonymous with radiation, stem
cell transplantation, or targeted therapies.
18. A patient with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on the
oncology unit. What nursing action should be prioritized in the patientts care plan?
A) Protective isolation and vigilant use of standard precautions
B) Provision of a high-calorie, low-texture diet and appropriate oral hygiene
C) Including the family in planning the patientts activities of daily living
D) Monitoring and treating the patientts pain
A) Protective isolation and vigilant use of standard precautions
Induction therapy causes neutropenia and a severe risk of infection. This risk must be addressed directly in order to
ensure the patient's survival. For this reason, infection control would be prioritized over nutritional interventions, family
care, and pain, even though each of these are important aspects of nursing care.
19. A nurse is caring for a patient who has been diagnosed with leukemia. The nursets most recent assessment
reveals the presence of ecchymoseson the patientts sacral area and petechiae in her forearms. In addition to
informing the patientts primary care provider, the nurse should perform what action?
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A) Initiate measures to prevent venous thromboembolism (VTE).
B) Check the patientts most recent platelet level.
C) Place the patient on protective isolation.
D) Ambulate the patient to promote circulatory function.
B) Check the patient's most recent platelet level.
The patient's signs are suggestive of thrombocytopenia, thus the nurse should check the patient's most recent platelet
level. VTE is not a risk and this does not constitute a need for isolation. Ambulation and activity may be contraindicated
due to the risk of bleeding.
20. A 60-year-old patient with chronic myeloid leukemia will be treated in the home setting and the nurse is
preparing appropriate health education. What topic should the nurse emphasize?
A) The importance of adhering to the prescribed drug regimen
B) The need to ensure that vaccinations are up to date
C) The importance of daily physical activity
D) The need to avoid shellfish and raw foods
A) The importance of adhering to the prescribed drug regimen
Nurses need to understand that the effectiveness of the drugs used to treat CML is based on the ability of the patient to
adhere to the medication regimen as prescribed. Adherence is often incomplete, thus this must be a focus of health
education. Vaccinations normally would not be administered during treatment and daily physical activity may be impossible
for the patient. Dietary restrictions are not normally necessary.
21. An older adult patient is undergoing diagnostic testing for chronic lymphocytic leukemia (CLL). What
assessment finding is certain to be present if the patient has CLL?
A) Increased numbers of blast cells
B) Increased lymphocyte levels
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C) Intractable bone pain
D) Thrombocytopenia with no evidence of bleeding
B) Increased lymphocyte levels
An increased lymphocyte count (lymphocytosis) is always present in patients with CLL. Each of the other listed symptoms
may or may not be present, and none is definitive for CLL.
22. A patient has been found to have an indolent neoplasm. The nurse should recognize what implication of this
condition?
A) The patient faces a significant risk of malignancy.
B) The patient has a myeloid form of leukemia.
C) The patient has a lymphocytic form of leukemia.
D) The patient has a major risk factor for hemophilia.
A) The patient faces a significant risk of malignancy.
Indolent neoplasms have the potential to develop into a neoplasm, but this is not always the case. The patient does not
necessary have, or go on to develop, leukemia. Indolent neoplasms are unrelated to the pathophysiology of hemophilia.
23. A nurse is caring for a patient who is being treated for leukemia in the hospital. The patient was able to maintain
her nutritional status for the first few weeks following her diagnosis but is now exhibiting early signs and
symptoms of malnutrition. In collaboration with the dietitian, the nurse should implement what intervention?
A) Arrange for total parenteral nutrition (TPN).
B) Facilitate placement of a percutaneous endoscopic gastrostomy (PEG) tube.
C) Provide the patient with several small, soft-textured meals each day.
D) Assign responsibility for the patientts nutrition to the patientts friends and family.
C) Provide the patient with several small, soft-textured meals each day.
For patients experiencing difficulties with oral intake, the provision of small, easily chewed meals may be beneficial. This
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option would be trialed before resorting to tube feeding or TPN. The family should be encouraged to participate in care,
but should not be assigned full responsibility.
24. A patient who is undergoing consolidation therapy for the treatment of leukemia has been experiencing
debilitating fatigue. How can the nurse best meet this patientts needs for physical activity?
A) Teach the patient about the risks of immobility and the benefits of exercise.
B) Assist the patient to a chair during awake times, as tolerated.
C) Collaborate with the physical therapist to arrange for stair exercises.
D) Teach the patient to perform deep breathing and coughing exercises.
B) Assist the patient to a chair during awake times, as tolerated.
Sitting is a chair is preferable to bed rest, even if a patient is experiencing severe fatigue. A patient who has debilitating
fatigue would not likely be able to perform stair exercises. Teaching about mobility may be necessary, but education must
be followed by interventions that actually involve mobility. Deep breathing and coughing reduce the risk of respiratory
complications but are not substitutes for physical mobility in preventing deconditioning.
25. An oncology nurse recognizes a patientts risk for fluid imbalance while the patient is undergoing treatment for
leukemia. What relevant assessments should the nurse include in the patientts plan of care? Select all that apply.
A) Monitoring the patientts electrolyte levels
B) Monitoring the patientts hepatic function
C) Measuring the patientts weight on a daily basis
D) Measuring and recording the patientts intake and output
E) Auscultating the patientts lungs frequently
A) Monitoring the patient's electrolyte levels
C) Measuring the patient's weight on a daily basis
D) Measuring and recording the patient's intake and output
E) Auscultating the patient's lungs frequently
Assessments that relate to fluid balance include monitoring the patient's electrolytes, auscultating the patient's chest for
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adventitious sounds, weighing the patient daily, and closely monitoring intake and output. Liver function is not directly
relevant to the patient's fluid status in most cases.
26. After receiving a diagnosis of acute lymphocytic leukemia, a patient is visibly distraught, stating, I have no idea
where to go from here. How should the nurse prepare to meet this patientts psychosocial needs?
A) Assess the patientts previous experience with the health care system.
B) Reassure the patient that treatment will be challenging but successful.
C) Assess the patientts specific needs for education and support.
D) Identify the patientts plan of medical care.
C) Assess the patient's specific needs for education and support.
In order to meets the patient's needs, the nurse must first identify the specific nature of these needs. According to the
nursing process, assessment must precede interventions. The plan of medical care is important, but not central to the
provision of support. The patient's previous health care is not a primary consideration, and the nurse cannot assure the
patient of successful treatment
27. A patient has completed the full course of treatment for acute lymphocytic leukemia and has failed to respond
appreciably. When preparing for the patientts subsequent care, the nurse should perform what action?
A) Arrange a meeting between the patientts family and the hospital chaplain.
B) Assess the factors underlying the patientts failure to adhere to the treatment regimen.
C) Encourage the patient to vigorously pursue complementary and alternative medicine (CAM).
D) Identify the patientts specific wishes around end-of-life care.
D) Identify the patient's specific wishes around end-of-life care
Should the patient not respond to therapy, it is important to identify and respect the patient's choices about treatment,
including measures to prolong life and other end-of-life measures. The patient may or may not be open to pursuing CAM.
Unsuccessful treatment is not necessarily the result of failure to adhere to the treatment plan. Assessment should precede
meetings with a chaplain, which may or may not be beneficial to the patient and congruent with the family's belief system.
28. Following an extensive diagnostic workup, an older adult patient has been diagnosed with a secondary
myelodysplastic syndrome (MDS). What assessment question most directly addresses the potential etiology of this
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patientts health problem?
A) Were you ever exposed to toxic chemicals in any of the jobs that you held?
B) When you were younger, did you tend to have recurrent infections of any kind?
C) Have your parents or siblings had any disease like this?
D) Would you say that youtve had a lot of sun exposure in your lifetime?"
A) Were you ever exposed to toxic chemicals in any of the jobs that you held?
Secondary MDS can occur at any age and results from prior toxic exposure to chemicals, including chemotherapeutic
medications. Family history, sun exposure, and previous infections are unrelated to the pathophysiology of secondary
MDS.
29. A patient with a myelodysplastic syndrome is being treated on the medical unit. What assessment finding
should prompt the nurse to contact the patientts primary care provider?
A) The patient is experiencing a frontal lobe headache.
B) The patient has an episode of urinary incontinence.
C) The patient has an oral temperature of 37.5ºC (99.5ºF).
D) The patientts SpO2 is 91% on room air.
C) The patient has an oral temperature of 37.5ºC (99.5ºF).
Because the patient with MDS is at a high risk for infection, any early signs of infection must be reported promptly. The
nurse should address each of the listed assessment findings, but none is as direct a threat to the patient's immediate
health as an infection.
30. A nurse is preparing health education for a patient who has received a diagnosis of myelodysplastic syndrome
(MDS). Which of the following topics should the nurse prioritize?
A) Techniques for energy conservation and activity management
B) Emergency management of bleeding episodes
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C) Technique for the administration of bronchodilators by metered-dose inhaler
D) Techniques for self-palpation of the lymph nodes
B) Emergency management of bleeding episodes
Because of patients' risks of hemorrhage, patients with MDS should be taught techniques for managing emergent
bleeding episodes. Bronchodilators are not indicated for the treatment of MDS and lymphedema is not normally
associated with the disease. Energy conservation techniques are likely to be useful, but management of hemorrhage is a
priority because of the potential consequences.
31. A clinic patient is being treated for polycythemia vera and the nurse is providing health education. What
practice should the nurse recommend in order to prevent the complications of this health problem?
A) Avoiding natural sources of vitamin K
B) Avoiding altitudes of 31500 feet (457 meters)
C) Performing active range of motion exercises daily
D) Avoiding tight and restrictive clothing on the legs
D) Avoiding tight and restrictive clothing on the legs
Because of the risk of DVT, patients with polycythemia vera should avoid tight and restrictive clothing. There is no need to
avoid foods with vitamin K or to avoid higher altitudes. Activity levels should be maintained, but there is no specific need
for ROM exercises.
32. A clinic nurse is working with a patient who has a long-standing diagnosis of polycythemia vera. How can the
nurse best gauge the course of the patientts disease?
A) Document the color of the patientts palms and face during each visit.
B) Follow the patientts erythrocyte sedimentation rate over time.
C) Document the patientts response to erythropoietin injections.
D) Follow the trends of the patientts hematocrit.
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D) Follow the trends of the patient's hematocrit
.
The course of polycythemia vera can be best ascertained by monitoring the patient's hematocrit, which should remain
below 45%. Erythropoietin injections would exacerbate the condition. Skin tone should be observed, but is a subjective
assessment finding. The patient's ESR is not relevant to the course of the disease.
33. A nurse is planning the care of a patient who has been diagnosed with essential thrombocythemia (ET). What
nursing diagnosis should the nurse prioritize when choosing interventions?
A) Risk for Ineffective Tissue Perfusion
B) Risk for Imbalanced Fluid Volume
C) Risk for Ineffective Breathing Pattern
D) Risk for Ineffective Thermoregulation
A) Risk for Ineffective Tissue Perfusion
Patients with ET are at risk for hypercoagulation and consequent ineffective tissue perfusion. Fluid volume, breathing, and
thermoregulation are not normally affected
34. A nurse at a long-term care facility is amending the care plan of a resident who has just been diagnosed with
essential thrombocythemia (ET). The nurse should anticipate the administration of what medication?
A) Dalteparin
B) Allopurinol
C) Hydroxyurea
D) Hydrochlorothiazide
C) Hydroxyurea
Hydroxyurea is effective in lowering the platelet count for patients with ET. Dalteparin, allopurinol, and HCTZ do not have
this therapeutic effect.
35. A nurse is writing the care plan of a patient who has been diagnosed with myelofibrosis. What nursing
diagnoses should the nurse address? Select all that apply.
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A) Disturbed Body Image
B) Impaired Mobility
C) Imbalanced Nutrition: Less than Body Requirements
D) Acute Confusion
E) Risk for Infection
A) Disturbed Body Image
B) Impaired Mobility
C) Imbalanced Nutrition: Less than Body Requirements
E) Risk for Infection
The profound splenomegaly that accompanies myelofibrosis can impact the patient's body image and mobility. As well,
nutritional deficits are common and the patient is at risk for infection. Cognitive effects are less common.
36. An adult patientts abnormal complete blood count (CBC) and physical assessment have prompted the primary
care provider to order a diagnostic workup for Hodgkin lymphoma. The presence of what assessment finding is
considered diagnostic of the disease?
A) Schwann cells
B) Reed-Sternberg cells
C) Lewy bodies
D) Loops of Henle
B) Reed-Sternberg cells
The malignant cell of Hodgkin lymphoma is the Reed-Sternberg cell, a gigantic tumor cell that is morphologically unique
and thought to be of immature lymphoid origin. It is the pathologic hallmark and essential diagnostic criterion. Schwann
cells exist in the peripheral nervous system and Lewy bodies are markers of Parkinson disease. Loops of Henle exist in
nephrons.
37. A young adult patient has received the news that her treatment for Hodgkin lymphoma has been deemed
successful and that no further treatment is necessary at this time. The care team should ensure that the patient
receives regular health assessments in the future due to the risk of what complication?
A) Iron-deficiency anemia
B) Hemophilia
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C) Hematologic cancers
D) Genitourinary cancers
C) Hematologic cancers
Survivors of Hodgkin lymphoma have a high risk of second cancers, with hematologic cancers being the most common.
There is no consequent risk of anemia or hemophilia, and hematologic cancers are much more common than GU
cancers.
38. The clinical nurse educator is presenting health promotion education to a patient who will be treated for nonHodgkin lymphoma on an outpatient basis. The nurse should recommend which of the following actions?
A) Avoiding direct sun exposure in excess of 15 minutes daily
B) Avoiding grapefruit juice and fresh grapefruit
C) Avoiding highly crowded public places
D) Using an electric shaver rather than a razor
C) Avoiding highly crowded public places
The risk of infection is significant for these patients, not only from treatment-related myelosuppression but also from the
defective immune response that results from the disease itself. Limiting infection exposure is thus necessary. The need to
avoid grapefruit is dependent on the patient's medication regimen. Sun exposure and the use of razors are not necessarily
contraindicated.
39. A patient has a diagnosis of multiple myeloma and the nurse is preparing health education in preparation for
discharge from the hospital. What action should the nurse promote?
A) Daily performance of weight-bearing exercise to prevent muscle atrophy
B) Close monitoring of urine output and kidney function
C) Daily administration of warfarin (Coumadin) as ordered
D) Safe use of supplementary oxygen in the home setting
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B) Close monitoring of urine output and kidney function
Renal function must be monitored closely in the patient with multiple myeloma. Excessive weight-bearing can cause
pathologic fractures. There is no direct indication for anticoagulation or supplementary oxygen.
40. A nurse is caring for patient whose diagnosis of multiple myeloma is being treated with bortezomib. The nurse
should assess for what adverse effect of this treatment?
A) Stomatitis
B) Nephropathy
C) Cognitive changes
D) Peripheral neuropathy
D) Peripheral neuropathy
A significant toxicity associated with the use of bortezomib for multiple myeloma is peripheral neuropathy. Stomatitis,
cognitive changes, and nephropathy are not noted to be adverse effects of this medication.
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UNIT 7 Immunologic Function
Brunner & Suddarth's Textbook of Medical Surgical Nursing 15th Edition
Chapter 31: Assessment of Immune Function
Which of the following is a age-related change associated with the immune system?
a) Decreased antibody production
b) Increased antibody production
c) Elevated phagocytic immune response
d) Ability to differentiate "self" from "nonself"
a) Decreased antibody production
Explanation:
Age-related changes associated with the immune response include decreased antibody production, suppressed
phagocytic immune response, and a failure of immune system to differentiate "self" from "nonself." pg.979
While taking the health history of a newly admitted client, the nurse asks for a list of the clientts current
medications. Which of the following medication classifications would place the client at risk for impaired immune
function?
a) Antimetabolites
b) Inotropics
c) Antihypertensives
d) Pancreatic enzymes
a) Antimetabolites
Explanation:
Antimetabolites can cause leukopenia, eosinoplilia, aplastic bone marrow, and pancytopenia. The other choices do not
directly affect the immune system.
A nurse is caring for a patient undergoing evaluation for possible immune system disorders. Which of the following
interventions will best help support the patient throughout the diagnostic process?
a) Assisting the patient with the scheduling of the procedures
b) Encouraging the patient to ask their physician for information about the treatment options for the possible
diagnosis
c) Educating the patient about the diagnostic procedures and answer questions they may have about the possible
diagnosis
d) Accompanying the patient to the diagnostic tests
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c) Educating the patient about the diagnostic procedures and answer questions they may have about the possible
diagnosis
Explanation:
It is the nurse's role to counsel, educate, and support patients throughout the diagnostic process. Many patients may be
extremely anxious about the results of diagnostic tests and the possible implications of those results for their employment,
insurance, and personal relationships. This is an ideal time for the nurse to provide counseling and education. pg.984
You are the clinic nurse caring for a client with a suspected diagnosis of HIV. You are preparing to draw blood for a
confirmatory diagnostic test on this client. What is the most important action that the nurse should perform before
testing a client for HIV?
a) Advise the client to take off any ornaments and metallic objects.
b) Advise the client to avoid excess fluid intake.
c) Advise the client to abstain from having intercourse.
d) Obtain a written consent from the client.
d) Obtain a written consent from the client.
Explanation:
It is important that the nurse obtain written consent from the client before performing an HIV test and keep the results of
HIV test confidential. The nurse may not ask the client to avoid excess fluid intake or abstain from intercourse before the
tests. The client also need not take off ornaments and metallic objects worn unless they are likely to interfere with the test
results. pg.1005
A 38-year-old female patient has begun to suffer from rheumatoid arthritis. She is also being assessed for disorders
of the immune system. She works as an aide at a facility that cares for children infected with AIDS. Which of the
following is the most important factor related to the patientts assessment?
a) Her age
b) Her home environment
c) Her diet
d) Her use of other drugs
d) Her use of other drugs
Explanation:
The nurse needs to review the patient's drug history. This data will help her to assess the patient's susceptibility to illness
because certain past illnesses and drugs, such as corticosteroids, suppress the inflammatory and immune responses. The
patient's age, home environment, and diet do not have any major implications during her assessment because they do not
indicate her susceptibility to illness. pg.982
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The nurse is caring for a client recovering from a major burn. Burns affect the immune system by causing a loss of
large amounts of which of the following?
a) Plasma, which depletes the bodyts store of catecholamines
b) Serum, which depletes the bodyts store of immunoglobulins
c) Plasma, which depletes the bodyts store of calcitonin
d) Serum, which depletes the bodyts store of glucagon
b) Serum, which depletes the body's store of immunoglobulins
Explanation:
Major burns cause impaired skin integrity and compromise the body's first line of defense. Loss of large amounts of serum
occurs with burn injuries and depletes the body of essential proteins, including immunoglobulins. Loss of serum or plasma
does not deplete the body of catecholamines (adrenal gland), calcitonin (thyroid gland), or glucagon (pancreas). pg.982
What is the function of the thymus gland?
a) Produce stem cells
b) Programs B lymphocytes to become regulator or effector Bcells.
c) Develop the lymphatic system
d) Programs T lymphocytes to become regulator or effector T cells.
d) Programs T lymphocytes to become regulator or effector T cells.
Explanation:
The thymus gland is located in the neck below the thyroid gland. It extends into the thorax behind the top of the sternum.
The thymus gland produces lymphocytes during fetal development. It may be the embryonic origin of other lymphoid
structures such as the spleen and lymph nodes. After birth, the thymus gland programs T lymphocytes to become
regulator or effector T cells. The thymus gland becomes smaller during adolescence but retains some activity throughout
the life cycle. Options A, B, and C are incorrect. pg.971
A patient undergoing a skin test has been intradermally injected with a disease-specific antigen on the inner
forearm. The patient becomes anxious because the area begins to swell. Which of the following may be used to
decrease anxiety in this patient?
a) Advise the patient to use prescribed analgesics
b) Apply ice packs to reduce the swelling
c) Gently rub the swollen area to accelerate the blood flow
d) Assure the patient that this is a normal reaction
d) Assure the patient that this is a normal reaction
Explanation:
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The nurse should assure the patient that this is a normal reaction. When disease-specific antigens are injected, the
injection area swells as a result of the patient developing antibodies against the antigen that is introduced. The nurse
should also keep in mind that the patient is not necessarily actively infectious if the test results are positive. Rubbing the
area gently or even applying ice packs may only aggravate the swelling. The swollen area should be left open to heal by
itself. The nurse should await the physician's instructions before advising the patient to use any prescribed analgesics.
pg.984
Which of the following protective responses begin with the B lymphocytes?
a) Recognition
b) Phagocytic
c) Humoral
d) Cellular
c) Humoral
Explanation:
A second protective response, the humoral immune response, begins with the B lymphocytes, which can transform
themselves into plasma cells that manufacture antibodies. The first line of defense, the phagocytic immune response,
involves the white blood cells (WBCs; granulocytes and macrophages), which have the ability to ingest foreign particles.
The third mechanism of defense, the cellular immune response, also involves T lymphocytes, which can turn into special
cytotoxic (or killer) T cells that can attack the pathogens. Recognition of antigens as foreign, or nonself, by the immune
system is the initiating even in any immune response. pg.972
The anatomy and physiology instructor is explaining a cell-mediated response to the pre-nursing students. What
actions would the instructor explain occur in a cell-mediated response?
a) T-cell lymphocytes survey proteins in the body and attack the invading antigens.
b) Toxins of invading antigens are neutralized.
c) The invading antigens precipitate.
d) The invading antigens link together (agglutination).
a) T-cell lymphocytes survey proteins in the body and attack the invading antigens.
Explanation:
During a cell-mediated response, T-cell lymphocytes survey proteins in the body, actively analyze the surface features,
and respond to those that differ from the host by directly attacking the invading antigen. For example, a cell-mediated
response occurs when an organ is transplanted. Immunoglobulins hinder the antigens physically by neutralizing their
toxins through agglutination or by causing them to precipitate. pg.971
The nurse is obtaining a history from a patient with severe psoriasis. What question would be the most important to
ask this patient to determine a genetic predisposition?
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a) "How did you know you developed this disease?"
b) "Does anyone in your family have more than one autoimmune disease?"
c) "How many children do you have?"
d) "Does your spouse or significant other have an autoimmune disease?"
b) "Does anyone in your family have more than one autoimmune disease?"
Explanation:
The patient is asked about any autoimmune disorders, such as lupus erythematosus, rheumatoid arthritis, multiple
sclerosis, or psoriasis. The onset, severity, remissions and exacerbations, functional limitations, treatments that the patient
has received or is currently receiving, and effectiveness of the treatments are described. The occurrence of different
autoimmune diseases within a family strongly suggests a genetic predisposition to more than one autoimmune disease
(Brooks, 2010) (Chart 35-4). pg.981
A patient comes into the emergency department with complaints of difficulty walking and loss of muscle control in
the arms. As the nurse begins the physical examination, which of the following assessment should be completed if
an immune dysfunction in the neurosensory system is suspected?
a) Assess for hepatosplenomegaly by measuring abdominal girth
b) Assess for ataxia using the finger-to-nose test and heel-to-shin test
c) Review the urinalysis report for hematuria
d) Assess joint mobility using passive range of motion.
b) Assess for ataxia using the finger-to-nose test and heel-to-shin test
Explanation:
Ataxia should be assessed when suspecting immune dysfunction in the neurosensory system. pg.979
A client has been diagnosed with AIDS and tuberculosis (TB). A nursing student asks the nurse why the clientts
skin test for TB is negative if the clientts physician has diagnosed TB. The nursets correct reply is which of the
following?
a) The client has only mild TB, which is not enough to cause a reaction.
b) The solution used for the skin test was probably outdated.
c) The clientts immune system cannot mount a response to the skin test.
d) The skin test was improperly performed.
c) The client's immune system cannot mount a response to the skin test.
Explanation:
The inflammatory response is a major function of the immune system that is elicited in response to invading foreign
material. A person with AIDS has a poorly functioning or non-functioning immune system that will not respond to the
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injected skin test. Any TB organisms should cause a reaction to the skin test in people with intact immune systems. The
nurse cannot accurately speculate on how the skin test was performed or that the solution was outdated. pg.984
Which of the following is associated with impaired immunity relating to the aging patient?
a) Increase in humoral immunity
b) Decrease in inflammatory cytokines
c) Breakdown and thinning of the skin
d) Increase in peripheral circulation
c) Breakdown and thinning of the skin
Explanation:
The aging process stimulates changes in the immune system. Age-related changes in many body systems also contribute
to impaired immunity. Changes such as poor circulation, as well as the breakdown of natural mechanical barriers such as
the skin, place the aging immune system at even greater disadvantage against infection. As the immune system
undergoes age-associated alterations, its response to infections progressively deteriorates. There is a decline in humoral
immunity and inflammatory cytokines increase with age. pg.978
What organ is considered lymphoid tissue?
a) Pancreas
b) Spleen
c) Intestines
d) Liver
b) Spleen
Explanation:
Lymphoid tissues, such as the thymus gland, tonsils and adenoids, spleen, and lymph nodes, play a role in the immune
response and prevention of infection. The pancreas, intestines, and liver are not lymphoid tissue. pg.971
Which of the following is associated with impaired immunity in the aging patient?
a) Incidence of autoimmune disease decreases with age
b) Skin becomes thicker
c) Decreased renal function
d) Increased antibody production
c) Decreased renal function
Explanation:
Decreased renal circulation, filtration, absorption, and excretion contribute to the risk for urinary tract infections. The
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antibody production decreases, skin become thinner, and the incidence of autoimmune disease increases with age.
pg.979
A laboring mother asks the nurse if the baby will have immunity to some illnesses when born. What type of
immunity does the nurse understand that the newborn will have?
a) Passive immunity transferred by the mother
b) Artificially acquired active immunity
c) Naturally acquired active immunity
d) There is no immunity passed down from mother to child.
a) Passive immunity transferred by the mother
Explanation:
Passive immunity develops when ready-made antibodies are given to a susceptible person. The antibodies provide
immediate but short-lived protection from the invading antigen. Newborns receive passive immunity to some diseases for
which their mothers have manufactured antibodies. Naturally acquired active immunity occurs as a direct result of infection
by a specific micro organism. An example is the immunity to measles that develops after the initial infection. Not all
invading microorganisms produce a response that gives lifelong immunity. Artificially acquired immunity is obtained by
receiving a killed or weakened microorganism or toxoid. pg.972
What are the primary participants in the immune system?
a) Lymphoblasts and gamma globulins
b) T- and B- cell lymphocytes
c) Macrophages and memory cells
d) Stem cells and monocytes
b) T- and B- cell lymphocytes
Explanation:
Lymphocytes, which are either T-cell or B-cell lymphocytes, comprise 20% to 30% of all leukocytes. T-cell and B-cell
lymphocytes are the primary participants in the immune response. Therefore options A, C, and D are incorrect. pg.969
A patient arrives at the clinic and informs the nurse that she has a very sore throat as well as a fever. A rapid strep
test returns a positive result and the patient is given a prescription for an antibiotic. How did the streptococcal
organism gain access to the patient to cause this infection?
a) Breathing in airborne dust
b) Through the mucous membranes of the throat
c) Through the skin
d) From being outside in the cold weather and decreasing resistance
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b) Through the mucous membranes of the throat
Explanation:
In a streptococcal throat infection, the streptococcal organism gains access to the mucous membranes of the throat.
pg.973
A 6-year-old patient is diagnosed with a viral infection of the respiratory system. Which of the following will most
likely be trying to fight the antigen?
a) Self-antigens
b) B cells
c) Complements
d) Interferons
d) Interferons
Explanation:
Interferon, one type of biologic response modifier, is a nonspecific viricidal protein that is naturally produced by the body
and is capable of activating other components of the immune system. Interferons have antiviral and antitumor properties.
In addition to responding to viral infection, interferons are produced by T lymphocytes, B lymphocytes, and macrophages
in response to antigens. They are thought to modify the immune response by suppressing antibody production and
cellular immunity. pg.977
Which of the following cell types are involved in humoral immunity?
a) Memory T lymphocyte
b) Helper T lymphocyte
c) Suppressor T lymphocyte
d) B lymphocytes
d) B lymphocytes
Explanation:
B lymphocytes are involved in the humoral immune response. T lymphocytes are involved in cellular immunity. pg.972
A school nurse is talking about infection with a high school health class. What would be the nursets best
explanation of the process of phagocytosis?
a) Removal of bacteria and dead blood cells from circulation
b) Release of chemicals to destroy bacteria and foreign material
c) Engulfment and digestion of bacteria and foreign material
d) Conversion of memory cells to plasma cells
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c) Engulfment and digestion of bacteria and foreign material
Explanation:
Phagocytosis is the process of engulfing and digesting bacteria and foreign materials. It does not involve the release of
chemicals or conversion of memory cells to plasma cells. The macrophages in the spleen remove bacteria and dead
blood cells from circulation. pg.972
A client is treated in the clinic for a sexually transmitted infection, and the nurse suspects that the client is at risk
for HIV. The physician determines that the client should be tested for the virus. What responsibility does the nurse
have?
a) The nurse will call the client with the results of the test.
b) The nurse will inform the client that the results will have to be reported to the Centers for Disease Control and
Prevention (CDC).
c) The nurse ensures a written consent is obtained prior to testing.
d) The nurse should send the client to have the blood drawn without informing him about the specific screening
test.
c) The nurse ensures a written consent is obtained prior to testing.
Explanation:
The nurse ensures that a written consent is obtained before testing for human immunodeficiency virus (HIV) and keeps
the results of HIV testing confidential. The client should never be tested without his knowledge. The physician will review
the results when the client comes in for a follow-up visit. It is not necessary for the nurse to report results to the CDC.
pg.1005
The nurse is beginning the physical examination of a client with a complaint of fatigue. What documentation will the
nurse provide to describe this general appraisal of the clientts health?
a) The client is alert and oriented to all spheres.
b) The client has palpable peripheral pulses in the upperextremities.
c) The client appears mildly ill, listless, and disheveled.
d) The client has a blood pressure of 120/72 mm Hg.
c) The client appears mildly ill, listless, and disheveled.
Explanation:
The beginning of the physical examination is a general appraisal of the client's health. The nurse notes whether the client
appears healthy, acutely or mildly ill, malnourished, extremely tired, or listless. The next thing the nurse will do is obtain
vital signs and then performs a more comprehensive examination. pg.65
An experiment is designed to determine specific cell types involved in cell-mediated immune response. The
experimenter is interested in finding cells that attack the antigen directly by altering the cell membrane and causing
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cell lysis. Which cells should be isolated?
a) B cells
b) Helper T cells
c) Macrophages
d) Cytotoxic T cells
d) Cytotoxic T cells
Explanation:
Cytotoxic T cells (killer T cells) attack the antigen directly by altering the cell membrane and causing cell lysis
(disintegration) and by releasing cytolytic enzymes and cytokines. Lymphokines can recruit, activate, and regulate other
lymphocytes and white blood cells (WBCs). These cells then assist in destroying the invading organism. pg.976
A 20-year-old male patient cut his hand while replacing a window. While reviewing the complete blood count (CBC)
with differential, the nurse would expect which of the following cell types to be elevated first in order to prevent an
infection in the patientts hand?
a) Monocytes
b) Neutrophils
c) Eosinophils
d) B cells
b) Neutrophils
Explanation:
Neutrophils (polymorphonuclear leukocytes [PMNs]) are the first cells to arrive at the site where inflammation occurs.
Eosinophils and basophils, other types of granulocytes, increase in number during allergic reactions and stress responses.
pg.971
During the immune response, cytotoxic cells bind to invading cells, destroy the targeted invader, and release
lymphokines to remove the debris. Which type of T-cell lymphocyte is cytotoxic?
a) Suppressor T cells
b) Helper T cells
c) Regulator T cells
d) Effector T cells
d) Effector T cells
Explanation:
Effector T cells are killer (cytotoxic) cells. pg.975
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When obtaining a health history from a patient with possible abnormal immune function, what question would be a
priority for the nurse to ask?
a) "Have you ever received a blood transfusion?"
b) "When was your last menstrual period?"
c) "Do you have abdominal pain or discomfort?"
d) "Have you ever been treated for a sexually transmitted infection?"
a) "Have you ever received a blood transfusion?"
Explanation:
A history of blood transfusions is obtained, because previous exposure to foreign antigens through transfusion may be
associated with abnormal immune function. pg.982
A client who is being treated for complications related to acquired immunodeficiency disorder syndrome (AIDS) is
receiving interferon parenterally as adjunctive therapy. Why does the nurse understand this route is being used?
a) The taste of the medication is not palatable.
b) The medication, given orally, will cause diarrhea.
c) Digestive enzymes destroy its protein structure.
d) The medication will work more rapidly parenterally.
c) Digestive enzymes destroy its protein structure.
Explanation:
Interferon is administered parenterally because digestive enzymes destroy its protein structure. The medicine does not
have an oral preparation. pg.1014
You are caring for a client with a suspected immune system disorder. What test would be ordered if a deficiency or
excess of immuneglobulins was suspected?
a) Protein electrophoresis
b) Plasmapheresis
c) T-cell and B-cell assays
d) Enzyme-linked immunosorbent assay
a) Protein electrophoresis
Explanation:
When an immune system disorder is suspected, protein electrophoresis screens for diseases associated with a deficiency
or excess of immuneglobulins may be ordered. Options B, C, and D are incorrect tests to diagnose a deficiency or excess
of immuneglobulins. pg.984
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Decades ago, a typical childhood surgery, after repeated bouts with tonsillitis, was to have a tonsillectomy and
adenoidectomy. That was before the role of the tonsils and adenoids were better understood. As it is understood
today, what are the roles of the tonsils and adenoids?
a) They are lymphoid tissues that filter bacteria from tissue fluid.
b) They are lymphoid tissues that increase the efficacy of antibiotics.
c) They are lymphoid tissues that program T lymphocytes.
d) They are lymphoid tissues that eliminate cancer cells.
a) They are lymphoid tissues that filter bacteria from tissue fluid.
Explanation:
The tonsils and adenoids filter bacteria from tissue fluid. Because they are exposed to pathogens in the oral and nasal
passages, they can become infected and locally inflamed. The tonsils and adenoids filter bacteria from tissue fluid. pg.970
The nurse is instructing clientts about the importance of taking the shingles vaccine. Which client would benefit
from this vaccine?
a) A 65-year-old client who had chicken pox when he was 12 years old
b) A 32-year-old client who has never had chickenpox
c) A 24-year-old client who is pregnant
d) A 17-year-old client who will be attending college and living in a dormitory
a) A 65-year-old client who had chicken pox when he was 12 years old
Explanation:
Half of individuals living to age 65 years have had or will develop shingles and may not understand the potential
seriousness and risk for complications. Nurses as client advocates should determine and provide health information
regarding the shingles vaccine. The other clients are not candidates for the vaccine. pg.1779
A client is admitted to the hospital with a diagnosis of pneumonia. The client informs the nurse that he has several
drug allergies. The physician has ordered an antibiotic as well as several other medications for cough and fever.
What should the nurse do prior to administering the medications?
a) Administer the medications that the physician ordered.
b) Call the pharmacy and let them know the client has several drug allergies.
c) Consult drug references to make sure the medicines do not contain substances which the client is
hypersensitive.
d) Give the client one medicine at a time and observe for allergic reactions.
c) Consult drug references to make sure the medicines do not contain substances which the client is hypersensitive.
Explanation:
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Clear identification of any substances to which the client is allergic is essential. The nurse must consult drug references to
verify that prescribed medications do not contain substances to which the client is hypersensitive. Administering the
medications or giving one at a time may cause the client to have an allergic reaction. The nurse may call the pharmacy
but still maintains responsibility for the medications administered. pg.978
A nurse is taking the health history of a newly admitted client. Which of the following conditions would NOT place
the client at risk for impaired immune function?
a) History of radiation therapy
b) Previous organ transplantation
c) Surgical removal of the appendix
d) Surgical history of a splenectomy
c) Surgical removal of the appendix
Explanation:
Removal of the appendix would have no direct effect on the immune system. Organ transplantaion requires
immunosupressive drugs, which cause impaired immune function. Radiation therapy destroys lymphocytes. The spleen is
an important part of the immune system, and removal of it increases the client's risk for poor immune function. pg.1556
A nurse is caring for a client with multiple sclerosis. Client education about the disease process includes which of
the following explanations about the cause of the disorder?
a) Regulatory mechanisms fail to halt the immune response.
b) The immune system recognizes onets own tissues as "self."
c) Excess cytokines cause tissue damage.
d) The immune system recognizes onets own tissues as "foreign."
d) The immune system recognizes one's own tissues as "foreign."
Explanation:
The immune system's recognition of one's own tissues as "foreign" rather than self is the basis of many autoimmune
disorders, including multiple scelrosis. When regulatory mechanisms fail to halt the immune response or excess cytokines
are produced, pathology occurs (eg, allergies, hypersensitivity). pg.970
Matt Carson, a 20-year-old college student, was riding his motorcycle home from class when he lost control of the
bike and sustained serious internal injuries, including a ruptured spleen. Matt has been taken to the OR to remove
his spleen and the ED nurse is meeting with Mattts parents to answer some of their additional questions. Which of
the following will be included in the nursets discussion regarding special considerations following the removal of
Mattts spleen?
a) Matt will be susceptible to bleeding because the spleen synthesizes vitamin K.
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b) Matt will be susceptible to infection because the spleen removes bacteria from the blood.
c) Matt will be susceptible to anemia because the spleen produces red blood cells.
d) Matt will be susceptible to acidosis because the spleen maintains acid-base balance.
b) Matt will be susceptible to infection because the spleen removes bacteria from the blood.
Explanation:
One function of the spleen is to remove bacteria from circulation; therefore, Matt will be more susceptible to infection.
pg.971
What type of immunoglobulin does the nurse recognize that promotes the release of vasoa ctive chemicals such as
histamine when a client is having an allergic reaction?
a) IgM
b) IgE
c) IgA
d) IgG
b)
IgE
Explanation:
IgE promotes the release of vasoactive chemicals such as histamine and bradykinin in allergic, hypersensitivity, and
inflammatory reaction. IgG neutralizes bacterial toxins and accelerates phagocytosis. IgA interferes with the entry of
pathogens through exposed structures or pathways. IgM agglutinates antigens and lyses cell walls. pg.975
During which stage of the immune response does the circulating lymphocyte containing the antigenic message
return to the nearest lymph node?
a) Proliferation
b) Recognition
c) Response
d) Effector
a) Proliferation
Explanation:
During the proliferation phase the circulating lymphocytes containing the antigenic message return 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. In the recognition stage, the immune system distinguishes an invader as foreign, or nonself. In the response stage, the changed lymphocytes function either in a humoral or cellular fashion. In the effector stage,
either the antibody of the humoral response or the cytotoxic T cell of the cellular response reaches and couples with the
antigen on the surface of the foreign invader. pg.973
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A client is informed that his white blood cell count is low and that he is at risk for the development of infections.
The client asks, "Where do I make new white blood cells?" What is the best response by the nurse?
a) "White blood cells are produced in the lymphatic tissue."
b) "White blood cells are produced in the plasma."
c) "White blood cells are produced in the bone marrow."
d) "White blood cells are produced in the thymus gland."
c) "White blood cells are produced in the bone marrow."
Explanation:
White blood cells (leukocytes) are produced in the bone marrow. They are not produced in the plasma, thymus gland, or
the lymphatic tissue. pg.970
The nurse is obtaining information from a client with Crohnts disease about his medication history. What
medication would the nurse include when asking about what medications the client has taken for suppression of
the inflammatory and immune response?
a) Corticosteroids
b) Ibuprofen (Advil)
c) Diuretics
d) Angiotensin-converting enzyme inhibitors (ACE-I)
a) Corticosteroids
Explanation:
The nurse obtains a history of immunizations, recent and past infectious diseases, and recent exposure to infectious
diseases. He or she reviews the client's drug history because certain drugs, such as corticosteroids, suppress the
inflammatory and immune responses. Advil is a nonsteroidal anti-inflammatory medication and does not suppress the
inflammatory and immune responses. An ACE-I prevents the conversion of angiotensin I to angiotensin II and does not
suppress the inflammatory or immune response. Diuretics also do not suppress the immune response but help reduce
excess fluid from the kidneys. pg.1502
A nursing instructor is giving a lecture on the immune system. Which of the following cells will the instructor
include in her discussion on phagocytosis?
a) Neutrophils and monocytes
b) Regulator T cells and Helper T cells
c) Lymphokines and Suppressor T cells
d) Plasma cells and memory cells
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a) Neutrophils and monocytes
Explanation:
Neutrophils and monocytes are phagocytes, cells that perform phagocytosis. pg.971
Which of the following immunity types becomes active as a result of infection by a specific microorganism?
a) Artificially acquired passive immunity
b) Artificially acquired active immunity
c) Naturally acquired passive immunity
d) Naturally acquired active immunity
d) Naturally acquired active immunity
Explanation:
Naturally acquired active immunity occurs as a direct result of an infection by a specific microorganism. pg.971
During an annual examination, an older patient tells the nurse, "I dontt understand why I need to have so many
cancer screening tests now. I feel just fine!" Based on the knowledge of neoplastic disease and the aging immune
system, what teaching should the nurse include in the patientts plan of care? Select all that apply.
a) The immune system is integrated with other psychophysiologic processes and is regulated by the brain. Aging of
the brain can have immunologic consequences and can affect neural and endocrine function increasing the risk of
cancer development.
b) Tumor cells may possess special blocking factors that coat tumor cells and prevent their destruction by killer T
lymphocytes; therefore, the body may not recognize the tumor as foreign and fail to destroy the malignant cells.
Routine screening increases the chance of finding and treating cancer early.
c) Education about the importance of adhering to a recommended vaccine schedule should be initiated to boost the
immune system function.
d) Nutritional intake to support a competent immune response plays an important role in reducing the incidence of
cancer. A healthy diet including protein, vitamins, minerals, and some fats can alter the risk of cancer development.
e) The increase in occurrence of autoimmune diseases due to aging strongly suggests a predisposition to various
types of cancer due to the bodyts inability to differentiate between self and nonself. Routine screening increases
the chance of finding and treating cancer early.
b) Tumor cells may possess special blocking factors that coat tumor cells and prevent their destruction by killer T
lymphocytes; therefore, the body may not recognize the tumor as foreign and fail to destroy the malignant cells. Routine
screening increases the chance of finding and treating cancer early.
e) The increase in occurrence of autoimmune diseases due to aging strongly suggests a predisposition to various types of
cancer due to the body's inability to differentiate between self and nonself. Routine screening increases the chance of
finding and treating cancer early.
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d) Nutritional intake to support a competent immune response plays an important role in reducing the incidence of cancer.
A healthy diet including protein, vitamins, minerals, and some fats can alter the risk of cancer development.
Explanation:
Large tumors can release antigens into the blood, and these antigens combine with circulating antibodies and prevent
them from attacking the tumor cells. Furthermore, tumor cells may possess special blocking factors that coat tumor cells
and prevent their destruction by killer T lymphocytes. During the early development of tumors, the body may fail to
recognize the tumor antigens as foreign and subsequently fail to initiate destruction of the malignant cells. The incidence
of autoimmune diseases also increases with age, possibly from a decreased ability of antibodies to differentiate between
self and nonself. Failure of the surveillance system to recognize mutant or abnormal cells also may be responsible, in
part, for the high incidence of cancer associated with increasing age. Vitamin D deficiency has been associated with
increased risk of common cancers. There is evidence that nutrition plays a role in the development of cancer and that diet
and lifestyle can alter the risk of cancer development as well as other chronic diseases. pg.978
A patient is being treated in the intensive care unit for sepsis related to ventilator-associated pneumonia. The
patient is on large doses of three different antibiotics. What severe outcome should the nurse monitor for in the lab
studies?
a) Bone marrow suppression
b) Leukocytosis
c) Rash
d) Oral thrush
a) Bone marrow suppression
Explanation:
Antibiotics, when given in large doses, can cause bone marrow suppression. pg.982
Which of the following statements accurately reflects current stem cell research?
a) The stem cell is known as a precursor cell that continually replenishes the bodyts entire supply of both red and
white cells.
b) Stem cell transplantation cannot restore immune system functioning.
c) Clinical trials are underway in patients with acquired immune deficiencies only.
d) Stem cell transplantation has been performed in the laboratory only.
a) The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white
cells.
Explanation:
The stem cell is known as a precursor cell that continually replenishes the body's entire supply of both red and white
cells. Stem cells comprise only a small portion of all types of bone marrow cells.Research conducted with mouse models
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has demonstrated that once the immune system has been destroyed experimentally, it can be completely restored with
the implantation of just a few purified stem cells. Stem cell transplantation has been carried out in human subjects with
certain types of immune dysfunction such as severe combined immunodeficiency (SCID). Clinical trails are underway in
patients with a variety of disorders with an autoimmune component including systemic lupus erythematosus, rheumatoid
arthritis, scleroderma, and multiple sclerosis. pg.978
As a nursing instructor, you realize the importance of your students understanding how the immune system works
and its role to protect and defend the body from potential harm. What type of cells are the primary targets of the
healthy immune system? Select all that apply.
a) Infectious cells
b) Cancerous cells
c) Foreign cells
d) Typical cells
a) Infectious cells
b) Cancerous cells
c) Foreign cells
Correct
Explanation:
The immune system's primary targets are infectious, foreign, or cancerous cells. pg.970
A client has had a kidney transplant performed for end-stage kidney disease. What type of immune response that Tcell lymphocytes perform is related to this type of surgery?
a) A cell-mediated response
b) Naturally acquired active immunity
c) Activation of the complement system
d) Stimulation of colony-stimulating factors
a) A cell-mediated response
Explanation:
A cell-mediated response occurs when T cells survey proteins in the body, actively analyze the surface features, and
respond to those that differ from the host by directly attacking the invading antigen. An example of a cell-mediated
response is one that occurs when an organ is transplanted. The complement system cooperates with antibodies to attract
phagocytes and coat antigens to make them more recognizable for phagocytosis and stimulate inflammation and is not
related to the surgery. Colony-stimulating factors prompt the bone marrow to produce, mature, and promote the functions
of blood cells. Naturally acquired active immunity is a direct result of infection by a specific microorganism. pg.971
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Which of the following medication classifications are known to inhibit prostaglandin synthesis or release?
a) Antibiotics in large doses
b) Antineoplastic agents
c) Adrenal corticosteroids
d) Nonsteroidal anti-inflammatory drugs (NSAIDs) in large doses
d) Nonsteroidal anti-inflammatory drugs (NSAIDs) in large doses
Explanation:
Nonsteroidal anti-inflammatory drugs (NSAIDs) (in large doses) inhibit prostaglandin synthesis or release. NSAIDs include
aspirin and ibuprofen. Antibiotics in large doses are known to cause bone marrow suppression. Adrenal corticosteroids
and antineoplastic agents are known to cause immunosuppression. pg.982
The body has several mechanisms to fight disease, one of which is sending chemical messengers. Specifically, the
messengers released by lymphocytes, monocytes, and macrophages have differing roles in the immune response.
Which messenger enables cells to resist viral replication and slow viral replication?
a) Colony-stimulating factor
b) Tumor necrosis factor
c) Interleukins
d) Interferons
d) Interferons
Explanation:
Interferons are chemicals that primarily protect cells from viral invasion. They enable cells to resist viral infection and slow
viral replication. They have been used as adjunctive therapy in the treatment of AIDS. Interferons also have been used to
treat some forms of cancer such as leukemia because they stimulate NK cell activity. Interferon is administered
parenterally because digestive enzymes destroy its protein structure. Interferons are chemicals that primarily protect cells
from viral invasion. They enable cells to resist viral infection and slow viral replication. pg.976
A nurse is explaining treatment options to a patient diagnosed with an immune dysfunction. Which of the following
statements made by the patient accurately reflects the teaching about current stem cell research?
a) "Currently stem cell transplantation has only been performed in the laboratory, but future research with
embryonic stem cell transplants for humans with immune dysfunction has been promising."
b) "Stem cell transplantation has been discontinued based on concerns about safety, efficacy, resource allocation,
and human cloning."
c) "Stem cell clinical trials have only been attempted in patients with acquired immune deficiencies but plans are
underway to begin human cloning using embryonic stem cells."
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d) "Stem cell transplantation has been carried out in humans with certain types of immune dysfunction and clinical
trials using stem cells are underway in patients with a variety of disorders having an autoimmune component."
d) "Stem cell transplantation has been carried out in humans with certain types of immune dysfunction and clinical trials
using stem cells are underway in patients with a variety of disorders having an autoimmune component."
Explanation:
Research has shown that stem cells can restore an immune system that has been destroyed (Ko, 2012). Stem cell
transplantation has been carried out in humans with certain types of immune dysfunction, such as severe combined
immunodeficiency (SCID); 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. Research with embryonic stem cells has enabled investigators to make substantial gains in developmental
biology, gene therapy, therapeutic tissue engineering, and the treatment of a variety of diseases (Ko, 2012). However,
along with these remarkable opportunities, many ethical challenges arise, which are largely based on concerns about
safety, efficacy, resource allocation, and human cloning. pg.978
The immune system is a complicated and intricate system that contains specialized cells and tissues that protect
us from external invaders and our own altered cells. Which of the following is the term used to define any
substance capable of inducing a specific immune response and of reacting with the products of that response?
a) Antibodies
b) Antigens
c) Lymphocytes
d) Lymphokines
b) Antigens
Explanation:
Antigens, which are protein markers on cells, are substance capable of inducing a specific immune response and of
reacting with the products of that response. pg.972
A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the
diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency
syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is
provided by which type of white blood cell?
a) Lymphocyte
b) Monocyte
c) Basophil
d) Neutrophil
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a) Lymphocyte
Explanation:
The lymphocyte provides humoral immunity — recognition of a foreign antigen and formation of memory cells against the
antigen. Humoral immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The neutrophil
is crucial to phagocytosis. The basophil plays an important role in the release of inflammatory mediators. The monocyte
functions in phagocytosis and monokine production. pg.973
The nurse is teaching a client who has been diagnosed with Hashimotots thyroiditis. Which of the following
statements correctly describes the process of autoimmunity?
a) The normal protective immune response attacks the body, damaging tissues.
b) The body overproduces immunoglobulins.
c) The body produces inappropriate or exaggerated responses to specific antigens.
d) A deficiency results from improper development of immune cells or tissues.
a) The normal protective immune response attacks the body, damaging tissues.
Explanation:
Autoimmunity happens when the normal protective immune response pradoxically turns against or attacks the body,
leading to tissue damage. It is not an immune deficiency. An exaggerated immune response describes a hypersensitivity.
An overproduction of immunoglobulins is the definition of gammopathies.
The nursing students are learning about the immune system in their anatomy and physiology class. What would
these students learn is a component of the immune system?
a) Red blood cells
b) Stem cells
c) Lymphoid tissues
d) Cytokines
c) Lymphoid tissues
Explanation:
The immune system actually is a collection of specialized white blood cells and lymphoid tissues that cooperate to protect
a person from external invaders and the body's own altered cells. The function of these structures is assisted and
supported by the activities of natural killer cells, antibodies, and nonantibody proteins such as cytokines and the
complement system. Red blood cells and stem cells are not part of the immune system. pg.970
A 25-year-old man receives a knife wound to the leg in a hunting accident. Which of the following types of immunity
was compromised?
a) Adaptive immunity
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b) Passive immunity
c) Specific immunity
d) Natural immunity
d) Natural immunity
Explanation:
Natural immunity, which is nonspecific, provides a broad spectrum of defense against and resistance to infection. It is
considered the first line of host defense following antigen exposure, because it protects the host without remembering
prior contact with an infectious agent. pg.971
A 38-year old female has recently been diagnosed with rheumatoid arthritis. She is also receiving further testing for
disorders of the immune system. She works as an aide at a facility which cares for children infected with AIDS.
Which of the following factors will hold the greatest implications during the clientts assessment? Select all that
apply.
a) Her diet
b) Her age
c) Her work environment
d) Her home environment
e) Her history of immunizations and allergies
f) Her use of other drugs
c) Her work environment
e) Her history of immunizations and allergies
f) Her use of other drugs
Explanation:
It is important for the nurse to obtain a history of past immunizations and infectious diseases, any allergies, and any
recent exposure to infectious diseases. The nurse also needs to review the client's drug history. These data will help the
nurse to assess the client's susceptibility to illness because certain past illnesses and drugs, such as corticosteroids,
suppress the inflammatory and immune responses. The nurse should question the client about the practices that put her
at risk for AIDS, such as her work environment. The client's age, home environment, and diet do not have any major
implications during the assessment because they do not indicate the client's susceptibility to illness. pg.978
Why would it be important for the nurse to question the client about sexual practices, history of substance abuse,
and his lifestyle during the interview process?
a) To determine if the client needs a referral to counseling services
b) To determine what type of personality the client has
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c) To find out if the client will be compliant with therapeutic treatments
d) To determine if the client has practices that put him at risk for acquired immunodeficiency syndrome (AIDS)
d) To determine if the client has practices that put him at risk for acquired immunodeficiency syndrome (AIDS)
Explanation:
The nurse investigates the client's allergy history and questions the client about practices that put him or her at risk for
AIDS. The interview will not determine the client's ability to be compliant. The physician would make the determination if a
counseling referral should be made. It is irrelevant to determine the personality traits in the initial interview. pg.1016
A client has undergone a kidney transplant. The nurse is concerned about a compromised immune system in this
client for which of the following reasons?
a) Use of anti-rejection drugs
b) Deficient circulating antibodies
c) Excess circulating lymphocytes
d) Excess circulating hemoglobin
a) Use of anti-rejection drugs
Explanation:
Clients who receive a kidney transplant must take immunosuppressant drugs to prevent rejection of the transplant. These
drugs cause a compromised immune system. Renal transplant is not associated with excess lymphocytes, deficient
circulating antibodies, or excess hemoglobin.
Which of the following immunoglobulins assumes a major role in blood-borne and tissue infections?
a) IgG
b) IgA
c) IgM
d) IgD
a)
IgG
Explanation:
IgG assumes a major role in blood-borne and tissue infections. IgA protects against respiratory, GI, and genitourinary
infections. IgM appears as the first immunoglobulin produced in response to bacterial and viral infections. IgD possibly
influences B-lymphocyte differentiation. pg.975
The nurse understands that which cells circulate throughout the body looking for virus-infected cells and cancer
cells?
a) Interferons
b) Natural killer cells
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c) Cytokines
d) Interleukins
b) Natural killer cells
Explanation:
Natural killer cells are lymphocyte-like cells that circulate throughout the body looking for virus-infected cells and cancer
cells. Cytokines are chemical messengers released by lymphocytes, monocytes, and macrophages. Interleukins carry
messages between leukocytes and tissues that form blood cells. Interferons are chemicals that primarily protect cells from
viral infections. pg.969
A child is brought to the clinic with a rash. The child is diagnosed with measles. The mother tells the nurse that she
had the measles when she was a little girl. What immunity to measles develops after the initial infection?
a) Naturally acquired passive immunity
b) Artificially acquired active immunity
c) Artificially acquired passive immunity
d) Naturally acquired active immunity
d) Naturally acquired active immunity
Explanation:
Immunity to measles that develops after the initial infection is an example of naturally acquired active immunity. Artificially
acquired active immunity results from the administration of a killed or weakened microorganism or toxoid (attenuated
toxin), whereas passive immunity develops when ready-made antibodies are given to a susceptible client. pg.972
Which of the following is accurate regarding acquired immunity? Select all that apply.
a) Usually develops as a result of exposure to an antigen through immunization
b) A nonspecific immunity present at birth
c) Also know as innate immunity
d) An immunologic response acquired during life but not present at birth
e) Can develop by contracting a disease
d) An immunologic response acquired during life but not present at birth
a) Usually develops as a result of exposure to an antigen through immunization
e) Can develop by contracting a disease
Explanation:
Acquired immunity is a immunologic responses acquired during life but not present at birth, and usually develops as a
result of exposure to an antigen through immunization (vaccination) or by contracting a disease, both of which generate a
protective immune response. Natural (innate) immunity is a nonspecific immunity present at birth that provides protection
against an infectious agent without ever encountering it before. pg.972
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The nurse is administering a skin test for detection of exposure to tuberculosis. How would the nurse determine if
the client was exposed to tuberculosis?
a) The client will have a productive cough.
b) The injection area will become painful with in duration if the client has antibodies against the antigen.
c) The injection area will break out in a fine macular rash.
d) The injection area swells if the client has developed antibodies against the antigen.
d) The injection area swells if the client has developed antibodies against the antigen.
Explanation:
The injection area swells if the client has developed antibodies against the antigen. The client is not necessarily actively
infectious if the test results are positive. Although a productive cough is one of the symptoms of active tuberculosis, it may
also indicate other diseases and disorders. The area should not be painful, and the client should not break out with a
rash. pg.588
Which type of cells is capable of recognizing and killing infected or stressed cells and producing cytokines?
a) Natural killer cells
b) Null lymphocytes
c) Cytotoxic T cells
d) Memory cells
a) Natural killer cells
Explanation:
NK cells are a class of lymphocytes that recognize infected and stressed cells and respond by killing these cells and by
secreting macrophage-activating cytokine. Natural killer cells defend against microorganisms and some type of malignant
cells. pg.976
A client has dilated cardiomyopathy and has just found out he will be receiving a heart. What medication does the
client understand that he will have to take for the duration of his life to help suppress the immune system to
prevent rejection of the new heart?
a) Etanercept (Enbrel)
b) Adalimumab (Humira)
c) Infliximab (Remicade)
d) Cyclosporine (Sandimmune)
d) Cyclosporine (Sandimmune)
Explanation:
After organ transplantation, the client's immune system may attack the new organ's cells because it recognizes them as
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nonself. Cyclosporine is used to intentionally suppress the immune system. The medications in A, B, and C are all used to
suppress inflammation. pg.782
While taking the health history of a newly admitted client, the nurse reviews general lifestyle behaviors. Which of
the following would have a positive effect on the immune system?
a) Biofeedback, relaxation, and hypnosis
b) Relaxation, intense competitive exercise, and humor
c) Humor, rigorous physical stress, and biofeedback
d) Hypnosis, humor, and chronic illness
a) Biofeedback, relaxation, and hypnosis
Explanation:
Growing evidence indicates that strategies such as relaxation, imagery techniques, biofeedback, humor, hypnosis, and
conditioning can positively influence a measurable immune system response. Intense or rigorous comptitive exercise can
cause negative effects on the immune system, especially if the environment is stressful while undergoing exercise. pg.983
T-cell and B-cell lymphocytes are the primary participants in the immune response. What do they do?
a) T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person.
b) T-cell and B-cell lymphocytes respond to the bodyts invasion by macrophages.
c) T-cell and B-cell lymphocytes react to the bodyts lack of B12 .
d) T-cell and B-cell lymphocytes distinguish harmful treatments from curative treatments.
a) T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person.
Explanation:
T-cell and B-cell lymphocytes are the primary participants in the immune response. They distinguish harmful substances
and ignore those natural and unique to a person. Options B, C, and D are incorrect. pg.971
The nurse is caring for an older adult patient hospitalized with cellulitis of the right lower extremity. Why is it
imperative that the nurse continually assess the physical and emotional status of this patient?
a) Older patients are at risk of developing dementia.
b) The patient will not respond to the antibiotic treatment as well as a younger patient would.
c) Older adult patients develop depression and suicidal tendencies when they are faced with chronic illness.
d) Early recognition and management of factors influencing immune response may decrease morbidity and
mortality.
c) Older adult patients develop depression and suicidal tendencies when they are faced with chronic illness.
Explanation:
The effects of the aging process and psychological stress interact, with the potential to negatively influence immune
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integrity (Masoro & Austad, 2011). Consequently, continual assessment of the physical and emotional status of older
adults is imperative, because early recognition and management of factors influencing immune response may prevent or
mitigate the high morbidity and mortality seen with illness in the older adult population (Brunner et al., 2011; Swain &
Nikolich-Zugich, 2009). pg.980
An elderly client is diagnosed with a respiratory infection. While reviewing age-related changes in the immune
system, the nurse identifies which of the following as having contributed to this clientts infection?
a) Decreased phagocytosis by Kupffer cells
b) Decreased sensation and slowing of reflexes
c) Impaired ciliary action from exposure to environmental toxins
d) Failure of the immune system to differentiate "self" from "non-self"
c) Impaired ciliary action from exposure to environmental toxins
Explanation:
Impaired ciliary action from exposure to smoke and environmental toxins contributes to impaired clearance of pulmonary
secretions and an increased incidence of respiratory infections in the elderly. Failure of the immune system to differentiate
"self" from "non-self" leads to an increase incidence of autoimmune diseases. Decreased phagocytosis by the liver's
Kupffer cells leads to increased incidence and severity of hepatitis B. Decreased sensation and slowing of reflexes leads
to increased risk of skin injury, skin ulcers, abrasions, burns, and other trauma. pg.979
A client has had mumps when he was 9 years old. He had a titer prior to entering nursing school and shows
immunity. What type of immunity does this reflect?
a) Passive immunity
b) Artificially acquired active immunity
c) Naturally acquired active immunity
d) Natural passive immunity
c) Naturally acquired active immunity
Explanation:
Naturally acquired active immunity occurs as a direct result of infection by a specific microorganism. An example is the
immunity to measles that develops after the initial infection. Not all invading microorganisms produce a response that
gives lifelong immunity. Artificially acquired immunity is obtained by receiving a killed or weakened microorganism or
toxoid. Passive immunity is acquired when ready-made antibodies are given to a susceptible person. pg.972
T-cells can be either regulator T cells or effector T cells. Regulator T cells are made up of helper and suppressor
cells. What function are helper T-cells important in?
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a) Fighting infection
b) Activating lymphokines
c) Producing antibodies
d) Turning off the immune response
a) Fighting infection
Explanation:
Helper T cells are especially important in fighting infection. They recognize antigens, which are protein markers on cells,
and form additional T-cell clones that stimulate B-cell lymphocytes to produce antibodies against foreign antigens. Helper
T cells do not produce antibodies, activate lymphokines, or turn off the immune response. pg.976
Which of the following adverse effects should the nurse closely monitor in a patient who takes immunosuppressive
drugs?
a) Depression, memory impairment, and coma
b) Respiratory or urinary system infections
c) Heart failure, infusion reactions, and life-threatening infections
d) Rheumatoid arthritis
b) Respiratory or urinary system infections
Explanation:
When taking drugs to suppress the immune system, the patient is vulnerable to an increased risk of infection, especially in
the respiratory or urinary systems. Depression, memory impairment, and coma are dose-related effects of the cytokines, a
biologic response modifier. Heart failure, infusion reactions, and life-threatening infections are the possible adverse effects
of taking infliximab, which minimizes inflammation. In addition, cytokines and infliximab are not immunosuppressive drugs.
Moreover, immunosuppressive drugs are not known to cause rheumatoid arthritis. pg.982
At 39 weekst gestation, a pregnant female, visits her physician for a scheduled prenatal checkup. The physician
determines that the fetus has developed an infection in utero and sends the patient for an emergency C section.
The patient is very concerned about the health of her unborn child. Based on the knowledge of the immune system,
the delivery room nurse explains about which of the following immunoglobulins that will be increased in the fetus
at the time of birth and actively fighting the infection?
a) IgA
b) IgG
c) IgM
d) IgD
b) IgG
Explanation:
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IgG is 75% of total immunoglobulin. It appears in serum and tissues, assumes a major role in bloodborne and tissue
infections and crosses the placenta. pg.975
A 34-year-old man is diagnosed with chronic hepatitis C. Testing reveals that he is a candidate for treatment. The
nurse anticipates that which of the following could be used to treat his condition?
a) Monoclonal antibodies
b) Interferon
c) Erythropoietin
d) Interleukin-5
b) Interferon
Explanation:
Interferons are used to treat immune-related disorders (e.g., multiple sclerosis) and chronic inflammatory conditions (e.g.,
chronic hepatitis). pg.977
Chronic illnesses may contribute to immune system impairment in various ways. Renal failure is associated with
which of the following?
a) Decreased bone marrow function
b) Deficiency in circulating lymphocytes
c) Altered production of white blood cells
d) Increased incidence of infection
b) Deficiency in circulating lymphocytes
Explanation:
Renal failure is associated with a deficiency in circulating lymphocytes. Diabetes mellitus is associated with increased
incidence of infection. Chemotherapy causes decreased bone marrow function. Leukemia is associated with altered
production of white blood cells. pg.981
What chemical is released by cytotoxic T cells?
a) Lymphokine
b) Antigen
c) Antibody
d) Microphages
a) Lymphokine
Explanation:
Cytotoxic T cells bind to invading cells, destroy the targeted invader by altering their cellular membrane and intracellular
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environment, and release chemicals called lymphokines. Lymphokines, a type of cytokine, attract neutrophils and
monocytes to remove the debris. Options B, C, and D are incorrect. pg.976
A nurse is teaching a community group about healthy lifestyles. A participant asks about how to maintain a healthy
immune system. The nurse informs the group that which of the following factors will positively affect the immune
system?
a) Poor nutritional status
b) Residential exposure to radiation
c) Rigorous, competitive exercise
d) Strong family and community connections
d) Strong family and community connections
Explanation:
Strong family and community ties will have a positive effect on the immune system. Rigorous or competitive exercise,
usually considered a positive lifestyle factor, can be a physiologic stressor and cause negative effects on immune
response. Any form of radiation can have a negative effect on the immune system, as can poor nutritional status. pg.1556
Which of the following is a center for immune cell proliferation?
a) Liver
b) Spleen
c) Pancreas
d) Lymph node
d) Lymph node
Explanation:
The lymph nodes remove foreign material from the lymph system before it enters the bloodstream. They are centers for
immune cell proliferation. pg.970
A client will be taking the tumor necrosis factor inhibitor, infliximab (Remicade), for the treatment of rheumatoid
arthritis. Prior to beginning this therapeutic regimen, what screening should the client have?
a) Screening for syphilis
b) Screening for peptic ulcer disease
c) Screening for tuberculosis
d) Screening for rubella
c) Screening for tuberculosis
Explanation:
Before prescribing a TNF inhibitor, clients should be screened for tuberculosis because there is a risk for activating latent
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tuberculosis. It is not necessary to screen for peptic ulcer disease, syphilis, or rubella prior to beginning TNF inhibitor
therapy. pg.1061
Which stage of the immune response occurs when the differentiated lymphocytes function in either a humoral or a
cellular capacity?
a) Response stage
b) Recognition stage
c) Proliferation stage
d) Effector stage
a) Response stage
Explanation:
In the response stage, the differentiated lymphocytes function in either a humoral or a cellular capacity. Recognition of
antigens as foreign or non-self, 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 effector
stage, either the antibody of the humoral response of the cytotoxic TA cell of the cellular response reaches and connects
with the antigen on the surface of the foreign invader. pg.973
The nurse is caring for a female patient who has an exacerbation of lupus erythematosus. What does the nurse
understand is the reason that females tend to develop autoimmune disorders more frequently than men?
a) Estrogen tends to enhance immunity.
b) Testosterone tends to enhance immunity.
c) Leukocytes are increased in females.
d) Androgen tends to enhance immunity.
a) Estrogen tends to enhance immunity.
Explanation:
Autoimmune disorders tend to be more common in women because estrogen tends to enhance immunity. Androgen, on
the other hand, tends to be immunosuppressive. pg.980
Which type of cells is capable of directly killing invading organisms and producing cytokines?
a) Null lymphocytes
b) Cytotoxic T cells
c) Natural killer cells
d) Memory cells
c) Natural killer cells
Explanation:
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Natural killer cells defend against microorganisms and some type of malignant cells. Memory cells are responsible for
recognizing antigens from previous exposure and mounting an immune response.Cytotoxic T cells attack the antigen
directly by altering the cell membrane and causing cell lysis and by releasing cytolytic enzymes and cytokines. pg.976
An older adult has developed a sacral pressure ulcer. What should the nurse assess in order to ensure adequate
wound healing and prevent poor outcomes for this patient? (Select all that apply.)
a) Nutritional status
b) The amount of carbohydrates the patient ingests
c) Quality of food ingested
d) Caloric intake
e) The patientts ability to perform her own wound care
a) Nutritional status
d) Caloric intake
c) Quality of food ingested
Explanation:
Nutritional intake that supports a competent immune response plays an important role in reducing the incidence of
infections; patients whose nutritional status is compromised have a delayed postoperative recovery and often experience
more severe infections and delayed wound healing. The nurse must assess the patient's nutritional status, caloric intake,
and quality of foods ingested. pg.980
A client is diagnosed with rheumatoid arthritis, an autoimmune disorder. When teaching the client and family about
autoimmune disorders, the nurse should provide which information?
a) Autoimmune disorders include connective tissue (collagen) disorders.
b) Autoimmune disorders are distinctive, aiding differential diagnosis.
c) Clients with autoimmune disorders may have false-negative but not false-positive serologic tests.
d) Advanced medical intervention can cure most autoimmune disorders.
a) Autoimmune disorders include connective tissue (collagen) disorders.
Explanation:
Connective tissue disorders are considered autoimmune disorders. Clients with autoimmune disorders may have either
false-positive or false-negative serologic tests for syphilis. Other common laboratory findings in these clients include
Coombs-positive hemolytic anemia, thrombocytopenia, leukopenia, immunoglobulin excesses or deficiencies, antinuclear
antibodies, antibodies to deoxyribonucleic acid and ribonucleic acid, rheumatoid factors, elevated muscle enzymes, and
changes in acute phase-reactive proteins. No cure exists for autoimmune disorders; treatment centers on controlling
symptoms. Autoimmune disorders aren't distinctive; they share common features, making differential diagnosis difficult.
pg.1555
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Which of the following is a process in which the antigen-antibody molecule is coated with a sticky substance that
facilitates phagocytosis?
a) Immunoregulation
b) Agglutination
c) Opsonization
d) Apoptosis
c) Opsonization
Explanation:
In the process of opsonization, the antigen-antibody molecule is coated with a sticky substance that also facilitates
phagocytosis. Apoptosis is programmed cell death that results from the digestion of DNA by endonucleases. Agglutination
is the clumping effect occurring when an antibody acts as a cross-link between two antigens. Immunoregulation is a
complex system of checks and balances that regulates or controls immune responses. pg.974
A 64-year-old male client, who leads a sedentary lifestyle, and a 31-year-old female client, who has a very stressful
and active lifestyle, require a vaccine against a particular viral disorder. As the nurse, you would know that in one
of these clients, the vaccine will be less effective. In which client is the vaccine more likely to be less effective and
why?
a) The female client because of her age
b) The male client because of his lifestyle
c) The male client because of his age
d) The female client because of her lifestyle
c) The male client because of his age
Explanation:
Vaccines are less effective in an older adult than in a younger adult because the activity of the immune system declines
with the aging process. The lifestyle or gender of the client does not have great implications on the effectiveness of a
vaccine. pg.978
A mother has brought her child to the clinic for a wellness check. While talking with the nurse, the mother asks the
nurse to suggest a diet that will maximize the immune function of her growing children. What dietary pattern should
the nurse suggest?
a) Diet rich in amino acids and essential fatty acids
b) Diet rich in iron, zinc, and vitamin E
c) Diet rich in potassium, magnesium, and sodium
d) Moderate diet that is balanced and varied
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d) Moderate diet that is balanced and varied
Explanation:
The best dietary advice to maximize immune function in healthy people is to eat a moderate diet that is balanced and
varied, because the optimum amount and proportion of nutrients required are yet unknown. Recent studies indicate that
the availability of one nutrient may impair or enhance the action of another nutrient in immune system functioning.
Although it is necessary to include vitamins, amino acids, essential fatty acids, and electrolytes in the diet of growing
children, excessive amounts are not advisable. pg.980
Which of the following is a humoral immune response?
a) Intracellular infections
b) Anaphylaxis
c) Transplant rejection
d) Delayed hypersensitivity
b) Anaphylaxis
Explanation:
A humoral response includes anaphylaxis. Cellular responses include transplant rejection, intracellular infections, and
delayed hypersensitivity. pg.973
A nurse is working in a pediatric clinic. After giving a hepatitis B immunization to an infant, the mother asks what
kind of protection this provides for her child. The correct response is which of the following?
a) Active acquired immunity, which is temporary
b) Passive acquired immunity, which is temporary
c) Passive acquired immunity, which lasts many years or a lifetime
d) Active acquired immunity, which lasts many years or a lifetime
d) Active acquired immunity, which lasts many years or a lifetime
Explanation:
Active acquired immunity refers to immunologic defenses developed by the person's own body. This mmunity typically
lasts many years or even a lifetime. Passive acquired immunity is temporary immunity transmitted from a source outside
the body that has developed immunity through previous disease or immunization. pg.972
A nurse is taking the health history of a newly admitted client and asks for a list of the clientts current medications.
Which of the following medication classifications would NOT place the client at risk for impaired immune function?
a) Antineoplastic agents
b) Antimetabolites
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c) Inotropics
d) Adrenal corticosteroids
c) Inotropics
Explanation:
Antimetabolites, antineoplastic agents, and adrnal corticosteroids all can cause immunosuppression. Inotropics do not
directly affect the immune system.
A nurse is taking health history from a new client, which includes asking about a history of blood transfusions. This
is important for which of the following reasons?
a) Blood products cause lower antibody titers.
b) Blood products cause a high risk for exposure to HIV.
c) Blood products cause a high risk for hepatitis B.
d) Exposure to foreign antigens may cause altered immune function.
d) Exposure to foreign antigens may cause altered immune function.
Explanation:
A history of blood transfusions is obtained because previous exposure to foreign antigens through transfusion may be
associated with abnormal immune function. There is only a small risk for HIV transmission from transfusions received after
1985. The risk for exposure to hepatitis B from blood transfusions is extremely small. pg.982
An elderly client is diagnosed with cancer. While reviewing age-related changes in the immune system, the nurse
identifies which of the following as having contributed to this clientts condition?
a) Impaired ciliary action from exposure to environmental toxins
b) Decreased sensation and slowing of reflexes
c) Failure of lymphocytes to recognize mutant cells
d) Failure of immune system to differentiate "self" from "non-self"
c) Failure of lymphocytes to recognize mutant cells
Explanation:
Failure of lymphocytes to recognize mutant or abnormal cells contributes to an increased incidence of cancers in the
elderly. Impaired ciliary action due to exposure to smoke and environmental toxins contributes to impaired clearance of
pulmonary secretions and an increased incidence of respiratory infections in the elderly. Failure of immune system to
differentiate "self" from "non-self" leads to an increase incidence of autoimmune diseases. Decreased sensation and
slowing of reflexes leads to increased risk of skin injury, skin ulcers, abrasions, burns, and other trauma. pg.979
Which of the following is an action of cytotoxic T cells?
a) Decrease B cell activity to a level at which the immune system is compatible with life
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b) Attack of foreign invaders (antigens) directly
c) Production of circulating antibodies
d) Lyse cells infected with virus
d) Lyse cells infected with virus
Explanation:
Cytotoxic T cells play a role in graft rejection. B cells are lymphocytes important in producing circulating antibodies.
Suppressor T cells are lymphocytes that decrease B-cell activity to a level at which the immune system is compatible with
life. Helper T cells are lymphocytes that attack antigens directly. pg.972
During a 12-month well-baby visit, a mother reports that the baby has been breast-fed since birth and has never
been ill. She is trying to convince her sister who is currently pregnant to breast-feed also and asks the nurse about
the benefits of breast-feeding. The nurse explains the immune benefits of breast-feeding and provides the mother
with pamphlets. The nurse determines the patient understands the teaching based on which of the following patient
statements?
a) "Breast-feeding is beneficial because the dominant antibody IgA in breast milk acts by functioning as an antigen
receptor in the mucosal membranes."
b) "Breast-feeding is beneficial because the dominant antibody IgM in breast milk is the first immunoglobulin
produced in response to bacterial and viral infections."
c) "Breast-feeding is beneficial because T lymphocytes found in breast milk are primarily responsible for cellular
immunity."
d) "Breastfeeding is beneficial because the dominant antibody IgG in breast milk assumes a major role in
bloodborne and tissue infections."
a) "Breast-feeding is beneficial because the dominant antibody IgA in breast milk acts by functioning as an antigen
receptor in the mucosal membranes."
Explanation:
IgA is 15% of total immunoglobulin. It appears in body fluids (blood, saliva, tears, breast milk, and pulmonary,
gastrointestinal, prostatic, and vaginal secretions). It protects against respiratory, gastrointestinal, and genitourinary
infections and passes to the neonate in breast milk for protection. pg.975
Which type of cells destroys antigens already coated with antibody?
a) Suppressor T-cell
b) Null
c) Memory T-cell
d) Natural killer (NK)
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b)
Null
Explanation:
Null cells destroy antigens already coated with antibody. NK cells defend against microorganisms and some types of
malignant cells. Memory T cells remember contact with an antigen and, on subsequent exposures, mount an immune
response. Suppressor T-cells suppress the immune response. pg.976
Which of the following responses identifies a role of T lymphocytes?
a) Bacterial phagocytosis and lysis
b) Allergic hay fever and asthma
c) Transplant rejection
d) Anaphylaxis
c) Transplant rejection
Explanation:
Most immune responses to antigens involve both humoral and cellular responses, although one usually predominates. For
example, during transplant rejection, the cellular response involving T cells predominates, whereas in the bacterial
pneumonias and sepsis, the humoral response involving B cells plays the dominant protective role. Transplant rejection
and graft-versus-host disease are cellular response roles of T cells. Anaphylaxis is a humoral response role of Blymphocytes. Allergic hay fever and asthma are humoral response roles of B-lymphocytes. Bacterial phagocytosis and
lysis are humoral response roles of B-lymphocytes. pg.973
The nursing instructor is discussing the development of human immunodeficiency disease (HIV) with the students.
What should the instructor inform the class about helper T cells?
a) They are activated on recognition of antigens and stimulate the rest of the immune system.
b) They have the ability to decrease B-cell production.
c) They are responsible for recognizing antigens from previous exposure and mounting an immune response.
d) They attack the antigen directly by altering the cell membrane and causing cell lysis.
a) They are activated on recognition of antigens and stimulate the rest of the immune system.
Explanation:
Helper T cells are activated on recognition of antigens and stimulate the rest of the immune system. pg.975
Proteins formed when cells are exposed to viral or foreign agents that are capable of activating other components
of the immune system are referred to as
a) antigens.
b) interferons.
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c) antibodies.
d) complements.
b) interferons.
Explanation:
Interferons are biologic response modifiers with nonspecific viricidal proteins. Antibodies are protein substances developed
by the body in response to and interacting with a specific foreign substance. Antigens are substances that induce
formation of antibodies. Complement refers to a series of enzymatic proteins in the serum that, when activated, destroy
bacteria and other cells. pg.977
A nurse is teaching a patient about the side effects of ibuprofen (Motrin). The patientts teaching is determined to be
effective based on which of the following patient statements explaining the drugs effect on the immune system?
a) "Motrin can cause hemolytic anemia, which will make me feel tired and short of breath."
b) "Motrin can cause pancytopenia, which is a decrease in all of my blood cells."
c) "Motrin can cause neutropenia, which can increase my risk of infection."
d) "Motrin can cause thrombocytopenia; I will need to watch for bruising and bleeding."
c) "Motrin can cause neutropenia, which can increase my risk of infection."
Explanation:
Motrin causes leukopenia and neutropenia. pg.56
The nurse is performing a physical assessment for a patient at the clinic and palpates enlarged inguinal lymph
nodes on the left. What should the nurse document? (Select all that apply.)
a) Size
b) Temperature
c) Consistency
d) Reports of tenderness
e) Location
a) Size
c) Consistency
d) Reports of tenderness
e) Location
Explanation:
The anterior and posterior cervical, supraclavicular, axillary, and inguinal lymph nodes are palpated for enlargement; if
palpable nodes are detected, their location, size, consistency, and reports of tenderness on palpation are noted. Joints are
assessed for tenderness, swelling, increased warmth, and limited range of motion. pg.983
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The nurse is caring for a patient in the hospital who is receiving a vitamin D supplement. What does the nurse
understand is the importance of supplementation with this vitamin? (Select all that apply.)
a) Vitamin D deficiency is associated with increased risk of inflammatory disorders.
b) Vitamin D deficiency is associated with increased risk of congenital anomalies.
c) Vitamin D deficiency is associated with increased risk of common cancers.
d) Vitamin D deficiency is associated with increased risk of autoimmune disease.
e) Vitamin D deficiency is associated with increased risk of celiac disease.
a) Vitamin D deficiency is associated with increased risk of inflammatory disorders.
c) Vitamin D deficiency is associated with increased risk of common cancers.
d) Vitamin D deficiency is associated with increased risk of autoimmune disease.
Explanation:
Vitamin D deficiency has been associated with increased risk of common cancers, autoimmune diseases, and
inflammatory disorders (DiRosa, Malaguarnera, Nicoletti, et al., 2011). pg.980
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Brunner & Suddarth's Textbook of Medical Surgical Nursing 15th Edition
Chapter 32: Management of Patients With Immune Deficiency Disorders
1. Since the emergence of HIV/AIDS, there have been significant changes in epidemiologic trends.
Members of what group currently have the greatest risk of contracting HIV?
A) Gay, bisexual, and other men who have sex with men
B) Recreational drug users
C) Blood transfusion recipients
D) Health care providers
Gay, bisexual, and other men who have sex with men
Feedback:
Gay, bisexual, and other men who have sex with men remain the population most affected by HIV and account for 2% of
the population but 61% of the new infections. This exceeds the incidence among drug users, health care workers, and
transfusion recipients.
2. A clinic nurse is caring for a patient admitted with AIDS. The nurse has assessed that the patient is
experiencing a progressive decline in cognitive, behavioral, and motor functions. The nurse recognizes that these
symptoms are most likely related to the onset of what complication?
A) HIV encephalopathy
B) B-cell lymphoma
C) Kaposis sarcoma
D) Wasting syndrome
HIV encephalopathy
Feedback:
HIV encephalopathy is a clinical syndrome characterized by a progressive decline in cognitive, behavioral, and motor
functions. The other listed complications do not normally have cognitive and behavioral manifestations.
3. A nurse is assessing a 28-year-old man with HIV who has been admitted with pneumonia. In assessing
the patient, which of the following observations takes immediate priority?
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A) Oral temperature of 100F
B) Tachypnea and restlessness
C) Frequent loose stools
D) Weight loss of 1 pound since yesterday
Tachypnea and restlessness
Feedback:
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In prioritizing care, the pneumonia would be assessed first by the nurse. Tachypnea and restlessness are symptoms of
altered respiratory status and need immediate priority. Weight loss of 1 pound is probably fluid related; frequent loose
stools would not take short-term precedence over a temperature or tachypnea and restlessness. An oral temperature of
100F is not considered a fever and would not be the first issue addressed.
4. A patient has come into the free clinic asking to be tested for HIV infection. The patient asks the nurse
how the test works. The nurse responds that if the testing shows that antibodies to the AIDS virus are present in
the blood, this indicates what?
A) The patient is immune to HIV.
B) The patients immune system is intact.
C) The patient has AIDS-related complications.
D) The patient has been infected with HIV.
The patient has been infected with HIV.
Feedback:
Positive test results indicate that antibodies to the AIDS virus are present in the blood. The presence of antibodies does
not imply an intact immune system or specific immunity to HIV. This finding does not indicate the presence of AIDSrelated complications.
5. A hospital patient is immunocompromised because of stage 3 HIV infection and the physician has
ordered a chest radiograph. How should the nurse most safely facilitate the test?
A) Arrange for a portable x-ray machine to be used.
B) Have the patient wear a mask to the x-ray department.
C) Ensure that the radiology department has been disinfected prior to the test.
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D) Send the patient to the x-ray department, and have the staff in the department wear masks.
Arrange for a portable x-ray machine to be used.
Feedback:
A patient who is immunocompromised is at an increased risk of contracting nosocomial infections due to suppressed
immunity. The safest way the test can be facilitated is to have a portable x-ray machine in the patients room. This confers
more protection than disinfecting the radiology department or using masks.
6. The mother of two young children has been diagnosed with HIV and expresses fear of dying. How
should the nurse best respond to the patient?
A) Would you like me to have the chaplain come speak with you?
B) Youll learn much about the promise of a cure for HIV.
C) Can you tell me what concerns you most about dying?
D) You need to maintain hope because you may live for several years.
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Can you tell me what concerns you most about dying?
Feedback:
The nurse can help the patient verbalize feelings and identify resources for support. The nurse should respond with an
open-ended question to help the patient to identify fears about being diagnosed with a life-threatening chronic illness.
Immediate deferral to spiritual care is not a substitute for engaging with the patient. The nurse should attempt to foster
hope, but not in a way that downplays the patients expressed fears.
7. The nurse is addressing condom use in the context of a health promotion workshop. When discussing the
correct use of condoms, what should the nurse tell the attendees?
A) Attach the condom prior to erection.
B) A condom may be reused with the same partner if ejaculation has not occurred.
C) Use skin lotion as a lubricant if alternatives are unavailable.
D) Hold the condom by the cuff upon withdrawal.
Hold the condom by the cuff upon withdrawal.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 696
Feedback:
The condom should be unrolled over the hard penis before any kind of sex. The condom should be held by the tip to
squeeze out air. Skin lotions, baby oil, petroleum jelly, or cold cream should not be used with condoms because they
cause latex deterioration/condom breakage. The condom should be held during withdrawal so it does not come off the
penis. Condoms should never be reused.
8. A nurse is planning the care of a patient with AIDS who is admitted to the unit withPneumocystis
pneumonia (PCP). Which nursing diagnosis has the highest priority for this patient?
A) Ineffective Airway Clearance
B) Impaired Oral Mucous Membranes
C) Imbalanced Nutrition: Less than Body Requirements
D) Activity Intolerance
Ineffective Airway Clearance
Feedback:
Although all these nursing diagnoses are appropriate for a patient with AIDS, Ineffective Airway Clearance is the priority
nursing diagnosis for the patient with Pneumocystis pneumonia (PCP). Airway and breathing take top priority over the
other listed concerns.
9. A public health nurse is preparing an educational campaign to address a recent local increase in the incidence of
HIV infection. The nurse should prioritize which of the following interventions?
A) Lifestyle actions that improve immune function
B) Educational programs that focus on control and prevention
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C) Appropriate use of standard precautions
D) Screening programs for youth and young adults
Educational programs that focus on control and preventio
Feedback:
Until an effective vaccine is developed, preventing HIV by eliminating and reducing risk behaviors is essential. Educational
interventions are the primary means by which behaviors can be influenced. Screening is appropriate, but education is
paramount. Enhancing immune function does not prevent HIV infection. Ineffective use of standard precautions apply to
very few cases of HIV infection.
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10. A nurse is working with a patient who was diagnosed with HIV several months earlier. The nurse should
recognize that a patient with HIV is considered to have AIDS at the point when the CD4+ T-lymphocyte cell count
drops below what threshold?
A) 75 cells/mm3 of blood
B) 200 cells/mm3 of blood
C) 325 cells/mm3 of blood
D) 450 cells/mm3 of blood
200 cells/mm3 of blood
Feedback:
When CD4+ T-cell levels drop below 200 cells/mm3 of blood, the person is said to have AIDS.
11. During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the
nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common
life-threatening infection?
A) Salmonella infection
B) Mycobacterium tuberculosis
C) Clostridium difficile
D) Pneumocystis pneumonia
Pneumocystis pneumonia
Feedback:
There are a number of opportunistic infections that can infect individuals with AIDS. The most common life-threatening
infection in those living with AIDS is Pneumocystis pneumonia (PCP), caused by P. jiroveci (formerly carinii). Other
opportunistic infections may involve Salmonella,Mycobacterium tuberculosis, and Clostridium difficile.
12. A patients current antiretroviral regimen includes nucleoside reverse transcriptase inhibitors (NRTIs).
What dietary counseling will the nurse provide based on the patients medication regimen?
A) Avoid high-fat meals while taking this medication.
B) Limit fluid intake to 2 liters a day.
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Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 698
C) Limit sodium intake to 2 grams per day.
D) Take this medication without regard to meals.
Take this medication without regard to meals.
Feedback:
Many NRTIs exist, but all of them may be safely taken without regard to meals. Protein, fluid, and sodium restrictions play
no role in relation to these drugs.
13. A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the
patients gastrointestinal system and analyzing the data, what is most likely to be the priority nursing diagnosis?
A) Acute Abdominal Pain
B) Diarrhea
C) Bowel Incontinence
D) Constipation
Diarrhea
Feedback:
Diarrhea is a problem in 50% to 60% of all AIDS patients. As such, this nursing diagnosis is more likely than abdominal
pain, incontinence, or constipation, though none of these diagnoses is guaranteed not to apply.
14. A patient with a recent diagnosis of HIV infection expresses an interest in exploring alternative and
complementary therapies. How should the nurse best respond?
A) Complementary therapies generally have not been approved, so patients are usually discouraged
from using them.
B) Researchers have not looked at the benefits of alternative therapy for patients with HIV, so we
suggest that you stay away from these therapies until there is solid research data available.
C) Many patients with HIV use some type of alternative therapy and, as with most health treatments,
there are benefits and risks.
D) Youll need to meet with your doctor to choose between an alternative approach to treatment and a
medical approach.
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 699
Many patients with HIV use some type of alternative therapy and, as with most health treatments, there are benefits and
risks.
Feedback:
The nurse should approach the topic of alternative or complementary therapies from an open-ended, supportive approach,
emphasizing the need to communicate with care providers. Complementary therapies and medical treatment are not
mutually exclusive, though some contraindications exist. Research supports the efficacy of some forms of complementary
and alternative treatment.
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15. A patient was tested for HIV using enzyme immunoassay (EIA) and results were positive. The nurse
should expect the primary care provider to order what test to confirm the EIA test results?
A) Another EIA test
B) Viral load test
C) Western blot test
D) CD4/CD8 ratio
Western blot test
Feedback:
The Western blot test detects antibodies to HIV and is used to confirm the EIA test results. The viral load test measures
HIV RNA in the plasma and is not used to confirm EIA test results, but instead to track the progression of the disease
process. The CD4/CD8 ratio test evaluates the ratio of CD4 and CD8 cells but is not used to confirm results of EIA
testing.
16. The nurses plan of care for a patient with stage 3 HIV addresses the diagnosis of Risk for Impaired Skin
Integrity Related to Candidiasis. What nursing intervention best addresses this risk?
A) Providing thorough oral care before and after meals
B) Administering prophylactic antibiotics
C) Promoting nutrition and adequate fluid intake
D) Applying skin emollients as needed
Providing thorough oral care before and after meals
Feedback:
Thorough mouth care has the potential to prevent or limit the severity of this infection. Antibiotics are
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 700
irrelevant because of the fungal etiology. The patient requires adequate food and fluids, but these do not necessarily
prevent candidiasis. Skin emollients are not appropriate because candidiasis is usually oral.
17. A patient with HIV infection has begun experiencing severe diarrhea. What is the most appropriate
nursing intervention to help alleviate the diarrhea?
A) Administer antidiarrheal medications on a scheduled basis, as ordered.
B) Encourage the patient to eat three balanced meals and a snack at bedtime.
C) Increase the patients oral fluid intake.
D) Encourage the patient to increase his or her activity level.
Administer antidiarrheal medications on a scheduled basis, as ordered.
Feedback:
Administering antidiarrheal agents on a regular schedule may be more beneficial than administering them on an asneeded basis, provided the patients diarrhea is not caused by an infectious microorganism. Increased oral fluid may
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exacerbate diarrhea; IV fluid replacement is often indicated. Small, more frequent meals may be beneficial, and it is
unrealistic to increase activity while the patient has frequent diarrhea.
18. A nurse is caring for a patient hospitalized with AIDS. A friend comes to visit the patient and privately asks the
nurse about the risk of contracting HIV when visiting the patient. What is the nurses best response?
A) Do you think that you might already have HIV?
B) Dont worry. Your immune system is likely very healthy.
C) AIDS isnt transmitted by casual contact.
D) You cant contract AIDS in a hospital setting.
AIDS isnt transmitted by casual contact.
Feedback:
AIDS is commonly transmitted by contact with blood and body fluids. Patients, family, and friends must be reassured that
HIV is not spread through casual contact. A healthy immune system is not necessarily a protection against HIV. A hospital
setting does not necessarily preclude HIV infection.
19. A patient with HIV has a nursing diagnosis of Risk for Impaired Skin Integrity. What nursing
intervention best addresses this risk?
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 701
A) Utilize a pressure-reducing mattress.
B) Limit the patients physical activity.
C) Apply antibiotic ointment to dependent skin surfaces.
D) Avoid contact with synthetic fabrics.
Utilize a pressure-reducing mattress.
Feedback:
Devices such as alternating-pressure mattresses and low-air-loss beds are used to prevent skin breakdown. Activity
should be promoted, not limited, and contact with synthetic fabrics does not necessary threaten skin integrity. Antibiotic
ointments are not normally used unless there is a break in the skin surface.
20. A nurse would identify that a colleague needs additional instruction on standard precautions when the
colleague exhibits which of the following behaviors?
A) The nurse wears face protection, gloves, and a gown when irrigating a wound.
B) The nurse washes the hands with a waterless antiseptic agent after removing a pair of soiled
gloves.
C) The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure.
D) The nurse places a used needle and syringe in the puncture-resistant container without capping the
needle.
The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure.
Feedback:
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Gloves must be changed after contact with materials that may contain high concentration of microorganisms, even when
working with the same patient. Each of the other listed actions adheres to standard precautions.
21. An 18-year-old pregnant female has tested positive for HIV and asks the nurse if her baby is going to be
born with HIV. What is the nurses best response?
A) There is no way to know that for certain, but we do know that your baby has a one in four chance
of being born with HIV.
B) Your physician is likely the best one to ask that question.
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C) If the baby is HIV positive there is nothing that can be done until it is born, so try your best not to
worry about it now.
D) Its possible that your baby could contract HIV, either before, during, or after delivery.
Its possible that your baby could contract HIV, either before, during, or after delivery.
Feedback:
Mother-to-child transmission of HIV-1 is possible and may occur in utero, at the time of delivery, or through breastfeeding. There is no evidence that the infants risk is 25%. Deferral to the physician is not a substitute for responding
appropriately to the patients concern. Downplaying the patients concerns is inappropriate.
22. A nurse is addressing the incidence and prevalence of HIV infection among older adults. What principle
should guide the nurses choice of educational interventions?
A) Many older adults do not see themselves as being at risk for HIV infection.
B) Many older adults are not aware of the difference between HIV and AIDS.
C) Older adults tend to have more sex partners than younger adults.
D) Older adults have the highest incidence of intravenous drug use.
Many older adults do not see themselves as being at risk for HIV infection.
Feedback:
It is known that many older adults do not see themselves as being at risk for HIV infection. Knowledge of the relationship
between HIV infection and AIDS is not known to affect the incidence of new cases. The statements about sex partners
and IV drug use are untrue.
23. A 16-year-old has come to the clinic and asks to talk to a nurse. The nurse asks the teen what she needs
and the teen responds that she has become sexually active and is concerned about getting HIV. The teen asks the
nurse what she can do keep from getting HIV. What would be the nurses best response?
A) Theres no way to be sure you wont get HIV except to use condoms correctly.
B) Only the correct use of a female condom protects against the transmission of HIV.
C) There are new ways of protecting yourself from HIV that are being discovered every day.
D) Other than abstinence, only the consistent and correct use of condoms is effective in preventing
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HIV.
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 703
Other than abstinence, only the consistent and correct use of condoms is effective in preventing HIV.
Feedback:
Other than abstinence, consistent and correct use of condoms is the only effective method to decrease the risk of sexual
transmission of HIV infection. Both female and male condoms confer significant protection. New prevention techniques are
not commonly discovered, though advances in treatment are constant.
24. A patient is in the primary infection stage of HIV. What is true of this patients current health status?
A) The patients HIV antibodies are successfully, but temporarily, killing the virus.
B) The patient is infected with HIV but lacks HIV-specific antibodies.
C) The patients risk for opportunistic infections is at its peak.
D) The patient may or may not develop long-standing HIV infection.
The patient is infected with HIV but lacks HIV-specific antibodie
Feedback:
The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection. The virus
is not being eradicated and infection is certain. Opportunistic infections emerge much later in the course of the disease.
25. A patients primary infection with HIV has subsided and an equilibrium now exists between HIV levels
and the patients immune response. This physiologic state is known as which of the following?
A) Static stage
B) Latent stage
C) Viral set point
D) Window period
Viral set point
Feedback:
The remaining amount of virus in the body after primary infection is referred to as the viral set point, which results in a
steady state of infection that lasts for years. This is not known as the static or latent stage. The window period is the time
a person infected with HIV tests negative even though he or she is
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 704
infected.
26. A patient with HIV will be receiving care in the home setting. What aspect of self-care should the nurse
emphasize during discharge education?
A) Appropriate use of prophylactic antibiotics
B) Importance of personal hygiene
C) Signs and symptoms of wasting syndrome
D) Strategies for adjusting antiretroviral dosages
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Importance of personal hygiene
Feedback:
Infection control is of high importance in patients living with HIV, thus personal hygiene is paramount. This is a more
important topic than signs and symptoms of one specific complication (wasting syndrome). Drug dosages should never be
independently adjusted. Prophylactic antibiotics are not normally prescribed unless the patients CD4 count is below 50.
27. A patient is beginning an antiretroviral drug regimen shortly after being diagnosed with HIV. What
nursing action is most likely to increase the likelihood of successful therapy?
A) Promoting appropriate use of complementary therapies
B) Addressing possible barriers to adherence
C) Educating the patient about the pathophysiology of HIV
D) Teaching the patient about the need for follow-up blood work
Addressing possible barriers to adherence
Feedback:
ART is highly dependent on adherence to treatment, and the nurse should proactively address this. Blood work is
necessary, but this will not have a direct bearing on the success or failure of treatment. Complementary therapies are
appropriate, but are not the main factor in successful treatment. The patient may or may not benefit from teaching about
HIV pathophysiology.
28. The nurse is caring for a patient who has been admitted for the treatment of AIDS. In the morning, the
patient tells the nurse that he experienced night sweats and recently coughed up some blood. What is the nurses
most appropriate action?
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 705
A) Assess the patient for additional signs and symptoms of Kaposis sarcoma.
B) Review the patients most recent viral load and CD4+ count.
C) Place the patient on respiratory isolation and inform the physician.
D) Perform oral suctioning to reduce the patients risk for aspiration.
Place the patient on respiratory isolation and inform the physician.
Feedback:
These signs and symptoms are suggestive of tuberculosis, not Kaposis sarcoma; prompt assessment and treatment is
necessary. There is no indication of a need for oral suctioning and the patients blood work will not reflect the onset of this
opportunistic infection.
29. A patient has come into contact with HIV. As a result, HIV glycoproteins have fused with the patients
CD4+ T-cell membranes. This process characterizes what phase in the HIV life cycle?
A) Integration
B) Attachment
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C) Cleavage
D) Budding
Attachment
Feedback:
During the process of attachment, glycoproteins of HIV bind with the hosts uninfected CD4+ receptor and chemokine
coreceptors, which results in fusion of HIV with the CD4+ T-cell membrane. Integration, cleavage, and budding are steps
that are subsequent to this initial phase of the HIV life cycle.
30. An HIV-infected patient presents at the clinic for a scheduled CD4+ count. The results of the test are 45 cells/mL,
and the nurse recognizes the patients increased risk for Mycobacterium aviumcomplex (MAC disease). The nurse
should anticipate the administration of what drug?
A) Azithromycin
B) Vancomycin
C) Levofloxacin
D) Fluconazole
Test Bank - Brunner & Suddarthts Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) 706
Azithromycin
Feedback:
HIV-infected adults and adolescents should receive chemoprophylaxis against disseminatedMycobacterium avium complex
(MAC disease) if they have a CD4+ count less than 50 cells/L. Azithromycin (Zithromax) or clarithromycin (Biaxin) are the
preferred prophylactic agents. Vancomycin, levofloxacin, and fluconazole are not prophylactic agents for MAC.
31. A patient with HIV is admitted to the hospital because of chronic severe diarrhea. The nurse caring for
this patient should expect the physician to order what drug for the management of the patients diarrhea?
A) Zithromax
B) Sandostatin
C) Levaquin
D) Biaxin
Sandostatin
Feedback:
Therapy with octreotide acetate (Sandostatin), a synthetic analogue of somatostatin, has been shown to be effective in
managing chronic severe diarrhea. Zithromax, Levaquin, and Biaxin are not used to treat chronic severe diarrhea.
32. A patient with AIDS is admitted to the hospital with AIDS-related wasting syndrome and AIDS-related
anorexia. What drug has been found to promote significant weight gain in AIDS patients