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Test bank - medical surgical nursing 10th edition ignatavicius
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Alterations in Adult Health 1 (West Virginia University)
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Medical Surgical Nursing 10th Edition
Ignatavicius Workman Test Bank
Chapter 01: Overview of Professional Nursing Concepts for Medical-Surgical Nursing
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises the
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new nurse that which is the priority when working as a professional nurse?
a. Attending to holistic client needs
b. Ensuring client safety
c. Not making medication errors
d. Providing client-focused care
ANS: B
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All actions are appropriate for the professional nurse. However, ensuring client safety is the
priority. Health care errors have been widely reported for 25 years, many of which result in
client injury, death, and increased health care costs. There are several national and
international organizations that have either recommended or mandated safety initiatives.
Every nurse has the responsibility to guard the client’s safety. The other actions are important
for quality nursing, but they are not as vital as providing safety. Not making medication errors
does provide safety, but is too narrow in scope to be the best answer.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Intervention
KEY: Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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2. A nurse is orienting a new client and family to the medical-surgical unit. What information
ANS: A
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does the nurse provide to best help the client promote his or her own safety?
a. Encourage the client and family to be active partners.
b. Have the client monitor hand hygiene in caregivers.
c. Offer the family the opportunity to stay with the client.
d. Tell the client to always wear his or her armband.
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Each action could be important for the client or family to perform. However, encouraging the
client to be active in his or her health care as a safety partner is the most critical. The other
actions are very limited in scope and do not provide the broad protection that being active and
involved does.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. A nurse is caring for a postoperative client on the surgical unit. The client’s blood pressure
was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the nurse
take first?
a. Call the Rapid Response Team.
b. Document and continue to monitor.
c. Notify the primary health care provider.
d. Repeat the blood pressure in 15 minutes.
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ANS: A
The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating
before they suffer either respiratory or cardiac arrest. Since the client has manifested a
significant change, the nurse would call the RRT. Changes in blood pressure, mental status,
heart rate, temperature, oxygen saturation, and last 2 hours’ urine output are particularly
significant and are part of the Modified Early Warning System guide. Documentation is vital,
but the nurse must do more than document. The primary health care provider would be
notified, but this is not more important than calling the RRT. The client’s blood pressure
would be reassessed frequently, but the priority is getting the rapid care to the client.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Rapid Response Team (RRT), Clinical judgment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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best demonstrates this concept?
a. Assesses for cultural influences affecting health care.
b. Ensures that all the client’s basic needs are met.
c. Tells the client and family about all upcoming tests.
d. Thoroughly orients the client and family to the room.
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4. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse
ANS: A
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Showing respect for the client and family’s preferences and needs is essential to ensure a
holistic or “whole-person” approach to care. By assessing the effect of the client’s culture on
health care, this nurse is practicing client-focused care. Providing for basic needs does not
demonstrate this competence. Simply telling the client about all upcoming tests is not
providing empowering education. Orienting the client and family to the room is an important
safety measure, but not directly related to demonstrating client-centered care.
TOP: Integrated Process: Culture and Spirituality
MSC: Client Needs Category: Psychosocial Integrity
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DIF: Understanding
KEY: Client-centered care, Culture
5. A client is going to be admitted for a scheduled surgical procedure. Which action does the
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nurse explain is the most important thing the client can do to protect against errors?
a. Bring a list of all medications and what they are for.
b. Keep the provider’s phone number by the telephone.
c. Make sure that all providers wash hands before entering the room.
d. Write down the name of each caregiver who comes in the room.
ANS: A
Medication reconciliation is a formal process in which the client’s actual current medications
are compared to the prescribed medications at the time of admission, transfer, or discharge.
This National client Safety Goal is important to reduce medication errors. The client would
not have to be responsible for providers washing their hands, and even if the client does so,
this is too narrow to be the most important action to prevent errors. Keeping the provider’s
phone number nearby and documenting everyone who enters the room also do not guarantee
safety.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Client safety, Informatics
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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6. Which action by the nurse working with a client best demonstrates respect for autonomy?
a. Asks if the client has questions before signing a consent.
b. Gives the client accurate information when questioned.
c. Keeps the promises made to the client and family.
d. Treats the client fairly compared to other clients.
ANS: A
Autonomy is self-determination. The client would make decisions regarding care. When the
nurse obtains a signature on the consent form, assessing if the client still has questions is vital,
because without full information the client cannot practice autonomy. Giving accurate
information is practicing with veracity. Keeping promises is upholding fidelity. Treating the
client fairly is providing social justice.
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DIF: Applying
TOP: Integrated Process: Caring
KEY: Ethics, Autonomy
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A nurse asks a more seasoned colleague to explain best practices when communicating with a
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person from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ)
community. What answer by the faculty is most accurate?
a. Avoid embarrassing the client by asking questions.
b. Don’t make assumptions about his or her health needs.
c. Most LGBTQ people do not want to share information.
d. No differences exist in communicating with this population.
ANS: B
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Many members of the LGBTQ community have faced discrimination from health care
providers and may be reluctant to seek health care. The nurse would never make assumptions
about the needs of members of this population. Rather, respectful questions are appropriate. If
approached with sensitivity, the client with any health care need is more likely to answer
honestly.
DIF: Understanding
KEY: Health care disparities, LGBTQ
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs Category: Psychosocial Integrity
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8. A nurse is calling the on-call health care provider about a client who had a hysterectomy 2
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days ago and has pain that is unrelieved by the prescribed opioid pain medication. Which
statement comprises the background portion of the SBAR format for communication?
a. “I would like you to order a different pain medication.”
b. “This client has allergies to morphine and codeine.”
c. “Dr. Smith doesn’t like nonsteroidal anti-inflammatory meds.”
d. “This client had a vaginal hysterectomy 2 days ago.”
ANS: B
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SBAR is a recommended form of communication, and the acronym stands for Situation,
Background, Assessment, and Recommendation. Appropriate background information
includes allergies to medications the on-call health care provider might order. Situation
describes what is happening right now that must be communicated; the client’s surgery 2 days
ago would be considered background. Assessment would include an analysis of the client’s
problem; none of the options has assessment information. Asking for a different pain
medication is a recommendation. Recommendation is a statement of what is needed or what
outcome is desired.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Teamwork and collaboration, SBAR
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
9. A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive
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personnel (AP). Four hours later, the nurse notes that the client’s blood pressure taken by the
AP was much higher than previous readings, and the client’s mental status has changed. What
action by the nurse would most likely have prevented this negative outcome?
a. Determining if the AP knew how to take blood pressure
b. Double-checking the AP by taking another blood pressure
c. Providing more appropriate supervision of the AP
d. Taking the blood pressure instead of delegating the task
ANS: C
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Supervision is one of the five rights of delegation and includes directing, evaluating, and
following up on delegated tasks. The nurse would either have asked the AP about the vital
signs or instructed the AP to report them right away. An experienced AP would know how to
take vital signs and the nurse would not have to assess this at this point. Double-checking the
work defeats the purpose of delegation. Vital signs are within the scope of practice for a AP
and are permissible to delegate. The only appropriate answer is that the nurse did not provide
adequate instruction to the AP.
DIF: Analyzing
TOP: Integrated Process: Communication and Documentation
KEY: Teamwork and collaboration, Delegation
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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10. A newly graduated nurse in the hospital states that because of being so new, participation in
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quality improvement (QI) projects is not wise. What response by the precepting nurse is best?
a. “All staff nurses are required to participate in quality improvement here.”
b. “Even being new, you can implement activities designed to improve care.”
c. “It’s easy to identify what indicators would be used to measure quality.”
d. “You should ask to be assigned to the research and quality committee.”
ANS: B
The preceptor would try to reassure the nurse that implementing QI measures is not out of line
for a newly licensed nurse. Simply stating that all nurses are required to participate does not
help the nurse understand how that is possible and is dismissive. Identifying indicators of
quality is not an easy, quick process and would not be the best place to suggest a new nurse to
start. Asking to be assigned to the QI committee does not give the nurse information about
how to implement QI in daily practice.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
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KEY: Systems thinking, Quality improvement
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
11. A nurse is talking with a co-worker who is moving to a new state and needs to find new
employment there. What advice by the nurse is best?
a. Ask the hospitals there about standard nurse–client ratios.
b. Choose the hospital that has the newest technology.
c. Find a hospital that has achieved Magnet status.
d. Work in a facility affiliated with a medical or nursing school.
ANS: C
Client Magnet status is awarded by The Joint Commission (TJC) and certifies that nurses can
demonstrate how best current evidence guides their practice. New technology doesn’t
necessarily mean that the hospital is safe. Affiliation with a health profession school has
several advantages, but safety is most important.
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DIF: Understanding
TOP: Integrated Process: Communication and Documentation
KEY: Evidence-based practice, Magnet status
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
MULTIPLE RESPONSE
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1. A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest
ANS: A, B, D, E
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levels of competency. Which areas would the manager assess to determine if the nursing staff
demonstrate competency according to the Institute of Medicine (IOM) report Health
Professions Education: A Bridge to Quality? (Select all that apply.)
a. Collaborating with an interprofessional team
b. Implementing evidence-based care
c. Providing family-focused care
d. Routinely using informatics in practice
e. Using quality improvement in client care
f. Formalizing systems thinking when implementing care
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The IOM report lists five broad core competencies that all health care providers should
practice. These include collaborating with the interprofessional team, implementing
evidence-based practice, providing patient-focused care, using informatics in client care, and
using quality improvement in client care. Systems thinking is required for quality
improvement but is not a specified part of the IOM report.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Competencies, Institute of Medicine (IOM)
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
2. A nurse is interested in making interprofessional work a high priority. Which actions by the
nurse best demonstrate this skill? (Select all that apply.)
a. Consults with other disciplines on client care.
b. Coordinates discharge planning for home safety.
c. Participates in comprehensive client rounding.
d. Routinely asks other disciplines about client progress.
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e. Shows the nursing care plans to other disciplines.
f. Delegate tasks to unlicensed personnel appropriately.
ANS: A, B, C, D, F
Collaborating with the interprofessional team involves planning, implementing, and
evaluating client care as a team with all other involved disciplines included. Simply showing
other caregivers the nursing care plan is not actively involving them or collaborating with
them.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Teamwork and collaboration, Interprofessional team
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. The nurse utilizing evidence-based practice (EBP) considers which factors when planning
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care? (Select all that apply.)
a. Cost-saving measures
b. Nurse’s expertise
c. Client preferences
d. Research findings
e. Values of the client
f. Plan-do-study-act model
ANS: B, C, D, E
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EBP consists of utilizing current evidence, the client’s values and preferences, and the nurse’s
expertise when planning care. It does not include cost-saving measures. The PDSA model is a
systematic model for quality improvement, but is not a specific component of EBP.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Planning
KEY: Evidence-based practice (EBP)
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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4. A nurse manager wants to improve hand-off communication among the staff. What actions by
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the manager would best help achieve this goal? (Select all that apply.)
a. Attend hand-off rounds to coach and mentor.
b. Create a template of suggested topics to include in report.
c. Encourage staff to ask questions during hand-off.
d. Give raises based on compliance with reporting.
e. Provide education on the SBAR method of communication
ANS: A, B, C, E
The SBAR method of communication has been identified as an excellent method of
communication between health care professionals. It is a formalized structure consisting of
Situation, Background, Assessment, and Recommendation/Request. Using a formalized
mechanism for communication helps ensure successful hand-off and fewer client errors. When
establishing this new format for report, the most helpful actions by the manager would be to
provide initial education on the process, develop a template with suggested topics under each
heading, attend rounds to coach and mentor, and encourage staff to ask questions to clarify
information. Basing raises on compliance would not be the most helpful method because
raises are often determined only once a year and are based on multiple criteria.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Teamwork and collaboration, Communication
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MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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Chapter 02: Clinical Judgment and Systems Thinking
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse asks the charge nurse to explain the difference between critical thinking and clinical
judgment. What statement by the charge nurse is best?
a. “Clinical judgment is often clouded by erroneous hypotheses.”
b. “Clinical judgment is the observable outcome of critical thinking.”
c. “Critical thinking requires synthesizing interactions within a situation.”
d. “Critical thinking is the highest level of nursing judgment.”
ANS: B
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Clinical judgment is the observable outcome of critical thinking and decision making. It can
be, but most often is not, clouded by erroneous hypotheses. Recognizing, understanding, and
synthesizing interactions and interdependencies in a set of components designed for a specific
purpose is systems thinking. Critical thinking is not the highest level of nursing judgment.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Clinical judgment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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2. The nurse understands which information regarding patient-centered care?
a. A competency recognizing the client as the source of control of his or her care
b. A project addressing challenges in implementing patient-centered care
c. Purposeful, informed, and outcome-focused care of clients or families
d. The ability to use best evidence and practice when making care-related decisions
ANS: A
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Patient-centered care is a QSEN competency that recognizes the patient or caregiver as the
source of control and full partner in providing compassionate and coordinated care based on
respect for the patient’s preferences, values, and needs. QSEN is a project addressing the
challenge of preparing future nurses with the knowledge, skills, and attitudes (KSAs)
necessary to continuously improve the quality and safety of the health care systems in which
they work. Critical thinking is the application of purposeful, informed, and outcome-focused
care. The ability to use best evidence and practice when making care-related decisions is
evidence-based practice.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Patient-centered care
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A nurse wishes to participate in an activity that will influence health outcomes. What action
by the nurse best meets this objective?
a. Creating a transportation system for health care appointments
b. Lobbying with a national organization for health care policy
c. Organizing a food pantry in an impoverished community
d. Running for election to the county public health board
ANS: B
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All options are good choices for an altruistic nurse wishing to influence health outcomes;
however, being involved in policy creation and health care reform is an activity specifically
recognized to improve health outcomes. This action will also affect a wider population than
the more local options.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Health outcomes
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. What factor best predicts a nurse’s willingness to employ critical thinking?
a. Caring
b. Knowledge
c. Presence
d. Skills
ANS: A
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All attributes are important in nursing, however; the nurse’s willingness to think critically is
predicted by caring behaviors, self-reflection, and insight.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Critical thinking
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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5. To demonstrate clinical reasoning skills, what action does the nurse take?
a. Collaborating with co-workers to buddy up for lunch breaks
b. Delegating frequent vital signs on a new postoperative patient
c. Documenting a complete history and physical on an admission
d. Requesting the provider order medication for a client with high potassium
ANS: D
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The components of clinical reasoning include assessing, analyzing, planning, implementing,
and evaluating. This nurse shows the ability to analyze by interpreting the meaning of the lab
value, to plan by anticipating the consequences of the lab value, and to implement by taking
action.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Clinical judgment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
6. The new nurse asks the preceptor how context affects clinical judgment. What response by the
preceptor is best?
a. “Context considers the whole of the patient’s story and circumstances.”
b. “It shouldn’t, only nursing knowledge would affect clinical judgment.”
c. “Outside influences such as environment in which you provide care, influence
your decisions.”
d. “The context of the situation provides an extra layer of complexity to consider.”
ANS: C
The context of a situation considers and supports clinical judgment. The factors within this
layer—such as environment, time pressure, availability or content of electronic health records,
resources, and individual nursing knowledge—have a direct impact on clinical judgment. The
other two options are too vague to provide appropriate information.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Clinical judgment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. Once the nurse has considered all possible collaborative and client problems, what action does
the nurse take next?
a. Act on the observed cues.
b. Determine desired outcomes.
c. Generate solutions.
d. Prioritize the hypotheses.
ANS: D
Analyzing cues lead to a list of potential hypotheses. The nurse prioritizes them, determines
the desired outcomes, generates solutions, and acts. This is part of the six-step clinical
judgment model.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Diagnosis
KEY: Clinical judgment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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8. A nurse working in a medical home would do which of the following as part of the job?
a. Advocate with insurance companies.
b. Coordinate interprofessional care.
c. Hold monthly team meetings.
d. Provide out-of-network specialty referrals.
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ANS: B
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The medical home concept came into being to decrease the fragmentation of care. On a daily
basis, this nurse would expect to coordinate with the interprofessional care team. Advocating
with insurance companies would not be a daily function. Monthly team meetings may or may
not be needed. Out of network referrals would not be needed as the interprofessional team
strives to provide comprehensive care.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Medical home
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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9. A nurse is confused on why systems thinking is important since working on the unit involves
caring for a few specific clients. What explanation by the nurse manager is best?
a. “It’s a good way to conduct root-cause analysis.”
b. “It is important for quality improvement and safety.”
c. “Systems thinking helps you see the bigger picture.”
d. “You may enter management 1 day and need to know this.”
ANS: B
A systems thinking approach to care reinforces the nurse’s role in safety and quality
improvement while expanding clinical judgment to include the patient’s place within the
greater health care system in the context of care decisions. Root-cause analyses would be a
small portion of systems thinking. It does give the nurse a big-picture view, but this answer is
vague. The nurse may or may not ever join management.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Systems thinking
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. The expert nurse understands that critical thinking requires which elements to be present?
(Select all that apply.)
a. Based on logic, creativity, and intuition
b. Driven by needs
c. Focused on safety and quality
d. Grounded in a specific theory
e. Guided by standards
f. Requires forming options about evidence
ANS: A, B, C, E
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Critical thinking must be based on logic, creativity, and intuition; driven by patient, family, or
community needs; focused on safety and quality; guided by standards, policies, ethics, and
laws; based on principles of nursing process, problem-solving, and the scientific method
(requires forming opinions and making decisions based on evidence); centered on
identification of the key problems, issues, and risks; and grounded in strategies that make the
most of human potential. It is not dependent on using a specific theory.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Planning
KEY: Critical thinking
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
2. The nurse manager is conducting an annual evaluation of a staff nurse and is appraising the
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nurse’s clinical reasoning. What nurse actions does the manager observe to help form this
judgment? (Select all that apply.)
a. Anticipating consequences of actions
b. Delegating appropriately
c. Interpreting data
d. Noticing cues
e. Setting priorities
ANS: A, C, D, E
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The phases of clinical reasoning include assessing (noticing cues), analyzing (interpreting
data), planning (anticipating consequences and setting priorities), implementing, and
evaluating. Delegating appropriately is not included in this model.
DIF: Applying
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Clinical reasoning
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. According to the WHO, what does primary care involve? (Select all that apply.)
a. Empowered people and communities
b. Essential public functions
c. Multisectoral policy and action
d. Primary care
e. Priority consideration of chronic diseases
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f.
Elimination of chronic diseases
ANS: A, B, C, D
According to the WHO, primary care involves three main areas: empowered people and
communities, primary care and essential public functions, and multisectoral policy and action.
Primary care focuses on both prevention and management of chronic disease.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Primary care, Systems thinking
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A nurse wishes to work in a community-based practice setting. Which areas would this nurse
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ANS: A, B, C, E, F
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explore for employment? (Select all that apply.)
a. Hospice facility
b. “Minute clinic”
c. Mobile mammography unit
d. Small community hospital
e. Telehealth
f. Home health care
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The multiple avenues providing community-based care include hospice, “minute” or retail
clinics, mobile screening and diagnostic services, telehealth, private medical practices,
outpatient services, freestanding points of care, home health care, long-term ambulatory care,
public health, and free clinics. Inpatient services in a hospital are not considered primary care
sites.
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DIF: Remembering
TOP: Integrated Process: NA
KEY: Community-based care
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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Chapter 03: Overview of Health Concepts for Medical-Surgical Nursing
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is caring for a client who is acidotic. The nurse asks the charge nurse why the client is
breathing rapidly. What response by the charge nurse is best?
a. Anxiety is causing the client to breathe rapidly.
b. The client is trying to get rid of excess body acids.
c. The rapid respirations cause buildup of bicarbonate.
d. An increased respiratory rate is due to increased metabolism.
ANS: B
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The client is acidotic, and the respiratory system is attempting to compensate by “blowing
off” excess acid in the form of carbon dioxide. The increased respiratory rate is not due to
anxiety or increased metabolism. An increased respiratory rate does not cause a buildup of
bicarbonate.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Acid-base balance
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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2. A client had a recent thromboembolism and must resume work which requires frequent car
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ANS: A
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and plane travel. What self-care measure does the nurse teach to reduce the risk of impaired
clotting in this client?
a. Get up and walk around at least every 2 hours while traveling.
b. Use a soft toothbrush and an electric razor for safety.
c. Be sure to sit with the legs elevated as much as possible.
d. Increase fiber in the diet so as not to strain to move the bowels.
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Clients who are at risk of increased clotting (as evidenced by prior thromboembolic event) can
take several measures to reduce their risk of further problems. One measure is to get up and
walk frequently when sitting for a long period of time. Using a soft toothbrush and an electric
razor and needing to prevent constipation would be important for a client at risk of bleeding.
Elevating the legs is not as beneficial as ambulating.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Clotting, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse is caring for four clients. Which client does the nurse assess first for impaired
cognition?
A 28-year-old client 2 days post-open cholecystectomy
An 88-year-old client 3 days post-hemorrhagic stroke
A 32-year-old client with a 20–pack-year history of smoking
A 42-year-old client with a serum sodium of 134 mEq/L (134 mmol/L)
a.
b.
c.
d.
ANS: B
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There are many risk factors for impaired cognition including advanced age and diseases and
disorders that affect the brain. The 88-year-old client who is recovering from a stroke has two
such risk factors and is at highest risk for impaired cognition. The nurse assesses this client
first. The other clients have a much lower risk of developing impaired cognition.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cognition, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. The assistive personnel (AP) reports to the registered nurse that a postoperative client has a
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pulse of 132 beats/min and a blood pressure of 168/90 mm Hg. What response by the nurse is
most appropriate?
a. Ask the AP to repeat the client’s vital signs in 15 minutes.
b. Assess the client for pain.
c. Ask the client if something is bothersome.
d. Instruct the AP to reposition the client.
ANS: B
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The “fight-or-flight” syndrome can occur from sympathetic nervous stimulation due to acute
pain. Symptoms can include nausea, vomiting, diaphoresis, tachycardia, tachypnea,
hypertension, and dilated pupils. Since this client is postoperative, it is reasonable to believe
that he or she might be in pain. The nurse first assesses for pain or discomfort and treats it. If
the client is not in pain, the nurse would conduct further assessments to determine the cause of
the abnormal vital signs.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Pain, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A client has urinary incontinence. Which assessment finding indicates that outcomes for a
ANS: C
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priority nursing diagnosis have been met?
a. Client reports satisfaction with undergarments for incontinence.
b. Client reports drinking 8 to 9 glasses of water each day.
c. Skin in perineal area is intact without redness on inspection.
d. Family states that client is more active and socializes more.
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Urinary incontinence can lead to skin breakdown and possibility of infection. Skin that is
intact without redness shows that a major goal for this client has been met. Becoming more
social is a positive finding as many adults with incontinence limit their social activities, but
this psychosocial outcome is not the priority over a physical outcome. Being satisfied with
undergarments is also not the priority. Drinking adequate water can sometimes help with
incontinence and is important for general health, but is not directly related to an important
goal for this client.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Tissue integrity, Incontinence
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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6. The registered nurse asks the nursing assistant why a cardiac client’s morning weight has not
yet been done. The nursing assistant says, “I’ll get to it, what’s the big deal?” When deciding
how to respond, the nurse considers what information about weight?
a. Decisions on treatment often depend on the daily weight.
b. The nursing assistant needs to ensure that tasks are done on time.
c. Weight is the most accurate noninvasive indicator of fluid status.
d. A change in weight may indicate the need to change IV fluids.
ANS: C
Weight is the best (noninvasive) indicator of fluid status. Primary health care providers may
base treatment decisions on weight, because the weight reflects fluid balance, but this answer
does not explain why. IV fluid rates or solutions may change for the same reason. The nursing
assistant would perform tasks on a timely basis, but this is not related to information about
weight.
m
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Fluid and electrolytes
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. The nurse in the emergency department (ED) is caring for four clients. Which client does the
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nurse assess for gas exchange abnormalities first?
a. Involved in motor vehicle crash, has broken femur.
b. Brought in unconscious by roommate after opioid overdose.
c. Asthmatic client being discharged after bronchodilator therapy.
d. History of COPD, presents to ED after being bitten by a dog.
ANS: B
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nk
Opioid medications can cause respiratory depression, so this client is most at risk for gas
exchange problems. Diminished respirations will allow a buildup of carbon dioxide in the
blood. The clients with asthma and COPD have the potential for gas exchange problems but
this is not indicated in answer option as he or she is being discharged. The client with a
broken femur does not have information suggesting gas exchange problems.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Gas exchange, Risk factors
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
8. The nurse caring for a client with malnutrition assesses which laboratory value as the
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priority?
Albumin
Prealbumin
Prothrombin time
Serum sodium
a.
b.
c.
d.
ANS: B
Both albumin and prealbumin are indicators for nutrition. However, prealbumin changes more
rapidly with decreased nutrition, so it is the better test. Prothrombin time and serum sodium
are not directly related to nutritional status.
DIF: Remembering
KEY: Nutrition, Laboratory values
TOP: Integrated Process: Nursing Process: Assessment
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9. A nurse is planning primary prevention measures for community-dwelling adults to prevent
visual impairment. What action by the nurse will best meet this objective?
a. Provide glaucoma screening.
b. Assess visual acuity.
c. Teach clients about instilling eyedrops.
d. Offer a healthy lifestyle class.
ANS: D
Primary prevention activities are those designed to actually prevent the onset of a disease or
health problem. Secondary prevention focuses on screening and early diagnosis/detection.
Tertiary measures are those that offer treatment and rehabilitation. Encouraging a healthy
lifestyle through classes may help prevent diabetes, a common cause of visual impairment,
and is a primary prevention measure. Assessing for glaucoma and visual acuity is a secondary
prevention measure. Teaching clients how to instill eyedrops is tertiary.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: Sensory perception, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
10. The nurse tells the staff development nurse he/she is very uncomfortable discussing sexuality
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with clients, especially those who are older. What suggestion by the staff development nurse
is most appropriate?
a. “Find a trusted friend and role play.”
b. “Don’t worry it will get easier.”
c. “A sexual assessment is usually not needed.”
d. “It’s hard for me to do, too.”
nk
ANS: A
ba
Discussing sexuality and sex is difficult for most people. Since it is important to be able to
assess this aspect of people’s lives, the nurse needs to become comfortable. Role-playing with
a trusted friend will build confidence and comfort. Saying that it will get easier and that it is
hard for the staff development nurse too does not give the nurse any ideas for improvement.
Sexuality is important to assess.
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DIF: Applying
TOP: Integrated Process: Caring
KEY: Sexuality, Nursing assessment
MSC: Client Needs Category: Psychosocial Integrity
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MULTIPLE RESPONSE
1. A nurse is planning a community education event-related to impaired cellular regulation.
What teaching topics would the nurse include in this event? (Select all that apply.)
a. Ways to minimize exposure to sunlight
b. Resources available for smoking cessation
c. Strategies to remain hydrated during hot weather
d. Use of indoor tanning beds instead of sunbathing
e. Creative cooking techniques to increase dietary fiber
f. How to determine sodium content in food?
ANS: A, B, E
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Disrupted cellular regulation can lead to both benign and malignant tumors (cancer). Ways to
minimize the risk of developing cancer include decreasing exposure to sunlight, smoking
cessation, and increasing dietary fiber. Tanning beds do not reduce the risk of cancer as
opposed to sunbathing. While staying hydrated is a good health measure, it is not related to
cellular regulation. Maintaining a normal intake of sodium is also not related to cellular
regulation.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: Cellular regulation, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
2. A nurse is caring for clients on an inclient surgical unit. Which clients does the nurse identify
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as having a risk for impaired immunity? (Select all that apply.)
a. 86 years old
b. Has type 2 diabetes
c. Taking prednisone
d. Has many allergies
e. Drinks a beer a day
f. Low socioeconomic status
ANS: A, B, C, F
nk
s.
Risk factors for impaired immunity include but are not limited to: older adults (diminished
immunity due to normal aging changes), low socioeconomic groups (inability to obtain proper
immunizations), nonimmunized adults, adults with chronic illnesses that weaken the immune
system, adults taking chronic drug therapy such as corticosteroids and chemotherapeutic
agents, adults experiencing substance use disorder, adults who do not practice a healthy
lifestyle, and adults who have a genetic risk for decreased or excessive immunity. Allergies
and one beer a day are not risk factors.
ba
DIF: Remembering
TOP: Integrated Process: Nursing Process: Planning
KEY: Immunity
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. The nurse is caring for a client with severely impaired mobility. What actions does the nurse
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place on the care plan to address potential complications? (Select all that apply.)
a. Perform a depression screen once a day.
b. Consult physical therapy for range of motion.
c. Increase fiber in the client’s diet.
d. Decrease fluid intake.
e. Allow client to stay in a position of comfort.
ANS: A, B, C
There are many complications of immobility including depression, pressure injuries,
constipation, urinary calculi, and muscle atrophy. The nurse would address these by assessing
for depression, consulting physical therapy for activities such as range of motion the client can
do, and increase fiber so the client does not become constipated. Decreasing fluid intake
would increase the possibility of calculi and allowing the client to stay in one position would
increase the risk of pressure injuries.
DIF: Applying
KEY: Mobility
TOP: Integrated Process: Nursing Process: Implementation
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MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. A client has impaired tissue integrity and a nonhealing wound. The nurse has taught the client
about diet changes to improve wound healing. What diet selections does the nurse evaluate as
good understanding by the client? (Select all that apply.)
a. Chicken breast
b. Orange juice
c. Boost supplement
d. Spinach salad
e. Cantaloupe
f. Whole wheat bread
ANS: A, B, C, D
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Protein and vitamin C are important for wound healing. Foods high in protein include meat
sources such as chicken and nutritional supplements. Foods high in vitamin C include orange
juice and spinach. Cantaloupe is a good source of vitamin A. Whole wheat bread, while
healthy, does not contribute directly to wound healing.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Nutrition
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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Chapter 04: Common Health Problems of Older Adults
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse learns that the fastest growing subset of the older population is which group?
a. Elite old
b. Middle old
c. Old old
d. Young old
ANS: C
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The old old is the fastest growing subset of the older population. This is the group comprising
those 85 to 99 years of age. The young old are between 65 and 74 years of age; the middle old
are between 75 and 84 years of age; and the elite old are over 100 years of age.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Older adults MSC: Client Needs Category: Health Promotion and Maintenance
2. A nurse working with older adults in the community plans programming to improve morale
s.
and emotional health in this population. What activity would best meet this goal?
a. Exercise program to improve physical function
b. Financial planning seminar series for older adults
c. Social events such as dances and group dinners
d. Workshop on prevention from becoming an abuse victim
nk
ANS: A
TOP: Integrated Process: Nursing Process: Planning
MSC: Client Needs Category: Psychosocial Integrity
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DIF: Applying
KEY: Older adult
ba
All activities would be beneficial for the older population in the community. However, failure
in performing one’s own activities of daily living and participating in society has direct effects
on morale and life satisfaction. Those who lose the ability to function independently often feel
worthless and empty. An exercise program designed to maintain and/or improve physical
functioning would best address this need.
3. A nurse caring for an older client on a medical-surgical unit notices the client reports frequent
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constipation and only wants to eat softer foods such as rice, bread, and puddings. What
assessment would the nurse perform first?
a. Auscultate bowel sounds.
b. Check skin turgor.
c. Perform an oral assessment.
d. Weigh the client.
ANS: C
Poorly fitting dentures and other dental problems are often manifested by a preference for soft
foods and constipation from the lack of fiber. The nurse would perform an oral assessment to
determine if these problems exist. The other assessments are important, but will not yield
information specific to the client’s food preferences as they relate to constipation.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Older adult, Nutrition
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
4. A nurse caring for an older adult has provided education on high-fiber foods. Which menu
selection by the client demonstrates a need for further review?
a. Barley soup
b. Black beans
c. White rice
d. Whole-wheat bread
ANS: C
Older adults need 35 to 50 g of fiber a day. White rice is low in fiber. Foods high in fiber
include barley, beans, and whole-wheat products.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Older adult, Nutrition
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse is working with an older client admitted with mild dehydration. What teaching does
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the nurse provide to best address this issue?
a. “Cut some sodium out of your diet.”
b. “Dehydration can cause incontinence.”
c. “Have something to drink every 1 to 2 hours.”
d. “Take your diuretic in the morning.”
ANS: C
ba
nk
Older adults often lose their sense of thirst. Plus older adults have less body water than
younger people. Since they should drink 1 to 2 L of water a day, the best remedy is to have
the older adult drink something each hour or two, whether or not he or she is thirsty. Cutting
“some” sodium from the diet will not address this issue and is vague. Although dehydration
can cause incontinence from the irritation of concentrated urine, this information will not help
prevent the problem of dehydration. Instructing the client to take a diuretic in the morning
rather than in the evening also will not directly address this issue.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Older adult, Fluid and electrolyte balance
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A home health care nurse is planning an exercise program with an older adult who lives at
home independently but whose mobility issues prevent much activity outside the home.
Which exercise regimen would be most beneficial to this adult?
a. Building strength and flexibility
b. Improving exercise endurance
c. Increasing aerobic capacity
d. Providing personal training
ANS: A
This older adult is mostly homebound. Exercise regimens for homebound clients include
things to increase functional fitness and ability for activities of daily living. Strength and
flexibility will help the client to be able to maintain independence longer. The other plans are
good but will not specifically maintain the client’s functional abilities.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: Older adult, Functional ability
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
7. An older adult recently retired and reports “being depressed and lonely.” What information
would the nurse assess as a priority?
a. History of previous depression
b. Previous stressful events
c. Role of work in the adult’s life
d. Usual leisure time activities
ANS: C
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Establishing and maintaining relationships with others throughout life are especially important
to the older person’s happiness. When people retire, they may lose much of their social
network, leading them to feeling depressed and lonely. This loss from a sudden change in
lifestyle can easily lead to depression. The nurse would first assess the role that work played
in the client’s life. The other factors can be assessed as well, but this circumstance is
commonly seen in the older population.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Older adult, Depression
MSC: Client Needs Category: Psychosocial Integrity
8. A nurse is assessing coping in older women in a support group for recent widows. Which
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statement by a participant best indicates potential for successful coping?
a. “I have had the same best friend for decades.”
b. “I think I am coping very well on my own.”
c. “My kids come to see me every weekend.”
d. “Oh, I have lots of friends at the senior center.”
ANS: A
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ba
Friendship and support enhance coping. The quality of the relationship is what is most
important, however. People who have close, intimate, stable relationships with others in
whom they confide are more likely to cope with crisis. The person who is “coping well on my
own” may actually need resources to help with this transition. Having children visit is
important but not as important as intimate, long-term friendships. “Friends at the senior
center” may refer to good acquaintances and not real friends.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Older adult, Coping
MSC: Client Needs Category: Psychosocial Integrity
9. A home health care nurse has conducted a home safety assessment for an older adult. There
are five concrete steps leading out from the front door. Which intervention would be most
helpful in keeping the older adult safe on the steps?
a. Have the client use a walker or cane on the steps.
b. Teach the client to hold the handrail when using the steps
c. Instruct the client to use the garage door instead.
d. Tell the client to use a two-footed gait on the steps.
ANS: B
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As a person ages, he or she may experience a decreased sense of touch. The older adult may
not be aware of where his or her foot is on the step. Combined with diminished visual acuity,
this can create a fall hazard. Holding the handrail would help keep the person safer. If the
client does not need an assistive device, he or she would not use a cane or walker just on
stairs. Using an alternative door may be necessary but does not address making the front steps
safer. A two-footed gait may not help if the client is unaware of where the foot is on the step.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Older adult, Safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
10. An older adult is brought to the emergency department because of sudden onset of confusion.
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After the client is stabilized and comfortable, what assessment by the nurse is most
important?
a. Assess for orthostatic hypotension.
b. Determine if there are new medications.
c. Evaluate the client for gait abnormalities.
d. Perform a delirium screening test.
ANS: B
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Medication side effects and adverse effects are common in the older population. Something as
simple as a new antibiotic can cause confusion and memory loss. The nurse would determine
if the client is taking any new medications. Assessments for orthostatic hypotension, gait
abnormalities, and delirium may be important once more is known about the client’s
condition.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Older adult, Medication safety
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
11. An older adult client takes medication three times a day and becomes confused about which
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medication should be taken at which time. The client refuses to use a pill sorter with slots for
different times, saying “Those are for old people.” What action by the nurse would be most
helpful?
a. Arrange medications by time in a drawer.
b. Encourage the client to use easy-open tops.
c. Put color-coded stickers on the bottle caps.
d. Write a list of when to take each medication.
ANS: C
Color-coded stickers are a fast, easy-to-remember system. One color is for morning meds, one
for evening meds, and the third color is for nighttime meds. Arranging medications by time in
a drawer might be helpful if the person doesn’t accidentally put them back in the wrong spot.
Easy-open tops are not related. Writing a list might be helpful, but not if it gets misplaced.
With stickers on the medication bottles themselves, the reminder is always with the
medication.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Older adult, Medication safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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12. An older adult client is in the hospital. The client is ambulatory and independent. What
intervention by the nurse would be most helpful in preventing falls in this client?
a. Keep the light on in the bathroom at night.
b. Order a bedside commode for the client.
c. Put the client on a toileting schedule.
d. Use side rails to keep the client in bed.
ANS: A
Although this older adult is independent and ambulatory, being hospitalized can create
confusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the
light on in the bathroom will help reduce the likelihood of falling. The client does not need a
commode or a toileting schedule. Side rails used to keep the client in bed are considered
restraints and would not be used in that fashion.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Older adult, Fall prevention
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
13. An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for
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pain. The client is allergic to morphine and reports pain and muscle spasms. When the nurse
calls the surgeon, which medication would he or she suggest in place of the morphine?
a. Cyclobenzaprine
b. Hydromorphone hydrochloride
c. Ketorolac
d. Meperidine
ANS: B
nk
Cyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are
all on the Beers list of potentially inappropriate medications for use in older adults and would
not be suggested. The nurse would suggest hydromorphone hydrochloride.
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DIF: Remembering
TOP: Integrated Process: Communication and Documentation
KEY: Older adult, Medication safety
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
14. A nurse admits an older adult from a home environment. The client lives with an adult son
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and daughter-in-law. The client has urine burns on the skin, no dentures, and several pressure
injuries. What action by the nurse is most appropriate?
a. Ask the family how these problems occurred.
b. Call the police department and file a report.
c. Notify Adult Protective Services.
d. Report the findings as per agency policy.
ANS: D
These findings are suspicious for abuse. Health care providers are mandatory reporters for
suspected abuse. The nurse would notify social work, case management, or whomever is
designated in facility policies. That person can then assess the situation further. If the police
need to be notified, that is the person who will notify them. Adult Protective Services is
notified in the community setting.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
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KEY: Older adult, Abuse
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
15. A nurse caring for an older client in the hospital is concerned the client is not competent to
give consent for upcoming surgery. What action by the nurse is best?
a. Call Adult Protective Services.
b. Discuss concerns with the health care team.
c. Do not allow the client to sign the consent.
d. Have the client’s family sign the consent.
ANS: B
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In this situation, each facility will have a policy designed for assessing competence. The nurse
would bring these concerns to an interprofessional care team meeting. There may be
physiologic reasons for the client to be temporarily too confused or incompetent to give
consent. If an acute condition is ruled out, the staff would follow the legal procedure and
policies in their facility and state for determining competence. The key is to bring the
concerns forward. Calling Adult Protective Services is not appropriate at this time. Signing
the consent would wait until competence is determined unless it is an emergency, in which
case the next of kin can sign if there are grave doubts as to the client’s ability to provide
consent. Simply not allowing the client to sign does not address the problem.
s.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Older adult, Autonomy
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
nk
MULTIPLE RESPONSE
1. A nurse working in an Acute Care of the Elderly unit learns that frailty in the older population
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includes which components? (Select all that apply.)
a. Dementia
b. Exhaustion
c. Slowed physical activity
d. Weakness
e. Weight gain
f. Frequent illness
ANS: B, C, D
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Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and
exhaustion, and weakness. Weight gain and dementia are not part of this syndrome. Frequent
illness could occur due to frailty, but is also not part of the syndrome.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Older adult, Frailty
MSC: Client Needs Category: Health Promotion and Maintenance
2. A home health care nurse assesses an older adult for the intake of nutrients needed in larger
amounts than in younger adults. Which foods found in an older adult’s kitchen might indicate
an adequate intake of these nutrients? (Select all that apply.)
a. 1% milk
b. Carrots
c. Lean ground beef
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d. Oranges
e. Vitamin D supplements
f. Cheese sticks
ANS: A, B, D, E
Older adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk and
cheese have calcium; carrots have vitamin A; vitamin D supplement has vitamin D; and
oranges have vitamin C. Lean ground beef is healthier than more fatty cuts, but does not
contain these needed nutrients.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Older adults, Nutrition
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
3. A nurse working with older adults assesses them for common potential adverse medication
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effects. For what does the nurse assess? (Select all that apply.)
a. Constipation
b. Dehydration
c. Mania
d. Urinary incontinence
e. Weakness
f. Anorexia
ANS: A, B, E, F
nk
s.
Common adverse medication effects include constipation/impaction, dehydration, anorexia,
and weakness. Mania and incontinence are not among the common adverse effects, although
urinary retention is.
ba
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Older adult, Adverse medication effects
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A nurse manager institutes the Fulmer SPICES Framework as part of the routine assessment
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of older adults in the hospital. The nursing staff assesses for which factors? (Select all that
apply.)
a. Confusion
b. Evidence of abuse
c. Incontinence
d. Problems with behavior
e. Sleep disorders
ANS: A, C, E
SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion,
and evidence of falls.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Older adult, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A visiting nurse is in the home of an older adult and notes a 7-lb weight loss since last
month’s visit. What actions would the nurse perform first? (Select all that apply.)
a. Assess the client’s ability to drive or transportation alternatives.
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b.
c.
d.
e.
Determine if the client has dentures that fit appropriately.
Encourage the client to continue the current exercise plan.
Have the client complete a 3-day diet recall diary.
Teach the client about proper nutrition in the older population.
ANS: A, B, D
Assessment is the first step of the nursing process and would be completed prior to
intervening. Asking about transportation to get food, dentures, and normal food patterns
would be part of an appropriate assessment for the client. There is no information in the
question about the older adult needing to lose weight, so encouraging him or her to continue
the current exercise regimen is premature and may not be appropriate. Teaching about proper
nutrition is a good idea, but teaching needs to be tailored to the client’s needs, which the nurse
does not yet know.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Older adult, Nutrition
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions
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does the registered nurse (RN) delegate to the assistive personnel (AP)? (Select all that apply.)
a. Assess skin redness when turning.
b. Document Braden Scale results.
c. Keep the client’s skin dry.
d. Obtain a pressure-relieving mattress.
e. Turn the client every 2 hours.
ANS: C, D, E
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The nurses’ aide or AP can assist in keeping the client’s skin dry, order a special mattress on
direction of the RN, and turn the client on a schedule. Assessing the skin is a nursing
responsibility, although the aide would be directed to report any redness noticed.
Documenting the Braden Scale results is the RN’s responsibility as the RN is the one who
performs that assessment.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Older adult, Tissue integrity
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A nurse admits an older adult to the hospital who lives at home with family. The nurse
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assesses that the client is malnourished. What actions by the nurse are best? (Select all that
apply.)
a. Contact Adult Protective Services or hospital social work.
b. Request the primary health care provider prescribes tube feedings.
c. Perform and document results of a Braden Scale assessment.
d. Request a dietary consultation from the health care provider.
e. Suggest a high-protein oral supplement between meals.
f. Assess the client’s own teeth or the dentures for proper fit.
ANS: C, D, E, F
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Malnutrition in the older population is multifactorial and has several potential adverse
outcomes. Appropriate actions by the nurse include assessing the client’s risk for skin
breakdown with the Braden Scale, requesting a consultation with a dietitian, suggesting a
high-protein meal supplement, and assessing the client’s dentures or own teeth. There is no
evidence that the client is being abused or needs a feeding tube at this time.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Older adult, Nutrition
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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Chapter 05: Assessment and Care of Patients With Pain
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A new nurse asks the precepting nurse “What is the best way to assess a client’s pain?” Which
response by the nurse is best?
a. Numeric pain scale
b. Behavioral assessment
c. Client’s self-report
d. Objective observation
ANS: C
m
Many ways to measure pain are in use, including numeric pain scales, behavioral assessments,
and other objective observations. However, the most accurate way to assess pain is to get a
self-report from the client.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Pain, Nursing assessment
MSC: Client Needs Category: Health Promotion and Maintenance
2. A new nurse reports to the nurse preceptor that a client requested pain medication, and when
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ANS: A
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the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly
sleep with the severe pain the client described. Which response by the experienced nurse is
best?
a. “Being able to sleep doesn’t mean pain doesn’t exist.”
b. “Have you ever experienced any type of pain?”
c. “The client should be assessed for drug addiction.”
d. “You’re right; I would put the medication back.”
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A client’s description is the most accurate assessment of pain. The nurse would believe the
client and provide pain relief. Physiologic changes due to pain vary from client to client, and
assessments of them would not supersede the client’s descriptions, especially if the pain is
chronic in nature. Asking if the new nurse has had pain is judgmental and flippant and does
not provide useful information. This amount of information does not warrant an assessment
for drug addiction. Putting the medication back and ignoring the client’s report of pain serves
no useful purpose and is unethical.
DIF: Understanding
TOP: Integrated Process: Communication and Documentation KEY: Pain, Nursing assessment
MSC: Client Needs Category: Health Promotion and Maintenance
3. The nurse in the outpatient surgery clinic is discussing an upcoming surgical procedure with a
client. Which information provided by the nurse is most appropriate for the client’s long-term
outcome?
a. “At least you know that the pain after surgery will diminish quickly.”
b. “Discuss acceptable pain control after your operation with the surgeon.”
c. “Opioids often cause nausea but you won’t have to take them for long.”
d. “The nursing staff will give you pain medication when you ask them for it.”
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ANS: B
The best outcome after a surgical procedure is timely and satisfactory pain control, which
diminishes the likelihood of chronic pain afterward. The nurse suggests that the client
advocate for himself or herself and discuss acceptable pain control with the surgeon. Stating
that pain after surgery is usually short lived does not provide the client with options to have
personalized pain control. To prevent or reduce nausea and other side effects from opioids, a
multimodal pain approach is desired. For acute pain after surgery, giving pain medications
around the clock instead of waiting until the client requests it is a better approach.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Pain, Acute pain
MSC: Client Needs Category: Health Promotion and Maintenance
4. A nurse is assessing pain on a confused older client who has difficulty with verbal expression.
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Which pain assessment tool would the nurse choose for this assessment?
a. Numeric rating scale
b. Verbal Descriptor Scale
c. FACES Pain Scale-Revised
d. Wong-Baker FACES Pain Scale
ANS: C
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All are valid pain rating scales; however, some research has shown that the FACES Pain
Scale-Revised is preferred by both cognitively intact and cognitively impaired adults. A
confused client with difficulty speaking would not be a good candidate for the numeric rating
scale or the verbal descriptor scale. The cartoon images on the Wong-Baker FACES Pain
Scale may not be appropriate for an adult client.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Pain, Nursing assessment
MSC: Client Needs Category: Health Promotion and Maintenance
5. The nurse is assessing a client’s pain and has elicited information on the location, quality,
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intensity, effect on functioning, aggravating and relieving factors, and onset and duration.
Which question by the nurse would be best to ask the client for completing a comprehensive
pain assessment?
a. “Are you worried about addiction to pain pills?”
b. “Do you attach any spiritual meaning to pain?”
c. “How high would you say your pain tolerance is?”
d. “What pain rating would be acceptable to you?”
ANS: D
A comprehensive pain assessment includes the items listed in the question plus the client’s
opinion on a comfort-function outcome, such as what pain rating would be acceptable to him
or her. Asking about addiction is not warranted in an initial pain assessment. Asking about
spiritual meanings for pain may give the nurse important information, but getting the basics
first is more important. Asking about pain tolerance may give the client the idea that pain
tolerance is being judged.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Pain, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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6. A nurse is assessing pain in an older adult. Which action by the nurse is best?
a. Ask only “yes-or-no” questions so the client doesn’t get too tired.
b. Give the client a picture of the pain scale and come back later.
c. Question the client about new pain only, not normal pain from aging.
d. Sit down, ask one question at a time, and allow the client to answer.
ANS: D
Some older clients do not report pain because they think it is a normal part of aging or
because they do not want to be a bother. Sitting down conveys time, interest, and availability.
Ask only one question at a time and allow the client enough time to answer it. Yes-or-no
questions are an example of poor communication technique. Giving the client a pain scale,
and then leaving, might give the impression that the nurse does not have time for the client.
Also, the client may not know how to use it. There is no normal pain from aging.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Pain, Nursing assessment
MSC: Client Needs Category: Psychosocial Integrity
7. The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed
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with even tiny changes in physical condition and is “on the light constantly” asking for more
pain medication. When assessing this client’s pain, which statement or question by the nurse
is most appropriate?
a. “Help me understand how pain is affecting you right now.”
b. “I wish I could do more; is there anything I can get for you?”
c. “You cannot have more pain medication for 3 hours.”
d. “Why do you think the medication is not helping your pain?”
nk
ANS: A
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A client who is preoccupied with physical symptoms and is “demanding” may have some
psychosocial impact from the pain that is not being addressed. The nurse is providing the
client the chance to explain the emotional effects of pain in addition to the physical ones.
Saying the nurse wishes he or she could do more is very empathetic, but this response does
not attempt to learn more about the pain. Simply telling the client when the next medication is
due also does not help the nurse understand the client’s situation. “Why” questions are
probing and often make clients defensive, plus the client may not have an answer for this
question.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Pain, Nursing assessment
MSC: Client Needs Category: Psychosocial Integrity
8. A nurse on the medical-surgical unit has received a hand-off report. Which client would the
nurse see first?
a. Client being discharged later on a complicated analgesia regimen.
b. Client with new-onset abdominal pain, rated as an 8 on a 0-10 scale.
c. Postoperative client who received oral opioid analgesia 45 minutes ago.
d. Client who has returned from physical therapy and is resting in the recliner.
ANS: B
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Acute pain often serves as a physiologic warning signal that something is wrong. The client
with new-onset abdominal pain needs to be seen first. The postoperative client needs at least
30 minutes for the oral medication to become effective and would be seen shortly to assess for
effectiveness. The client going home requires teaching, which would be done after the first
two clients have been seen and cared for, as this teaching will take some time. The client
resting comfortably can be checked on quickly before spending time teaching the client who
is going home.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Acute pain, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
9. A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client
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with advanced dementia but no other medical history except well-controlled hypertension and
high cholesterol. The client scores a zero. Which action by the nurse is best?
a. Assess physiologic indicators and vital signs.
b. Do not give pain medication as no pain is indicated.
c. Document the findings and continue to monitor.
d. Try a small dose of analgesic medication for pain.
ANS: A
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s.
Assessing pain in a nonverbal client is difficult despite the use of a scale specifically designed
for this population. The hierarchy for assessing pain consists of (1) obtaining a verbal report,
which is not possible in this client, (2) consider conditions that might reasonably be painful,
(3) observe behaviors, (4) evaluate physiologic indicators, and (5) attempt an analgesic trial.
The client is not known to have any conditions that reasonably would cause pain. The nurse
would next look at physiologic indicators of pain and vital signs for clues to the presence of
pain. Even a low score on this index does not mean that the client does not have pain; he or
she may be holding very still to prevent more pain. Documenting pain is important but not the
most important action in this case until the nurse has conducted a full assessment. The nurse
can try a small dose of analgesia, but without having indices to monitor, it will be difficult to
assess for effectiveness.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Pain, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. A nurse asks why several clients are getting more than one type of pain medication instead of
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very high doses of one medication. Which response by the charge nurse is best?
a. “A multimodal approach is the preferred method of control.”
b. “Clients are consumers and they demand lots of pain medicine.”
c. “We are all much more liberal with pain medications now.”
d. “Pain is so complex it takes different approaches to control it.”
ANS: D
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Pain is a complex phenomenon and often responds best to a regimen that uses different types
of analgesia. This is called a multimodal approach. Using this terminology, however, may not
be clear to the newer nurse if the terminology is not understood. Primary health care providers
and nurses may be more liberal with different types of pain medications, but that is not the
best reason for this approach, especially in light of the opioid epidemic. Saying that clients are
consumers who demand medications sounds as if the charge nurse is discounting their pain
experiences.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Pain, Pharmacologic pain management
MSC: Client Needs Category: Physiological Adaptation: Pharmacological and Parenteral Therapies
11. A client who had surgery has extreme postoperative pain that is worsened when trying to
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participate in physical therapy. Which intervention for pain management does the nurse
include in the client’s care plan?
a. As-needed pain medication after therapy
b. Pain medications prior to therapy only
c. Patient-controlled analgesia with a basal rate
d. Round-the-clock analgesia with PRN analgesics
ANS: D
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Severe pain related to surgery or tissue trauma is best managed with round-the-clock dosing.
Breakthrough pain associated with specific procedures is managed with additional medication.
An as-needed regimen will not control postoperative pain. A patient-controlled analgesia
pump might be a good idea but needs bolus (intermittent) settings to accomplish adequate
pain control, with or without a basal rate. Pain control needs to be continuous, not just
administered prior to therapy.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Pain, Pharmacologic pain management
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
12. A nurse on the postoperative inpatient unit receives hand-off report on four clients using
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patient-controlled analgesia (PCA) pumps. Which client would the nurse see first?
a. Client who appears to be sleeping soundly.
b. Client with no bolus request in 6 hours.
c. Client who is pressing the button every 10 minutes.
d. Client with a respiratory rate of 8 breaths/min.
ANS: D
Continuous delivery of opioid analgesia can lead to respiratory depression and extreme
sedation. A respiratory rate of 8 breaths/min is below normal, so the nurse would first check
this client. The client “sleeping soundly” could be comfortable (no indicators of respiratory
distress) and would be checked next. Pressing the button every 10 minutes indicates that the
client has a high level of pain, but the device has a lockout determining how often a bolus can
be delivered. Therefore, the client cannot overdose. The nurse would next assess that client’s
pain. The client who has not needed a bolus of pain medicine in several hours has
well-controlled pain.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Pain, Pharmacologic pain management
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MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
13. A registered nurse is caring for a client who is receiving pain medication via
patient-controlled analgesia (PCA). Which action by the nurse indicates the need for further
education on pain control with PCA?
a. Assesses the client’s pain level per agency policy.
b. Monitors the client’s respiratory rate and sedation.
c. Presses the button when the client cannot reach it.
d. Reinforces client teaching about using the PCA pump.
ANS: C
The client is the only person who should press the PCA button. If the client cannot reach it,
the nurse would either reposition the client or the button, and would not press the button for
the client. Pressing the button for the client (“PCA by proxy”) indicates the need to review the
information about this treatment modality. The other actions are appropriate.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Pain, Pharmacologic pain management
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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14. A client is put on twice-daily acetaminophen for osteoarthritis. Which finding in the client’s
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health history would lead the nurse to consult with the primary health care provider over the
choice of medication?
a. 25–pack-year smoking history
b. Drinking 3 to 5 beers a day
c. Previous peptic ulcer
d. Taking warfarin
ANS: B
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The major serious side effect of acetaminophen is hepatotoxicity and liver damage. Drinking
3 to 5 beers each day may indicate underlying liver disease, which would be investigated prior
to prescribing chronic acetaminophen. The nurse would relay this information to the primary
health care provider. Smoking is not related to acetaminophen side effects. Acetaminophen
does not cause bleeding, so a previous peptic ulcer or taking warfarin would not be a problem.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Pharmacologic pain management, Adverse drug reactions
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
15. A nurse is preparing to give a client ketorolac intravenously for pain. Which assessment
findings would lead the nurse to consult with the primary health care provider?
a. Bilateral lung crackles
b. Hypoactive bowel sounds
c. Self-reported pain of 3/10
d. Urine output of 20 mL/2 hr
ANS: D
Drugs in this category can affect renal function. Clients need to be adequately hydrated and
demonstrate good renal function prior to administering ketorolac. A urine output of 20 mL/2
hr is well below normal, and the nurse would consult with the primary health care provider
(PHCP) about the choice of drug. Crackles and hypoactive bowel sounds are not related. A
pain report of 3 does not warrant a call to the PHCP.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Pharmacologic pain management, Adverse drug reactions
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
16. A hospitalized client has a history of depression for which sertraline is prescribed. The client
also has a morphine allergy and a history of alcoholism. After surgery, several opioid
analgesics are prescribed. Which one would the nurse choose?
a. Hydrocodone and acetaminophen
b. Hydromorphone
c. Meperidine
d. Tramadol
ANS: B
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Hydromorphone is a good alternative to morphine for moderate to severe pain. The nurse
would not choose the combination with acetaminophen because it contains acetaminophen
and the client has a history of alcoholism. Tramadol would not be used due to the potential for
interactions with the client’s sertraline. Meperidine is rarely used and is often restricted.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Pharmacologic pain management, Opioid analgesics
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
17. A client has received an opioid analgesic for pain. The nurse assesses that the client has a
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ANS: B
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Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The client’s oxygen
saturation is 87%. Which action would the nurse perform first?
a. Apply oxygen at 4 L/min.
b. Attempt to arouse the client.
c. Give naloxone (Narcan).
d. Notify the Rapid Response Team.
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The Pasero Opioid-Induced Sedation Scale is used to assess for unwanted opioid-associated
sedation. A Pasero Scale score of 3 is unacceptable but is managed by trying to arouse the
client in order to take deep breaths and staying with the client until he or she is more alert.
Administering oxygen will not help if the client’s respiratory rate is 7 breaths/min. Giving
naloxone and calling for a Rapid Response Team would be appropriate for a higher Pasero
Scale score.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Pharmacologic pain management, Opioid analgesics
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
18. An older adult has diabetic neuropathy and often reports unbearable foot pain. About which
medication would the nurse plan to educate the client?
a. Desipramine
b. Duloxetine
c. Morphine sulfate
d. Nortriptyline
ANS: B
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Antidepressants and anticonvulsants often are used for neuropathic pain relief. Morphine
would not be used for this client. However, SNRIs are better tolerated than tricyclics, which
eliminate desipramine and nortriptyline. Duloxetine would be the best choice for this older
client.
DIF: Applying
TOP: Integrated Process: Nursing Process: Analysis
KEY: Pharmacologic pain management, Adjuvant analgesics
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
19. A nurse is caring for four clients receiving pain medication. After the hand-off report, which
client would the nurse see first?
a. Client who is crying and agitated
b. Client with a heart rate of 104 beats/min
c. Client with a Pasero Scale score of 4
d. Client with a verbal pain report of 9
m
ANS: C
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The Pasero Opioid-Induced Sedation Scale has scores ranging from S to 1 to 4. A score of 4
indicates unacceptable somnolence and is an emergency. The nurse would see this client first.
The nurse can delegate visiting with the crying client to a nursing assistant; the client may be
upset and might benefit from talking or a comforting presence. The client whose pain score is
9 needs to be seen next, or the nurse can delegate this assessment to another nurse while
working with the priority client. A heart rate of 104 beats/min is slightly above normal, and
that client can be seen after the other two clients are cared for.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Pharmacologic pain management, Critical rescue
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
20. A nurse is caring for a client who received intraspinal analgesia. Which action by the nurse is
ANS: B
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most important to ensure client safety?
a. Assess and record vital signs every 4 hours.
b. Instruct the client to report any unrelieved pain.
c. Monitor for numbness and tingling in the legs.
d. Perform frequent neurologic assessments.
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Complications from intraspinal anesthesia are rare, but can be life threatening. The nurse
would perform frequent neurologic assessments and notify the primary health care provider
for abnormal findings. Vital signs are taken every 1 to 2 hours for at least 12 hours.
Unreported pain is managed, but this is not a safety concern. Numbness and tingling outside
of the surgical site is not normal, but can usually be abated by decreasing the opioid dose. The
nurse can also keep the client on bedrest, decreasing safety concerns, while reporting to the
primary health care provider.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Pharmacologic pain management, Epidural analgesia
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
MULTIPLE RESPONSE
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1. Nurses at a conference learn the process by which pain is perceived by the client. Which
processes are included in the discussion? (Select all that apply.)
a. Induction
b. Modulation
c. Sensory perception
d. Transduction
e. Transmission
f. Transition
ANS: B, C, D, E
The four processes involved in making pain a conscious experience are modulation, sensory
perception, transduction, and transmission.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Pain, Physiology
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse learns the concepts of addiction, tolerance, and dependence. Which information is
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accurate? (Select all that apply.)
a. Addiction is a chronic physiologic disease process.
b. Physical dependence and addiction are the same thing.
c. Pseudoaddiction can result in withdrawal symptoms.
d. Tolerance is a normal response to regular opioid use.
e. Tolerance is said to occur when opioid effects decrease.
f. Physical dependence occurs after repeated doses of an opioid.
ANS: A, D, E, F
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Addiction, tolerance, and dependence are important concepts. Addiction is a chronic, treatable
disease with a neurologic and biologic basis. Tolerance occurs with regular administration of
opioid analgesics and is seen when the effect of the analgesic decreases (either therapeutic
effect or side effects). Dependence and addiction are not the same; dependence occurs with
regular administration of analgesics and can result in withdrawal symptoms when they are
discontinued abruptly. Pseudoaddiction is the mistaken diagnosis of addictive disease.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Pharmacological pain management
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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3. A postoperative client has an epidural infusion of morphine and bupivacaine. Which actions
does the nurse delegate to the assistive personnel (AP)? (Select all that apply.)
a. Ask the client to point out any areas of numbness or tingling.
b. Determine how many people are needed to ambulate the client.
c. Perform a bladder scan if the client is unable to void after 4 hours.
d. Remind the client to use the incentive spirometer every hour.
e. Take and record the client’s vital signs per agency protocol.
ANS: C, D, E
The AP can assess and record vital signs, perform a bladder scan and report the results to the
nurse, and remind the client to use the spirometer. The nurse is legally responsible for
assessments and would ask the client about areas of numbness or tingling, and assess if the
client is able to bear weight and walk.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Pharmacologic pain management, Opioid analgesics
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A client with a broken arm had ice placed on it for 20 minutes. A short time after the ice was
removed, the client reports that the effect has worn off and requests pain medication, which
cannot be given yet. Which actions by the nurse are most appropriate? (Select all that apply.)
a. Ask for a physical therapy consult.
b. Educate the client on cold therapy.
c. Offer to provide a heating pad.
d. Repeat the ice application.
e. Teach the client relaxation techniques.
f. Offer the client headphones with music.
ANS: B, D, E
s.
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Nonpharmacologic pain management can be very effective. These modalities include ice,
heat, pressure, massage, vibration, and transcutaneous electrical stimulation. Since the client
is unable to have more pain medication at this time, the nurse would focus on
nonpharmacologic modalities. First the client must be educated; the effects of ice wear off
quickly once it is removed, and the client may have had unrealistic expectations. The nurse
can repeat the ice application and teach relaxation techniques if the client is open to them.
Other nonpharmacologic methods to reduce pain include distraction, imagery, and
mindfulness. A physical therapy consult will not help relieve acute pain of a fracture. Heat
would not be a good choice for this type of injury.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Pain, Nonpharmacologic pain management
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
5. A nurse learns that there are physical consequences to unrelieved pain. Which factors are
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included in this problem? (Select all that apply.)
a. Decreased immune response
b. Development of chronic pain
c. Increased gastrointestinal (GI) motility
d. Possible immobility
e. Slower healing
f. Negative quality of life
ANS: A, B, D, E, F
There are many physiologic impacts of unrelieved pain, including decreased immune
response; development of chronic pain; decreased GI motility; immobility; slower healing;
prolonged stress response; and increased heart rate, blood pressure, and oxygen demand.
Decreased quality of life includes depression, anxiety, fear, anger, hopelessness, and
insomnia; impaired family, work, and social relationships; and difficulty with ADLs.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Pain
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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6. A nurse is studying pain sources. Which statements accurately describe different types of
pain? (Select all that apply.)
a. Neuropathic pain sometimes accompanies amputation.
b. Nociceptive pain originates from abnormal pain processing.
c. Deep somatic pain is pain arising from bone and connective tissues.
d. Somatic pain originates from skin and subcutaneous tissues.
e. Visceral pain is often diffuse and poorly localized.
ANS: A, C, D, E
Neuropathic pain results from abnormal pain processing and is seen in amputations and
neuropathies. Somatic pain can arise from superficial sources such as skin, or deep sources
such as bone and connective tissues. Visceral pain originates from organs or their linings and
is often diffuse and poorly localized. Nociceptive pain is normal pain processing and consists
of somatic and visceral pain.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Pain, Physiology
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. A nurse on the postoperative unit administers many opioid analgesics. Which actions by the
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nurse are best to prevent unwanted sedation as a complication of these medications? (Select
all that apply.)
a. Avoid using other medications that cause sedation.
b. Delay giving medication if the client is sleeping.
c. Give the lowest dose that produces good control.
d. Identify clients at high risk for unwanted sedation.
e. Use an oximeter to monitor clients receiving analgesia.
ANS: A, C, D, E
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Sedation is a side effect of opioid analgesics. Some sedation can be expected, but protecting
the client against unwanted and dangerous sedation is a critical nursing responsibility. The
nurse would identify clients at high risk for unwanted sedation and give the lowest possible
dose that produces satisfactory pain control. Avoid using other sedating medications such as
antihistamines to treat itching. An oximeter can alert the nurse to a decrease in the client’s
oxygen saturation, which often follows sedation. A postoperative client frequently needs to be
awakened for pain medication in order to avoid waking to out-of-control pain later.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Pain, Pharmacological pain management
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
8. A client reports a great deal of pain following a fairly minor operation. The surgeon leaves a
prescription for the nurse to administer a placebo instead of pain medication. Which actions
by the nurse are most appropriate? (Select all that apply.)
a. Consult with the surgeon and voice objections.
b. Delegate administration of the placebo to another nurse.
c. Give the placebo and reassess the client’s pain.
d. Notify the nurse manager of the placebo prescription.
e. Tell the client what medications were prescribed.
ANS: A, D
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Nurses would never give placebos to treat a client’s pain (unless the client is in a research
study). This practice is unethical and, in many states, illegal. The nurse would voice concerns
with the prescriber and, if needed, contact the nurse manager. The nurse would not delegate
giving the placebo to someone else, nor would the nurse give it. Telling the client about the
placebo prescription before voicing objections would not be beneficial.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Pharmacological pain management, Ethics
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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Chapter 06: Concepts of Genetics and Genomics
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is educating a client about genetic screening. The client asks why red-green color
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blindness, an X-linked recessive disorder noted in some family members, is expressed more
frequently in males than females. How would the nurse respond?
a. “Females have a decreased penetrance rate for this gene mutation and are therefore
less likely to express the trait.”
b. “Females have two X chromosomes and one is always inactive. This inactivity
decreases the effect of the gene.”
c. “The incidence of X-linked recessive disorders is higher in males because they do
not have a second X chromosome to balance expression of the gene.”
d. “Males have only one X chromosome, which allows the X-linked recessive
disorder to be transmitted from father to son.”
ANS: C
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Because the number of X chromosomes in males and females is not the same (1:2), the
number of X-linked chromosome genes in the two genders is also unequal. Males have only
one X chromosome, a condition called hemizygosity, for any gene on the X chromosome. As
a result, X-linked recessive genes have a dominant expressive pattern of inheritance in males
and a recessive expressive pattern of inheritance in females. This difference in expression
occurs because males do not have a second X chromosome to balance the expression of any
recessive gene on the first X chromosome. It is incorrect to say that one X chromosome of a
pair is always inactive in females, or that females have a decreased penetrance rate for this
gene mutation. X-linked recessive disorders cannot be transmitted from father to son, but the
trait is transmitted from father to all daughters who will be carriers.
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DIF: Understanding
KEY: Genetics, Patterns of inheritance
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs Category: Physiological Integrity
2. A client is typed and crossmatched for a unit of blood. Which statement by the nurse indicates
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a need for further genetic education?
a. “Blood type is formed from three gene alleles: A, B, and O.”
b. “Each blood type allele is inherited from the mother or the father.”
c. “If the patient’s blood type is AB, then the client is homozygous for that trait.”
d. “If the client has dominant and recessive alleles, the dominant will be expressed.”
ANS: C
There are three possible gene alleles for blood type: A, B, and O, which are inherited from the
parents. If both a dominant and recessive gene allele are present, the dominant one is always
expressed. Blood type AB is a heterozygous type, meaning the two alleles are different. The
nurse stating that type AB is homozygous needs further education.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Intervention
KEY: Genetics, Patterns of inheritance
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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3. A nurse obtains health histories when admitting clients to a medical-surgical unit. With which
client would the nurse discuss predisposition genetic testing?
a. Middle-age woman whose mother died at age 48 of breast cancer.
b. Young man who has all the symptoms of rheumatoid arthritis.
c. Pregnant woman whose father has sickle cell disease.
d. Middle-age man of Eastern European Jewish ancestry.
ANS: A
A client with a family history of breast cancer would be provided information about
predisposition testing. Predisposition testing would be discussed with clients who are at high
risk of hereditary breast, ovarian, and colorectal cancers so that the client can engage in
heightened screening activities or interventions that reduce risk. The client with symptoms of
rheumatoid arthritis would be given information about symptomatic diagnostic testing. The
client with a familial history of sickle cell disease and the client who is of Eastern European
Jewish ancestry would be given information about carrier testing.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Genetics, Genetic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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4. A client who tests positive for a mutation in the BRCA1 gene allele asks a nurse to be present
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ANS: D
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when she discloses this information to her adult daughter. How would the nurse respond?
a. “I will request a genetic counselor who is more qualified to be present for this
conversation.”
b. “The test results can be confusing; I will help you interpret them for your
daughter.”
c. “Are you sure you want to share this information with your daughter, who may not
test positive for this gene mutation?”
d. “This conversation may be difficult for both of you; I will be there to provide
support.”
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A nurse would provide emotional support while the client tells her daughter the information
she has learned about the test results. The nurse would not interpret the results or counsel the
client or her daughter. The nurse would refer the client for counseling or support, if necessary.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Genetics, Coping
MSC: Client Needs Category: Psychosocial Integrity
5. A nurse consults a genetic counselor for a client whose mother has Huntington disease and is
considering genetic testing. The client states, “I know I want this test. Why do I need to see a
counselor?” How would the nurse respond?
a. “The counselor will advise you on whether you can have children or need to
adopt.”
b. “Genetic testing can be a stressful experience. Counseling can provide support and
education throughout the process.”
c. “There is no cure for this disease. The counselor will determine if there is any
benefit to genetic testing.”
d. “Genetic testing is expensive. The counselor will advocate for you and help you
obtain financial support.”
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ANS: B
Genetic testing is a stressful experience, and clients would be provided with support,
education, and assistance with coping. Genetic testing would be performed only after genetic
counseling has occurred. The client has the right to decide whether to have children or to
participate in genetic testing. Nursing staff would provide both benefits and risks to genetic
testing so that the client can make an informed decision. Financial support is not part of
genetic counseling.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Genetics, Coping
MSC: Client Needs Category: Psychosocial Integrity
6. A primary health care provider prescribes genetic testing for a client who has a family history
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of colorectal cancer. Which action would the nurse take before scheduling the client for the
procedure?
a. Confirm that informed consent was obtained and placed on the patient’s chart.
b. Provide genetic counseling to the client and the patient’s family members.
c. Assess if the client is prepared for the risk of psychological side effects.
d. Respect the patient’s right not to share the results of the genetic test.
ANS: A
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Informed consent is required before genetic testing. The person tested is the one who gives
consent. An advanced practice provider would explain the procedure and provide genetic
counseling. Although the client would be prepared for the risk of psychological side effects
and the patient’s rights would be respected, the procedure cannot occur without informed
consent.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Genetics, Informed consent
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A nurse cares for an adult client who has received genetic testing. The patient’s mother asks to
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receive the results of the genetic tests. Which action would the nurse take?
a. Obtain a signed consent from the client allowing test results to be released to the
mother.
b. Invite the mother and other family members to participate in genetic counseling
with the client.
c. Encourage the mother to undergo genetic testing to determine if she has the same
risks as her child.
d. Direct the mother to speak with the client and support the client’s decision to share
or not share the results.
ANS: D
All conversations and test results must be kept confidential. The client has the right to
determine who may be involved in discussions related to diagnosis and genetic testing, who
may participate in genetic counseling with the patient, and what information may be disclosed
to family members. It is the nurse’s responsibility to provide a private environment for
discussions and protect the patient’s information from improper disclosure. The nurse would
support the patient’s right to disclose or not disclose information.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Genetics, Confidentiality
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MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
8. A nurse cares for a client who has a genetic mutation that increases the risk for colon cancer.
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The client states that he/she does not want any family to know about this result. How would
the nurse respond?
a. “It is required by law that you inform your siblings and children about this result
so that they also can be tested and monitored for colon cancer.”
b. “It is not necessary to tell your siblings because they are adults, but you would tell
your children so that they can be tested before they decide to have children of their
own.”
c. “It is not required that you tell anyone about this result. However, your siblings
and children may also be at risk for colon cancer and this information might help
them.”
d. “It is your decision to determine with whom, if anyone, you discuss this test result.
However, you may be held liable if you withhold this information and a family
member gets colon cancer.”
ANS: C
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This situation represents an ethical dilemma. It is the client’s decision whether to disclose the
information. However, the information can affect others in the client’s family. The law does
not require the client to tell family members about the results, nor can the client be held liable
for not telling them. The nurse may consider it ethically correct for clients to tell family
members so that they can take action to prevent the development of cancer, but the nurse must
respect the client’s decision.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Genetics, Confidentiality
MSC: Client Needs Category: Psychosocial Integrity
9. A nurse cares for a client who has a specific mutation in the a1AT (alpha1-antitrypsin) gene.
What action would the nurse take?
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a. Teach the client to perform monthly breast self-examinations and schedule an
annual mammogram.
b. Support the client when sharing test results and encourages family members to be
screened for cancer.
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c. Advise the client to limit exposure to secondhand smoke and other respiratory
irritants.
d. Obtain a complete health history to identify other genetic problems associated with
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this gene mutation.
ANS: C
The a1AT gene mutation increases risk for developing early-onset emphysema. Clients would
be advised to limit exposure to smoke and other respiratory irritants as a means of decreasing
environmental influences that may aggravate an early onset of emphysema. This gene
mutation does not promote cancer, nor does it occur with other identified genetic problems.
The BRCA1 gene mutation gives the client a higher risk for developing breast cancer.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Genetics, Genetic mutations
MSC: Client Needs Category: Health Promotion and Maintenance
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10. A nurse cares for a pregnant client who has a family history of sickle cell disease. The client is
unsure if she wants to participate in genetic testing. What action would the nurse take?
a. Provide information about the risks and benefits of genetic testing.
b. Empathize with the client and share a personal story about a hereditary disorder.
c. Teach the client that early detection can minimize transmission to the fetus.
d. Advocate for the client and her baby by encouraging genetic testing.
ANS: A
Genetic counseling is to be nondirective. The nurse would provide as much information as
possible about the risks and benefits but would not influence the patient’s decision to test or
not test. Once the client has made a decision, the nurse would support the client in that
decision. Carrier testing will determine if a client without symptoms has an allele for a
recessive disorder that could be transmitted to his or her child. Genetic testing will not
minimize transmission of the disorder.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Genetics, Genetic counseling
MSC: Client Needs Category: Psychosocial Integrity
11. A nurse cares for a client who recently completed genetic testing and received a negative
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result. The client states, “I feel guilty because so many of my family members are carriers of
this disease and I am not.” How would the nurse respond?
a. “You are not genetically predisposed for this disease but you could still become ill.
Let’s discuss a plan for prevention.”
b. “Since many of your family members are carriers, you would undergo further
testing to verify the results are accurate.”
c. “We usually encourage clients to participate in counseling after receiving test
results. Can I arrange this for you?”
d. “It is normal to feel this way. I think you would share this news with your family
so that they can support you.”
ANS: C
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Clients who have negative genetic test results need counseling and support. Some clients may
have an unrealistic view of what a negative result means for their general health. Others may
feel guilty that they were “spared” when some family members were not. The client will not
be symptomatic if he or she is not a carrier of the disease. A second round of testing is not
recommended, because false negatives are rare with this type of testing. It is the client’s
choice to reveal test results to family members; the nurse would not encourage this.
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DIF: Applying
TOP: Integrated Process: Caring
KEY: Genetics, Genetic counseling
MSC: Client Needs Category: Psychosocial Integrity
MULTIPLE RESPONSE
1. A nurse cares for a client who recently completed genetic testing that revealed that she has a
BRCA1 gene mutation. What actions would the nurse take next? (Select all that apply.)
a. Assess the patient’s response to the test results.
b. Assist the client to make a plan for prevention and risk reduction.
c. Disclose the information to the medical insurance company.
d. Discuss potential risks for other members of her family.
e. Encourage support by sharing the results with family members.
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f.
Recommend the client complete weekly breast self-examinations.
ANS: A, B, D
The medical-surgical nurse can assess the patient’s response to the test results, discuss
potential risks for other family members, encourage genetic counseling, and assist the client to
make a plan for prevention, risk reduction, and early detection. For some positive genetic test
results, such as having a BRCA1 gene mutation, the risk for developing breast cancer is high
but is not a certainty. Because the risk is high, the client would have a plan for prevention and
risk reduction. One form of prevention is early detection. Breast self-examinations may be
helpful when performed monthly, but those performed every week may not be useful,
especially around the time of menses. A client who tests positive for a BRCA1 mutation would
have at least yearly mammograms and ovarian ultrasounds to detect cancer at an early stage,
when it is more easily cured. Owing to confidentiality, the nurse would never reveal any
information about a client to an insurance company or family members without the patient’s
permission.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: Genetics, Genetic testing
MSC: Client Needs Category: Health Promotion and Maintenance
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2. A nurse completes pedigree charts for clients at a community health center. Which diagnoses
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would the nurse refer for carrier genetic testing? (Select all that apply.)
a. Breast cancer
b. Colorectal cancer
c. Cystic fibrosis
d. Hemophilia
e. Huntington disease
f. Sickle cell disease
ANS: C, D, F
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Of the disease processes listed, the ones that would make the client a candidate for carrier
genetic testing would be hemophilia, sickle cell disease, and cystic fibrosis. Although
Huntington disease, breast cancer, and colorectal cancer all have genetic components, there is
no evidence that carrier genetic testing would be beneficial in diseases such as these.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Genetics, Genetic testing
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse teaches clients about patterns of inheritance for genetic disorders among adults.
Which disorders have an autosomal dominant pattern of inheritance? (Select all that apply.)
a. Breast cancer
b. Alzheimer disease
c. Hemophilia
d. Huntington disease
e. Marfan syndrome
f. Cystic fibrosis
ANS: A, D, E
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Breast cancer, Huntington disease, and Marfan syndrome have an autosomal dominant pattern
of inheritance. Alzheimer disease is a complex disorder with familial clustering, hemophilia is
a sex-linked recessive disorder, and cystic fibrosis has an autosomal recessive pattern of
inheritance.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Genetics, Patterns of inheritance
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A nurse cares for a client who is scheduled for genetic testing. What actions would the nurse
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include in the patient’s pretesting assessment? (Select all that apply.)
a. Assess the client’s understanding of the genetic test.
b. Obtain physical assessment data relevant to the at-risk disorder.
c. Discuss prevention, early detection, and treatment options.
d. Assess the client’s perception of the test results.
e. Discuss client rights and obligations regarding disclosure of information.
ANS: A, B, E
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During the pretesting assessment, the nurse would evaluate the patient’s understanding of the
genetic test being sought and obtain relevant information including physical assessment,
family history, psychosocial status, and social support. The nurse would also discuss client
rights and obligations regarding disclosure of information, risks and benefits of testing, and
testing options. Discussion of prevention, early detection and treatment options, and an
assessment of the patient’s perception of the test results would occur after genetic testing is
complete.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Genetics, Patterns of inheritance
MSC: Client Needs Category: Health Promotion and Maintenance
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Chapter 07: Concepts of Rehabilitation for Chronic and Disabling Health Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse assesses a client recovering from coronary artery bypass graft surgery in an inpatient
rehabilitation unit. Which assessment would the nurse complete to evaluate the client’s
activity tolerance?
a. Vital signs before, during, and after activity
b. Body image and self-care abilities
c. Ability to use assistive or adaptive devices
d. Client’s electrocardiography readings
ANS: A
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Alterations in the cardiac system can affect a client’s ability to tolerate activity. Signs of this
include changes in blood pressure and pulse since they are directly affected by cardiac output.
A body image assessment is not necessary before basic activities are performed. Self-care
abilities and ability to use assistive or adaptive devices is an important assessment when
planning rehabilitation activities, but will not provide essential information about the client’s
activity tolerance. Electrocardiography is not used to monitor clients in a rehabilitation
setting.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Rehabilitation care, Activity tolerance
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse teaches a client with a past history of angina who has had a total knee replacement.
ANS: B
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Which statement would the nurse include in this client’s teaching prior to beginning
rehabilitation activities?
a. “Use analgesics before and after activity, even if you are not experiencing pain.”
b. “Let me know if you start to experience shortness of breath, chest pain, or fatigue.”
c. “Do not take your prescribed beta blocker until after you exercise with physical
therapy.”
d. “If you experience knee pain, ask the physical therapist to reschedule your
therapy.”
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Participation in exercise may increase myocardial oxygen demand beyond the ability of the
coronary circulation to deliver enough oxygen to meet the increased need. The nurse must
determine the client’s ability to tolerate different activity levels. Asking the client to notify the
nurse if symptoms of shortness of breath, chest pain, or fatigue occur will assist the nurse in
developing an appropriate rehabilitation plan the client can tolerate. Analgesics before and
after activity are not warranted. The rehabilitation nurse would not change the client’s
medication schedule without consulting the physiatrist or primary health care provider.
Therapy would not be cancelled if this client had knee pain postoperatively.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Rehabilitation care, Activity tolerance
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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3. A rehabilitation nurse prepares to move a client who has new bilateral leg amputations. Which
is the best approach?
a. Use the bear-hug method to transfer the client safely.
b. Ask several members of the health care team to carry the client.
c. Utilize the facility’s mechanical lift to move the client.
d. Consult physical therapy before performing all transfers.
ANS: C
Use mechanical lifts to minimize staff work-related musculoskeletal injuries. Many facilities
have implemented no-lift or minimal-lift policies to reduce staff and client injury. The
bear-hug method does not eliminate staff injuries. Staff would not carry the client. Physical
therapy would be consulted but cannot be depended upon for all transfers. Nursing staff must
be capable of transferring a client safely.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Rehabilitation care, Safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
4. A rehabilitation nurse in a skilled nursing facility (SNF) cares for a client who has generalized
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weakness and needs assistance with activities of daily living. Which exercise would the nurse
implement?
a. Passive range of motion
b. Active range of motion
c. Resistive range of motion
d. Aerobic exercise
ANS: B
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Active range of motion is a part of a restorative nursing program. Active range of motion will
promote strength, range of motion, and independence with activities of daily living. Passive
range of motion will not increase the client’s strength. Performing range of motion against
resistance may be too advanced for the client. This client is not yet ready for aerobic exercise.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Rehabilitation care, Functional ability
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse plans care for a client who is bedridden. Which assessment would the nurse complete
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to ensure to prevent pressure injury formation?
a. Nutritional intake and serum albumin levels
b. Pressure injury diameter and depth
c. Wound drainage, including color, odor, and consistency
d. Dressing site and antibiotic ointment application
ANS: A
Assessing serum albumin levels helps determine the client’s nutritional status and allows care
providers to alter the diet, as needed, to provide protein to prevent pressure injuries. All other
options are treatment oriented rather than prevention oriented.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Rehabilitation care, Tissue integrity
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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6. A nurse teaches a client about performing intermittent self-catheterization. The client states, “I
am not sure if I will be able to afford these catheters.” How would the nurse respond?
a. “I will try to find out whether you qualify for money to purchase these necessary
supplies.”
b. “Even though it is expensive, the cost of taking care of urinary tract infections
would be even higher.”
c. “Instead of purchasing new catheters, you can boil the catheters and reuse them up
to 10 times each.”
d. “I will contact the social worker who will discuss potential resources with you.”
ANS: D
Social workers help patients identify support services and resources, including financial
assistance. The nurse would refer the client to the social worker to explore financial concerns.
The nurse would not threaten the client, nor would the client be instructed to boil the
catheters.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Rehabilitation care, Interprofessional team
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
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7. A nurse delegates the ambulation of an older adult client to a nursing assistant. Which
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statement would the nurse include when delegating this task?
a. “The client has skid-proof socks, so there is no need to use your gait belt.”
b. “Teach the client how to use the walker while you are ambulating up the hall.”
c. “Sit the client on the edge of the bed with legs dangling before ambulating.”
d. “Ask the client if pain medication is needed before you walk the client.”
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ANS: C
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Before the client gets out of bed, have the client sit on the bed with legs dangling on the side.
This will enhance safety for the client because it gives the body time to adjust after changing
position and can prevent safety concerns from orthostatic hypotension. A gait belt would be
used for all clients. The nursing assistant cannot teach the client to use a walker or assess the
client’s pain.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Rehabilitation care, Fall prevention
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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8. A nurse assesses a client who is admitted to the inpatient rehabilitation unit with hip
problems. The client asks, “Why are you asking about my bowels and bladder?” How would
the nurse respond?
a. “To plan your care based on your normal elimination routine.”
b. “So we can help prevent side effects of your medications.”
c. “We need to evaluate your ability to function independently.”
d. “To schedule your activities around your elimination pattern.”
ANS: A
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Bowel and bladder elimination varies from client to client and must be evaluated on the basis
of the client’s normal routine. The nurse asks about bowel and bladder habits to develop a
client-centered plan of care. The other answers are correct but are not the best responses. Oral
analgesics may cause constipation, but they do not interfere with bladder control. The client is
in rehabilitation to assist his or her ability to function independently.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Rehabilitation care, Elimination
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
9. A nurse is caring for a client who has a flaccid bladder after a spinal cord injury. Which
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intervention would the nurse implement to assist with bladder dysfunction?
a. Insert an indwelling urinary catheter.
b. Stroke the medial aspect of the thigh.
c. Use the Credé maneuver every 3 hours.
d. Apply an external (condom) catheter with a leg bag.
ANS: C
s.
co
When the patient has a lower motor neuron problem, the voiding reflex arc is not intact
(flaccid bladder pattern), and additional stimulation may be needed to initiate voiding. Two
techniques are used to facilitate voiding in a client with a flaccid bladder: the Valsalva
maneuver and the Credé maneuver. Indwelling urinary catheters generally are not used
because of the increased incidence of urinary tract infection. Stroking the medial aspect of the
thigh facilitates voiding in clients with upper motor neuron problems. An external catheter is
not ideal for this lesion which causes urinary retention and overflow.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Rehabilitation care, Elimination
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation: Basic Care and
Comfort
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10. A nurse teaches a client who has a reflex (spastic) bladder after a spinal cord injury. Which
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ANS: A
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bladder training technique would the nurse teach?
a. Stroking the medial aspect of the thigh
b. Valsalva maneuver
c. Self-catheterization
d. Frequent toileting
If there is an upper motor neuron problem but the reflex arc is intact (reflex bladder pattern),
the voiding response can be initiated by any stimulus that sends the message to the spinal cord
level S2-4 that the bladder might be full. Such techniques include stroking the medial aspect
of the thigh, pinching the area above the groin, massaging the peno-scrotal area, pinching the
posterior aspect of the glans penis, and providing digital anal stimulation. The Valsalva
maneuver is used for a flaccid bladder. Intermittent catheterization may be necessary if
nothing else works. A consistent toileting schedule may be included in the regimen.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Rehabilitation care, Elimination
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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11. A rehabilitation nurse cares for a client who is wheelchair bound. Which intervention would
the nurse implement to prevent skin breakdown?
a. Place pillows under the client’s heels.
b. Have the client do wheelchair push-ups.
c. Perform wound care as prescribed.
d. Massage the client’s calves and feet with lotion.
ANS: B
m
Clients who sit for prolonged periods in a wheelchair would perform wheelchair push-ups for
at least 20 seconds every hour. Chair-bound clients also need to be repositioned at least every
1 to 2 hours. The lower legs, where the wheelchair could rub against the legs, also need to be
assessed. Pillows under the heels may or may not be beneficial, but repositioning and
redistributing weight are more important. Performing wound care as prescribed is important to
improve the healing of pressure injuries, but this intervention will not prevent skin
breakdown. The calves of a client with no or decreased lower extremity mobility would not be
massaged because of the risk of embolization or thrombus.
co
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Rehabilitation care, Tissue integrity
MSC: Client Needs Category: Health Promotion and Maintenance
MULTIPLE RESPONSE
s.
1. A nurse collaborates with an occupational therapist when providing care for a rehabilitation
ANS: B, E
ba
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client. With which activities would the occupational therapist assist the client? (Select all that
apply.)
a. Achieving mobility
b. Attaining independence with dressing
c. Using a walker in public
d. Learning techniques for transferring
e. Performing activities of daily living (ADLs)
f. Completing job training
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The role of the occupational therapist is to assist the client with fine motor control activities,
such as ADLs and dressing. The physical therapist assists with gross motor function, muscle
strength development, and ambulation. Vocational counselors assist with job placement,
training, and further education.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Implementation
KEY: Rehabilitation care, Interprofessional team
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
2. An interprofessional team is caring for a client on a rehabilitation unit. Which team members
are paired with the correct roles and responsibilities? (Select all that apply.)
a. Speech–language pathologist—evaluates and retrains clients with swallowing
problems
b. Physical therapist—assists clients with ambulation and walker training
c. Recreational therapist—assists physical therapists to complete rehabilitation
therapy
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d. Vocational counselor—works with clients who have experienced head injuries
e. Registered dietitian—develops client-specific diets to ensure that client needs are
f.
met
Clinical psychologist—assesses and diagnoses mental health/behavioral health or
cognition issues resulting from the disability or chronic condition and help both
the patient and family identify strategies to foster coping.
ANS: A, B, E, F
m
Speech–language pathologists evaluate and retrain clients with speech, language, or
swallowing problems. Physical therapists help clients to achieve self-management by focusing
on gross mobility. Registered dietitians develop client-specific diets to ensure that clients meet
their needs for nutrition. Recreational therapists work to help clients continue or develop
hobbies or interests. Vocational counselors assist with job placement, training, or further
education. The clinical psychologist assesses and diagnoses mental health/behavioral health or
cognition issues resulting from the disability or chronic condition and help both the patient
and family identify strategies to foster coping.
co
DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Rehabilitation care, Intraprofessional team
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A rehabilitation nurse is caring for an older adult client who states, “I tire easily.” How would
ba
ANS: A, B, D, E
nk
s.
the nurse respond? (Select all that apply.)
a. “Schedule all of your tasks for the morning when you have the most energy.”
b. “Try to rest before and after eating or going to the bathroom.”
c. “Your family could hire someone who can assist you with daily chores.”
d. “Plan to gather all of the supplies needed for a chore prior to starting the activity.”
e. “Try to break large activities into smaller parts to allow rest periods between
activities.”
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Resting before and after eating or going to the bathroom reduces strain and fatigue. Gathering
equipment before performing a chore decreases unneeded steps. Breaking larger chores into
smaller ones allows rest periods between activities and still gives the client a sense of
completion even if the client is unable to complete the whole task. Major tasks would be
performed in the morning, when energy levels are high, while lesser tasks would be done
throughout the day after frequent rest periods. Someone would be hired to do the chores only
if the client cannot do them. The outcome would be achieving independence as close to the
predisability level as possible.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Rehabilitation care, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
4. A nurse is caring for clients as a member of the rehabilitation team. Which activities would
the nurse complete as part of the nurse’s role? (Select all that apply.)
a. Maintain the function of assistive technology by making needed repairs.
b. Coordinate rehabilitation team activities to ensure implementation of the plan of
care.
c. Assist clients to identify support services and resources for the coordination of
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services.
d. Counsel clients and family members on strategies to cope with disability.
e. Support the client’s choices by acting as an advocate for the client and family.
ANS: B, E
The rehabilitation nurse’s role includes coordination of rehabilitation activities to ensure that
the client’s plan of care is effectively implemented and advocating for the client and family.
Assistive technology (computer keyboards, door locks) would be maintained by the vendor,
not the nurse. The social worker assists clients with support services and resources. The
clinical psychologist counsels clients and families on their psychological problems and on
strategies to cope with disability.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Implementation
KEY: Rehabilitation care
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
m
5. A rehabilitation nurse assesses a client upon admission. Which assessments would the nurse
s.
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complete to determine actual or potential interruption in skin and tissue integrity? (Select all
that apply.)
a. Oxygen saturation
b. Cognitive abilities
c. Functional mobility
d. Spiritual needs
e. Urinary output
f. Nutrition
ANS: A, B, C, E, F
ba
nk
To identify actual or potential interruptions in skin and tissue integrity, the nurse would assess
for adequate oxygenation, cognition, bladder and bowel patterns and incontinence, sensation,
adequate nutrition, and functional ability. The client’s spiritual needs do not impact skin
integrity.
st
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Rehabilitation care, Tissue integrity
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A nurse begins discharge planning for a rehabilitation client who will be discharged in a
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wheelchair. Which would the nurse include in this predischarge assessment? (Select all that
apply.)
a. Doorway widths within the client’s home
b. Nutritional status including laboratory results
c. Feelings and concerns related to the discharge
d. Vital signs before, during, and after exercise activities
e. Client’s ability to perform activities of daily living
ANS: A, C, E
In preparation for discharge, the nurse in collaboration with the health care team would assess
the client’s home to ensure accessibility given the client’s mobility impairments,
psychological and mental readiness for discharge, ability to perform ADLs and IADLs, and
support resources needed. Vital signs and nutritional status would be assessed during the
rehabilitation stay but are not part of the predischarge assessment.
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ba
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m
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Rehabilitation care, Transition management
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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Chapter 08: Concepts of Care for Patients at End of Life
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse cares for a dying client. Which manifestation of dying does the nurse treat first?
a. Anorexia
b. Pain
c. Nausea
d. Hair loss
ANS: B
KEY: End-of-life care, Comfort
co
DIF: Applying
TOP: Integrated Process: Caring
MSC: Client Needs Category: Psychosocial Integrity
m
Only symptoms that cause distress for a dying client would be treated. Such symptoms
include pain, nausea and vomiting, dyspnea, and agitation. These problems interfere with the
client’s comfort. Even when symptoms, such as anorexia or hair loss, disturb the family, they
would be treated only if the client is distressed by their presence. The nurse would treat the
client’s pain first.
2. A nurse plans care for a client who is nearing end of life. Which question will the nurse ask
ba
ANS: B
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s.
when developing this client’s plan of care?
a. “Is your advance directive up to date and notarized?”
b. “Do you want to be at home at the end of your life?”
c. “Would you like a physical therapist to assist you with range-of-motion
activities?”
d. “Have your children discussed resuscitation with your primary health care
provider?”
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When developing a plan of care for a dying client, consideration would be given for where the
client wants to die. Different states have different laws regarding legal requirements for
advance directives, but this would not take priority over establishing client preferences. A
physical therapist would not be involved in end-of-life care. The client would discuss
resuscitation with the primary health care provider and children; do-not-resuscitate status
would be the client’s decision, not the family’s decision.
DIF: Applying
TOP: Integrated Process: Caring
KEY: End-of-life care, Advance directives
MSC: Client Needs Category: Psychosocial Integrity
3. A nurse is caring for a client who has lung cancer and is dying. Which prescription does the
nurse question?
a. Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5
b. Albuterol metered dose inhaler every 4 hours PRN for wheezes
c. Atropine solution 1% sublingual every 4 hours PRN for excessive oral secretions
d. Sodium biphosphate enema once a day PRN for impacted stool
ANS: A
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Pain medications would be scheduled around the clock to maintain comfort and prevent
reoccurrence of pain. The dying client should not have to request medications for serious pain.
The other medications are appropriate for this client.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: End-of-life care, Pharmacologic pain management
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A nurse is caring for a dying client whose adult child confides frequent crying episodes to the
nurse. How does the nurse respond?
a. “It’s normal. Most people move on within a few months.”
b. “Whenever you start to cry, distract yourself with pleasant thoughts of your
parent.”
c. “You should try not to cry. Your parent will be in a better place soon.”
d. “Your feelings are completely normal and may continue for a long time.”
m
ANS: D
co
Everyone grieves and mourns differently. The nurse would offer support to the client and
family during this time. By telling the adult child that the feelings are normal and may
continue, the nurse is providing support to whatever the person is feeling. The other
statements all show lack of compassion and respect to the family member’s feelings.
KEY: End-of-life care, Caring
s.
DIF: Applying
TOP: Integrated Process: Caring
MSC: Client Needs Category: Psychological Integrity
5. After teaching a client about advance directives, a nurse assesses the client’s understanding.
ANS: C
st
ba
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Which statement indicates that the client correctly understands the teaching?
a. “An advance directive will keep my children from selling my home when I’m
old.”
b. “An advance directive will be completed as soon as I’m incapacitated and can’t
think for myself.”
c. “An advance directive will specify what I want done when I can no longer make
decisions about health care.”
d. “An advance directive will allow me to keep my money out of the reach of my
family.”
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An advance directive is a written document prepared by a competent individual that specifies
what, if any, extraordinary actions a person would want to be taken when he or she can no
longer make decisions about personal health care. It does not address issues such as the
client’s residence or financial matters.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: End-of-life care, Advance directives
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
6. A nurse teaches a client who is considering being admitted to hospice. Which statement does
the nurse include in this client’s teaching?
a. “Hospice admission has specific criteria. You may not be a viable candidate, so we
will look at alternative plans for your discharge.”
b. “Hospice care focuses on a holistic approach to health care. It is not designed to
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hasten death, but rather to relieve symptoms.”
c. “Hospice care will not help with your symptoms of depression. I will refer you to
the facility’s counseling services instead.”
d. “You seem to be experiencing some difficulty with this stage of the grieving
process. Let’s talk about your feelings.”
ANS: B
As both a philosophy and a system of care, hospice care uses an interprofessional approach to
assess and address the holistic needs of clients and families to facilitate quality of life and a
peaceful death. This holistic approach neither hastens nor postpones death but provides relief
of symptoms experienced by the dying client.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: End-of-life care, Palliative, hospice care
MSC: Client Needs Category: Psychosocial Integrity
m
7. A nurse is caring for a dying client. The client’s spouse states, “I think he is choking to
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death.” How would the nurse respond?
a. “Do not worry. The choking sound is normal during the dying process.”
b. “I will administer more morphine to keep your spouse comfortable.”
c. “I can ask the respiratory therapist to suction secretions out through his nose.”
d. “I will have another nurse assist me to turn your spouse onto the side.”
ANS: D
nk
s.
The choking sound or “death rattle” is common in dying clients. The nurse acknowledges the
spouse’s concerns and provides interventions that will reduce the choking sounds.
Repositioning the client onto one side with a towel under the mouth to collect secretions is the
best intervention. The nurse would not minimize the spouse’s concerns. Morphine will assist
with comfort but will not decrease the choking sounds. Nasotracheal suctioning is not
appropriate in a dying client and may cause agitation.
ba
DIF: Applying
TOP: Integrated Process: Caring
MSC: Client Needs Category: Psychosocial Integrity
KEY: End-of-life care, Comfort
8. The nurse is teaching a family member about various types of complementary therapies that
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might be effective for relieving the dying client’s anxiety and restlessness. Which statement
made by the family member indicates understanding of the nurse’s teaching?
a. “Maybe we should just hire an around-the-clock sitter to stay with Grandmother.”
b. “I have some of her favorite hymns on a CD that I could bring for music therapy.”
c. “I don’t think that she’ll need pain medication along with her herbal treatments.”
d. “I will burn therapeutic incense in the room so we can stop the anxiety pills.”
ANS: B
Music therapy is a complementary therapy that may produce relaxation by quieting the mind
and removing a client’s inner restlessness. Hiring an around-the-clock sitter does not
demonstrate that the client’s family understands complementary therapies. Complementary
therapies are used in conjunction with traditional therapy. Complementary therapy would not
replace pain or anxiety medication but may help decrease the need for these medications.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: End-of-life care, Nonpharmacologic comfort measures
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
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9. A nurse is caring for a terminally ill client who has just died in a hospital setting with family
members at the bedside. Which action will the nurse take first?
a. Call for emergency assistance so that resuscitation procedures can begin.
b. Ask family members if they would like to spend time alone with the client.
c. Ensure the primary health care provider completed the death certificate.
d. Request family members to prepare the client’s body for the funeral home.
ANS: B
Before moving the client’s body to the funeral home, the nurse asks family members if they
would like to be alone with the client. Emergency assistance will not be necessary. Although
it is important to ensure that a death certificate has been completed before the client is moved
to the mortuary, the nurse first would ask family members if they would like to be alone with
the client. The client’s family would not be expected to prepare the body for the funeral home
but they could be asked if they wish to provide some care such as brushing the hair.
m
DIF: Applying
TOP: Integrated Process: Caring
KEY: End-of-life care, Postmortem care MSC: Client Needs Category: Psychosocial Integrity
s.
determine whether the client is near death?
a. Level of consciousness
b. Respiratory rate
c. Bowel sounds
d. Pain level on a 0-10 scale
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10. A nurse assesses a client who is dying. Which sign or symptoms does the nurse assess to
ANS: B
ba
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Although all of these assessments would be performed during the dying process, periods of
apnea and Cheyne-Stokes respirations indicate that death is near. As peripheral circulation
decreases, the client’s level of consciousness and bowel sounds decrease, and the client would
be unable to provide a numeric number on a pain scale. Even with these other symptoms, the
nurse would continue to assess respiratory rate throughout the dying process. As the rate drops
significantly and breathing becomes agonal, death is near.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: End-of-life care
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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11. A nurse is caring for a client who is terminally ill. The client’s spouse states, “I am concerned
because he does not want to eat.” How does the nurse respond?
a. “Let him know that food is available if he wants it, but do not insist that he eat.”
b. “A feeding tube can be placed in the nose to provide important nutrients.”
c. “Force him to eat even if he does not feel hungry, or he will die sooner.”
d. “He is getting all the nutrients he needs through his intravenous catheter.”
ANS: A
Anorexia often causes distress in family members. When family members understand that the
client is not suffering from hunger and is not “starving to death,” they may allow the client to
determine when, what, or if to eat. Often, as death approaches, metabolic needs decrease and
clients do not feel the sensation of hunger. Forcing them to eat frustrates the client and the
family and contributes to client discomfort.
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DIF: Applying
TOP: Integrated Process: Caring
KEY: End-of-life care, Comfort
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
12. A nurse discusses palliative care with a client and the client’s family. A family member
expresses concern that the loved one will receive only custodial care. How will the nurse
respond?
a. “The goal of palliative care is to provide the greatest degree of comfort possible
and help the dying person enjoy whatever time is left.”
b. “Palliative care will release you from the burden of having to care for someone in
the home. It does not mean that curative treatment will stop.”
c. “A palliative care facility is like a nursing home and costs less than a hospital
because only pain medications are given.”
d. “Your relative is unaware of her surroundings and will not notice the difference
between her home and a palliative care facility.”
m
ANS: A
co
Palliative care provides an increased level of personal care designed to manage symptom
distress. It does not specifically relieve the family’s burden of caring for a client at home. It is
not a place where only pain medications are given. The client is involved in this discussion so
the nurse would not state he or she is unaware of surroundings. The goal of palliative care is
to improve the quality of life for the patient and the family.
s.
DIF: Understanding
TOP: Integrated Process: Caring
KEY: End-of-life care, Palliative, hospice care
MSC: Client Needs Category: Psychosocial Integrity
nk
13. An intensive care nurse discusses withdrawal of care with a client’s family. The family
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ANS: C
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expresses concerns related to discontinuation of therapy. How will the nurse respond?
a. “I understand your concerns, but in this state, discontinuation of care is not a form
of active euthanasia.”
b. “You will need to talk to the primary health care provider because I am not legally
allowed to participate in the withdrawal of life support.”
c. “I realize this is a difficult decision. Discontinuation of therapy will allow the
client to die a natural death.”
d. “There is no need to worry. Most religious organizations support the client’s
decision to stop medical treatment.”
The nurse validates the family’s concerns and provides accurate information about the
discontinuation of therapy. The other statements address specific issues related to the
withdrawal of care but do not provide appropriate information about their purpose. If the
client’s family asks for specific information about euthanasia, legal, or religious issues, the
nurse would provide unbiased information about these topics.
DIF: Applying
TOP: Integrated Process: Caring
KEY: End-of-life care, Withdrawal of care
MSC: Client Needs Category: Psychosocial Integrity
14. A hospice nurse is caring for a variety of clients who are dying. Which end-of-life and death
ritual is paired with the correct religion?
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a. Roman Catholic—autopsies are not allowed except under special circumstances.
b. Christian—upon death, a religious leader should perform rituals of bathing and
wrapping the body in cloth.
c. Judaism—a person who is extremely ill and dying should not be left alone.
d. Islam—an ill or a dying person should receive the Sacrament of the Sick.
ANS: C
According to Jewish law, a person who is extremely ill or dying should not be left alone.
Orthodox Jews do not allow autopsies except under special circumstances. The Islamic faith
requires a religious leader to perform rituals of bathing and wrapping the body in cloth upon
death. A Catholic priest usually performs the Sacrament of the Sick for ill or dying people.
DIF: Remembering
TOP: Integrated Process: Caring
KEY: End-of-life care, Religion, spirituality
MSC: Client Needs Category: Psychosocial Integrity
m
MULTIPLE RESPONSE
1. A hospice nurse is caring for a dying client and family members. Which interventions does
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the nurse implement? (Select all that apply.)
a. Teach family members about physical signs of impending death.
b. Encourage the management of adverse symptoms.
c. Assist family members by offering an explanation for their loss.
d. Encourage reminiscence by both client and family members.
e. Avoid spirituality because the client’s and the nurse’s beliefs may not be
congruent.
f. Allow the client and family to voice concerns and fears.
ANS: A, B, D, F
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The nurse would teach family members about the physical signs of death, because family
members often become upset when they see physiologic changes in their loved one. Palliative
care includes management of symptoms so that the peaceful death of the client is facilitated.
Reminiscence will help both the client and family members cope with the dying process. The
nurse is not expected to explain why this is happening to the family’s loved one. The nurse
can encourage spirituality if the client is agreeable, regardless of whether the client’s religion
is the same. The nurse shows presence by allowing the client and family members to voice
their fears and concerns openly.
DIF: Applying
TOP: Integrated Process: Caring
MSC: Client Needs Category: Psychosocial Integrity
KEY: End-of-life care
2. A nurse admits an older adult client to the hospital. Which criteria does the nurse use to
determine if the client can make his or her own medical decisions? (Select all that apply.)
a. Can communicate treatment preferences.
b. Is able to read and write at an eighth-grade level.
c. Is oriented enough to understand information provided.
d. Can evaluate and deliberate information.
e. Has completed an advance directive.
f. The family states the client can make decisions.
ANS: A, C, D
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To have decision-making ability, a person must be able to perform three tasks: receive
information (but not necessarily oriented  4); evaluate, deliberate, and mentally manipulate
information; and communicate a treatment preference. The client does not have to read or
write at a specific level. Education can be provided at the client’s level so that he can make
the necessary decisions. The client does not need to complete an advance directive to make his
own medical decisions. An advance directive will be necessary if he wants to designate
someone to make medical decisions when he is unable to. The family may or may not be
correct in stating the client is capable, but the nurse would listen openly to their statements.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: End-of-life care, Advance directives
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A hospice nurse plans care for a client who is experiencing pain. Which complementary
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therapies does the nurse incorporate in this client’s pain management plan? (Select all that
apply.)
a. Play music that the client enjoys.
b. Massage tissue that is tender from radiation therapy.
c. Rub lavender lotion on the client’s feet.
d. Ambulate the client in the hall twice a day.
e. Administer intravenous morphine.
f. Involve the client in guided imagery.
s.
ANS: A, C, F
nk
Complementary therapies for pain management include massage therapy, music therapy,
therapeutic touch, guided imagery, and aromatherapy. Nurses would not massage over sites of
tissue damage from radiation therapy. Ambulation and intravenous morphine are not
complementary therapies for pain management.
ba
DIF: Understanding
TOP: Integrated Process: Nursing Process: Implementation
KEY: End-of-life care, Complementary therapy
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
4. A nurse teaches a client’s family members about signs and symptoms of approaching death.
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Which of the following does the nurse include in this teaching? (Select all that apply.)
a. Warm and flushed extremities
b. Long periods of insomnia
c. Increased respiratory rate
d. Decreased appetite
e. Congestion and gurgling
f. Incontinence
ANS: D, E, F
Common physical signs and symptoms of approaching death include coolness of extremities,
increased sleeping, irregular and slowed breathing rate, a decrease in fluid and food intake,
congestion and gurgling, incontinence, disorientation, and restlessness.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: End-of-life care
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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Chapter 09: Concepts of Care for Perioperative Patients
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A preoperative nurse is assessing a client prior to surgery. Which information would be most
important for the nurse to relay to the surgical team?
a. Allergy to bee and wasp stings
b. History of lactose intolerance
c. No previous experience with surgery
d. Use of multiple herbs and supplements
ANS: D
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Some herbs and supplements can interact with medications, so this information needs to be
reported as the priority. An allergy to bee and wasp stings should not affect the client during
surgery. Lactose intolerance should also not affect the client during surgery but will need to
be noted before a postoperative diet is ordered. Lack of experience with surgery may increase
anxiety and may require higher teaching needs, but client safety is more important.
s.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Perioperative nursing, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
2. A nurse works on the postoperative floor and has four clients who are being discharged
ANS: C
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tomorrow. Which one has the greatest need for the nurse to consult other members of the
health care team for postdischarge care?
a. Married young adult who is the primary caregiver for children.
b. Middle-age client who is post-knee replacement, and needs physical therapy.
c. Older adult who lives alone at home despite some memory loss.
d. Young client who lives alone, and has family and friends nearby.
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The older adult has the most potentially complex discharge needs. With memory loss, the
client may not be able to follow the prescribed home regimen. The client’s physical abilities
may be limited by chronic illness. This client has several safety needs that should be assessed.
The other clients all have evidence of a support system and no known potential for serious
safety issues.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Perioperative nursing, Interprofessional team
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend
the teaching, forgets a lot of what is said, and asks the same questions again and again. What
action by the nurse is best?
a. Assess the client for anxiety.
b. Break the information into smaller bits.
c. Give the client written information.
d. Review the information again.
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ANS: A
Anxiety can interfere with learning, coping, and cooperation. The nurse should assess the
client for anxiety. The other actions are appropriate too, and can be included in the teaching
plan, but effective teaching cannot occur if the client is highly anxious.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Perioperative nursing, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
4. A preoperative nurse is reviewing morning laboratory values on four clients waiting for
surgery. Which result warrants immediate communication with the surgical team?
a. Creatinine: 1.2 mg/dL (106.1 umol/L)
b. Hemoglobin: 14.8 mg/dL (148 mmol/L)
c. Potassium: 2.9 mEq/L (2.9 mmol/L)
d. Sodium: 134 mEq/L (134 mmol/L)
ANS: C
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The potassium level is critically low and can affect cardiac and respiratory status. The nurse
would communicate this laboratory value immediately. The creatinine is at the high end of
normal, the hemoglobin is normal, and the sodium is only slightly low so these values do not
need to be reported immediately.
s.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Perioperative nursing, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. An inpatient nurse brings an informed consent form to a client for an operation scheduled for
ANS: B
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tomorrow. The client asks about possible complications from the operation. What response by
the nurse is best?
a. Answer the questions and document that teaching was done.
b. Do not have the client sign the consent and call the primary health care provider.
c. Have the client sign the consent, and then call the primary health care provider.
d. Remind the client of what teaching the primary health care provider has done.
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In order to give informed consent, the client needs sufficient information. Questions about
potential complications should be answered by the primary health care provider. The nurse
can repeat some facts taught by the primary health care provider, but this topic is too broad for
the nurse to address alone. The nurse should notify the primary health care provider to come
back and answer the client’s questions before the client signs the consent form. The other
actions are not appropriate.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Perioperative nursing, Informed consent
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
6. A client has a great deal of pain when coughing and deep breathing after abdominal surgery
despite having pain medication. What action by the nurse is best?
a. Call the primary health care provider to request more analgesia.
b. Demonstrate how to splint the incision.
c. Have the client take shallower breaths.
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d. Tell the client that a little pain is expected.
ANS: B
Splinting an incision provides extra support during coughing and activity and helps decrease
pain. If the client is otherwise comfortable, no more analgesia is required. Shallow breathing
can lead to atelectasis and pneumonia. The client should know that some pain is normal and
expected after surgery, but that answer alone does not provide any interventions to help the
client.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Perioperative nursing, Nonpharmacologic pain management
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
7. A nurse is giving a client instructions for showering the night before surgery. What instruction
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is most appropriate?
a. “After you wash the surgical site, shave that area with your own razor.”
b. “Use the prescribed solution and wash the area where you will have surgery very
thoroughly.”
c. “Use a washcloth to wash the surgical site; do not take a full shower or bath.”
d. “Use warm water and scrub the surgical area vigorously.”
ANS: B
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One or two days before the scheduled surgery, the surgeon may ask the patient to shower
using an antiseptic solution, often chlorhexidine gluconate. This cleaning reduces
contamination of the surgical field and the number of organisms at the site. Hair removal if
needed is done in the operating suite using evidence-based practices such as clipping or a
depilatory agent. While the client should wash the area thoroughly, vigorous scrubbing might
scrape the skin, increasing the risk of infection.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Perioperative nursing, Health teaching
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
8. A postoperative client has an abdominal drain. What assessment by the nurse indicates that
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goals for the priority client problems related to the drain are being met?
a. Drainage from the surgical site is 30 mL less than yesterday.
b. There is no redness, warmth, or drainage at the insertion site.
c. The client reports adequate pain control with medications.
d. Urine is clear yellow and urine output is greater than 40 mL/hr.
ANS: B
The skin is the body’s first line of defense against infection and a drain of any type increases
this risk. The priority client problem related to a surgical drain is the potential for infection.
An insertion site that is free of redness, warmth, and drainage indicates that goals for this
client problem are being met. The other assessments are normal, but not related to the drain.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Perioperative nursing, Infection
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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9. The perioperative nurse manager and the postoperative unit manager are concerned about the
increasing number of surgical infections in their hospital. What action by the managers is
best?
a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes
were met.
b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene
policy.
c. Hold educational meetings with the nursing and surgical staff on infection
prevention.
d. Monitor staff on both units for consistent adherence to established hand hygiene
practices.
ANS: A
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The SCIP project contains core measures to reduce surgical complications. Examples of focus
included administration of prophylactic antibiotics, correct hair removal processes, the timing
of discontinuation of urinary catheterization after surgery, and venous thromboembolism
prophylaxis. These practices are now standard in surgical care. Prevention of infection is a
heavy emphasis, so the managers would start by reviewing charts to see if the guidelines of
this project were implemented. The other actions may be necessary too, but first the managers
need to assess the situation.
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Perioperative nursing, Surgical Care Improvement Project (SCIP)
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
10. A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry
ANS: A
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skin turgor, and muscle wasting. What action by the nurse is best?
a. Consult the primary health care provider about a dietitian referral.
b. Document the findings thoroughly in the client’s chart.
c. Encourage the client to eat more after recovering from surgery.
d. Refer the client to Meals on Wheels after discharge.
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This client has signs of malnutrition, which can impact recovery from surgery. The nurse
should consult the primary health care provider about prescribing a consultation with a
dietitian in the postoperative period. The nurse should document the findings but needs to do
more. Encouraging the client to eat more may be helpful, but the client needs a professional
nutritional assessment so that the appropriate diet and supplements can be ordered. The client
may or may not need Meals on Wheels after discharge.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Perioperative nursing, Nutrition
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
11. A client has arrived in the inpatient postoperative unit. What action by the inpatient nurse
takes priority?
a. Assessing fluid and blood output
b. Checking the surgical dressings
c. Ensuring the client is warm
d. Participating in hand-off report
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ANS: D
Hand-offs are a critical time in client care, and poor communication during this time can lead
to serious errors. The inpatient nurse and postanesthesia care nurse participate in hand-off
report as the priority. Assessing fluid losses and dressings can be done together as part of the
report. Ensuring the client is warm is a lower priority.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Perioperative nursing, Hand-off communication
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
12. The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative
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clients. Which client would the nurse assess first?
a. Client with a blood pressure of 100/50 mm Hg
b. Client with a pulse of 118 beats/min
c. Client with a respiratory rate of 6 breaths/min
d. Client with a temperature of 96° F (35.6° C)
ANS: C
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The respiratory rate is the most important vital sign for any client who has undergone general
anesthesia or moderate sedation, or has received opioid analgesia. This respiratory rate is too
low and indicates respiratory depression. The nurse would assess this client first. A blood
pressure of 100/50 mm Hg is slightly low and may be within that client’s baseline. A pulse of
118 beats/min is slightly fast, which could be due to several causes, including pain and
anxiety. A temperature of 96° F (35.6° C) is slightly low and the client needs to be warmed.
But none of these other vital signs take priority over the respiratory rate.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Perioperative nursing, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
13. A client had a surgical procedure with spinal anesthesia. The client’s blood pressure was
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ANS: C
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122/78 mm Hg 30 minutes ago and is now 138/60 and the client reports nausea. What action
by the nurse is best?
a. Call the Rapid Response Team.
b. Increase the IV fluid rate.
c. Notify the primary health care provider.
d. Nothing; this is expected.
A widening pulse pressure (44 to 78 mm Hg) and nausea may indicate autonomic blockade, a
complication of spinal anesthesia causing widespread vasodilation. The nurse would notify
the primary health care provider. The Rapid Response Team is not yet warranted; the nurse
would not increase the IV rate without a prescription.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Perioperative nursing, Adverse drug effects
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
14. A postoperative client vomited. After cleaning and comforting the client, which action by the
nurse is most important?
a. Allow the client to rest.
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b. Auscultate lung sounds.
c. Document the episode.
d. Encourage the client to eat dry toast.
ANS: B
Vomiting after surgery has several complications, including aspiration. The nurse would listen
to the client’s lung sounds. The client should be allowed to rest after an assessment.
Documenting is important, but the nurse needs to be able to document fully, including an
assessment. The client should not eat until nausea has subsided.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Perioperative nursing, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
15. A postoperative client has just been admitted to the postanesthesia care unit (PACU). What
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assessment by the PACU nurse takes priority?
a. Airway
b. Bleeding
c. Breathing
d. Cardiac rhythm
ANS: A
s.
Assessing the airway always takes priority, followed by breathing and circulation. Bleeding is
part of the circulation assessment, as is cardiac rhythm.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Perioperative nursing, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
16. A postoperative client has respiratory depression after receiving morphine for pain. Which
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ANS: C
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medication and dose does the nurse prepare to administer?
a. Flumazenil 0.2 to 1 mg
b. Flumazenil 2 to 10 mg
c. Naloxone 0.4 to 2 mg
d. Naloxone 4 to 20 mg
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The nurse would prepare to administer naloxone, an opioid antagonist, at a dose of between
0.04 and 0.05 mg up to 2 mg, depending on the client’s symptoms. Flumazenil is a
benzodiazepine antagonist.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Perioperative nursing, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
17. A nurse on the postsurgical inpatient unit is observing a client perform leg exercises. What
action by the client indicates a need for further instruction?
a. Client states “This will help prevent blood clots in my legs.”
b. Bends both knees, pushes against the bed until calf and thigh muscles contract.
c. Dorsiflexes and plantar flexes each foot several times an hour.
d. Makes several clockwise then counterclockwise ankle circles with each foot.
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ANS: B
The client should perform this leg exercise one leg at a time. The other actions are correct.
DIF: Analyzing
TOP: Integrated Process: Teaching/Learning
KEY: Perioperative nursing, Health teaching
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
18. A registered nurse (RN) is watching a new nurse change a dressing and perform care around a
Penrose drain. What action by the new nurse warrants intervention?
a. Cleaning around the drain per agency protocol
b. Placing a new sterile gauze under the drain
c. Securing the drain’s safety pin to the sheets
d. Using sterile technique to empty the drain
ANS: C
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The safety pin that prevents the drain from slipping back into the client’s body would not be
pinned to the client’s bedding. Pinning it to the sheets will cause it to pull out when the client
turns. The other actions are appropriate.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Postoperative nursing, Drains
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
s.
19. A postoperative nurse is caring for a client who received a neuromuscular blocking agent
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ANS: C
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during surgery. On assessment the nurse notes the client has weak hand grasps. What
assessment does the nurse conduct next?
a. Ability to raise head off the bed
b. Blood pressure and pulse
c. Signs of oxygenation
d. Level of orientation
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When neuromuscular blocking agents are retained, muscle weakness could affect the
diaphragm and impair gas exchange. Symptoms include the inability to maintain a head lift,
weak hand grasps, and an abdominal breathing pattern. Since the client has weak hand grasps,
the nurse would assess for signs of systemic oxygenation next. The nurse would assess head
lift ability, but this does not take priority over oxygenation. Blood pressure, pulse, and level of
orientation are all important in the postoperative period, but oxygenation would come first.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Perioperative nursing, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
20. The postanesthesia care unit (PACU) nurse is caring for an older client following a lengthy
surgery. The client’s pulse is 48 beats/min which is 20 beats/min lower than the preoperative
baseline. What assessment does the nurse make next?
a. Temperature
b. Level of consciousness
c. Blood pressure
d. Rate of IV infusion
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ANS: A
Bradycardia in the immediate postoperative client can indicate anesthesia effect or
hypothermia. Older adults are at higher risk for hypothermia because of age-related changes in
temperature regulation, decreased body fat, or prolonged exposure to cool environments, such
as an OR suite. The nurse would first assess the client’s temperature and take measures to
correct any existing hypothermia. Level of consciousness, blood pressure, and IV infusion rate
are not related, although all are important assessments in the postoperative period.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Perioperative nursing, Older adult
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
21. The postoperative nurse is caring for a client who reports feeling “something popped” after
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vomiting. What action by the nurse is best?
a. Administer an antiemetic medication.
b. Call the primary health care provider.
c. Instruct client to avoid coughing.
d. Gather sterile nonadherent dressings.
ANS: D
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The client may have a wound dehiscence. The nurse would gather needed supplies and assess
the wound under the dressing. If the incision has dehisced, the nurse would cover it with a
sterile nonadherent dressing or saline-moistened gauze dressing then call the primary health
care provider. The client may need an antiemetic, but this is not the most important action at
this time.
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MULTIPLE RESPONSE
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Perioperative nursing, Wound dehiscence
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
1. A new perioperative nurse is receiving orientation to the surgical area and learns about the
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Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus
on? (Select all that apply.)
a. Hemorrhage prevention
b. Infection prevention
c. Malignant hyperthermia testing
d. Stroke recognition
e. Thromboembolism prevention
f. Correct hair removal
ANS: B, E, F
The Surgical Care Improvement Project (SCIP), a set of core compliance measures, was
initiated in 2006 to reduce surgical complications. Examples of focus included administration
of prophylactic antibiotics to prevent infection, correct hair removal processes, the timing of
discontinuation of urinary catheterization after surgery, and venous thromboembolism
prophylaxis. These practices are now standard in surgical care.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Perioperative nursing, Surgical Care Improvement Project (SCIP)
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MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
2. A nurse is learning about different surgical procedures and their classifications. Which
examples below does this include? (Select all that apply.)
a. Rhinoplasty: curative
b. Liver biopsy: diagnostic
c. Arthroscopy: preventative. Ileostomy: palliative. Total shoulder replacement:
reconstructive
d. Body contouring: cosmetic
ANS: B, C, D
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A cosmetic procedure is designed to improve the client’s appearance or self-confidence; a
body contouring procedure is an example. A diagnostic procedure is performed to determine
the origin and cause of a disorder by taking a tissue sample with the intention of diagnosing
(and staging, if applicable) a condition, such as a liver biopsy. A preventative procedure is
performed with the intention that a specific condition will not occur. An example of this is a
prophylactic bilateral mastectomy in a woman who carries the BRCA 1 or BRCA 2 gene to
prevent the development of breast cancer. A palliative procedure is designed to improve
quality of life; an example is an ileostomy. A reconstructive operation improves functional
ability is an abnormal or damaged structure. A total shoulder replacement would be an
example. A curative operation is performed to resolve a health problem by repairing or
removing the cause; a gallbladder removal is an example.
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s.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Perioperative nursing, Surgical procedures
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse is caring for several clients in the morning prior to surgery. Which medications taken
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by the clients require the nurse to consult with the primary health care provider about their
administration? (Select all that apply.)
a. Insulin
b. Omega-3 fatty acids
c. Phenytoin
d. Metoprolol
e. Warfarin
f. Prednisone
ANS: A, C, D, E, F
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Although the client will be on NPO status before surgery, the nurse should check with the
primary health care provider about allowing the client to take medications prescribed for
diabetes, hypertension, cardiac disease, seizure disorders, depression, glaucoma,
anticoagulation, or depression and steroids. Metformin is used to treat diabetes; phenytoin is
for seizures; metoprolol is for cardiac disease and/or hypertension; and warfarin is an
anticoagulant. The omega-3 fatty acids can be held the day of surgery.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Analysis
KEY: Perioperative nursing, Medication safety
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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4. A nurse recently hired to the preoperative area learns that certain clients are at higher risk for
venous thromboembolism (VTE). Which clients are considered to be at high risk? (Select all
that apply.)
a. Client with a humerus fracture
b. Morbidly obese client
c. Client who smokes
d. Client with severe heart failure
e. Wheelchair-bound client
f. 50 years of age or older
ANS: B, C, D, E
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All surgical clients should be assessed for VTE risk. Those considered to be at higher risk
include those who are obese; are over 40; have cancer; have decreased mobility, immobility,
or a spinal cord injury; have a history of any thrombotic event, varicose veins, or edema; take
oral contraceptives or smoke; have decreased cardiac output; have a hip fracture; or are having
total hip or knee surgery.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Perioperative nursing, Venous thromboembolism
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A client has received several doses of midazolam. The nurse assesses the client to be difficult
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ANS: A, D, E
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to arouse with respirations of 6 breaths/min. What actions by the nurse are most important?
(Select all that apply.)
a. Administer oxygen per protocol.
b. Obtain one dose of flumazenil.
c. Obtain naloxone, 0.04 mg for IV push.
d. Ensure suction is working
e. Transfer the client to intensive care.
f. Monitor client every 10 to 15 minutes for the next 2 hours.
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Midazolam is a benzodiazepine and its reversal agent is flumazenil. Naloxone is for opioid
reversal. The nurse would apply oxygen as prescribed or by policy and obtain several doses at
once because the drug can be given every 2 to 3 minutes if needed. Flumazenil can cause
vomiting, so the nurse ensures suction equipment is present and working. Since flumazenil is
metabolized more quickly than the midazolam, the client must be monitored every 10 to 15
minutes for the next 2 hours. The client may or may not need to be transferred.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Perioperative nursing, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A nurse learns older adults are at higher risk for complications after surgery. What reasons for
this does the nurse understand? (Select all that apply.)
a. Decreased cardiac output
b. Decreased oxygenation
c. Frequent nocturia
d. Mobility alterations
e. Inability to adapt to changes
f. Slower reaction times
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ANS: A, B, C, D, F
Older adults have many age-related physiologic changes that put them at higher risk of falling
and other complications after surgery. Some of these include decreased cardiac output,
decreased oxygenation of tissues, nocturia, mobility alterations, and slower reaction times.
They also have a decreased ability to adapt to new surroundings, but that is not the same as
being unable to adapt.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Perioperative nursing, Older adult
MSC: Client Needs Category: Health Promotion and Maintenance
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safety? (Select all that apply.)
a. Allow small sips of plain water.
b. Check that consent is on the chart.
c. Ensure that the client has an armband on.
d. Have the client help mark the surgical site.
e. Allow the client to use the toilet before giving sedation.
f. Assess the client for fall risks.
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7. A nurse working in the preoperative holding area performs which functions to ensure client
ANS: B, C, D, E, F
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s.
Providing for client safety is a priority function of the preoperative nurse. Checking for
appropriately completed consent, verifying the client’s identity, having the client assist in
marking the surgical site if applicable, assessing for fall risk, and allowing the client to use the
toilet prior to sedating him or her are just some examples of important safety measures. The
preoperative client should be NPO, so water should not be provided unless an oral medication
is ordered to be given in pre-op.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Perioperative nursing, Safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
8. A nurse orienting to the postoperative area learns which principles about the postoperative
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period? (Select all that apply.)
a. All phases require the client to be in the hospital.
b. Phase I care may last for several days in some clients.
c. Phase I requires intensive care unit monitoring.
d. Phase II ends when the client is stable and awake.
e. Vital signs may be taken only once a day in phase III.
f. Some clients may be discharged directly after phase I.
ANS: C, D, E
There are three phases of postoperative care. Phase I is the most intense, with clients coming
right from surgery until they are completely awake and hemodynamically stable. This may
take hours or days and can occur in the intensive care unit or the postoperative care unit.
Some patients achieve this level of recovery in phase I and can be discharged directly to
home. Phase II ends when the client is at a pre-surgical level of consciousness and baseline
oxygen saturation, and vital signs are stable. Phase III involves the extended-care environment
and may continue at home or in an extended-care facility if needed.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
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KEY: Perioperative nursing, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric
(NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that
apply.)
a. Blood glucose: 120 mg/dL (6.7 mmol/L)
b. Hemoglobin: 7.8 mg/dL (78 mmol/L)
c. pH: 7.68
d. Potassium: 2.9 mEq/L (2.9 mmol/L)
e. Sodium: 142 mEq/L (142 mmol/L)
ANS: B, C, D
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Fluid and electrolyte balance are assessed carefully in the postoperative client because many
imbalances can occur. The low hemoglobin may be from blood loss in surgery. The higher pH
level indicates alkalosis, possibly from losses through the NG tube. The potassium is very
low. The blood glucose is within normal limits for a postsurgical client who has been fasting.
The sodium level is normal.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Perioperative nursing, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
10. A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical
ba
ANS: B, D, E
nk
s.
wound infection. What actions are best to achieve this goal? (Select all that apply.)
a. Administering antibiotics for 72 hours
b. Disposing of dressings properly
c. Leaving draining wounds open to air
d. Performing proper hand hygiene
e. Removing and replacing wet dressings
st
Interventions necessary to prevent surgical wound infection include proper disposal of soiled
dressings, performing proper hand hygiene, and removing wet dressings as they can be a
source of infection. Prophylactic antibiotics may be given to clients at risk for infection, but
not all clients need them for 72 hours. Draining wounds would always be covered.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Perioperative nursing, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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Chapter 10: Concepts of Emergency and Trauma Nursing
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. An emergency department nurse assesses a client who has been raped. With which health care
team member would the nurse collaborate when planning this client’s care?
a. Primary health care provider
b. Case manager
c. Forensic nurse examiner
d. Psychiatric crisis nurse
ANS: C
m
All other members of the health care team listed may be used in the management of this
client’s care. However, the forensic nurse examiner is educated to obtain client histories and
collect evidence dealing with the assault, and can offer the counseling and follow-up needed
when dealing with the victim of an assault.
co
DIF: Understanding
TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency nursing, Interprofessional team
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
s.
2. The emergency department team is performing cardiopulmonary resuscitation on a client
nk
when the client’s spouse arrives. Which action would the nurse take first?
a. Request that the client’s spouse sit in the waiting room.
b. Ask the spouse if he or she wishes to be present during the resuscitation.
c. Suggest that the spouse begin to pray for the patient.
d. Refer the client’s spouse to the hospital’s crisis team.
ANS: B
ba
If resuscitation efforts are still under way when the family arrives, one or two family members
may be given the opportunity to be present during lifesaving procedures. The other options do
not give the spouse the opportunity to be present for the client or to begin to have closure.
st
DIF: Applying
TOP: Integrated Process: Caring
MSC: Client Needs Category: Psychosocial Integrity
KEY: Emergency nursing
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3. An emergency department nurse is triaging victims of a multi-casualty event. Which client
would receive care first?
a. A 30-year-old distraught mother holding her crying child
b. A 65-year-old conscious male with a head laceration
c. A 26-year-old male who has pale, cool, clammy skin
d. A 48 year old with a simple fracture of the lower leg
ANS: C
The client with pale, cool, clammy skin may be in shock and needs immediate medical
attention. The mother does not have injuries and so would be the lowest priority. The other
two people need medical attention soon, but not at the expense of a person in shock.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Emergency nursing, Triage
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MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. While triaging clients in a crowded emergency department, a nurse assesses a client who
presents with symptoms of tuberculosis. Which action would the nurse take first?
a. Apply oxygen via nasal cannula.
b. Administer intravenous 0.9% saline solution.
c. Transfer the client to a negative-pressure room.
d. Obtain a sputum culture and sensitivity.
ANS: C
A client with signs and symptoms of tuberculosis or other airborne pathogens would be placed
in a negative-pressure room to prevent contamination of staff, clients, and family members in
the crowded emergency department. The client may or may not need oxygen or an IV. A
sputum culture would be obtained but is not the priority.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Emergency nursing, Transmission-Based Precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5. A nurse is triaging clients in the emergency department (ED). Which client would the nurse
s.
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prioritize to receive care first?
a. A 22 year old with a painful and swollen right wrist
b. A 45 year old reporting chest pain and diaphoresis
c. A 60 year old reporting difficulty swallowing and nausea
d. An 81 year old, respiratory rate 28 breaths/min and temperature of 101° F (38.8°
C)
nk
ANS: B
A client experiencing chest pain and diaphoresis would be classified as emergent and would
be triaged immediately to a treatment room in the ED. The other clients are more stable.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency nursing, Triage
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
st
6. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately
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paired with the level of the trauma center?
a. Level I—located within remote areas and provides advanced life support within
resource capabilities
b. Level II—located within community hospitals and provides care to most injured
clients
c. Level III—located in rural communities and provides only basic care to clients
d. Level IV—located in large teaching hospitals and provides a full continuum of
trauma care for all clients
ANS: B
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Level I trauma centers are usually located in large teaching hospital systems and provide a full
continuum of trauma care for all clients. Both Level II and Level III facilities are usually
located in community hospitals. These trauma centers provide care for most clients and
transport to Level I centers when client needs exceed resource capabilities. Level IV trauma
centers are usually located in rural and remote areas. These centers provide basic care,
stabilization, and advanced life support while transfer arrangements to higher level trauma
centers are made.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency nursing, Levels of trauma centers
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. Emergency medical technicians arrive at the emergency department with an unresponsive
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client who has an oxygen mask in place. Which action would the nurse take first?
a. Assess that the client is breathing adequately.
b. Insert a large-bore intravenous line.
c. Place the client on a cardiac monitor.
d. Assess for the best neurologic response.
ANS: A
s.
co
After establishing an airway, the highest priority intervention in the primary survey is to
establish that the client is breathing adequately. Even though this client has an oxygen mask
on, he or she may not be breathing, or may be breathing inadequately with the device in place.
Inserting an IV line and placing the client on a monitor would come after ensuring a patent
airway and effective breathing.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Emergency nursing, Primary survey
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
8. A trauma client with multiple open wounds is brought to the emergency department in cardiac
ANS: B
st
ba
arrest. Which action would the nurse take prior to providing advanced cardiac life support?
a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic.
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Nurses must recognize and plan for a high risk of contamination with blood and body fluids
when engaging in trauma resuscitation. Standard Precautions would be taken in all
resuscitation situations and at other times when exposure to blood and body fluids is likely.
Proper attire consists of an impervious cover gown, gloves, eye protection, a facemask, a
surgical cap, and shoe covers. It is not known if this client has orthopedic injuries. The Rapid
Response Team is not needed in the ED. A complete history is needed but the staff’s
protection comes first.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency nursing, Standard Precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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9. A nurse is triaging clients in the emergency department. Which client would be considered
“urgent”?
a. A 20-year-old female with a chest stab wound and tachycardia
b. A 45-year-old homeless man with a skin rash and sore throat
c. A 75-year-old female with a cough and a temperature of 102° F (38.9° C)
d. A 50-year-old male with new-onset confusion and slurred speech
ANS: C
A client with a cough and a temperature of 102° F (38.9° C) is urgent. This client is at risk for
deterioration and needs to be seen quickly, but is not in an immediately life-threatening
situation. The client with a chest stab wound and tachycardia and the client with new-onset
confusion and slurred speech would be triaged as emergent. The client with a skin rash and a
sore throat is not at risk for deterioration and would be triaged as nonurgent.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency nursing, Triage
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
10. An emergency department nurse is caring for a client who has died from a suspected
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homicide. Which action does the nurse take?
a. Remove all tubes and wires in preparation for the medical examiner.
b. Limit the number of visitors to minimize the family’s trauma.
c. Consult the bereavement committee to follow up with the grieving family.
d. Communicate the client’s death to the family in a simple and concrete manner.
ANS: D
ba
nk
When dealing with clients and families in crisis, communicate in a simple and concrete
manner to minimize confusion. Tubes must remain in place for the medical examiner. Family
would be allowed to view the body. Offering to call for additional family support during the
crisis is suggested. The bereavement committee would be consulted, but this is not the priority
at this time.
DIF: Applying
TOP: Integrated Process: Caring
MSC: Client Needs Category: Psychosocial Integrity
KEY: Emergency nursing, Death
st
11. An emergency department (ED) case manager is consulted for a client who is homeless.
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Which intervention would the case manager provide?
a. Communicate client needs and restrictions to support staff.
b. Prescribe low-cost antibiotics to treat community-acquired infection.
c. Provide referrals to subsidized community-based health clinics.
d. Offer counseling for substance abuse and mental health disorders.
ANS: C
Case management interventions include facilitating referrals to primary care providers who
are accepting new clients or to subsidized community-based health clinics for clients or
families in need of routine services. The ED nurse is accountable for communicating pertinent
staff considerations, client needs, and restrictions to support staff (e.g., physical limitations,
Isolation Precautions) to ensure that ongoing client and staff safety issues are addressed. The
ED provider prescribes medications and treatments. The psychiatric nurse team evaluates
clients with emotional behaviors or mental illness and facilitates the follow-up treatment plan,
including possible admission to an appropriate psychiatric facility.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency nursing, Interprofessional team
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
12. An emergency department nurse is caring for a client who is homeless. Which action would
the nurse take to gain the client’s trust?
a. Speak in a quiet and monotone voice.
b. Avoid eye contact with the patient.
c. Listen to the client’s concerns and needs.
d. Ask security to store the client’s belongings.
ANS: C
m
To demonstrate behaviors that promote trust with homeless clients, the emergency department
nurse makes eye contact (if culturally appropriate), speaks calmly, avoids any prejudicial or
stereotypical remarks, shows genuine care and concern by listening, and follows through on
promises. The nurse would also respect the client’s belongings and personal space.
co
DIF: Understanding
TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency nursing, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
13. A nurse is triaging clients in the emergency department. Which client would the nurse classify
nk
s.
as “nonurgent?”
a. A 44 year old with chest pain and diaphoresis
b. A 50 year old with chest trauma and absent breath sounds
c. A 62 year old with a simple fracture of the left arm
d. A 79 year old with a temperature of 104° F (40.0° C)
ANS: C
st
ba
A client in a nonurgent category can tolerate waiting several hours for health care services
without a significant risk of clinical deterioration. The client with a simple arm fracture and
palpable radial pulses is currently stable, is not at significant risk of clinical deterioration, and
would be considered nonurgent. The client with chest pain and diaphoresis and the client with
chest trauma are emergent owing to the potential for clinical deterioration and would be seen
immediately. The client with a high fever may be stable now but also has a risk of
deterioration.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency nursing, Triage
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
14. What is the primary goal of a triage system used by the nurse with clients presenting to the
emergency department?
a. Determine the acuity of the client’s condition to determine priority of care.
b. Assess the status of the airway, breathing, circulation, or presence of deficits.
c. Determine whether the client is responsive enough to provide needed information.
d. Evaluate the emergency department’s resources to adequately treat the patient.
ANS: A
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ED triage is an organized system for sorting and classifying clients into priority levels
depending on illness or injury severity. The primary goal of the triage system is to facilitate
the ED nurse’s ability to prioritize care according to the acuity of the patient, having the
clients with the more severe illness or injury seen first. Airway, breathing, and circulation are
part of the primary survey. Determining responsiveness is done during the disability phase of
the primary survey and is not the primary goal. Evaluating the ED’s resources is also not a
goal of triage.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency nursing, Triage
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
15. An elderly client who has fallen from a roof is transported to the emergency department by
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ambulance. The client was unconscious at the scene but is conscious on arrival and is triaged
as urgent. What is the priority assessment the nurse includes during the primary survey of the
patient?
a. A full set of vital signs
b. Cardiac rhythm
c. Neurologic status
d. Client history
ANS: C
nk
s.
The primary survey for a trauma client organizes the approach to the client so that
life-threatening injuries are rapidly identified and managed. Injuries from this type of fall have
a high risk for cervical spine injuries. In addition, with the loss of consciousness at the scene
the client would be at risk for head trauma. A full set of vital signs is obtained as part of the
secondary survey. The cardiac rhythm is important but not specifically related to this client’s
presentation. Client history would be obtained as able.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Emergency nursing, Primary survey
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
st
MULTIPLE RESPONSE
1. A nurse is caring for clients in a busy emergency department. What actions would the nurse
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take to ensure client and staff safety? (Select all that apply.)
a. Leave the stretcher in the lowest position with rails down so that the client can
access the bathroom.
b. Use two identifiers before each intervention and before mediation administration.
c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors.
d. Search the belongings of clients with altered mental status to gain essential
medical information.
e. Use facility policy identification procedures for “Jane/John Doe” clients.
f. Check clients for a medical alert bracelets or necklaces.
g. Avoid using Security personnel to prevent escalation of client behaviors.
ANS: B, C, D, E, F
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Best practices for client and staff safety in the emergency department include leaving beds in
the lowest position with side rails up, using two unique identifiers for medications and
procedures, using de-escalation strategies for clients or visitors showing hostile or aggressive
behaviors, searching the belongings of confused clients for medical information, using facility
identification systems for Jane/John Doe clients, observing for medical alert jewelry, and
using security staff as needed.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Emergency nursing, Safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
2. An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive
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care unit. Which information would the nurse include in the nurse-to-nurse hand-off report?
(Select all that apply.)
a. Mechanism of injury
b. Diagnostic test results
c. Immunizations
d. List of home medications
e. Isolation Precautions
f. Safety concerns
ANS: A, B, E, F
ba
nk
s.
Hand-off communication would be comprehensive so that the receiving nurse can continue
care for the client fluidly. Communication would be concise and would include only the most
essential information for a safe transition in care. Hand-off communication would include the
client’s situation (reason for being in the ED), brief medical history, assessment and
diagnostic findings, Transmission-Based Precautions needed, safety concerns interventions
provided, and response to those interventions. Immunization history is not usually considered
critical unless it relates to the reason for admission. Medication reconciliation will occur when
the client reaches the inpatient unit.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Emergency nursing, Hand-off communication
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
st
3. An emergency department nurse is caring for a trauma patient. Which interventions does the
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nurse perform during the primary survey? (Select all that apply.)
a. Foley catheterization
b. Needle decompression
c. Initiating IV fluids
d. Splinting open fractures
e. Endotracheal intubation
f. Removing wet clothing
g. Laceration repair
ANS: B, C, E, F
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The primary survey for a trauma client organizes the approach to the client so that
life-threatening injuries are rapidly identified and managed. The primary survey is based on
the standard mnemonic ABC, with an added D and E: Airway and cervical spinal motion
restriction; Breathing; Circulation; Disability; and Exposure. After the completion of primary
diagnostic and laboratory studies, and the insertion of gastric and urinary tubes, the secondary
survey (a complete head-to-toe assessment) can be carried out.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Emergency nursing, Primary survey
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. The complex care provided during an emergency requires interprofessional collaboration.
s.
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Which team members are paired with the correct responsibilities? (Select all that apply.)
a. Psychiatric crisis nurse—interacts with clients and families when sudden illness,
serious injury, or death of a loved one may cause a crisis
b. Forensic nurse examiner—performs rapid assessments to ensure that clients with
the highest acuity receive the quickest evaluation, treatment, and prioritization of
resources
c. Triage nurse—provides basic life support interventions such as oxygen, basic
wound care, splinting, spinal motion restriction, and monitoring of vital signs
d. Emergency medical technician—obtains client histories, collects evidence, and
offers counseling and follow up care for victims of rape, child abuse, and domestic
violence
e. Paramedic—provides prehospital advanced life support, including cardiac
monitoring, advanced airway management, and medication administration
nk
ANS: A, E
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st
ba
The psychiatric crisis nurse evaluates clients with emotional behaviors or mental illness and
facilitates follow-up treatment plans. The psychiatric crisis nurse also works with clients and
families when experiencing a crisis. Paramedics are advanced life support providers who can
perform advanced techniques that may include cardiac monitoring, advanced airway
management and intubation, establishing IV access, and administering drugs en route to the
emergency department. The forensic nurse examiner is trained to recognize evidence of abuse
and to intervene on the client’s behalf. The forensic nurse examiner will obtain client
histories, collect evidence, and offer counseling and follow up care for victims of rape, child
abuse, and domestic violence. The triage nurse performs rapid assessments to ensure that
clients with the highest acuity receive the quickest evaluation, treatment, and prioritization of
resources. The emergency medical technician is usually the first caregiver and provides basic
life support and transportation to the emergency department.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency nursing, Interprofessional team
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
5. A nurse prepares to discharge an older adult client home from the emergency department
(ED). What actions does the nurse take to prevent future ED visits? (Select all that apply.)
a. Provide medical supplies to the family.
b. Consult a home health agency.
c. Encourage participation in community activities.
d. Screen for depression and suicide.
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e. Complete a functional assessment.
ANS: D, E
Due to the high rate of suicide among older adults, a nurse would assess all older adults for
depression and suicide. The nurse would also screen older adults for functional assessment,
cognitive assessment, and risk for falls to prevent future ED visits.
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ba
nk
s.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Implementation
KEY: Emergency nursing, Older adult
MSC: Client Needs Category: Health Promotion and Maintenance
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Chapter 11: Concepts of Care for Patients With Common Environmental Emergencies
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. On a hot humid day, an emergency department nurse is caring for a client who is confused
and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26
breaths/min, and blood pressure 106/66 mm Hg. What action would the nurse take?
a. Encourage the client to drink cool water or sports drinks.
b. Start an intravenous line and infuse 0.9% saline solution.
c. Administer acetaminophen (Tylenol) 650 mg orally.
d. Encourage rest and reassess in 15 minutes.
ANS: B
s.
co
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The client demonstrates signs of heat stroke. This is a medical emergency and priority care
includes oxygen therapy, IV infusion with 0.9% saline solution, insertion of a urinary catheter,
and aggressive interventions to cool the patient, including external cooling and internal
cooling methods. Oral hydration would not be appropriate for a client who has symptoms of
heat stroke because oral fluids would not provide necessary rapid rehydration, and the
confused client would be at risk for aspiration. Acetaminophen would not decrease this
patient’s temperature or improve the patient’s symptoms. The client needs immediate medical
treatment; therefore, rest and reassessing in 15 minutes are inappropriate.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Environmental emergencies, Heat-related illness
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. While at a public park, a nurse encounters a person immediately after a bee sting. The
st
ANS: D
ba
person’s lips are swollen, and wheezes are audible. What action would the nurse take first?
a. Elevate the site and notify the person’s next of kin.
b. Remove the stinger with tweezers and encourage rest.
c. Administer diphenhydramine and apply ice.
d. Administer an epinephrine autoinjector and call 911.
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The client’s swollen lips indicate that anaphylaxis may be developing, and this is a medical
emergency. The nurse would call 911 would immediately, and the client transported to the
emergency department as quickly as possible. If an EpiPen is available, it would be
administered at the first sign of an anaphylactic reaction. The other answers do not provide
adequate interventions to treat airway obstruction due to anaphylaxis, although the nurse
would remove the stinger as soon as possible after administering the autoinjector.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Environmental emergencies, Bee and insect stings
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A client presents to the emergency department after prolonged exposure to the cold. The client
is difficult to arouse and speech is incoherent. What action would the nurse take first?
a. Reposition the client into a prone position.
b. Administer warmed intravenous fluids to the client.
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c. Wrap the client’s extremities in warm blankets.
d. Initiate extracorporeal rewarming via hemodialysis.
ANS: B
Moderate hypothermia manifests with muscle weakness, increased loss of coordination, acute
confusion, apathy, incoherence, stupor, and impaired clotting. Moderate hypothermia is
treated by core rewarming methods, which include administration of warm IV fluids; heated
oxygen; and heated peritoneal, pleural, gastric, or bladder lavage. The client’s trunk would be
warmed prior to the extremities to prevent peripheral vasodilation. Extracorporeal warming
with cardiopulmonary bypass or hemodialysis is a treatment for severe hypothermia.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Environmental emergencies, Cold-related illness
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. An emergency department nurse cares for a middle-age mountain climber who is confused,
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ataxic, and exhibits impaired judgement. After administering oxygen, which intervention
would the nurse implement next?
a. Administer dexamethasone.
b. Complete a mini mental state examination.
c. Prepare the client for computed tomography of the brain.
d. Request a psychiatric consult.
ANS: A
nk
s.
The client is exhibiting signs of mountain sickness and high-altitude cerebral edema (HACE).
Dexamethasone reduces cerebral edema by acting as an anti-inflammatory in the central
nervous system. The other interventions will not specifically treat HACE, although a thorough
mental status exam would be performed.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: Environmental emergencies, Altitude-related illness
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
5. An emergency department nurse assesses a client admitted after a lightning strike. The client
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st
is awake but somewhat confused. Which assessment would the nurse complete first?
a. Electrocardiogram (ECG)
b. Wound inspection
c. Creatinine kinase
d. Computed tomography of head
ANS: A
Clients who survive a lightning strike can have serious myocardial injury, which can be
manifested by ECG and myocardial perfusion abnormalities. The nurse would prioritize the
ECG over the other assessments which would be completed later.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Environmental emergencies, Lightning injury
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A nurse teaches a community health class about water safety. Which statement by a
participant indicates that additional teaching is needed?
a. “I can go swimming all by myself because I am a certified lifeguard.”
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b. “I cannot leave my toddler alone in the bathtub for even a minute.”
c. “I will appoint one adult to supervise the pool at all times during a party.”
d. “I will make sure that there is a phone near my pool in case of an emergency.”
ANS: A
People would never swim alone, regardless of lifeguard status. The other statements indicate
good understanding of the teaching.
DIF: Analyzing
TOP: Integrated Process: Teaching/Learning
KEY: Environmental emergencies, Drowning, Health teaching
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
7. A primary health care provider prescribes a rewarming bath for a client who presents with
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Grade 3 frostbite. What action would the nurse take prior to starting this treatment?
a. Administer intravenous morphine.
b. Wrap the limb with a compression dressing.
c. Massage the frostbitten areas.
d. Assess the limb for compartment syndrome.
ANS: A
co
Rapid rewarming in a water bath is recommended for all instances of partial-thickness and
full-thickness frostbite. Patients experience severe pain during the rewarming process and
nurses would administer intravenous analgesics.
nk
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Environmental emergencies, Cold-related illness
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. A nurse assesses a client recently bitten by a coral snake. Which assessment would the nurse
ANS: C
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complete first?
a. Unilateral peripheral swelling
b. Clotting times
c. Cardiopulmonary status
d. Electrocardiogram rhythm
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st
Signs and symptoms of coral snake envenomation are the result of its neurotoxic properties.
The physiologic effect is to block neurotransmission, which produces ascending paralysis,
reduced perception of pain, and, ultimately, respiratory paralysis. The nurse would monitor
for respiratory rate and depth. Severe swelling and clotting problems do not occur with coral
snakes but do occur with pit viper snakes. Electrocardiogram rhythm is not affected by
neurotoxins.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Environmental emergencies, Snakebites
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. A nurse plans care for a client admitted with a snakebite to the right leg. With whom would
the nurse collaborate?
a. The facility’s neurologist
b. The poison control center
c. The physical therapy department
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d. A herpetologist (snake specialist)
ANS: B
For the client with a snakebite, the nurse would contact the regional poison control center
immediately for specific advice on antivenom administration and client management.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Planning
KEY: Environmental emergencies, Snakebites
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
10. While on a camping trip, a nurse cares for an adult client who had a drowning incident in a
m
lake and is experiencing agonal breathing with a palpable pulse. What action would the nurse
take first?
a. Deliver rescue breaths.
b. Wrap the client in dry blankets.
c. Assess for signs of bleeding.
d. Check for a carotid pulse.
ANS: A
co
In this emergency situation, the nurse immediately initiates airway clearance and ventilator
support measures, including delivering rescue breaths.
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Environmental emergencies, Drowning
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
11. A nurse assesses a client admitted with a brown recluse spider bite. Which assessment does
ANS: D
ba
nk
the nurse perform to identify complications of this bite?
a. Ask the client about pruritus at the bite site.
b. Inspect the bite site for a bluish purple vesicle.
c. Assess the extremity for redness and swelling.
d. Monitor the client’s temperature every 4 hours.
st
Fever and chills indicate systemic toxicity, which can lead to hemolytic anemia,
thrombocytopenia, DIC, and death. Assessing for a fever would indicate this complication.
All other symptoms are normal for a brown recluse bite and would be assessed, but they do
not provide information about complications from the bite.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Environmental emergencies, Arthropod bites
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
12. A primary health care provider prescribes diazepam to a client who was bitten by a black
widow spider. The client asks, “What is this medication for?” How does the nurse respond?
a. “This medication is an antivenom for this type of bite.”
b. “It will relieve your muscle rigidity and spasms.”
c. “It prevents respiratory difficulty from excessive secretions.”
d. “This medication will prevent respiratory failure.”
ANS: B
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Black widow spider venom can produce muscle rigidity and spasms, which are treated with
the muscle relaxant, diazepam. It does not prevent respiratory difficulty or failure nor is it
antivenom.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Environmental emergencies, Arthropod bites
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
13. After teaching a client how to prevent altitude-related illnesses, a nurse assesses the client’s
m
understanding. Which statement indicates that the client needs additional teaching?
a. “If my climbing partner can’t think straight, we should descend to a lower
altitude.”
b. “I will ask my primary health care provider about medications to help prevent
acute mountain sickness.”
c. “My partner and I will plan to sleep at a higher elevation to acclimate more
quickly.”
d. “I will drink plenty of fluids to stay hydrated while on the mountain.”
ANS: C
co
Teaching to prevent altitude-related illness would include descending when symptoms start,
staying hydrated, and taking acetazolamide, which is commonly used to prevent and treat
acute mountain sickness. The nurse would teach the client to sleep at a lower elevation.
s.
DIF: Analyzing
TOP: Integrated Process: Teaching/Learning
KEY: Environmental emergencies, Altitude-related illness, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
nk
14. A client admitted to the emergency department following a lightning strike. What is the
ANS: A
ba
priority assessment the nurse focuses on?
a. Cardiopulmonary
b. Integumentary
c. Peripheral vascular
d. Renal
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st
Lightning strikes can profoundly affect the cardiopulmonary and the central nervous system
as a serious cardiac and/or respiratory arrest. The nurse would be alert for reports of chest pain
and would watch for dysrhythmias on the cardiac monitor. As impairment of the respiratory
center can also be affected, the nurse would assess the respiratory system second.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Environmental emergencies, Lightning injuries
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
15. A middle-age mountain hiker is admitted to the emergency department exhibiting a cough
with pink, frothy sputum and cyanosis of lips and nail beds. What priority action would the
nurse implement?
a. Administer acetazolamide.
b. Administer oxygen via a nonrebreather mask.
c. Complete a thorough pulmonary assessment.
d. Obtain arterial blood gas (ABG) specimen for analysis.
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ANS: B
The client is exhibiting signs of AMS with high-altitude pulmonary edema (HAPE). Cyanosis
indicates hypoxia and must be treated immediately. A complete pulmonary assessment and
ABG analysis are indicated but the priority is oxygen administration. Acetazolamide is used
to prevent AMS.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Environmental emergencies, Altitude-related illness
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
1. A nurse is teaching a wilderness survival class. Which statements would the nurse include
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about the prevention of hypothermia and frostbite? (Select all that apply.)
a. “Wear synthetic clothing instead of cotton to keep your skin dry.”
b. “Drink plenty of fluids. Brandy can be used to keep your body warm.”
c. “Remove your hat when exercising to prevent overheating.”
d. “Wear sunglasses to protect skin and eyes from harmful rays.”
e. “Know your physical limits. Come in out of the cold when limits are reached.”
f. “Change your gloves and socks if they become wet.”
ANS: A, D, E, F
nk
s.
To prevent hypothermia and frostbite, the nurse would teach patients to wear synthetic
clothing (which moves moisture away from the body and dries quickly), layer clothing, and a
hat, facemask, sunscreen, and sunglasses. The client would also be taught to drink plenty of
fluids, but to avoid alcohol when participating in winter activities. Clients need to know their
physical limits and come in out of the cold when these limits have been reached. Wet clothing
contributes to heat loss so clients would be taught to change any clothing that becomes wet.
ba
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Environmental emergencies, Cold-related illness, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse teaches a client who has severe allergies ways to prevent insect bites. Which
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statements does the nurse include in this client’s teaching? (Select all that apply.)
a. “Consult an exterminator to control bugs in and around your home.”
b. “Do not swat at insects or wasps.”
c. “Wear sandals whenever you go outside.”
d. “Keep your prescribed epinephrine autoinjector in a bedside drawer.”
e. “Use screens in your windows and doors to prevent flying insects from entering.”
f. “Identify and remove potential nesting sites in your yard.”
ANS: A, B, E, F
To prevent arthropod bites and stings, patients should wear protective clothing, cover garbage
cans, use screens in windows and doors, inspect clothing and shoes before putting them on,
consult an exterminator, remove nests, avoid swatting at insects, and carry a prescription
epinephrine autoinjector at all times if they are known to be allergic to bee or wasp stings.
Shoes are needed when working in areas known or suspected to harbor arthropods, but sandals
will not protect the feet. Removing nesting sites may help eliminate the population.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
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KEY: Environmental emergencies, Bee and insect sting, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
3. A nurse is providing health education at a community center. Which instructions does the
nurse include in teaching about prevention of lightning injuries during a storm? (Select all that
apply.)
a. Seek shelter inside a building or vehicle.
b. Hide under a tall tree.
c. Do not take a bath or shower.
d. Turn off the television.
e. Remove all body piercings.
f. Put down golf clubs or gardening tools.
ANS: A, C, D, F
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When thunder is heard, individuals should seek shelter in a safe area such as a building or an
enclosed vehicle. Electrical equipment such as TVs and stereos should be turned off. Stay
away from plumbing, water, and metal objects such as golf clubs or gardening tools. Do not
stand under an isolated tall tree or a structure such as a flagpole. Body piercings will not
increase a person’s chances of being struck by lightning.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Environmental emergencies, Lightning injuries
MSC: Client Needs Category: Health Promotion and Maintenance
s.
4. An emergency department nurse moves to a new city where heat-related illnesses are
ANS: A, B, E, F
ba
nk
common. Which clients does the nurse anticipate being at highest risk for heat-related
illnesses? (Select all that apply.)
a. Homeless individuals
b. People with substance abuse disorders
c. Caucasians
d. Hockey players
e. Older adults
f. Obese individuals
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Some of the most vulnerable, at-risk populations for heat-related illness include older adults;
people who work outside, such as construction and agricultural workers; homeless people;
people who abuse substances; outdoor athletes (recreational and professional); and members
of the military who are stationed in countries with hot climates (e.g., Iraq, Afghanistan).
Hockey is generally a cold-air game whether played indoors or outdoors and wouldn’t have as
much risk for heat-related illness as other sports.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Environmental emergencies, Heat-related illness
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. An emergency department nurse plans care for a client who is admitted with heat stroke.
Which interventions does the nurse include in this patient’s plan of care? (Select all that
apply.)
a. Administer oxygen via mask or nasal cannula.
b. Administer ibuprofen, an antipyretic medication.
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c. Apply cooling techniques until core body temperature is less than 101° F (38.3°
C).
d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula.
e. Obtain baseline serum electrolytes and cardiac enzymes.
f. Insert an indwelling urinary catheter for urine output measurements.
ANS: A, D, E
Heat stroke is a medical emergency. Oxygen therapy and intravenous fluids would be
provided, and baseline laboratory tests would be performed as quickly as possible. Urinary
output is measured via an indwelling urinary catheter. The client would be cooled until core
body temperature is reduced to 102° F (38.9° C). Antipyretics would not be administered.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Planning
KEY: Environmental emergencies, Heat-related illness
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
m
6. A nurse is in charge of a first-aid tent at an all-day outdoor sports event on a hot and humid
s.
co
day. A participant comes to the tent reporting a headache, weakness, and nausea. What actions
would the nurse take? (Select all that apply.)
a. Have the client lie down in a cool place.
b. Force fluids with large quantities of plain water.
c. Administer acetaminophen and send home.
d. Apply cold packs to neck, arm pits, and groin.
e. Encourage drinking a sports drink.
f. Remove all clothing and cover with a towel.
ANS: A, D, E
ba
nk
Heat exhaustion manifests as flulike symptoms with headache, weakness, nausea, and/or
vomiting. Treatment includes stopping the activity, moving to a cool place, and using cooling
measures such as cold packs, cool water soaks, or fanning while spraying cool water on skin.
Sodium deficits may occur from drinking plain water, so sports drinks or an oral rehydration
therapy solution would be provided. The nurse would remove constrictive clothing only.
st
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Environmental emergencies, Heat-related illness
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. Which assessment findings would indicate to the nurse that a client has suffered from a heat
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stroke? (Select all that apply.)
a. Confusion and bizarre behavior
b. Headache and fatigue
c. Hypotension
d. Presence of perspiration
e. Tachycardia and tachypnea
f. Body temperature more than 104° F (40° C)
ANS: A, C, E, F
Signs and symptoms of heat stroke include as elevated body temperature (above 104° F [40°
C]), mental status changes such as confusion and decreasing level of consciousness,
hypotension, tachycardia, and tachypnea. Perspiration is an inconsistent finding.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
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KEY: Environmental emergencies, Heat-related illness
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. An emergency department nurse is caring for a client who had been hiking in the mountains
for the past 2 days. What are the most important indicators that a client is experiencing
high-altitude pulmonary edema (HAPE)? (Select all that apply.)
a. Ataxia
b. Confusion
c. Crackles in both lung fields
d. Decreased level of consciousness
e. Persistent dry cough
f. Reports “feeling hung over”
ANS: C, E
co
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Signs and symptoms of high-altitude pulmonary edema (HAPE) include poor exercise
tolerance, prolonged recovery time after exertion, fatigue, and weakness that progresses to a
persistent dry cough and cyanosis of lips and nail beds. Crackles may be auscultated in one or
both lung fields. A late sign of HAPE is pink, frothy sputum. Ataxia and confusion or
decreased level of consciousness are seen in HACE—high-altitude cerebral edema. Acute
mountain sickness produces a syndrome similar to an alcohol-induced hangover.
s.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Environmental emergencies, Altitude-related illness
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. A client resuscitated after drowning is admitted to the emergency department. What
ANS: A, B, C, D
ba
nk
assessment findings does the nurse recognize as symptoms of a drowning? (Select all that
apply.)
a. Bilateral crackles
b. Bradycardia
c. Cyanosis of the lips
d. Hypotension
e. Flushed, diaphoretic skin
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st
Drowning victims will exhibit signs of pulmonary edema which includes crackles in one or
both lungs, persistent dry cough, and cyanosis of the lips and/or nail beds. The diving reflex as
a response to asphyxia produces bradycardia, signs of decreased cardiac output with
hypotension, and vasoconstriction of vessels in the intestine, skeletal muscles, and kidneys.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Environmental emergencies, Drowning
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. The nurse is teaching participants in a family-oriented community center ways to prevent their
older relatives and friends from getting heat-related illnesses. What information does the nurse
include? (Select all that apply.)
a. Use sunscreen with an SPF of at least 15 when outdoors.
b. Take cool baths or showers after outdoor activities.
c. Check on the older adult daily in hot weather.
d. Drink plenty of liquids throughout the day.
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e. Wear light-colored, snugly-fitting clothing to wick sweat away.
ANS: B, C, D
To best prevent heat-related illnesses, the nurse would teach individuals to use sunscreen with
at least an SPF of 30 for both UVA and UVB rays, to shower or bathe in cool water after
being outdoors to reduce body heat, to remain hydrated, and to wear light-colored,
loose-fitting clothes. Families and friends should check older adults at least twice a day during
a heat wave; however, this may not prevent heat-related illness but could catch it quickly and
limit its severity.
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ba
nk
s.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Environmental emergencies, Heat-related illness
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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Chapter 12: Concepts of Disaster Preparedness
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A hospital responds to a local mass casualty event. What action would the nurse supervisor
take to prevent staff posttraumatic stress disorder during and after the event?
a. Provide water and healthy snacks for energy throughout the event.
b. Schedule 16-hour shifts to allow for greater rest between shifts.
c. Encourage counseling upon deactivation of the emergency response plan.
d. Assign staff to different roles and units within the medical facility.
ANS: A
s.
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To prevent staff posttraumatic stress disorder during a mass casualty event, the nurses would
use available counseling, encourage and support co-workers, monitor each other’s stress level
and performance, take breaks when needed, talk about feelings with staff and managers, and
drink plenty of water and eat healthy snacks for energy. Nurses would also keep in touch with
family, friends, and significant others, and not work for more than 12 hours/day. Encouraging
counseling upon deactivation of the plan, or after the emergency response is over, does not
prevent stress during the casualty event. Assigning staff to unfamiliar roles or units may
increase situational stress and is not an approach to prevent posttraumatic stress disorder.
These actions also help mitigate PTSD after the event.
nk
DIF: Remembering
TOP: Integrated Process: Communication and Documentation
KEY: Emergency and Disaster Preparedness, Psychosocial response
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
2. A client who is hospitalized with burns after losing the family home in a fire becomes angry
ANS: D
st
ba
and screams at a nurse when dinner is served late. How would the nurse respond?
a. “Do you need something for pain right now?”
b. “Please stop yelling. I brought dinner as soon as I could.”
c. “I suggest that you get control of yourself.”
d. “You seem upset. I have time to talk if you’d like.”
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Clients would be allowed to ventilate their feelings of anger and despair after a catastrophic
event. The nurse establishes rapport through active listening and honest communication and
by recognizing cues that the client wishes to talk. Asking whether the client is in pain as the
first response closes the door to open communication and limits the client’s options. Simply
telling the client to stop yelling and to gain control does nothing to promote therapeutic
communication.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Emergency and Disaster Preparedness, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
3. A nurse is field-triaging clients after an industrial accident. Which client condition would the
nurse triage with a red tag?
a. Dislocated right hip and an open fracture of the right lower leg
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b. Large contusion to the forehead and a bloody nose
c. Closed fracture of the right clavicle and arm numbness
d. Multiple fractured ribs and shortness of breath
ANS: D
Clients who have an immediate threat to life are given the highest priority, are placed in the
emergent or class I category, and are given a red triage tag. The client with multiple rib
fractures and shortness of breath has a threat to oxygenation and is the most critical. The client
with the hip and leg problem and the client with the clavicle fracture would be classified as
class II (urgent, yellow tag); these major but stable injuries can wait for 30 minutes to 2 hours
for definitive care. The client with facial wounds would be considered the “walking wounded”
and classified as nonurgent (class III, green tag).
m
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Emergency and Disaster Preparedness, Triage
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. An emergency department (ED) charge nurse prepares to receive clients from a mass casualty
nk
s.
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within the community. What is the role of this nurse during the event?
a. Ask nursing staff to discharge clients from the medical-surgical units in order to
make room for critically injured victims.
b. Call additional medical-surgical and critical care nursing staff to come to the
hospital to assist when victims are brought in.
c. Inform the incident commander at the mass casualty scene about how many
victims may be handled by the ED.
d. Direct medical-surgical and critical care nurses to assist with clients currently in
the ED while emergency staff prepare to receive the mass casualty victims.
ANS: D
st
ba
The ED charge nurse would direct additional nursing staff to help care for current ED clients
while the ED staff prepares to receive mass casualty victims; however, they would not be
assigned to the most critically ill or injured clients. The hospital incident commander’s role is
to take a global view of the entire situation and facilitate patient movement through the
system, while bringing in personnel and supply resources to meet patient needs. The medical
command physician would kept the incident commander informed about victims and capacity
of the ED.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency and Disaster Preparedness, Interprofessional team
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
5. An emergency department manager wants to mitigate the possible acute and chronic stress
after mass casualty events in the staff. What action would the manager take?
a. Encourage all staff to join a Disaster Medical Assistance Team.
b. Instruct all staff members to prepare go bags for all family members.
c. Use available resources for broad education and training in disaster management.
d. Provide incentives and bonuses for responding to mass casualty events.
ANS: C
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Research indicates that education and training in disaster management before an incident
occurs is associated with improved confidence and better coping after the incident. Go bags
are important to maintain for all family members but would not be effective in mitigating
stress. A DMAT is a medical relief team made up of civilian medical, paraprofessional, and
support personnel that is deployed to a disaster area with enough medical equipment and
supplies to sustain operations for 72 hours. Incentives and bonuses will not help mitigate
stress.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Emergency and Disaster Preparedness, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
6. A nurse is caring for a client whose spouse died in a recent mass casualty accident. The client
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says, “I can’t believe that my spouse is gone and I am left to raise my children all by myself.”
How would the nurse respond?
a. “Please accept my sympathies for your loss.”
b. “I can call the hospital chaplain if you wish.”
c. “You sound anxious about being a single parent.”
d. “At least your children still have you in their lives.”
ANS: C
nk
s.
Therapeutic communication includes active listening and honesty. This statement
demonstrates that the nurse recognizes the client’s distress and has provided an opening for
discussion. Extending sympathy and offering to call the chaplain do not give the client the
opportunity to discuss feelings. Stating that the children still have one parent discounts the
client’s feelings and situation.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Emergency and Disaster Preparedness, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
ba
7. A nurse cares for victims during a community-wide disaster drill. One of the victims asks,
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“Why are the individuals with black tags not receiving any care?” How does the nurse
respond?
a. “To do the greatest good for the greatest number of people, it is necessary to
sacrifice some.”
b. “Not everyone will survive a disaster, so it is best to identify those people early
and move on.”
c. “In a disaster, extensive resources are not used for one person at the expense of
many others.”
d. “With black tags, volunteers can identify those who are dying and can give them
comfort care.”
ANS: C
In a disaster, military-style triage is used; this approach identifies the dead or expectant dead
with black tags. This practice helps to maintain the goal of triage, which is doing the most
good for the most people. Precious resources are not used for those with overwhelming
critical injury or illness, so that they can be allocated to others who have a reasonable
expectation of survival. Victims are not “sacrificed.” Telling victims that is important to move
on after identifying the expectant dead does not provide an adequate explanation and is
callous. Victims are not black-tagged to allow volunteers to give comfort care.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Emergency and Disaster Preparedness, Triage
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
8. A nurse wants to become involved in community disaster preparedness and is interested in
helping setup and staff first-aid stations or community acute care centers in the event of a
disaster. Which organization is the best fit for this nurse’s interests?
a. The Medical Reserve Corps
b. The National Guard
c. The health department
d. A Disaster Medical Assistance Team
ANS: A
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The Medical Reserve Corps (MRC) consists of volunteer medical and public health care
professionals who support the community during times of need. They may help staff hospitals,
establish first-aid stations or special needs shelters, or set up acute care centers in the
community. The National Guard often performs search-and-rescue operations and law
enforcement. The health department focuses on communicable disease tracking, treatment,
and prevention. A Disaster Medical Assistance Team is deployed to a disaster area for up to
72 hours, providing many types of relief services.
s.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Emergency and Disaster Preparedness, Emergency nursing
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
nk
9. A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is
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concerned about maintaining licensure in several different states. Which statement best
addresses these concerns?
a. “Deployed DMAT providers are federal employees, so their licenses are good in
all 50 states.”
b. “The government has a program for quick licensure activation wherever you are
deployed.”
c. “During a time of crisis, licensure issues would not be the government’s priority
concern.”
d. “If you are deployed, you will be issued a temporary license in the state in which
you are working.”
ANS: A
When deployed, DMAT health care providers act as agents of the federal government, and so
are considered federal employees. Thus their licenses are valid in all 50 states. Licensure is an
issue that the government would be concerned with, but no programs for temporary licensure
or rapid activation are available.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Emergency and Disaster Preparedness, Emergency nursing
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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10. After a hospital’s emergency department (ED) has efficiently triaged, treated, and transferred
clients from a community disaster to appropriate units, the hospital incident command officer
wants to “stand down” from the emergency plan. Which question would the nursing
supervisor ask at this time?
a. “Are you sure no more victims are coming into the ED?”
b. “Do all areas of the hospital have the supplies and personnel they need?”
c. “Have all ED staff had the chance to eat and rest recently?”
d. “Does the Chief Medical Officer agree this disaster is under control?”
ANS: B
m
Before “standing down,” the incident command officer ensures that the needs of the other
hospital departments have been taken care of because they may still be stressed and may need
continued support to keep functioning. Many more “walking wounded” victims may present
to the ED; that number may not be predictable. Giving staff the chance to eat and rest is
important, but all areas of the facility need that too. Although the Chief Medical Officer
(CMO) may be involved in the incident, the CMO does not determine when the hospital can
“stand down.”
co
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Emergency and Disaster Preparedness, Interprofessional team
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
11. A nurse is volunteering in a temporary shelter for survivors of a hurricane. Which client does
nk
s.
the nurse anticipate has the highest need for further assessment and referral?
a. Client who is still trying to locate relatives who are missing
b. Family awaiting the ability to travel out of state for temporary housing
c. Client with a score of 48 on the Impact of Event Scale-Revised (IES-R)
d. Client who has trouble sleeping and who startles easily
ANS: C
st
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The IES-R is an assessment tool is a 22-item self-administered questionnaire that scores
individuals on signs and symptoms of acute stress disorder or posttraumatic stress disorder. A
score of 33 or higher out of 88 is a positive finding and this client would be referred a
psychiatrist or other licensed mental health care provider. The nurse would administer the
assessment to the client with difficulty sleeping after ensuring he or she can read at the 10th
grade level, which is the reading level of the tool. The other two clients do not show evidence
of particular needs for referral beyond what is usually provided in a natural disaster.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Emergency and Disaster Preparedness, Interprofessional team
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
12. An emergency department charge nurse notes an increase in sick calls and bickering among
the staff after a week with multiple trauma incidents. What action would the nurse take?
a. Organize a pizza party for each shift.
b. Remind the staff of the facility’s sick-leave policy.
c. Arrange for postincident crisis support.
d. Talk individually with staff members.
ANS: C
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The staff may be suffering from stress related to the multiple traumas and needs to have crisis
support. A crisis support team can assist the staff with developing appropriate coping
methods. Speaking with staff members individually does not provide the same level of
support as trained health care providers who can offer emotional first aid. Organizing a party
and revisiting the sick-leave policy may be helpful, but are not as important and beneficial as
formalized crisis support.
DIF: Applying
TOP: Integrated Process: Caring
KEY: Emergency and Disaster Preparedness, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
consider in making this plan?
a. Store basic supplies to last for at least 3 days.
b. Have short-term arrangements for child care.
c. Store enough frozen foods in freezer for 5 days.
d. Keep cooking utensils needed in a separate bag.
ANS: A
m
13. A nurse is constructing a personal preparedness plan in case of a disaster. What does the nurse
s.
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Concerns for their home and family can impact the willingness to report in an emergency and
can be diminished by being prepared with a personal preparedness plan with enough supplies
for 3 days. Any food needs to be nonperishable with no cooking required. Arrangements for
children, pets, or older adults would be made for extended period of time.
MULTIPLE RESPONSE
nk
DIF: Remembering
TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency and Disaster Preparedness
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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1. Emergency medical services (EMS) brings a large number of clients to the emergency
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department following a mass casualty incident. The nurse identifies the clients with which
injuries with yellow tags? (Select all that apply.)
a. Partial-thickness burns covering both legs
b. Open fractures of both legs with absent pedal pulses
c. Neck injury and numbness of both legs
d. Small pieces of shrapnel embedded in both eyes
e. Head injury and difficult to arouse
f. Bruising and pain in the right lower abdomen
ANS: A, C, D, F
Clients with burns, spine injuries, eye injuries, and stable abdominal injuries would be treated
within 30 minutes to 2 hours, and therefore would be identified with yellow tags. The client
with the open fractures and the client with the head injury would be classified as urgent with
red tags.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Emergency and Disaster Preparedness, Triage
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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2. A nurse triages clients arriving at the hospital after a mass casualty. Which clients are
correctly classified? (Select all that apply.)
a. A 35-year-old female with severe chest pain: red tag
b. A 42-year-old male with full-thickness body burns: green tag
c. A 55-year-old female with a scalp laceration: black tag
d. A 60-year-old male with an open fracture with distal pulses: yellow tag
e. An 88-year-old male with shortness of breath and chest bruises: green tag
f. A 33-year-old male unconscious with bilateral leg amputations: yellow tag
ANS: A, D
m
Red-tagged clients need immediate care due to life-threatening injuries. A client with severe
chest pain would receive a red tag. Yellow-tagged clients have major injuries that need to be
treated within 30 minutes to 2 hours. A client with an open fracture with distal pulses would
receive a yellow tag. The client with full-thickness body burns would receive a black tag. The
client with a scalp laceration would receive a green tag, and the client with shortness of breath
would receive a red tag. The client with the amputated legs will probably be black tagged if
the unconsciousness is from massive blood loss.
co
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Emergency and Disaster Preparedness, Triage
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A hospital prepares to receive large numbers of casualties from a community disaster. Which
ANS: B, E
ba
nk
s.
clients would the nurse identify as appropriate for discharge or transfer to another facility?
(Select all that apply.)
a. Older adult in the medical decision unit for evaluation of chest pain
b. Client who had open reduction and internal fixation of a femur fracture 3 days ago
c. Client admitted last night with community-acquired pneumonia
d. Infant who has a fever of unknown origin
e. Client on the medical unit for wound care
f. Client with symptoms of influenza after traveling abroad
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The client with the femur fracture could be transferred to a rehabilitation facility, and the
client on the medical unit for wound care could be transferred home with home health or to a
long-term care facility for ongoing wound care. The client in the medical decision unit would
be identified for dismissal if diagnostic testing reveals a noncardiac source of chest pain. The
newly admitted client with pneumonia would not be a good choice because culture results are
not yet available and antibiotics have not been administered long enough. The infant does not
have a definitive diagnosis. The client who has recently traveled abroad may have either
seasonal influenza or may have a novel or potential pandemic respiratory virus and should not
be transferred to avoid spreading the illness.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Emergency and Disaster Preparedness, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A hospital prepares for a mass casualty event. Which functions are correctly paired with the
personnel role? (Select all that apply.)
a. Paramedic—decides the number, acuity, and resource needs of clients
b. Hospital incident commander—assumes overall leadership for implementing the
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emergency plan
c. Public information officer—provides advanced life support during transportation
to the hospital
d. Triage officer—rapidly evaluates each client to determine priorities for treatment
e. Medical command physician—serves as a liaison between the health care facility
and the media
ANS: B, D
The hospital incident commander assumes overall leadership for implementing the emergency
plan. The triage officer rapidly evaluates each client to determine priorities for treatment. The
paramedic provides advanced life support during transportation to the hospital. The public
information officer serves as a liaison between the health care facility and the media. The
medical command physician decides the number, acuity, and resource needs of clients.
m
DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Emergency and Disaster Preparedness, Interprofessional team
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
5. A new graduate nurse has started working on a medical-surgical unit. What actions would the
ANS: A, B, C, D, F
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s.
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nurse take to be prepared for a disaster? (Select all that apply.)
a. Know the institution’s Emergency Response Plan.
b. Participate in the institution’s disaster drill.
c. Develop a personal preparedness plan.
d. Understand that nurses play a role in every phase of a disaster.
e. Be prepared to report immediately to the emergency department.
f. Be willing to be flexible working during a crisis situation.
st
ba
Nurses play a major role in disaster and need to be prepared for any type of disaster. Knowing
the institution’s emergency management plan and participating in disaster drills will help the
nurse be prepared for a disaster. Concerns for their home and family can impact the
willingness to report in an emergency and can be diminished by being prepared with a
personal preparedness plan. Nurses play key roles before, during, and after a disaster in the
development of emergency management plan in defining specific nursing roles. During a
crisis, nurses may be assigned to different areas of the facility or to different job functions and
must remain flexible while working to their best ability.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Planning
KEY: Emergency and Disaster Preparedness, Interprofessional team
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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Chapter 13: Concepts of Fluid and Electrolyte Balance
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse assesses clients at a family practice clinic for risk factors that could lead to
dehydration. Which client is at greatest risk for dehydration?
a. A 36 year old who is prescribed long-term steroid therapy.
b. A 55 year old who recently received intravenous fluids.
c. A 76 year old who is cognitively impaired.
d. An 83 year old with congestive heart failure.
ANS: C
co
m
Older adults, because they have less total body water than younger adults, are at greater risk
for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids
independently or cannot make his or her need for fluids known is at high risk for dehydration.
The client with heart failure has a risk for both fluid imbalances. Long-term steroids and
recent IV fluid administration do not increase the risk of dehydration.
s.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Fluid and electrolyte imbalances, Dehydration
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
2. A nurse is caring for an older client who exhibits dehydration-induced confusion. Which
ba
ANS: B
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intervention by the nurse is best?
a. Measure intake and output every 4 hours.
b. Assess client further for fall risk.
c. Increase the IV flow rate to 250 mL/hr.
d. Place the client in a high-Fowler position.
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Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing
confusion. The client with dehydration is at risk for falls because of this confusion, orthostatic
hypotension, dysrhythmia, and/or muscle weakness. The nurse’s best response is to do a more
thorough evaluation of the client’s risk for falls. Measuring intake and output may need to
occur more frequently than every 4 hours, but does not address a critical need. The nurse
would not adjust the IV flow rate without a prescription or standing protocol. For an older
adult, this rapid an infusion rate could lead to fluid overload. Sitting the client in a
high-Fowler position may or may not be comfortable but still does not address the most
important issue which is safety.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Fluid and electrolyte imbalances, Dehydration
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. After teaching a client who is being treated for dehydration, a nurse assesses the client’s
understanding. Which statement indicates that the client correctly understood the teaching?
a. “I must drink a quart (liter) of water or other liquid each day.”
b. “I will weigh myself each morning before I eat or drink.”
c. “I will use a salt substitute when making and eating my meals.”
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d. “I will not drink liquids after 6 p.m. so I won’t have to get up at night.”
ANS: B
One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of
excess fluid loss or fluid retention. Weight loss greater than 0.5 lb (0.2 kg) daily is indicative
of excessive fluid loss. One liter of fluid a day is insufficient. A salt substitute is not related to
dehydration. Clients may want to limit fluids after dinner so they won’t have to get up, but
this does not address dehydration if the patient drinks the recommended amount of fluid
during the earlier parts of the day.
DIF: Analyzing
TOP: Integrated Process: Teaching/Learning
KEY: Fluid and electrolyte imbalances, Dehydration, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
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identify as being at greatest risk for insensible water loss?
a. Client taking furosemide.
b. Anxious client who has tachypnea.
c. Client who is on fluid restrictions.
d. Client who is constipated with abdominal pain.
m
4. A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse
ANS: B
nk
s.
Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for
insensible water loss include those being mechanically ventilated, those with rapid
respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis,
trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking
furosemide will have increased fluid loss, but not insensible water loss. The other two clients
on a fluid restriction and with constipation are not at risk for insensible fluid loss.
ba
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Fluid and electrolyte imbalances, Dehydration
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse is evaluating a client who is being treated for dehydration. Which assessment result
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does the nurse correlate with a therapeutic response to the treatment plan?
a. Increased respiratory rate from 12 to 22 breaths/min
b. Decreased skin turgor on the client’s posterior hand and forehead
c. Increased urine specific gravity from 1.012 to 1.030 g/mL
d. Decreased orthostatic changes when standing
ANS: D
The focus of management for clients with dehydration is to increase fluid volumes to normal.
When blood volume is normal, orthostatic blood pressure and pulse changes will not occur.
This assessment finding shows a therapeutic response to treatment. Increased respirations,
decreased skin turgor, and higher urine specific gravity all are indicators of continuing
dehydration.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Fluid and electrolyte imbalances, Dehydration
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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6. After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client’s
understanding. Which food choice for lunch indicates that the client correctly understood the
teaching?
a. Slices of smoked ham with potato salad
b. Bowl of tomato soup with a grilled cheese sandwich
c. Salami and cheese on whole-wheat crackers
d. Grilled chicken breast with glazed carrots
ANS: D
Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and
those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and
fresh produce. The ham, tomato soup, salami, and crackers are usually high in sodium.
m
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Fluid and electrolyte imbalances, Sodium imbalances
MSC: Client Needs Category: Health Promotion and Maintenance
7. A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse
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assess first for potential hyponatremia?
a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions.
b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic.
c. A 67 year old who is experiencing pain and is prescribed ibuprofen.
d. A 73 year old with tachycardia who is receiving digoxin.
s.
ANS: A
nk
Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized
when infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic
solutions can lead to hyponatremia. Because the client is not taking any food or fluids by
mouth (NPO), normal sodium excretion can also lead to hyponatremia. The sulfonamide
antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.
ba
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Fluid and electrolyte imbalances, Sodium imbalances
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
st
8. A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse
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include in this client’s teaching?
a. “Have you spouse watch you for irritability and anxiety.”
b. “Notify the clinic if you notice muscle twitching.”
c. “Call your primary health care provider for diarrhea.”
d. “Bake or grill your meat rather than frying it.”
ANS: C
One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be
taught to call the primary health care provider if this is noticed. Irritability and anxiety are
common neurologic signs of hypokalemia. Muscle twitching is related to hypernatremia.
Cooking methods are not a cause of hyponatremia.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Fluid and electrolyte imbalances, Sodium imbalances, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
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9. A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L
(2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and
sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first?
a. Depth of respirations
b. Bowel sounds
c. Grip strength
d. Electrocardiography
ANS: A
A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac
dysrhythmias, and muscle weakness resulting in shallow respirations and decreased
handgrips. The nurse would assess the client’s respiratory status first to ensure that
respirations are sufficient. The respiratory assessment would include rate and depth of
respirations, respiratory effort, and oxygen saturation. The other assessments are important
but are secondary to the client’s respiratory status.
m
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Fluid and electrolyte imbalances, Potassium imbalances
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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10. A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is
s.
exhibiting cardiovascular changes. Which intervention will the nurse implement first?
a. Prepare to administer patiromer by mouth.
b. Provide a heart-healthy, low-potassium diet.
c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
d. Prepare the client for hemodialysis treatment.
nk
ANS: C
st
ba
A client with a critically high serum potassium level and cardiac changes would be treated
immediately to reduce the extracellular potassium level. Potassium movement into the cells is
enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will
decrease both serum potassium and glucose levels and therefore would be administered with
dextrose to prevent hypoglycemia. Patiromer may be ordered, but this therapy may take hours
to reduce potassium levels. Dialysis may also be needed, but this treatment will take much
longer to implement and is not the first intervention the nurse would implement. Decreasing
potassium intake may help prevent hyperkalemia in the future but will not decrease the
client’s current potassium level.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Fluid and electrolyte imbalances, Potassium imbalances
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
11. The nurse is caring for a client who has fluid overload. What action by the nurse takes
priority?
a. Administer high-ceiling (loop) diuretics.
b. Assess the client’s lung sounds every 2 hours.
c. Place a pressure-relieving overlay on the mattress.
d. Weigh the client daily at the same time on the same scale.
ANS: B
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All interventions are appropriate for the client who is overhydrated. However, client safety is
the priority. A client with fluid overload can easily go into pulmonary edema, which can be
life threatening. The nurse would closely monitor the client’s respiratory status.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Fluid and electrolyte imbalances, Overhydration
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
12. A nurse is assessing a client with hypokalemia, and notes that the client’s handgrip strength
has diminished since the previous assessment 1 hour ago. What action does the nurse take
first?
a. Assess the client’s respiratory rate, rhythm, and depth.
b. Measure the client’s pulse and blood pressure.
c. Document findings and monitor the client.
d. Call the health care primary health care provider.
m
ANS: A
s.
co
In a client with hypokalemia, progressive skeletal muscle weakness is associated with
increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is
respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment
first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also
associated with hypokalemia. The client’s pulse and blood pressure would be assessed after
assessing respiratory status. Next, the nurse would call the health care primary health care
provider to obtain orders for potassium replacement. Documenting findings and continuing to
monitor the client would occur during and after potassium replacement therapy.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Fluid and electrolyte imbalances, Potassium imbalances
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
13. A new nurse is preparing to administer IV potassium to a client with hypokalemia. What
ANS: C
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action indicates the nurse needs to review this procedure?
a. Notifies the pharmacy of the IV potassium order.
b. Assesses the client’s IV site every hour during infusion.
c. Sets the IV pump to deliver 30 mEq of potassium an hour.
d. Double-checks the IV bag against the order with the precepting nurse.
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IV potassium should not be infused at a rate exceeding 20mEq/hr under any circumstances.
This action shows a need for further knowledge. The other actions are acceptable for this
high-alert drug.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Fluid and electrolyte imbalances, Potassium imbalances
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
14. A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor
understanding of this condition?
a. Assesses the client’s Chvostek and Trousseau sign.
b. Keeps the client’s room quiet and dimly lit.
c. Moves the client carefully to avoid fracturing bones.
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d. Administers bisphosphonates as prescribed.
ANS: D
Bisphosphonates are used to treat hypercalcemia. The Chvostek and Trousseau signs are used
to assess for hypocalcemia. Keeping the client in a low stimulus environment is important
because the excitable nervous system cells are overstimulated. Long-standing hypocalcemia
can cause fragile, brittle bones which can be fractured.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Fluid and electrolyte imbalances, Calcium imbalances
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
15. A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L).
m
Which primary health care provider order does the nurse implement first?
a. Encourage oral fluid intake.
b. Connect the client to a cardiac monitor.
c. Assess urinary output.
d. Administer oral calcitonin.
ANS: B
s.
co
This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and
cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess
for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering
calcitonin are treatments for hypercalcemia, but are not the highest priority.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Fluid and electrolyte imbalances, Calcium imbalances
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
16. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which
st
ANS: D
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intervention will the nurse implement to prevent injury while in the hospital?
a. Ask family members to speak quietly to keep the client calm.
b. Assess urine color, amount, and specific gravity each day.
c. Encourage the client to drink at least 1 L of fluids each shift.
d. Dangle the client on the bedside before ambulating.
Bt
e
An older adult with moderate dehydration may experience orthostatic hypotension. The client
needs to dangle on the bedside before ambulating. Although dehydration in an older adult may
cause confusion, speaking quietly will not help the client remain calm or decrease confusion.
Assessing the client’s urine may assist with the diagnosis of dehydration but would not
prevent injury. Clients are encouraged to drink fluids, but 1 L of fluid each shift for an older
adult may cause respiratory distress and symptoms of fluid overload, especially if the client
has heart failure or renal insufficiency.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Fluid and electrolyte imbalances, Dehydration
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
MULTIPLE RESPONSE
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1. A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and
symptoms does the nurse expect to find? (Select all that apply.)
a. Increased pulse rate
b. Distended neck veins
c. Decreased blood pressure
d. Warm and pink skin
e. Skeletal muscle weakness
f. Visual disturbances
ANS: A, B, E, F
Signs and symptoms of fluid overload include increased pulse rate, distended neck veins,
increased blood pressure, pale and cool skin, skeletal muscle weakness, and visual
disturbances. Decreased blood pressure would be seen in dehydration. Warm and pink skin is
a normal finding.
m
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Fluid and electrolyte imbalances, Overhydration
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion
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and release. For which potential complications will the nurse assess? (Select all that apply.)
a. Urine output of 25 mL/hr
b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L)
c. Urine specific gravity of 1.02 g/mL
d. Serum sodium level of 128 mEq/L (128 mmol/L)
e. Blood osmolality of 250 mOsm/kg (250 mmol/kg)
nk
ANS: B, E
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Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the
reabsorption of water and sodium in the kidney at the same time that it promotes excretion of
potassium. Any drug or condition that disrupts aldosterone secretion or release increases the
client’s risk for excessive water loss (increased urine output), increased potassium
reabsorption, decreased blood osmolality, and increased urine specific gravity. The client
would not be at risk for sodium imbalance.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Fluid and electrolyte imbalances
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
3. A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For
which potential complications of this electrolyte imbalance does the nurse assess? (Select all
that apply.)
a. Reports of palpitations
b. Slow, shallow respirations
c. Orthostatic hypotension
d. Paralytic ileus
e. Skeletal muscle weakness
f. Tall, peaked T waves on ECG
ANS: A, E, F
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Electrolyte imbalances associated with acute renal failure include hyperkalemia. The nurse
would assess for electrocardiogram changes, including tall, peaked T waves, reports of
palpitations or “skipped beats,” diarrhea, and skeletal muscle weakness in clients with
hyperkalemia. The other choices are potential complications of hypokalemia. Respiratory
muscles may be affected with lethally high hyperkalemia.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Fluid and electrolyte imbalances, Potassium imbalances
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which
co
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clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance?
(Select all that apply.)
a. Hypokalemia—muscle weakness with respiratory depression
b. Hypermagnesemia—bradycardia and hypotension
c. Hyponatremia—decreased level of consciousness
d. Hypercalcemia—positive Trousseau and Chvostek signs
e. Hypomagnesemia—hyperactive deep tendon reflexes
f. Hypernatremia—weak peripheral pulses
ANS: A, B, C, E, F
nk
s.
Hypokalemia is associated with muscle weakness and respiratory depression.
Hypermagnesemia manifests with bradycardia and hypotension. Hyponatremia can present
with decreased level of consciousness. Hypomagnesemia can be assessed through hyperactive
deep tendon reflexes. Weak peripheral pulses are felt in hypernatremia. Positive Trousseau
and Chvostek signs are seen in hypocalcemia.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Fluid and electrolyte imbalances
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
ba
5. After administering potassium chloride, a nurse evaluates the client’s response. Which signs
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and symptoms indicate that treatment is improving the client’s hypokalemia? (Select all that
apply.)
a. Respiratory rate of 8 breaths/min
b. Absent deep tendon reflexes
c. Strong productive cough
d. Active bowel sounds
e. U waves present on the electrocardiogram (ECG)
ANS: C, D
A strong, productive cough indicates an increase in muscle strength and improved potassium
imbalance. Active bowel sounds also indicate that treatment is working. A respiratory rate of
8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all signs and
symptoms of hypokalemia and do not demonstrate that treatment is working.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Fluid and electrolyte imbalances, Potassium imbalances
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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6. A nurse develops a plan of care for an older client who has a fluid overload. What
interventions will the nurse include in this client’s care plan? (Select all that apply.)
a. Calculate pulse pressure with each blood pressure reading.
b. Assess skin turgor using the back of the client’s hand.
c. Assess for pitting edema in dependent body areas.
d. Monitor trends in the client’s daily weights.
e. Assist the client to change positions frequently.
f. Teach client and family how to read food labels for sodium.
ANS: A, C, D, E, F
m
Appropriate interventions for the client who has overhydration include calculating the pulse
pressure with each BP reading as this is a sign of cardiovascular involvement, assessing for
pitting edema in the client’s dependent body areas, monitoring trends in the client’s daily
weight as fluid retention is not always visible, protecting the client’s skin by helping him or
her change positions, and teaching the client and family to read food labels some type of
sodium restriction may be required at home. The nurse assesses skin turgor on the chest or
forehead.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Fluid and electrolyte imbalances, Overhydration
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
7. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which
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s.
common causes are correctly paired with the corresponding electrolyte imbalance? (Select all
that apply.)
a. Hypomagnesemia—kidney failure
b. Hyperkalemia—salt substitutes
c. Hyponatremia—heart failure
d. Hypernatremia—hyperaldosteronism
e. Hypocalcemia—diarrhea
f. Hypokalemia—loop diuretics
ANS: B, C, D, E, F
st
Salt substitutes contain potassium and are a cause of hyperkalemia. Hyponatremia can be
caused by heart failure with fluid overload. Hyperaldosterone is a cause of hypernatremia and
diarrhea causes actual calcium deficits. Loop diuretics excrete potassium. Decreased kidney
function is a cause of magnesium excess, not deficit.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Fluid and electrolyte imbalances
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are
paired with the correct potential imbalance? (Select all that apply.)
a. Sodium: 160 mEq/L (mmol/L): Overhydration
b. Potassium: 5.4 mEq/L (mmol/L): Dehydration
c. Osmolarity: 250 mOsm/L: Overhydration
d. Hematocrit: 68%: Dehydration
e. BUN: 39 mg/dL: Overhydration
f. Magnesium: 0.8 mg/dL: Dehydration
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ANS: B, C, D, F
In dehydration, hemoconcentration usually results in higher levels of hemoglobin, hematocrit,
serum osmolarity, glucose, protein, blood urea nitrogen, and electrolytes. The opposite is true
of overhydration. The sodium level is high, indicating dehydration. The potassium level is
high, also indicating possible dehydration. The osmolarity is low, indicating overhydration,
the hematocrit is high indicating dehydration, the BUN is high indicating dehydration, and the
magnesium level is low, indicating possible dehydration and malnutrition from
diarrhea-causing diseases.
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m
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Fluid and electrolyte imbalances
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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Chapter 14: Concepts of Acid–Base Balance
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse assesses a client with diabetes mellitus who is admitted with an acid–base imbalance.
The client’s arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and
HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an
example of the client’s compensatory mechanisms?
a. Increased rate and depth of respirations
b. Increased urinary output
c. Increased thirst and hunger
d. Increased release of acids from the kidneys
ANS: A
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m
This client has metabolic acidosis. The respiratory system compensates by increasing its
activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger
are signs and symptoms of hyperglycemia but are not compensatory mechanisms for acid–
base imbalances. The kidneys do not release acids.
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Acid-base imbalances, Acidosis
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse assesses a client who is experiencing an acid–base imbalance. The client’s arterial
ANS: A
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blood gas values are pH 7.2, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L (19
mmol/L). Which assessment would the nurse perform first?
a. Cardiac rate and rhythm
b. Skin and mucous membranes
c. Musculoskeletal strength
d. Level of orientation
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Early cardiovascular changes for a client experiencing moderate acidosis include increased
heart rate and cardiac output. As the acidosis worsens, the heart rate decreases and
electrocardiographic changes will be present. The nurse responds by performing a thorough
cardiovascular assessment. Changes will occur in the integumentary system, musculoskeletal
system, and neurologic system, but assessing for the cardiovascular complications comes first.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Acid-base imbalance, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A nurse assesses a client who is prescribed furosemide for hypertension. For which acid–base
imbalance does the nurse assess to prevent complications of this therapy?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
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ANS: D
Many diuretics, especially loop and thiazide diuretics, increase the excretion of hydrogen ions,
leading to excess acid loss through the renal system. This situation is an actual acid deficit.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Acid-base imbalance, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. What action
would the nurse take?
a. Monitor daily hemoglobin and hematocrit values.
b. Administer furosemide intravenously.
c. Encourage the client to take deep breaths.
d. Teach the client fall prevention measures.
ANS: D
m
The most important nursing care for a client who is experiencing moderate metabolic alkalosis
is providing client safety. Client’s with metabolic alkalosis have muscle weakness and are at
risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.
s.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Acid-base imbalance, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid–base
ANS: B
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imbalance. For which manifestation of this acid–base imbalance would the nurse assess?
a. Agitation
b. Kussmaul respirations
c. Seizures
d. Positive Chvostek sign
st
The pancreas is a major site of bicarbonate production. Pancreatitis can cause metabolic
acidosis through underproduction of bicarbonate ions. Signs and symptoms of acidosis
include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvostek sign
are signs and symptoms of the electrolyte imbalances that accompany alkalosis.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Acid-base imbalances, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A nurse assesses a client who is admitted with an acid–base imbalance. The client’s arterial
blood gas values were pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L
(16 mmol/L). The most recent blood gasses show a drop in the pH. What action does the nurse
take next?
a. Assess client’s rate, rhythm, and depth of respiration.
b. Measure the client’s pulse and blood pressure.
c. Document the findings and continue to monitor.
d. Notify the primary health care provider.
ANS: A
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Progressive skeletal muscle weakness is associated with increasing severity of acidosis.
Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to
dysrhythmias (due to hyperkalemia), but these would best be assessed with cardiac
monitoring. Findings would be documented, but simply continuing to monitor is not
sufficient. Before notifying the primary care provider, the nurse must have more data to
report.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Acid-base imbalances, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
7. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56
m
mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which clinical situation does
the nurse correlate with these values?
a. Diabetic ketoacidosis in a person with emphysema
b. Bronchial obstruction related to aspiration of a hot dog
c. Anxiety-induced hyperventilation in an adolescent
d. Diarrhea for 36 hours in an older, frail woman
co
ANS: B
nk
s.
Arterial blood gas values indicate that the client has acidosis with normal levels of
bicarbonate, suggesting that the problem is not metabolic. Arterial concentrations of oxygen
and carbon dioxide are abnormal, with low oxygen and high carbon dioxide levels. Thus, this
client has respiratory acidosis from inadequate gas exchange. The fact that the bicarbonate
level is normal indicates that this is an acute respiratory problem rather than a chronic
problem, because no renal compensation has occurred. The client who would have these ABG
values is the one with the new onset of airway obstruction.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Acid-base imbalances, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
8. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The
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client’s arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3
22 mEq/L (22 mmol/L). What action would the nurse take first?
a. Apply oxygen by mask or nasal cannula.
b. Apply a paper bag over the client’s nose and mouth.
c. Administer 50 mL of sodium bicarbonate intravenously.
d. Administer 50 mL of 20% glucose and 20 units of regular insulin.
ANS: A
This client is severely hypoxic and needs oxygen. Now that the seizure has ended, the client
can breathe again normally, so oxygen administration will rapidly increase the PaO2.
Rebreathing carbon dioxide with a paper bag would make the acidosis worse. Bicarbonate is
only indicated with extremely low pH and serum bicarbonate levels. Glucose and insulin are
administered to decrease the high potassium levels associated with acidosis, but this situation
should reverse itself with oxygen and breathing.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Acid-base imbalance, Critical rescue
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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9. After teaching a client who was malnourished and is being discharged, a nurse assesses the
client’s understanding. Which statement indicates that the client correctly understood
teaching to decrease risk for the development of metabolic acidosis?
a. “I will drink at least three glasses of milk each day.”
b. “I will eat three well-balanced meals and a snack daily.”
c. “I will not take pain medication and antihistamines together.”
d. “I will avoid salting my food when cooking or during meals.”
ANS: B
Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells
to switch to using fats for fuel and by creating ketoacids as a by-product of excessive fat
metabolism. Eating sufficient calories from all food groups helps reduce this risk. Milk, taking
pain medications with antihistamines, and salting food are not related.
m
DIF: Analyzing
TOP: Integrated Process: Teaching/Learning
KEY: Acid-base imbalances, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm
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Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which client condition does the
nurse correlate with these results?
a. Diarrhea and vomiting for 36 hours
b. Anxiety-induced hyperventilation
c. Chronic obstructive pulmonary disease (COPD)
d. Diabetic ketoacidosis and emphysema
nk
ANS: B
ba
The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the
oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would
occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic acidosis
and COPD would lead to respiratory acidosis. The client with emphysema most likely would
have combined metabolic acidosis on top of a mild, chronic respiratory acidosis.
st
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Acid-base imbalances, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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11. After providing discharge teaching, a nurse assesses the client’s understanding regarding
increased risk for metabolic alkalosis. Which statement indicates that the client needs
additional teaching?
a. “I don’t drink milk because it gives me gas and diarrhea.”
b. “I have been taking digoxin every day for the last 15 years.”
c. “I take sodium bicarbonate after every meal to prevent heartburn.”
d. “In hot weather, I sweat so much that I drink six glasses of water each day.”
ANS: C
Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can
cause metabolic alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to
increased risk of metabolic alkalosis.
DIF: Analyzing
TOP: Integrated Process: Teaching/Learning
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KEY: Acid-base imbalances, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
12. A nurse is caring for a client who is experiencing excessive diarrhea. The client’s arterial
blood gas values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L (16
mmol/L). Which primary health care provider order does the nurse expect to receive?
a. Furosemide 40 mg
b. Sodium bicarbonate
c. Mechanical ventilation
d. Indwelling urinary catheter
ANS: B
co
m
This client’s arterial blood gas values represent metabolic acidosis related to a loss of
bicarbonate ions from diarrhea. The bicarbonate would be replaced to help restore this client’s
acid–base balance as the pH is below 7.2 and the bicarbonate level is low. Furosemide would
cause an increase in acid fluid and acid elimination via the urinary tract; although this may
improve the client’s pH, the client has excessive diarrhea and cannot afford to lose more fluid.
Mechanical ventilation is used to treat respiratory acidosis for clients who cannot keep their
oxygen saturation at 90%, or who have respiratory muscle fatigue. Mechanical ventilation and
an indwelling urinary catheter would not be prescribed for that client.
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Acid-base imbalances, Medications
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
13. A nurse evaluates a client’s arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg,
ANS: A
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PaCO2 55 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which intervention does the nurse
implement first?
a. Assess the airway.
b. Administer prescribed bronchodilators.
c. Provide oxygen.
d. Administer prescribed mucolytics.
st
All interventions are important for clients with respiratory acidosis; this is indicated by the
ABGs. However, the priority is assessing and maintaining an airway. Without a patent airway,
other interventions will not be helpful.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Acid-base imbalance, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
14. A nurse is planning care for a client who is hyperventilating. The client’s arterial blood gas
values are pH 7.52, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L (26 mmol/L).
Which question would the nurse ask when developing this client’s plan of care?
a. “Do you take any over-the-counter medications?”
b. “You appear anxious. What is causing your distress?”
c. “Do you have a history of anxiety attacks?”
d. “You are breathing fast. Is this causing you to feel light-headed?
ANS: B
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The nurse would assist the client who is experiencing anxiety-induced respiratory alkalosis to
identify causes of the anxiety. The other questions will not identify the cause of the acid–base
imbalance. The other three questions are also yes/no and close-ended.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Acid-base imbalance, Nursing assessment
MSC: Client Needs Category: Psychosocial Integrity
15. A diabetic client becomes septic after a bowel resection and is having problems with
m
respiratory distress. The nurse reviews the labs and finds the following ABG results: pH 7.50,
PaCO2 30, HCO3 : 24, and PaO2 68. What does the nurse recognize as the primary factor
causing this the acid–base imbalance?
a. Atelectasis due to respiratory muscle fatigue
b. Hyperventilation due to poor oxygenation
c. Hypoventilation due to morphine PCA
d. Kussmaul respirations due to glucose of 102 mg/dL (5.7 mmol/L)
ANS: B
s.
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The ABG results indicate respiratory alkalosis. The client has low oxygenation as indicated by
low partial pressure of arterial oxygen causing a compensatory mechanism of increased
respirations and hyperventilation. Respiratory muscle fatigue and hypoventilation would
cause respiratory acidosis with a low pH and high PaCO2. Kussmaul respirations are
characterized by deep labored breathing and are a compensatory mechanism to metabolic
acidosis, not hypoxemia or alkalosis.
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MULTIPLE RESPONSE
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Acid-base imbalances, Alkalosis
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
1. A nurse is planning interventions that regulate acid–base balance to ensure that the pH of a
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client’s blood remains within the normal range. Which abnormal physiologic functions may
occur if the client experiences an acid–base imbalance? (Select all that apply.)
a. Reduction in the function of hormones
b. Fluid and electrolyte imbalances
c. Increase in the function of selected enzymes
d. Excitable cardiac muscle membranes
e. Increase in the effectiveness of many drugs
f. Changes in GI tract excitability
ANS: A, B, D, F
Acid–base imbalances interfere with normal physiology, including reducing the function of
hormones and enzymes, causing fluid and electrolyte imbalances, causing heart membranes
and GI tract to be more or less excitable, and decreasing the effectiveness of many drugs.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Acid-base imbalances
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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2. A nurse assesses a client who is experiencing an acid–base imbalance. The client’s arterial
blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 18 mEq/L (18
mmol/L). For which clinical signs and symptoms would the nurse assess? (Select all that
apply.)
a. Reduced deep tendon reflexes
b. Drowsiness
c. Increased respiratory rate
d. Decreased urinary output
e. Positive Trousseau sign
f. Flaccid paralysis
ANS: A, B, C
m
Metabolic acidosis causes neuromuscular changes, including reduced muscle tone and deep
tendon reflexes. Clients usually present with lethargy and drowsiness. The respiratory system
will attempt to compensate for the metabolic acidosis; therefore, respirations will increase rate
and depth. Flaccid paralysis can occur. A positive Trousseau sign is associated with alkalosis.
Decreased urine output is not a sign of metabolic acidosis.
co
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Acid-base imbalances, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse is assessing clients who are at risk for acid–base imbalance. Which clients are
ANS: B, C, E
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s.
correctly paired with the acid–base imbalance? (Select all that apply.)
a. Metabolic alkalosis—young adult who is prescribed intravenous morphine sulfate
for pain
b. Metabolic acidosis—older adult who is following a carbohydrate-free diet
c. Respiratory alkalosis—client on mechanical ventilation at a rate of 28 breaths/min
d. Respiratory acidosis—postoperative client who received 6 units of packed red
blood cells
e. Metabolic alkalosis—older client prescribed antacids for gastroesophageal reflux
disease
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Respiratory acidosis often occurs as the result of underventilation. The client who is taking
opioids, especially IV opioids, is at risk for respiratory depression and respiratory acidosis.
One cause of metabolic acidosis is a strict low-calorie diet or one that is low in carbohydrate
content. Such a diet increases the rate of fat catabolism and results in the formation of
excessive ketoacids. A ventilator set at a high respiratory rate or tidal volume will cause the
client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis.
Citrate is a substance used as a preservative in blood products. It is not only a base, but also a
precursor for bicarbonate. Multiple units of packed red blood cells could cause metabolic
alkalosis. Sodium bicarbonate antacids may increase the risk of metabolic alkalosis.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Acid-base imbalances
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects
related to an acid–base imbalance would the nurse assess? (Select all that apply.)
a. Positive Chvostek sign
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b.
c.
d.
e.
f.
Elevated blood pressure
Bradycardia
Increased muscle strength
Anxiety and irritability
Tetany
ANS: A, E
A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Signs and
symptoms of metabolic alkalosis include positive Chvostek sign, normal or low blood
pressure, increased heart rate, skeletal muscle weakness, possible tetany and seizures, and
anxiety and irritability.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Acid-base imbalances, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
m
5. A nurse is planning care for a client who is lethargic and confused. The client’s arterial blood
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gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 19 mEq/L (19
mmol/L). Which questions would the nurse ask the client and spouse when developing the
plan of care? (Select all that apply.)
a. “Are you taking any antacid medications?”
b. “Is your spouse’s current behavior typical?”
c. “Do you drink any alcoholic beverages?”
d. “Have you been participating in strenuous activity?”
e. “Are you experiencing any shortness of breath?”
ANS: B, C, D
ba
nk
This client’s symptoms of lethargy and confusion are related to a state of metabolic acidosis.
The nurse would ask the client’s spouse or family members if the client’s behavior is typical
for him or her, and establish a baseline for comparison with later assessment findings. The
nurse would also assess for alcohol intake because alcohol can cause metabolic acidosis.
Excessive and strenuous activity can lead to overproduction of hydrogen ions. The other
options are not causes of metabolic acidosis.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Acid-base imbalance, Acidosis
MSC: Client Needs Category: Psychosocial Integrity
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Chapter 15: Concepts of Infusion Therapy
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is caring for a client who has just had a central venous access line inserted. What
action will the nurse take next?
a. Begin the prescribed infusion via the new access.
b. Ensure that an x-ray is completed to confirm placement.
c. Check medication calculations with a second RN.
d. Make sure that the solution is appropriate for a central line.
ANS: B
m
A central venous access device, once placed, needs an x-ray confirmation of proper placement
before it is used. The bedside nurse would be responsible for beginning the infusion once
placement has been verified. Any IV solution can be given through a central line.
co
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infusion therapy, Vascular access device
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
2. A nurse assesses a client who has a radial artery catheter. Which assessment will the nurse
nk
s.
complete first?
a. Amount of pressure in fluid container
b. Date of catheter tubing change
c. Type of dressing over the site
d. Skin color and capillary refill
ANS: D
st
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An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased
perfusion to the extremity. Assessment of color, warmth, sensation, capillary refill time, and
distal pulses (if appropriate) are assessments for circulation distal to the catheter site. The
nurse would note that there is enough pressure in the fluid container to keep the system
flushed, and would check to see whether the catheter tubing needs to be changed. However,
these are not assessments of greatest concern. The type of dressing over the site would be
noted and most likely prescribed by policy.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Infusion therapy, Vascular access device
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A nurse teaches a client who is being discharged home with a peripherally inserted central
catheter (PICC). Which statement will the nurse include in this client’s teaching?
a. “Avoid carrying your grandchild with the arm that has the central catheter.”
b. “Be sure to place the arm with the central catheter in a sling during the day.”
c. “Flush the peripherally inserted central catheter line with normal saline daily.”
d. “You can use the arm with the central catheter for most activities of daily living.”
ANS: A
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A properly placed PICC (in the antecubital fossa or the basilic vein) allows the client
considerable freedom of movement. Clients can participate in most activities of daily living;
however, heavy lifting can dislodge the catheter or occlude the lumen. Although it is
important to keep the insertion site and tubing dry, the client can shower. The device is
flushed with heparin.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Infusion therapy, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
4. A nurse is caring for a client who is receiving an epidural infusion for pain management.
m
Which assessment finding requires immediate intervention from the nurse?
a. Redness at the catheter insertion site
b. Report of headache and stiff neck
c. Temperature of 100.1° F (37.8° C)
d. Pain rating of 8 on a scale of 0-10
ANS: B
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Complications of epidural therapy include infection, bleeding, leakage of cerebrospinal fluid,
occlusion of the catheter lumen, and catheter migration. Headache, neck stiffness, and a
temperature higher than 101° F (37.8° C) are signs of meningitis and would be reported to the
primary health care provider immediately. The other findings are important but do not require
immediate intervention.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infusion therapy, Complications
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
5. A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which
st
ANS: D
ba
assessment finding is of greatest concern?
a. The catheter has been in place for 20 hours.
b. The client has poor vascular access in the upper extremities.
c. The catheter is placed in the proximal tibia.
d. The client’s left lower extremity is cool to the touch.
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Compartment syndrome is a condition in which increased tissue pressure in a confined
anatomic space causes decreased blood flow to the area. A cool extremity can signal the
possibility of this syndrome. All other findings are important; however, the possible
development of compartment syndrome requires immediate intervention because the client
could require amputation of the limb if the nurse does not correctly assess and respond to this
perfusion problem.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Infusion therapy, Complications
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
6. A nurse is assessing clients who have intravenous therapy prescribed. Which assessment
finding for a client with a peripherally inserted central catheter (PICC) requires immediate
attention?
a. The initial site dressing is 3 days old.
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b. The PICC was inserted 4 weeks ago.
c. A securement device is absent.
d. Upper extremity swelling is noted.
ANS: D
Upper extremity swelling could indicate infiltration, and the PICC will need to be removed.
The initial dressing over the PICC site would be changed within 24 hours. This does not
require immediate attention, but the swelling does. The dwell time for PICCs can be months
or even years. Securement devices are being used more often now to secure the catheter in
place and prevent complications such as phlebitis and infiltration. The IV lacking one does not
take priority over the client whose arm is swollen.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Infusion therapy, Vascular access device
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
ANS: D
co
What action will the nurse take next?
a. Apply cold compresses to the IV site.
b. Elevate the extremity on a pillow.
c. Flush the catheter with normal saline.
d. Stop the infusion of intravenous fluids.
m
7. A nurse assesses a client’s peripheral IV site, and notices edema and tenderness above the site.
nk
s.
Infiltration occurs when the needle dislodges partially or completely from the vein. Signs of
infiltration include edema and tenderness above the site. The nurse would stop the infusion
and remove the catheter. Cold compresses and elevation of the extremity can be done after the
catheter is discontinued to increase client comfort. Alternatively, warm compresses may be
prescribed per institutional policy and may help speed circulation to the area.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Infusion therapy, Complications
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. While assessing a client’s peripheral IV site, the nurse observes a streak of red along the vein
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path and palpates a 1.5 inch (4-cm) venous cord. How will the nurse document this finding?
a. “Grade 3 phlebitis at IV site”
b. “Infection at IV site”
c. “Thrombosed area at IV site”
d. “Infiltration at IV site”
ANS: A
The presence of a red streak and palpable cord indicates grade 3 phlebitis. No information in
the description indicates that infection, thrombosis, or infiltration is present.
DIF: Understanding
TOP: Integrated Process: Communication and Documentation
KEY: Infusion therapy, Complications
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
9. A new nurse is caring for a client receiving drug therapy via a smart pump. What statement by
the new nurse demonstrates the need for more instruction on this technology?
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a.
b.
c.
d.
“I don’t need to manually calculate IV infusion rates with smart pumps.”
“Responding to IV pump alarms is a high priority for client safety.”
“The hospital can preprogram the pumps for high-alert drug limits.”
“These pumps have a system to prevent fluids from free-flowing into the client.”
ANS: A
The “smarter” the pump is the more programming needs to occur and errors can happen and
systems can fail. Using a programmable pump does not relieve the nurse of his or her
responsibility to monitor the infusion site and rates and ensure the client is receiving the fluids
or medications as prescribed. The Joint Commission continues to include responding to
alarms as a National Patient Safety Goal. Pumps can be preprogrammed so that upper limits
exist for high-alert drugs. All electronic infusion devices have some mechanism for
preventing free flow of fluids if the cassette or tubing is removed from the pump.
m
DIF: Analyzing
TOP: Integrated Process: Teaching/Learning
KEY: Infusion therapy, Client safety
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
10. A nurse prepares to insert a peripheral venous catheter in an older adult. What action will the
s.
co
nurse take to protect the client’s skin during this procedure?
a. Lower the extremity below the level of the heart.
b. Apply warm compresses to the extremity.
c. Tap the skin lightly and avoid slapping.
d. Place a washcloth between the skin and tourniquet.
ANS: D
nk
To protect the client’s skin, the nurse will place a washcloth or the client’s gown between the
skin and tourniquet. The other interventions are methods to distend the vein but will not
protect the client’s skin.
ba
DIF: Understanding
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infusion therapy, Older adult
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
11. A nurse delegates care to an assistive personnel (AP). Which statement will the nurse include
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when delegating hygiene for a client who has a vascular access device?
a. “Provide a bed bath instead of letting the client take a shower.”
b. “Use sterile technique when changing the dressing.”
c. “Disconnect the intravenous fluid tubing prior to the client’s bath.”
d. “Use a plastic bag to cover the extremity with the device.”
ANS: D
The nurse will ask the AP to cover the extremity with the vascular access device with a plastic
bag or wrap to keep the dressing and site dry. The client may take a shower or bath with a
vascular device. The nurse will disconnect IV fluid tubing prior to the bath and change the
dressing using sterile technique if necessary. These options are not appropriate to delegate to
the AP.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Infusion therapy, Delegation
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
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12. A nurse teaches a client who is prescribed a central vascular access device and is transferring
to a skilled facility for long-term treatment. Which statement will the nurse include in this
client’s teaching?
a. “You will need to wear a sling on your arm while the device is in place.”
b. “There is no risk of infection because sterile technique will be used during
insertion.”
c. “Ask all providers to vigorously clean the connections prior to accessing the
device.”
d. “You will not be able to take a bath with this vascular access device.”
ANS: C
The nurse would actively engage the client in the prevention of catheter-related bloodstream
infections and taught to remind all providers to perform hand hygiene and vigorously clean
connections prior to accessing the device. The other statements are incorrect.
m
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Infusion therapy, Infection control
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
13. A nurse is caring for a client with a peripheral vascular access device who is experiencing
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pain, redness, and swelling at the site. After removing the device, what action will the nurse
take to relieve pain?
a. Administer topical lidocaine to the site.
b. Place warm compresses on the site.
c. Administer prescribed oral pain medication.
d. Massage the site with scented oils.
nk
ANS: B
At the first sign of phlebitis, the catheter will be removed and warm compresses used to
relieve pain. The other options are not appropriate for this type of pain.
ba
DIF: Applying
TOP: Integrated Process: Caring
KEY: Infusion therapy, Nonpharmacologic comfort measures
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
st
14. A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client
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reports abdominal pain and “feeling warm.” For which complication of this therapy will the
nurse assess the client?
a. Allergic reaction
b. Bowel obstruction
c. Catheter lumen occlusion
d. Infection
ANS: D
Fever, abdominal pain, abdominal rigidity, and rebound tenderness may be present in the
client who has peritonitis related to intraperitoneal therapy. Peritonitis is preventable by using
strict aseptic technique in handling all equipment and infusion supplies. An allergic reaction
would show other signs and symptoms. Bowel obstruction and catheter lumen occlusion can
occur but would present clinically in different ways.
DIF: Applying
TOP: Integrated Process: Nursing Process: Analysis
KEY: Infusion therapy, Complications
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MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
15. A medical-surgical nurse is concerned about the incidence of complications related to IV
therapy, including bloodstream infection. Which intervention will the nurse suggest to the
management team to make the biggest impact on decreasing complications?
a. Initiate a dedicated team to insert access devices.
b. Require additional education for all nurses.
c. Limit the use of peripheral venous access devices.
d. Perform quality control testing on skin preparation products.
ANS: A
m
The Centers for Disease Control and Prevention recommends having a dedicated IV team to
reduce complications, save money, and improve client satisfaction and outcomes. In-service
education would always be helpful, but it would not have the same outcomes as an IV team.
Limiting the use of various access devices may not be practical. The quality of skin
preparation products is only one aspect of IV insertion that could contribute to infection.
co
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infusion therapy, Quality improvement
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
16. A nurse prepares to flush a peripherally inserted central catheter (PICC) line with 50 units of
s.
heparin. The pharmacy supplies a multidose vial of heparin with a concentration of 100
units/mL. Which of the syringes shown below will the nurse use to draw up and administer
the heparin?
ba
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e
st
b.
nk
a.
c.
d.
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ANS: D
Always use a 10-mL syringe when flushing PICC lines because a smaller syringe creates
higher pressure, which could rupture the lumen of the PICC. The PICC line would be
accessed with a needleless syringe.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infusion therapy, Vascular access device
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
17. A home care nurse prepares to administer intravenous medication to a client. The nurse
m
assesses the site and reviews the client’s chart prior to administering the medication and notes
it to have been inserted 4 months ago. The site has no redness, warmth, or swelling and
flushes easily. What action does the nurse take?
a. Notify the primary health care provider.
b. Administer the prescribed medication.
c. Discontinue the PICC.
d. Switch the medication to the oral route.
ANS: B
s.
co
A PICC that is functioning well without inflammation or infection may remain in place for
months. Because the line shows no signs of complications, it is permissible to administer the
IV antibiotic. There is no need to call the primary health care provider or to have the IV
medication changed to an oral route.
MULTIPLE RESPONSE
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infusion therapy, Vascular access device
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
ba
1. A registered nurse (RN) occasionally delegates client care to licensed practical nurses (LPNs)
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or technicians. What information does the RN consider when delegating components of IV
therapy? (Select all that apply.)
a. Each state’s Nurse Practice Act will regulate who can perform care related to IVs.
b. The nurse would check the facility’s Policies and Procedures manual.
c. The LPN’s level of experience primarily guides the decision.
d. Technicians cannot participate in any part of caring for IV infusions.
e. The RN remains accountable for all aspects of IV care and delegated actions.
f. The Infusion Nurses Society has guidelines and standards of IV therapy
competency.
ANS: A, B, E, F
The state Nurse Practice Act will have the information the RN needs to determine scope of
practice, and in some states, LPNs and technicians are able to perform specific aspects of IV
therapy. The nurse would also be familiar with facility policies and procedures regarding
delegation of IV therapy. Amount of experience is not a criterion as LPNs and technicians can
have their knowledge and skills verified. The nurse remains accountable for all aspects of IV
therapy include what has been delegated. The Infusion Nurses Society has published
guidelines and standards related to competency for IV therapy.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Infusion therapy, Delegation
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
2. A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which
common complications will the nurse assess? (Select all that apply.)
a. Phlebitis
b. Pneumothorax
c. Thrombophlebitis
d. Excessive bleeding
e. Extravasation
f. Pneumothorax
g. Infiltration
ANS: A, C
m
Although the complication rate with PICCs is fairly low, the most common complications are
phlebitis, thrombophlebitis, and catheter-related bloodstream infection. Excessive bleeding,
infiltration, and extravasation are not common complications. Pneumothorax does not occur.
co
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Infusion therapy, Complications
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A nurse prepares to administer a blood transfusion to a client, and checks the blood label with
st
ANS: A, B, D
ba
nk
s.
a second registered nurse using the International Society of Blood Transfusion (ISBT)
universal bar-coding system to ensure the right blood for the right client. Which components
must be present on the blood label in bar code and in eye-readable format? (Select all that
apply.)
a. Unique facility identifier
b. Lot number related to the donor
c. Name of the client receiving blood
d. ABO group and Rh type of the donor
e. Blood type of the client receiving blood
f. Signature line for 2-person verification
Bt
e
The ISBT universal bar-coding system includes four components: (1) the unique facility
identifier, (2) the lot number relating to the donor, (3) the product code, and (4) the ABO
group and Rh type of the donor. Positive identification by two qualified health care providers
is essential although automated bar coding is acceptable in some care areas. However, a
signature line is not required on the blood label.
DIF: Remembering
TOP: Integrated Process: Communication and Documentation
KEY: Infusion therapy, Blood component transfusion, Safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
4. A nurse assists with the insertion of a central vascular access device. Which actions will the
nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that
apply.)
a. Include a review for the need of the device each day in the client’s plan of care.
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b. Remind the primary health care provider to perform hand hygiene prior to
c.
d.
e.
f.
insertion if he or she forgets.
Cleanse the preferred site with alcohol and let it dry completely before insertion.
Ask everyone in the room to wear a surgical mask during the procedure.
Plan to complete a sterile dressing change on the device every day.
Minimal client draping and barrier precautions as blood loss are minimal.
ANS: A, B, D
m
The central vascular access device bundle to prevent catheter-related bloodstream infections
includes using a checklist during insertion, performing hand hygiene before inserting the
catheter and anytime someone touches the catheter, using chlorhexidine to disinfect the skin at
the site of insertion, using preferred sites, and reviewing the need for the catheter every day.
The practitioner who inserts the device would wear sterile gloves, gown, and mask, and
anyone in the room would wear a mask. Maximal barrier precautions are used which requires
the client to be draped sterilely from head to toe. The initial dressing on a central vascular
access device is changed in 24 hours. Gauze and tape dressings are changed every 48 hours
and transparent membrane dressings are changed every 5 to 7 days.
co
DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infusion therapy, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
s.
5. A nurse prepares to insert a short peripheral venous catheter. What actions will the nurse take
ANS: A, B, E
ba
nk
to use best practices? (Select all that apply.)
a. Choose a distal site on the client’s nondominant arm.
b. Verify that the prescription is appropriate for peripheral infusion.
c. Place the venous catheter near an area of joint flexion.
d. Wear a surgical mask during the catheter insertion procedure.
e. Perform hand hygiene before inserting the catheter.
f. Limit unsuccessful attempts by up to three clinicians to one attempt each.
Bt
e
st
Best practices for the insertion of a short peripheral venous catheter include hand hygiene
prior to the procedure, verification of the prescription for intravenous therapy and its
appropriateness for infusion through a short peripheral catheter, and placement of the catheter
in a distal site, away from an area of joint flexion and when possible in the client’s
nondominant arm. Surgical masks are needed for central venous catheter placement but not
for short peripheral venous catheter placement. Unsuccessful attempts to insert the catheter
should be limited to two per person and no more than four total.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infusion therapy, Vascular access device
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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Chapter 16: Concepts of Inflammation and Immunity
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse learns that the most important function of inflammation and immunity is which
purpose?
a. Destroying bacteria before damage occurs
b. Preventing any entry of foreign material
c. Providing maximum protection against infection
d. Regulating the process of self-tolerance
ANS: C
co
m
Immunity and Inflammation working together are critical to maintaining health, preventing
disease, and repairing tissue damage. When all the different parts and functions of immunity
are working well, the adult is immunocompetent and has maximum protection against
infection. Working together, their function is not limited to destroying bacteria before damage
occurs. They do not prevent the entry of all foreign materials and immunity alone regulates
the process of self-tolerance.
s.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Immunity, Inflammation, Infection control
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse is assessing an older client for the presence of infection. The client’s temperature is
ba
ANS: A
nk
97.6° F (36.4° C). What response by the nurse is best?
Assess the client for more specific signs.
Conclude that an infection is not present.
Document findings and continue to monitor.
Request the primary health care provider order blood cultures.
a.
b.
c.
d.
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st
Because older adults have decreased immune function, including reduced neutrophil function,
fever may not be present during an episode of infection. The nurse would assess the client for
specific signs of infection. Documentation needs to occur, but a more thorough assessment
comes first. Blood cultures may or may not be needed depending on the results of further
assessment.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Inflammation, Immunity
MSC: Client Needs Category: Health Promotion and Maintenance
3. A clinic nurse is working with an older client. What action is most important for preventing
infections in this client?
a. Assessing vaccination records for booster shot needs
b. Encouraging the client to eat a nutritious diet
c. Instructing the client to wash minor wounds carefully
d. Teaching hand hygiene to prevent the spread of microbes
ANS: A
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Older adults may have insufficient antibodies that have already been produced against
microbes to which they have been exposed. Therefore, older adults need booster shots for
many vaccinations they received as younger people. A nutritious diet, proper wound care, and
hand hygiene are relevant for all populations.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Immunity, Inflammation
MSC: Client Needs Category: Health Promotion and Maintenance
4. A client has a leg wound that is in Stage II of the inflammatory response. For what sign or
symptom does the nurse assess?
a. Noticeable rubor
b. Purulent drainage
c. Swelling and pain
d. Warmth at the site
m
ANS: B
co
During the second phase of the inflammatory response, neutrophilia occurs, producing pus.
Rubor (redness), swelling, pain, and warmth are cardinal signs of the general inflammatory
process.
s.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Inflammation, Inflammatory response
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A nurse learning about antibody-mediated immunity learns that the cell with the most direct
ANS: A
ba
nk
role in this process begins development in which tissue or organ?
a. Bone marrow
b. Spleen
c. Thymus
d. Tonsils
st
The B-cell is the primary cell in antibody-mediated immunity and is released from the bone
marrow. These cells then travel to other organs and tissues, known as the secondary lymphoid
tissues for B-cells.
Bt
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Immunity, Antibody-mediated immunity
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. The nurse understands that which type of immunity is the longest acting?
a. Artificial active
b. Inflammatory
c. Natural active
d. Natural passive
ANS: C
Natural active immunity is the most effective and longest acting type of immunity. Artificial
and natural passive do not last as long. “Inflammatory” is not a type of immunity.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
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KEY: Immunity, Antibody-mediated immunity
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. The nurse working with clients who have autoimmune diseases understands that what
component of cell-mediated immunity is the problem?
a. CD4+ cells
b. Cytotoxic T-cells
c. Natural killer cells
d. Regulator T-cells
ANS: D
m
Regulator T-cells help prevent hypersensitivity to one’s own cells, which is the basis for
autoimmune disease. CD4+ cells are also known as helper/inducer cells, which secrete
cytokines. Natural killer cells have direct cytotoxic effects on some non-self cells without first
being sensitized. Regulator T-cells have an inhibitory action on the immune system. Cytotoxic
T-cells are effective against self cells infected by parasites such as viruses or protozoa.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Immunity, Cell-mediated immunity
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
nk
does the nurse anticipate?
a. Administer antibiotics.
b. Place the client in isolation.
c. Administer IV leukocytes.
d. Obtain an immunization history.
s.
8. A primary health care provider notifies the nurse that a client has a “bandemia.” What action
ANS: A
ba
A bandemia, or shift to the left, in the white count differential means that an acute, continuing
infection has placed so much stress on the immune system that the most numerous type of
neutrophil in circulation are immature, or band cells. The nurse would anticipate
administering antibiotics. The client may or may not need isolation. Leukocyte infusion and
immunization history are not relevant.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Immunity, Decreased immunity, Older adult risk factors
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. What does the nurse learn about the function of colony-stimulating factor?
a. Triggers the bone marrow to shorten the time needed to produce mature WBCs.
b. Causes capillary leak in acute inflammation.
c. Responsible for creating exudate (pus) at infectious sites.
d. Dilates blood vessels at the site of inflammation leading to hyperemia.
ANS: A
Colony-stimulating factor triggers the bone marrow to shorten the time needed to produce
mature WBCs from about 14 days to hours. Increased blood flow to the local area of
inflammation produces hyperemia, or redness. Exudate is formed by neutrophils and consists
of dead WBCs, necrotic tissue, and fluids that escape from damaged cells. Histamine,
serotonin, and kinins dilate arterioles leading to redness and warmth.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Immunity, Older adult risk factors
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. The older client’s adult child questions the nurse as to why the client is at higher risk for
infection when the client’s white cell count is within the normal range. What response by the
nurse is best?
a. “The white cell count does not tell us everything about immunity.”
b. “White blood cells are less active in older people so they are not as efficient.”
c. “Older people typically have poor nutrition which makes them prone to infection.”
d. “As one ages, immunoglobulins cease to be produced in response to illness.”
ANS: B
m
An age-related change in immunity is that neutrophils in the older adult are less active and
therefore less effective in immunity. The white blood cell count is not the only thing that can
inform about immunity, but this response is too vague to be useful. Many older adults do have
poor nutrition that does affect immunity, but this is not true for everyone and the stem does
not contain information stating that is problematic for this older adult. Immunoglobulins do
not cease to be produced with age.
s.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Immunity, Older adult risk factors
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
nk
1. For a person to be immunocompetent, which processes need to be functional and interact
ANS: A, B, C
ba
appropriately with each other? (Select all that apply.)
a. Antibody-mediated immunity
b. Cell-mediated immunity
c. Inflammation
d. Red blood cells
e. White blood cells
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st
The three processes that need to be functional and interact with each other for a person to be
immunocompetent are antibody-mediated immunity, cell-mediated immunity, and
inflammation. Red and white blood cells are not processes.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Immunity, Inflammation
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse is learning about the types of different cells involved in the inflammatory response.
Which principles does the nurse learn? (Select all that apply.)
a. Basophils are only involved in the general inflammatory process.
b. Eosinophils increase during allergic reactions and parasitic invasion.
c. Macrophages can participate in many episodes of phagocytosis.
d. Monocytes turn into macrophages after they enter body tissues.
e. Neutrophils can only take part in one episode of phagocytosis.
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ANS: B, C, D, E
Eosinophils do increase during allergic and parasitic invasion. Macrophages participate in
many episodes of phagocytosis. Monocytes turn into macrophages after they enter body
tissues. Neutrophils only take part in one episode of phagocytosis. Basophils are involved in
both the general inflammatory response and allergic or hypersensitivity responses.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Inflammation, Immunity
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does
m
this include? (Select all that apply.)
a. Edema
b. Pulselessness
c. Pallor
d. Redness
e. Warmth
f. Decreased function
ANS: A, D, E, F
co
The five cardinal signs of inflammation include redness, warmth, pain, swelling, and
decreased function.
s.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Inflammation, Immunity, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
ba
nk
4. Which are steps in the process of making an antigen-specific antibody? (Select all that apply.)
a. Antibody-antigen binding
b. Invasion
c. Opsonization
d. Recognition
e. Sensitization
f. Production
st
ANS: A, B, D, E, F
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The seven steps in the process of making antigen-specific antibodies are: exposure/invasion,
antigen recognition, sensitization, antibody production and release, antigen-antibody binding,
antibody binding actions, and sustained immunity. Opsonization is the adherence of an
antibody to the antigen, marking it for destruction.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Immunity, Antibody-mediated immunity
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. The nurse is learning about immunoglobulins. . Which principles does the nurse learn? (Select
all that apply.)
a. IgA is found in high concentrations in secretions from mucous membranes.
b. IgD is present in the highest concentrations in mucous membranes.
c. IgE is associated with antibody-mediated hypersensitivity reactions.
d. IgG comprises the majority of the circulating antibody population.
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e. IgM is the first antibody formed by a newly sensitized B-cell.
ANS: A, C, D, E
Immunoglobulin A (IgA) is found in high concentrations in secretions from mucous
membranes. Immunoglobulin E (IgE) is associated with antibody-mediated hypersensitivity
reactions. The majority of the circulating antibody population consists of immunoglobulin G
(IgG). The first antibody formed by a newly sensitized B-cell is immunoglobulin M (IgM).
Immunoglobulin D (IgD) is typically present in low concentrations.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Immunity, Antibodies
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
m
6. The nurse learns that which risk factors can affect immunity? (Select all that apply.)
a. Age
b. Environmental factors
c. Ethnicity
d. Drugs
e. Nutritional status
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ANS: A, B, D, E
s.
Immunity changes during an adult’s life as a result of nutritional status, environmental
conditions, drugs, disease, and age. Immunity is most efficient in young adults and older
adults have decreased immune function. Ethnicity does not affect immunity.
nk
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Immunity, Older adult risk factors
MSC: Client Needs Category: Health Promotion and Maintenance
7. The nurse is teaching an elderly client the risks of infection for older adults. Which of the
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following factors would the nurse include in the education? (Select all that apply.)
a. Higher risk for respiratory tract and genitourinary infections.
b. May not have a fever with severe infection.
c. Show expected changes in white blood cell counts.
d. Should receive influenza, pneumococcal, and shingles vaccinations.
e. Skin tests for tuberculosis may be falsely negative.
f. Booster vaccinations are not likely needed as one ages.
ANS: A, B, D, E
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Immunity changes during an adult’s life and older adults have decreased immune function.
The number and function of neutrophils and macrophages are reduced leading to reduced
response to infection and injury, such as temperature elevation. The usual response of an
increased white blood cell count is delayed or absent. Older adults are less able to make new
antibodies in response to the presence of new antigens requiring repeat vaccinations and
immunizations. Skin tests for tuberculosis may be falsely negative and there is an increased
risk for bacterial and fungal infections due to the decreased number of circulating
T-lymphocytes.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Immunity, Older adult risk factors
MSC: Client Needs Category: Health Promotion and Maintenance
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8. A nurse is studying the functions of specific leukocytes. Which leukocytes are matched
correctly with their function? (Select all that apply.)
a. Monocyte: matures into a macrophage.
b. Basophil: releases vasoactive amines during an allergic reaction.
c. Plasma cell: secretes immunoglobulins in response to the presence of a specific
antigen.
d. Cytotoxic T-cells: attacks and destroys ingested poisons and toxins.
e. Natural killer cell: nonselectively attacks non-self cells.
f. Regulator T-cells: become sensitized for self-recognition in the bone marrow.
ANS: A, C, E
m
Monocytes mature into macrophages, plasma cells secrete immunoglobulin in the presence of
specific antigens, and natural killer cells nonselectively attack non-self cells. Basophils release
histamines, kinins, and heparin in areas of tissue damage. Cytotoxic T-cells selectively attack
and destroy non-self cells, including virally infected cells, grafts, and transplanted organs.
Regulator T-cells become sensitized for self-recognition in the thymus.
co
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Immunity, Leukocytes
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. A nurse is studying the function of immunoglobulins. Which immunoglobulins are correctly
ba
ANS: A, C, D, E
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s.
matched to their function? (Select all that apply.)
a. IgA: most responsible for preventing infection in the respiratory tracts, the GI
tract, and the genitourinary tract.
b. IgD: provides protection against parasite infestations, especially helminths.
c. IgE: associated with antibody-mediated immediate hypersensitivity reactions.
d. IgG: activates classic complement pathway and enhances neutrophil and
macrophage actions.
e. IgM: first antibody formed by a newly sensitized B-lymphocyte plasma cell.
All options are true except IgD acts as a B-cell antigen receptor. IgE provides protection
against parasite infestations, especially helminths.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Immunity, Immunoglobulins
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. The nurse caring for clients assesses their daily laboratory profiles. Which lab results are
considered to be in the normal range? (Select all that apply.)
a. Segmented neutrophils: 68%
b. Bands: 19%
c. Monocytes: 12%
d. Lymphocytes: 38%
e. Eosinophils: 2%
f. Basophils: 1%
ANS: A, D, E, F
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The normal range for segmented neutrophils is 55% to 70%. The normal range for bands is
5%. The normal range for monocytes is 2% to 8%. The normal range for lymphocytes is 20%
to 40%. The normal range for eosinophils is 1% to 4%. The normal range for basophils is
0.5% to 1%.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Immunity, White blood cells
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
m
11. What statements about the complement system are correct? (Select all that apply.)
a. Comprised of 20 types of inactive plasma proteins.
b. Act as enzymes when activated to enhance innate immunity.
c. Phagocytize foreign invaders quickly by destroying their membranes.
d. Sticks to the antigen and forms a membrane attack complex.
e. Maintain and prolong inflammation from non-self cells.
f. Is part of the innate immune system.
ANS: A, B, D, F
s.
co
The complement system is made up of 20 different types of inactive plasma proteins that,
when activated, act as enzymes to enhance (or complement) cell actions in innate immunity.
They join other proteins to surround antigens and “fix” or stick to the antigen quickly forming
a membrane attack complex on the antigen surface. This action makes immune cell
attachment to antigens and phagocytosis more efficient. They are part of innate immunity.
They do not phagocytize invaders themselves nor do they maintain and prolong inflammation
from allergens.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Immunity, Complement System
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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Chapter 17: Concepts of Care for Patients With HIV Disease
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is caring for a client diagnosed with HIV-II. The client’s CD4+ cell count is
399/mm3 (0.399  109/L). What action by the nurse is best?
a. Counsel the client on safer sex practices/abstinence.
b. Encourage the client to abstain from alcohol.
c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors.
d. Help the client plan high-protein/iron meals.
ANS: A
co
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This client is in the Centers for Disease Control and Prevention HIV-II case definition group.
He or she remains highly infectious and would be counseled on either safer sex practices or
abstinence. Abstaining from alcohol is healthy but not required, although some medications
may need to be taken while abstaining. Genetic testing is not commonly done, but an
alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors.
High-protein/iron meals are important for people who are immunosuppressed, but helping to
plan them does not take precedence over stopping the spread of the disease.
s.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: HIV disease, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
nk
2. The nurse is presenting information to a community group on safer sex practices. The nurse
ANS: A
ba
would teach that which sexual practice is the riskiest?
a. Anal intercourse
b. Masturbation
c. Oral sex
d. Vaginal intercourse
st
Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating
a portal of entry for human immune deficiency virus in addition to providing mucus
membrane contact with the virus.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: HIV disease, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
3. The nurse providing direct client care uses specific practices to reduce the chance of acquiring
infection with human immune deficiency virus (HIV) from clients. Which practice is most
effective?
a. Consistent use of Standard Precautions
b. Double-gloving before body fluid exposure
c. Labeling charts and armbands “HIV+”
d. Wearing a mask within 3 feet (1 m) of the client
ANS: A
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According to The Joint Commission, the most effective preventative measure to avoid HIV
exposure is consistent use of Standard Precautions. Standard Precautions are required by the
CDC. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a
violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a
mask within 3 feet (1 m) of the client is not necessary with every client contact.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: HIV disease, Standard precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
4. A client with known HIV-II is admitted to the hospital with fever, night sweats, and severe
m
cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis
(TB) skin test 4 days ago. What action would the nurse take first?
a. Initiate Droplet Precautions for the client.
b. Notify the primary health care provider about the CD4+ results.
c. Place the client under Airborne Precautions.
d. Use Standard Precautions to provide care.
ANS: C
nk
s.
co
Since this client’s CD4+ cell count is so low, he or she may have energy, or the inability to
mount an immune response to the TB test. The client also appears to have progressed to
HIV-III. The nurse would first place the client on Airborne Precautions to prevent the spread
of TB if it is present. Next the nurse notifies the primary health care provider about the low
CD4+ count and requests alterative testing for TB. Droplet Precautions are not used for TB.
Standard Precautions are not adequate in this case.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: HIV disease, Transmission-based precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
ba
5. A nurse is talking with a client about a negative enzyme-linked immunosorbent assay
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st
(ELISA) test for human immune deficiency virus (HIV). The test is negative and the client
states “Whew! I was really worried about that result.” What action by the nurse is most
important?
a. Assess the client’s sexual activity and patterns.
b. Express happiness over the test result.
c. Remind the client about safer sex practices.
d. Tell the client to be retested in 3 months.
ANS: A
The ELISA test can be falsely negative if testing occurs after the client has become infected
but prior to making antibodies to HIV. This period of time is known as the window period and
can last up to 21 days. The confirmatory Western Blot test takes an additional 7 days, so using
that testing algorithm, the client’s status may not truly be known for up to 28 days. The client
may have had exposure that has not yet been confirmed. The nurse needs to assess the client’s
sexual behavior further to determine the proper response. The other actions are not the most
important, but discussing safer sex practices is always appropriate. Testing would be
recommended every 3 months for someone engaging in high risk behaviors.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
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KEY: HIV disease, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A client with HIV-II has had a sudden decline in status with a large increase in viral load.
What action would the nurse take first?
a. Ask the client about travel to any foreign countries.
b. Assess the client for adherence to the drug regimen.
c. Determine if the client has any new sexual partners.
d. Request information about new living quarters or pets.
ANS: B
Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients
must take their medications on time and correctly at a minimum of 90% of the time to be
effective. Since this client’s viral load has increased dramatically, the nurse would first assess
this factor. After this, the other assessments may or may not be needed.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: HIV disease, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
co
7. A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of
s.
breath with activity and extreme fatigue. What intervention is best to promote comfort?
a. Administer sleeping medication.
b. Perform most activities for the client.
c. Increase the client’s oxygen during activity.
d. Pace activities, allowing for adequate rest.
nk
ANS: D
ba
This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The
nurse would not do everything for the client but rather let the client do as much as possible
within limits and allow for adequate rest in between. Sleeping medications may be needed but
not as the first step, and only with caution. Increasing oxygen during activities may or may
not be warranted, but first the nurse must try pacing the client’s activity.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: HIV disease, Fatigue
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
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8. A client with HIV-III and wasting syndrome has inadequate nutrition. What assessment
finding by the nurse best indicates that goals have been met for this client problem?
a. Chooses high-protein food.
b. Has decreased oral discomfort.
c. Eats 90% of meals and snacks.
d. Has a weight gain of 2 lb (1 kg)/1 mo.
ANS: D
The weight gain is the best indicator that goals for this client problem have been met because
it demonstrates that the client not only is eating well but also is able to absorb the nutrients.
Choosing high-protein food is important, but only if the client eats and absorbs the nutrients.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: HIV disease, Nutrition
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MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
9. A client with HIV-III is hospitalized and has weeping Kaposi sarcoma lesions. The nurse
dresses them with sterile gauze. When changing these dressings, which action is most
important for the nurse’s safety?
a. Adhering to Standard Precautions
b. Assessing tolerance to dressing changes
c. Performing hand hygiene before and after care
d. Disposing of soiled dressings properly
ANS: A
All of the actions are important, but due to the infectious nature of this illness, the nurse
would ensure he or she is following Standard Precautions (and Transmission-Based
Precautions when necessary) to avoid a potential exposure.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: HIV disease, Standard precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
s.
action by the nurse is most appropriate?
a. Initiate Contact Precautions.
b. Conduct frequent neurologic assessments.
c. Conduct frequent respiratory assessments.
d. Initiate Protective Precautions.
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10. A client with HIV-III is admitted to the hospital with Toxoplasma gondii infection. Which
ANS: D
ba
nk
Toxoplasma gondii infection is an opportunistic infection that causes an encephalitis but poses
only a rare threat to immunocompetent individuals The nurse would perform ongoing
neurologic assessments. Contact and Protective Precautions are not needed. Good respiratory
assessments are important to the client, but toxoplasmosis will demonstrate neurologic signs
and symptoms.
st
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: HIV disease, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
11. A client has just been informed of a positive HIV test. The client is distraught and does not
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know what to do. What intervention by the nurse is best?
a. Assess the client for support systems.
b. Determine if a clergy member would help.
c. Explain legal requirements to tell sex partners.
d. Offer to tell the family for the client.
ANS: A
This client needs the assistance of support systems. The nurse would help the client identify
them and what role they can play in supporting him or her. A clergy member may or may not
be welcome. Positive HIV test results are reportable in all 50 states, Washington, D.C., and
Canada but the nurse works with the client to support his or her choices in disclosure. The
nurse would not tell the family for the client.
DIF: Applying
TOP: Integrated Process: Caring
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KEY: HIV disease, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
12. A nurse is caring for a client with HIV-III who was admitted with HAND. What sign or
symptom would be most important for the nurse to report to the primary health care provider?
a. Nausea
b. Change in pupil size
c. Weeping open lesions
d. Cough
ANS: B
HIV-associated neurocognitive disorder (HAND) is a sign of neurologic involvement. The
nurse would report any sign of increasing intracranial pressure immediately, including change
in pupil size, level of consciousness, vital signs, or limb strength. The other signs and
symptoms are not life threatening and would be documented and reported appropriately.
m
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: HIV disease
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
co
13. A client has been hospitalized with an opportunistic infection secondary to HIV-III. The
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s.
client’s partner is listed as the emergency contact, but the client’s mother insists that she
should be listed instead. What action by the nurse is best?
a. Contact the social worker to assist the client with advance directives.
b. Ignore the mother; the client does not want her to be involved.
c. Let the client know, gently, that nurses cannot be involved in these disputes.
d. Tell the client that, legally, the mother is the emergency contact.
ANS: A
ba
The client should make his or her wishes known and formalize them through advance
directives. The nurse would help the client by contacting someone to help with this process.
Ignoring the mother or telling the client that nurses cannot be involved does not help the
situation. Legal statutes vary by state, but the nurse would be the client’s advocate and help
ensure his or her wishes are met.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: HIV disease, Ethics
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
14. A client with HIV-II is hospitalized for an unrelated condition, and several medications are
prescribed in addition to the regimen already being used. What action by the nurse is most
important?
a. Consult with the pharmacy about drug interactions.
b. Ensure that the client understands the new medications.
c. Give the new drugs without considering the old ones.
d. Schedule all medications at standard times.
ANS: A
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The drug regimen for someone with HIV/AIDS is complex and consists of many medications
that must be given at specific times of the day, and that have many interactions with other
drugs and food. The nurse would consult with a pharmacist about possible interactions. Client
teaching is important but does not take precedence over ensuring the medications do not
interfere with each other, which could lead to drug resistance or a resurgence of symptoms.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: HIV disease, Medication safety
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
15. A client with HIV-III has been hospitalized with suspected cryptosporidiosis. What physical
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assessment would be most important with this condition?
a. Auscultating the lungs
b. Assessing mucous membranes
c. Listening to bowel sounds
d. Performing a neurologic examination
ANS: B
co
Cryptosporidiosis can cause diarrhea and wasting with extreme loss of fluids and electrolytes.
The nurse would assess signs of hydration/dehydration as the priority, including checking the
client’s mucous membranes for dryness. The nurse will perform the other assessments as part
of a comprehensive assessment.
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: HIV disease, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
nk
16. A client with HIV-III asks the nurse why gabapentin is part of the drug regimen when the
ANS: C
ba
client does not have a history of seizures. What response by the nurse is best?
a. “Gabapentin can be used as an antidepressant too.”
b. “I have no idea why you would be taking this drug.”
c. “This drug helps treat the pain from nerve irritation.”
d. “You are at risk for seizures due to fungal infections.”
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Many classes of medications are used for neuropathic pain, including tricyclic antidepressants
and anticonvulsants such as gabapentin. It is not being used to prevent seizures from fungal
infections. If the nurse does not know the answer, he or she would find out for the client.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: HIV disease, Pharmacologic pain management
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
17. An HIV-negative client who has an HIV-positive partner asks the nurse about receiving
tenofovir/emtricitabine. What information is most important to teach the client about this
drug?
a. Does not reduce the need for safe sex practices.
b. Has been taken off the market due to increases in cancer.
c. Reduces the number of HIV tests you will need.
d. Is only used for postexposure prophylaxis.
ANS: A
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Tenofovir/emtricitabine is a newer drug used for preexposure prophylaxis and appears to
reduce transmission of human immune deficiency virus (HIV) from known HIV-positive
people to HIV-negative people. The drug does not reduce the need for practicing safe sex.
Since the drug can lead to drug resistance if used, clients will still need HIV testing every 3
months. This drug has not been taken off the market and is not used for postexposure
prophylaxis.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: HIV disease, Health teaching
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
MULTIPLE RESPONSE
1. A nurse is learning about human immune deficiency virus (HIV) infection. Which statements
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about HIV infection are correct? (Select all that apply.)
a. CD4+ cells begin to create new HIV virus particles.
b. Antibodies produced are incomplete and do not function well.
c. Macrophages stop functioning properly.
d. Opportunistic infections and cancer are leading causes of death.
e. People with HIV-I disease are not infectious to others.
f. The CD4+ T-cell is only affected when the disease has progressed to HIV-III
ANS: A, B, C, D
nk
s.
In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produce are
incomplete and do not function well. Macrophages also stop functioning properly.
Opportunistic infections and cancer are the two leading causes of death in client’s with HIV
infection. People infected with HIV are infectious in all stages of the disease. The CD4+
T-cell is the immune system cell most affected by infection with the HIV virus.
ba
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: HIV disease, Pathophysiology
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
st
2. Which findings are AIDS-defining characteristics? (Select all that apply.)
a. CD4+ cell count less than 200/mm3 (0.2  109/L) or less than 14%
b. Infection with P. jiroveci
c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune
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deficiency virus (HIV)
d. Presence of HIV wasting syndrome
e. Taking antiretroviral medications
f. Confusion, dementia, or memory loss
ANS: A, B, D, F
A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell
count of less than 200 cells/mm3 (0.2  109/L) or less than 14% (even if the total CD4+ count
is above 200 cells/mm3) or an opportunistic infection such as P. jiroveci and HIV wasting
syndrome. Confusion, dementia, and memory loss are central nervous system indications.
Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining
characteristics.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
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KEY: HIV disease
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. The nurse is teaching a client about medications for HIV-II treatment. What drugs are paired
with the correct information? (Select all that apply.)
a. Abacavir: avoid fatty and fried foods.
b. Efavirenz: take 1 hour before or 2 hours after antacids.
c. Atazanavir: check pulse daily and report pulse greater than 100 beats/min.
d. Dolutegravir: do not take this medication if you become pregnant.
e. Enfuvirtide: teach client how to operate syringe infusion pump for administration.
f. All drugs: you must adhere to the drug schedule at least 90% of the time for
effectiveness.
ANS: A, B, F
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Abacavir is a nucleoside reverse transcriptase inhibitor and clients are taught to avoid fried
and fatty foods because they can lead to digestive upsets and even pancreatitis. Efavirenz is a
nonnucleoside reverse transcriptase inhibitor and clients are taught to take them (doraverene)
all except spaced 1 hour before or 2 hours after antacids to avoid inhibiting drug absorption.
Atazanavir is a protease inhibitor and can cause bradycardia which should be reported.
Dolutegravir is an integrase inhibitor and can cause birth defects. Enfuvirtide is a fusion
inhibitor and is given subcutaneously. All drugs must be taken as scheduled 90% of the time
in order to remain effective.
s.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: HIV disease, Medications
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
nk
4. A client with HIV-III is hospitalized with P. jiroveci pneumonia and is started on the drug of
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choice for this infection. What laboratory values would be most important for the nurse report
to the primary health care provider? (Select all that apply.)
a. Aspartate transaminase, alanine transaminase: elevated
b. CD4+ cell count: 180/mm3
c. Creatinine: 1.0 mg/dL (88 mcmol/L)
d. Platelet count: 80,000/mm3 (80  109/L)
e. Serum sodium: 120 mEq/L (120 mmol/L)
f. Serum potassium: 3.4 mEq/L (3.4 mmol/L)
ANS: A, D, E
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The drug of choice to treat P. jiroveci pneumonia is trimethoprim with sulfamethoxazole. Side
effects of this drug include hepatitis, hyponatremia, and thrombocytopenia. The elevated liver
enzymes, low platelet count, and low sodium would all be reported. The CD4+ cell count is
within the expected range for a client with an AIDS-defining infection. The creatinine level is
normal and the potassium is just below normal.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: HIV disease, Medication side effects
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
5. A client with HIV-III has oral thrush and difficulty eating. What actions does the nurse
delegate to the assistive personnel (AP)? (Select all that apply.)
a. Apply oral anesthetic gels before meals.
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b.
c.
d.
e.
f.
Assist the client with oral care every 2 hours.
Offer the client frequent sips of cool drinks.
Provide the client with alcohol-based mouthwash.
Remind the client to use only a soft toothbrush.
Offer the client soft foods like gelatin or pudding.
ANS: B, C, E, F
The AP can help the client with oral care, offer fluids, and remind the client of things the
nurse (or other professional) has already taught. Soft foods and liquids are tolerated better
than harder foods. Applying medications is performed by the nurse. Alcohol-based
mouthwashes are harsh and drying and would not be used.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: HIV disease, Delegation
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
m
6. A client with HIV-III is in the hospital with severe diarrhea. What actions does the nurse
co
delegate to assistive personnel (AP)? (Select all that apply.)
a. Assessing the client’s fluid and electrolyte status
b. Assisting the client to get out of bed to prevent falls
c. Obtaining a bedside commode if the client is weak
d. Providing gentle perianal cleansing after stools
e. Reporting any perianal abnormalities
s.
ANS: B, C, D, E
nk
The AP can assist the client with getting out of bed, obtain a bedside commode for the client’s
use, cleanse the client’s perianal area after bowel movements, and report any abnormal
observations such as redness or open areas. The nurse assesses fluid and electrolyte status.
ba
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: HIV disease, Delegation
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. The nurse is educating a client with HIV-II and the partner on self-care measures to prevent
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infection when blood counts are low. What information does the nurse provide? (Select all
that apply.)
a. Do not work in the garden or with houseplants.
b. Do not empty the kitty litter boxes.
c. Clean your toothbrush in the dishwasher daily.
d. Bathe daily using antimicrobial soap.
e. Avoid people who are sick and large crowds.
f. Make sure meat, fish, and eggs are cooked well.
ANS: A, B, D, E, F
Ways to avoid infection when immunocompromised include not working in the garden or
with houseplants; not emptying litter boxes; running the toothbrush through the dishwasher at
least weekly; bathing daily using antimicrobial soap; avoiding sick people and large crowds;
and making sure meat, fish, and eggs are cooked well prior to eating them.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: HIV disease, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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8. A nurse is providing education about HIV risks at a health fair. What groups would the nurse
include as needing to be tested for HIV on an annual basis? (Select all that apply.)
a. Anyone who received a blood product in 1989
b. Couples planning on getting married
c. Those who are sexually active with multiple partners
d. Injection drugs users
e. Sex workers and their customers
f. Adults over the age of 65 years
ANS: B, C, D, E
m
The CDC recommends that HIV testing would be performed on those who received a
transfusion between 1978 and 1985 only. People planning on getting married should be tested
and all sexually active people should know their HIV status. Those engaged in sex work and
their customers should also be tested, as well as injection drug users. Those over the age of 65
years need a one-time screen.
co
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: HIV disease, Secondary prevention
MSC: Client Needs Category: Health Promotion and Maintenance
9. A nurse begins a job at a Veterans Administration Hospital and asks why so much emphasis is
ANS: A, B, C, D, E
nk
s.
on HIV testing for the veterans. What reasons is this nurse given? (Select all that apply.)
a. Veterans have a high prevalence of substance abuse.
b. Many veterans may engage in high risk behaviors.
c. Many older veterans may not know their risks.
d. Everyone should know their HIV status.
e. Belief that the VA has tested them and would notify them if positive.
ba
All options are correct for the veteran population. The nurse interacting with veteran would
ensure they know about the HIV testing offered by the VA.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: HIV disease, Veterans' health considerations
MSC: Client Needs Category: Health Promotion and Wellness
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Chapter 18: Concepts of Care for Patients With Hypersensitivity (Allergy) and
Autoimmunity
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is teaching the client with systemic lupus erythematosus about prednisone. What
information is the priority?
a. Might make the client feel jittery or nervous.
b. Can cause sodium and fluid retention.
c. Long-term effects include fat redistribution.
d. Never stop prednisone abruptly.
ANS: D
co
m
The nurse teaches the client to avoid stopping the drug abruptly as the priority because this
can lead to a life-threatening adrenal crisis. Short-term side effects do include jitteriness or
nervousness, sodium and water retention. One long-term side effect is fat redistribution
resulting in “moon face” and “buffalo hump.”
s.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: SLE, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help
ba
ANS: B
nk
prevent a client from having a type II hypersensitivity reaction?
a. Administering steroids for a positive TB test
b. Correctly identifying the client prior to a blood transfusion
c. Keeping the client free of the offending agent
d. Providing a latex-free environment for the client
st
A classic example of a type II hypersensitivity reaction is a blood transfusion reaction. These
can be prevented by correctly identifying the client and cross-checking the unit of blood to be
administered. A positive type IV response is a positive TB test. Avoidance therapy is the
cornerstone of treatment for a type IV hypersensitivity to substances that are known and can
be avoided such as poison ivy and insect stings. Latex allergies are a type I hypersensitivity.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Hypersensitivities, Immunity
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. A client has been newly diagnosed with systemic lupus erythematosus and is reviewing
self-care measures with the nurse. Which statement by the client indicates a need to review the
material?
a. “I will avoid direct sunlight as much as possible.”
b. “Baby powder is good for the constant sweating.”
c. “Grouping errands will help prevent fatigue.”
d. “Rest time will have to become a priority.”
ANS: B
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Constant sweating is not a sign of SLE and powders are drying so they should not be used, at
least not in excess. The client is correct in stating he/she should avoid direct sunlight, that
grouping errands can prevent or reduce fatigue, and that rest will have to become a priority.
DIF: Analyzing
TOP: Integrated Process: Teaching/Learning
KEY: SLE, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped
with over-the-counter antihistamines. What response by the nurse is most appropriate?
a. “Antihistamines do not help poison ivy.”
b. “There are different antihistamines to try.”
c. “You should be seen in the clinic right away.”
d. “You will need to take some IV steroids.”
ANS: A
co
m
Since histamine is not the mediator of a type IV reaction such as with poison ivy,
antihistamines will not provide relief. The nurse would educate the client about this. The
client does not need to be seen right away. The client may or may not need steroids; they may
be given either IV or orally.
s.
DIF: Understanding
TOP: Integrated Process: Communication and Documentation KEY: Hypersensitivities, Immunity
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
5. A nurse has educated a client on an epinephrine autoinjector. What statement by the client
ANS: A
ba
nk
indicates additional instruction is needed?
a. “I don’t need to go to the hospital after using it.”
b. “I must carry two autoinjectors with me at all times.”
c. “I will write the expiration date on my calendar.”
d. “This can be injected right through my clothes.”
st
Clients would be instructed to call 911 and go to the hospital for monitoring after using the
autoinjector. The medication may wear off before the offending agent has cleared the client’s
system. The other statements show good understanding of this treatment.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Allergic response, Drug therapy
MSC: Client Needs Category: Health Promotion and Maintenance
6. A nurse has presented an educational program to a community group on Lyme disease. What
statement by a participant indicates the need to review the material?
a. “I should take precautions against ticks, especially in the summer.”
b. “A red rash that looks like a bull’s-eye may be one of the symptoms.”
c. “If Lyme disease is not treated successfully, it is usually fatal.”
d. “For Stage I disease, antibiotics are usually needed for 14 to 21 days.”
ANS: C
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Untreated Lyme disease can lead to chronic complications, or Stage III Lyme disease, such as
arthritis, chronic fatigue, memory/thinking problems. It is not usually a fatal disease so this
information would need to be corrected by the nurse. The other participant statements are
correct.
DIF: Analyzing
TOP: Integrated Process: Teaching/Learning
KEY: Lyme disease, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
7. A client is in the hospital and has received two doses of an angiotensin-converting enzyme for
nk
s.
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m
hypertension. When the nurse answers the client’s call light, the client presents an appearance
as shown below:
ANS: C
ba
What action by the nurse takes is most appropriate?
a. Administer epinephrine 1:1000, 0.3 mg IV push immediately.
b. Apply oxygen by facemask at 100% and a pulse oximeter.
c. Ensure a patent airway while calling the Rapid Response Team.
d. Reassure the client that these symptoms will go away.
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This client has angioedema which is a severe type I hypersensitivity reaction and is most
commonly caused by ACE-inhibitors. The nurse would ensure the client’s airway is patent
and either call the Rapid Response Team or delegate this to someone else. Epinephrine needs
to be administered right away, but not without a prescription by the primary health care
provider unless standing orders exist. The client may need oxygen, but a patent airway comes
first. Reassurance is important, but airway and calling the Rapid Response Team are the
priorities.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Rapid Response Team, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
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1. The nurse is studying hypersensitivity reactions. Which reactions are correctly matched with
their hypersensitivity types? (Select all that apply.)
a. Type I—examples include hay fever and anaphylaxis.
b. Type II—mediated by action of immunoglobulin M (IgM).
c. Type III—immune complex deposits in blood vessel walls.
d. Type IV—examples are poison ivy and transplant rejection.
e. Type IV—involve both antibodies and complement.
ANS: A, C, D
Type I reactions are mediated by immunoglobulin E (IgE) and include hay fever, anaphylaxis,
and allergic asthma. Type III reactions consist of immune complexes that form and deposit in
the walls of blood vessels. Type IV reactions include responses to poison ivy exposure,
positive tuberculosis tests, and graft rejection. Type II reactions are mediated by
immunoglobulin G, not IgM. Type IV hypersensitivity reactions do not involve either
antibodies or complement.
m
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Hypersensitivities, Immunity
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
co
2. The nurse is assessing a client for signs and symptoms of systemic lupus erythematosus
nk
s.
(SLE). Which of the following would be consistent with this disorder? (Select all that apply.)
a. Discoid rash on skin exposed to sunlight
b. Urinalysis positive for casts and protein
c. Painful, deformed small joints
d. Pain on inspiration
e. Thrombocytosis
f. Serum positive for antinuclear antibodies (ANA)
ANS: A, B, D, F
ba
Signs and symptoms of SLE include (but are not limited to) a discoid rash on skin exposed to
the sun, urinalysis with casts and protein, pleurisy as manifested by pain on inspiration, and
positive ANA titers in the blood. Nonerosive arthritis in peripheral joints can occur but does
not lead to deformity. Thrombocytopenia is another sign.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: SLE, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A client is being administered the first dose of belimumab for a systemic lupus erythematosus
flare. What actions by the nurse are most appropriate? (Select all that apply.)
a. Observe the client for at least 2 hours afterward.
b. Instruct the client about the monthly infusion schedule.
c. Inform the client not to drive or sign legal papers for 24 hours.
d. Ensure emergency equipment is working and nearby.
e. Make a follow-up appointment for a lipid panel in 2 months.
f. Instruct the client to hold other medications for 72 hours.
ANS: A, D
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This drug is a monoclonal antibody to tumor necrosis factor. The first dose would be
administered in a place where severe allergic reactions and/or anaphylaxis can be managed.
This includes having emergency equipment nearby. The client would be observed for at least
2 hours after this first dose. This drug does not cause drowsiness, so there would be no
restrictions on driving or signing legal documents. Elevated lipids are not associated with this
drug. This drug is used in combination with other therapies, especially during a flare.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: SLE, Drug therapy
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
4. A nurse caring for clients with systemic lupus erythematosus (SLE) plans care understanding
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the most common causes of death for these clients is which of the following? (Select all that
apply.)
a. Infection
b. Cardiovascular impairment
c. Vasculitis
d. Chronic kidney disease
e. Liver failure
f. Blood dyscrasias
ANS: B, D
s.
Any and all organs and tissues may be affected in SLE but the most common causes of death
in clients with SLE include cardiovascular impairment and chronic kidney disease.
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ba
nk
DIF: Remembering
TOP: Integrated Process: Nursing Process: Planning
KEY: SLE, Complications
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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Chapter 19: Concepts of Cancer Development
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse learning about cellular regulation understands that which process occurs during the
S phase of the cell cycle?
a. Actual division (mitosis)
b. Doubling of DNA
c. Growing extra membrane
d. No reproductive activity
ANS: B
m
During the S phase, the cell must double its DNA content through DNA synthesis. Actual
division, or mitosis, occurs during the M phase. Growing extra membrane occurs in the G1
phase. During the G0 phase, the cell is working but is not involved in any reproductive
activity.
co
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Cancer development
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
nk
s.
2. A nurse asks the staff development nurse what “apoptosis” means. What response best?
a. Growth by cells enlarging
b. Having the normal number of chromosomes
c. Inhibition of cell growth
d. Programmed cell death
ANS: D
ba
Apoptosis is programmed cell death. With this characteristic, organs and tissues function with
cells that are at their peak of performance. Growth by cells enlarging is hyperplasia. Having
the normal number of chromosomes is euploidy. Inhibition of cell growth is contact
inhibition.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Cancer development
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse is learning the difference between normal cells and benign tumor cells. What
information does this include?
a. Benign tumors grow through invasion of other tissue.
b. Benign tumors have lost their cellular regulation from contact inhibition.
c. Growing in the wrong place or time is typical of benign tumors.
d. The loss of characteristics of the parent cells is called anaplasia.
ANS: C
Benign tumors are basically normal cells growing in the wrong place or at the wrong time.
Benign cells grow through hyperplasia, not invasion. Benign tumor cells retain contact
inhibition. Anaplasia is a characteristic of cancer cells.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
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KEY: Cancer development
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A nurse learns that which of the following is the single biggest risk factor for developing
cancer?
a. Exposure to tobacco
b. Advancing age
c. Occupational chemicals
d. Oncovirus infection
ANS: B
The single biggest risk factor for developing cancer is advancing age. As one ages, immunity
decreases and exposures increase. Tobacco use is the single most preventable cause of cancer.
Exposure to chemicals and oncoviruses cause fewer cancers.
m
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Cancer development
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
s.
co
5. Which statement about carcinogenesis is accurate?
a. An initiated cell will always become clinical cancer.
b. Cancer becomes a health problem once it is 1 cm in size.
c. Normal hormones and proteins do not promote cancer growth.
d. Tumor cells need to develop their own blood supply.
ANS: D
nk
Tumors need to develop their own blood supply through a process called angiogenesis. An
initiated cell needs a promoter to continue its malignant path. Normal hormones and proteins
in the body can act as promoters. A 1-cm tumor is a detectable size, but other events have to
occur for it to become a health problem.
ba
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Cancer development
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
st
6. The nurse caring for oncology clients knows that which form of metastasis is the most
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common?
a. Bloodborne
b. Direct invasion
c. Lymphatic spread
d. Via bone marrow
ANS: A
Bloodborne metastasis is the most common way for cancer to metastasize. Direct invasion and
lymphatic spread are other methods. Bone marrow is not a medium in which cancer spreads,
although cancer can occur in the bone marrow.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Cancer development
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. A nurse is assessing a client with glioblastoma. What assessment is most important?
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a.
b.
c.
d.
Abdominal palpation
Abdominal percussion
Lung auscultation
Neurologic examination
ANS: D
A glioblastoma arises in the brain. The most important assessment for this client is the
neurologic examination.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cancer development
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
8. A nurse has taught a client about dietary changes that can reduce the chances of developing
m
cancer. What statement by the client indicates the nurse needs to provide additional teaching?
a. “Foods high in vitamin A and vitamin C are important.”
b. “I’ll have to cut down on the amount of bacon I eat.”
c. “I’m so glad I don’t have to give up my juicy steaks.”
d. “Vegetables, fruit, and high-fiber grains are important.”
co
ANS: C
To decrease the risk of developing cancer, one should cut down on the consumption of red
meats and animal fat. The other statements are correct.
nk
s.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Cancer development, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
9. A client is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse
st
ANS: D
ba
reads in the client’s chart that the cancer classification is TISN0M0. What does the nurse
conclude about this client’s cancer?
a. The primary site of the cancer cannot be determined.
b. Regional lymph nodes could not be assessed.
c. There are multiple lymph nodes involved already.
d. There are no distant metastases noted in the report.
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TIS stands for carcinoma in situ; N0 stands for no regional lymph node metastasis; and M0
stands for no distant metastasis.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cancer development, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
10. A client asks the nurse if eating only preservative- and dye-free foods will decrease cancer
risk. What response by the nurse is best?
a. “Maybe; preservatives, dyes, and preparation methods may be risk factors.”
b. “No; research studies have never shown those things to cause cancer.”
c. “There are other things you can do that will more effectively lower your risk.”
d. “Yes; preservatives and dyes are well known to be carcinogens.”
ANS: A
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Dietary factors related to cancer development are poorly understood, although dietary
practices are suspected to alter cancer risk. Suspected dietary risk factors include low-fiber
intake and a high intake of red meat or animal fat. Preservatives, preparation methods, and
additives (dyes, flavorings, sweeteners) may have cancer-promoting effects. It is correct to say
that other things can lower risk more effectively, but this does not give the client concrete
information about how to do so, and also does not answer the client’s question.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Cancer development, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
1. The nurse learning about cancer development remembers characteristics of normal cells.
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Which characteristics does this include? (Select all that apply.)
a. Differentiated function
b. Large nucleus-to-cytoplasm ratio
c. Loose adherence
d. Nonmigratory
e. Specific morphology
f. Orderly and specific growth
ANS: A, D, E, F
nk
s.
Normal cells have the characteristics of differentiated function, nonmigratory, specific
morphology, a smaller nucleus-to-cytoplasm ratio, tight adherence, and orderly and
well-regulated growth.
ba
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Cancer development
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. The nurse working with oncology clients understands that interacting factors affect cancer
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development. Which factors does this include? (Select all that apply.)
a. Exposure to carcinogens
b. Genetic predisposition
c. Immune function
d. Normal doubling time
e. State of euploidy
ANS: A, B, C
The three interacting factors needed for cancer development are exposure to carcinogens,
genetic predisposition, and immune function.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Cancer development
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse is participating in primary prevention efforts directed against cancer. In which
activities is this nurse most likely to engage? (Select all that apply.)
a. Demonstrating breast self-examination methods to women
b. Instructing people on the use of chemoprevention
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c.
d.
e.
f.
Providing vaccinations against certain cancers
Screening teenage girls for cervical cancer
Teaching teens the dangers of tanning booths
Educating adults about healthy eating habits
ANS: B, C, E, F
Primary prevention aims to prevent the occurrence of a disease or disorder, in this case cancer.
Secondary prevention includes screening and early diagnosis. Primary prevention activities
include teaching people about chemoprevention, providing approved vaccinations to prevent
cancer, teaching teens the dangers of tanning beds, and educating adults on eating habits to
reduce the risk of getting cancer. Breast examinations and screening for cervical cancer are
secondary prevention methods.
m
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Cancer development, Primary prevention
MSC: Client Needs Category: Health Promotion and Maintenance
ANS: A, B, C, E, F
s.
are included? (Select all that apply.)
a. A sore that does not heal
b. Changes in menstrual patterns
c. Indigestion or trouble swallowing
d. Near-daily abdominal pain
e. Obvious change in a mole
f. Frequent indigestion
co
4. A nurse is providing community education on the seven warning signs of cancer. Which signs
ba
nk
The seven warning signs for cancer can be remembered with the acronym CAUTION:
changes in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge,
thickening or lump in the breast or elsewhere, indigestion or difficulty swallowing, obvious
change in a wart or mole, and nagging cough or hoarseness. Abdominal pain is not a warning
sign.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Cancer development, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
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Chapter 20: Concepts of Care for Patients With Cancer
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse in the oncology clinic is providing preoperative education to a client just diagnosed
with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is
best?
a. Call the client at home the next day to review teaching.
b. Give the client information about a cancer support group.
c. Provide all the preoperative instructions in writing.
d. Reassure the client that surgery will be over soon.
ANS: A
s.
co
m
Clients are often overwhelmed at a sudden diagnosis of cancer and may be more
overwhelmed at the idea of a major operation so soon. This stress significantly impacts the
client’s ability to understand, retain, and recall information. The nurse would call the client at
home the next day to review the teaching and to answer questions. The client may or may not
be ready to investigate a support group, but this does not help with teaching. Giving
information in writing is important (if the client can read it), but in itself will not be enough.
Telling the client that surgery will be over soon is giving false reassurance and does nothing
for teaching.
nk
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Cancer, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
2. A nurse is caring for a client admitted for Non-Hodgkin’s lymphoma and chemotherapy. The
st
ANS: A
ba
client reports nausea, flank pain, and muscle cramps. What action by the nurse is most
important?
a. Request an order for serum electrolytes and uric acid.
b. Increase the client’s IV infusion rate.
c. Instruct assistive personnel to strain all urine.
d. Administer an IV antiemetic.
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This client’s reports are consistent with tumor lysis syndrome, for which he or she is at risk
due to the diagnosis. Early symptoms of TLS stem from electrolyte imbalances and can
include lethargy, nausea, vomiting, anorexia, flank pain, muscle weakness, cramps, seizures,
and altered mental status. The nurse would notify the primary health care provider and request
an order for serum electrolytes. Hydration is important in both preventing and managing this
syndrome, but the nurse would not just increase the IV rate. Assistive personnel may need to
strain the client’s urine and the client may need an antiemetic, but first the nurse would assess
the situation further by obtaining pertinent lab tests.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Cancer, Oncologic emergencies
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment.
Which action by the nurse is best?
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a.
b.
c.
d.
Ensure the client is placed in protective isolation.
Have pregnant visitors stay 6 feet from the client
No special action is necessary to care for this client.
Read the policy on handling radioactive excreta.
ANS: D
This type of radioisotope is excreted in body fluids and excreta (urine and feces) and would
not be handled directly. The nurse would read the facility’s policy for handling and disposing
of this type of waste. The other actions are not warranted.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Cancer, Radiation therapy
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
4. A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months
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after radiation therapy for breast cancer. What response by the nurse is most appropriate?
a. “Are you getting adequate rest and sleep each day?”
b. “It is normal to be fatigued even for months afterward.”
c. “This is not normal and I’ll let the primary health care provider know.”
d. “Try adding more vitamins B and C to your diet.”
ANS: B
s.
Radiation-induced fatigue can be debilitating and may last for months after treatment has
ended. Rest and adequate nutrition can affect fatigue, but it is most important that the client
(and family) understands this is normal.
nk
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Cancer, Radiation therapy
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A client tells the oncology nurse about an upcoming vacation to the beach to celebrate
ANS: B
st
ba
completing radiation treatments for cancer. What response by the nurse is most appropriate?
a. “Avoid getting salt water on the radiation site.”
b. “Do not expose the radiation area to direct sunlight.”
c. “Have a wonderful time and enjoy your vacation!”
d. “Remember you should not drink alcohol for a year.”
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The skin overlying the radiation site is extremely sensitive to sunlight after radiation therapy
has been completed. The nurse would inform the client to avoid sun exposure to this area.
This advice continues for 1 year after treatment has been completed. The other statements are
not appropriate.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Cancer, Radiation therapy
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is
most important?
a. Assessing the IV site and blood return every hour
b. Educating the client on side effects
c. Monitoring the client for nausea
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d. Providing warm packs for comfort
ANS: A
Intravenous chemotherapy can cause local tissue destruction if it extravasates into the
surrounding tissues. Peripheral IV lines are more prone to this than centrally placed lines. The
most important intervention is prevention, so the nurse would check hourly to ensure the IV
site is patent, or frequently depending on facility policy. Education and monitoring for side
effects such as nausea are important for all clients receiving chemotherapy. Warm packs may
be helpful for some drugs, whereas for others ice is more comfortable. would monitor the site
and check for blood return to prevent injury from infiltration or extravasation.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cancer, Chemotherapy
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
7. A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to
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administer the client’s oral chemotherapy medications. What action by the nurse is most
appropriate?
a. Crush the medications if the client cannot swallow them.
b. Give one medication at a time with a full glass of water.
c. No special precautions are needed for these medications.
d. Wear personal protective equipment when handling the medications.
ANS: D
nk
s.
During the administration of oral chemotherapy agents, nurses must take the same precautions
that are used when administering IV chemotherapy. This includes using personal protective
equipment. These medications cannot be crushed, split, or chewed. Giving one at a time is not
needed.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Cancer, Medication administration
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
8. The nurse working with oncology clients understands that which age-related change increases
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the older client’s susceptibility to infection during chemotherapy?
a. Decreased immune function
b. Diminished nutritional stores
c. Existing cognitive deficits
d. Poor physical reserves
ANS: A
As people age, there is an age-related decrease in immune function, causing the older adult to
be more susceptible to infection than other clients. Not all older adults have diminished
nutritional stores, cognitive dysfunction, or poor physical reserves.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Cancer, Older adult
MSC: Client Needs Category: Health Promotion and Maintenance
9. The nurse has educated a client on precautions to take with thrombocytopenia. What
statement by the client indicates a need to review the information?
a. “I will be careful if I need enemas for constipation.”
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b. “I will use an electric shaver instead of a razor.”
c. “I should only eat soft food that is either cool or warm.”
d. “I won’t be able to play sports with my grandkids.”
ANS: A
The thrombocytopenic client is at high risk for bleeding even from minor trauma. Due to the
risk of injuring rectal and anal tissue, the client should not use enemas or rectal thermometers.
This statement would indicate the client needs more information. The other statements are
appropriate for the thrombocytopenic client.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Cancer, Client safety
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
appropriate?
Assess the client for calf pain, warmth, and redness.
Instruct the client to call for help to get out of bed.
Obtain cultures as per the facility’s standing policy.
Place the client on protective Isolation Precautions.
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a.
b.
c.
d.
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10. A client has a platelet count of 9800/mm3 (9800  109/L). What action by the nurse is most
ANS: B
s.
A client with a platelet count this low is at high risk for serious bleeding episodes. To prevent
injury, the client would be instructed to call for help prior to getting out of bed. Calf pain,
warmth, and redness might indicate a deep vein thrombosis, not associated with low platelets.
Cultures and isolation relate to low white cell counts.
nk
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Cancer, Client safety
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
ba
11. A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL (61 mmol/L). The
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client is symptomatic but refuses blood transfusions. What medication does the nurse prepare
to administer?
a. Epoetin alfa
b. Filgrastim
c. Mesna
d. Dexrazoxane
ANS: A
The client’s hemoglobin is very low, so the nurse prepares to administer epoetin alfa, a
colony-stimulating factor that increases production of red blood cells. Filgrastim is for
neutropenia. Mesna is used to decrease bladder toxicity from some chemotherapeutic agents.
Dexrazoxane helps protect the heart from cardiotoxicity from other agents.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Cancer, Medications
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
12. A nurse works with clients who have alopecia from chemotherapy. What action by the nurse
takes priority?
a. Helping clients adjust to their appearance
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b. Reassuring clients that this change is temporary
c. Referring clients to a reputable wig shop
d. Teaching measures to prevent scalp injury
ANS: D
All of the actions are appropriate for clients with alopecia. However, the priority is client
safety, so the nurse would first teach ways to prevent scalp injury.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Cancer, Injury prevention
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
m
13. A client is receiving rituximab. What assessment by the nurse takes priority?
a. Blood pressure
b. Temperature
c. Oral mucous membranes
d. Pain
ANS: A
s.
co
Rituximab can cause infusion-related reactions, including hypotension, so monitoring blood
pressure is the priority. Other complications of this drug include fever with chills/rigors,
headache and abdominal pain, shortness of breath, bronchospasm, nausea and vomiting, and
rash. Assessing the client’s temperature and for pain are both pertinent assessments, but do
not take priority over the blood pressure. Oral mucus membrane assessment is important for
clients with cancer, but are not specific for this treatment.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cancer, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
st
ANS: C
ba
14. A client is receiving rituximab and asks how it works. What response by the nurse is best?
a. “It causes rapid lysis of the cancer cell membranes.”
b. “It destroys the enzymes needed to create cancer cells.”
c. “It prevents the start of cell division in the cancer cells.”
d. “It sensitizes certain cancer cells to chemotherapy.”
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e
Rituximab prevents the initiation of cancer cell division. The other statements are not
accurate.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Cancer, Biological response modifiers
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
15. Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients would
the nurse assess first?
a. Dry, itchy, peeling skin
b. Serum calcium of 9.2 mg/dL (2.3 mmol/L)
c. Serum potassium of 2.8 mEq/L (2.8 mmol/L)
d. Weight gain of 0.5 lb (1.1 kg) in 1 day
ANS: C
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TKIs can cause electrolyte imbalances. This potassium level is very low, so the nurse would
assess this client first. Dry, itchy, peeling skin can be a problem in clients receiving cancer
treatments, and the nurse would assess that client next because of the potential for discomfort
and infection. This calcium level is normal. TKIs can also cause weight gain, but the client
with the low potassium level is more critical.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cancer, Biological response modifiers
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
16. A nurse is assessing a female client who is taking hormone therapy for breast cancer. What
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assessment finding requires the nurse to notify the primary health care provider immediately?
a. Irregular menses
b. Edema in the lower extremities
c. Ongoing breast tenderness
d. Red, warm, swollen calf
ANS: D
co
Clients receiving hormone therapy are at risk for thromboembolism. A red, warm, swollen
calf is indicative of deep vein thrombosis and would be reported to the provider. Irregular
menses, edema in the lower extremities, and breast tenderness are not as urgent as the possible
thromboembolism.
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cancer, Hormone therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
nk
17. A client with a history of prostate cancer is in the clinic and reports new onset of severe low
ANS: A
ba
back pain. What action by the nurse is most important?
a. Assess the client’s gait and balance.
b. Ask the client about the ease of urine flow.
c. Document the report completely.
d. Inquire about the client’s job risks.
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This client has symptoms of spinal cord compression, which can be seen with prostate cancer.
This may affect both gait and balance and urinary function. For client safety, assessing gait
and balance is most important. Documentation would be complete. The client may or may not
have occupational risks for low back pain, but with his history of prostate cancer, this would
not be where the nurse starts investigating.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cancer, Oncologic emergencies
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
18. The nurse has taught a client with cancer ways to prevent infection. What statement by the
client indicates that more teaching is needed?
a. “I should take my temperature daily and when I don’t feel well.”
b. “I will discard perishable liquids after sitting out for over an hour.”
c. “I won’t let anyone share any of my personal toiletries.”
d. “It’s alright for me to keep my pets and change the litter box.”
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ANS: D
Clients should wash their hands after touching their pets and would not empty or scoop the cat
litter box. The other statements are appropriate for self-management.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Cancer, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
19. A client with long-standing heart failure being treated for cancer has received a dose of
ondansetron for nausea. What action by the nurse is most important?
a. Assess the client for a headache or dizziness.
b. Request a prescription for cardiac monitoring
c. Instruct the client to change positions slowly.
d. Weigh the client daily before eating.
ANS: B
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5-HT3 antagonists, such as ondansetron, can prolong the QT interval within the cardiac
conduction cycle. ECG monitoring is recommended in patients with electrolyte abnormalities
(e.g., hypokalemia or hypomagnesemia), heart failure, bradyarrhythmias or patients taking
other medications that can cause QT prolongation. The nurse would contact the primary
health care provider and request cardiac monitoring. The nurse would assess the client for any
other reported changes, but this is not a critical safety factor. Weight is not related directly to
this drug.
nk
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Cancer, Client safety
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
20. A nurse working with clients who experience alopecia knows that which is the best method of
st
ANS: A
ba
helping clients manage the psychosocial impact of this problem?
a. Assisting the client to pre-plan for this event
b. Reassuring the client that alopecia is temporary
c. Teaching the client ways to protect the scalp
d. Telling the client that there are worse side effects
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Alopecia does not occur for all clients who have cancer, but when it does, it can be
devastating. The best action by the nurse is to teach the client about the possibility and to give
the client multiple choices for preparing for this event. Not all clients will have the same
reaction, but some possible actions the client can take are buying a wig ahead of time, buying
attractive hats and scarves, and having a hairdresser modify a wig to look like the client’s own
hair. Teaching about scalp protection is important but does not address the psychosocial
impact. Reassuring the client that hair loss is temporary and telling him or her that there are
worse side effects are both patronizing and do not give the client tools to manage this
condition.
DIF: Applying
TOP: Integrated Process: Caring
KEY: Cancer, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
21. A client is admitted with superior vena cava syndrome. What action by the nurse is most
appropriate?
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a.
b.
c.
d.
Administer a dose of allopurinol.
Assess the client’s serum potassium level.
Gently inquire about advance directives.
Prepare the client for emergency surgery.
ANS: C
Superior vena cava syndrome is often a late-stage manifestation. After the client is stabilized
and comfortable, the nurse would initiate a conversation about advance directives. Allopurinol
is used for tumor lysis syndrome. Potassium levels are important in tumor lysis syndrome, in
which cell destruction leads to large quantities of potassium being released into the
bloodstream. Surgery is rarely done for superior vena cava syndrome.
DIF: Applying
TOP: Integrated Process: Caring
KEY: Cancer, Oncologic emergencies
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
m
22. A client is having a catheter placed to deliver chemotherapy beads into a liver tumor via the
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femoral artery. What action by the nurse is most important?
a. Assessing the client’s abdomen beforehand
b. Ensuring that informed consent is on the chart
c. Marking the client’s bilateral pedal pulses
d. Reviewing client teaching done previously
ANS: B
nk
s.
This is an invasive procedure requiring informed consent. The nurse would ensure that
consent is on the chart. The other actions are also appropriate but not as important as ensuring
the client has given consent.
ba
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Cancer, Informed consent
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
23. A nurse works on an oncology unit and delegates personal hygiene to assistive personnel
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(AP). What action by the AP requires intervention from the nurse?
a. Allowing a very tired client to skip oral hygiene and sleep
b. Assisting clients with washing the perianal area every 12 hours
c. Helping the client use a soft-bristled toothbrush for oral care
d. Reminding the client to rinse the mouth with water or saline
ANS: A
Even though clients may be tired, they still need to participate in hygiene to help prevent
infection. The nurse would intervene and explain this to AP. The other options are all
appropriate.
DIF: Remembering
TOP: Integrated Process: Communication and Documentation
KEY: Cancer, Infection, Delegation (UAP)
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
24. A client with cancer has anorexia and mucositis, and is losing weight. The client’s family
members continually bring favorite foods to the client and are distressed when the client
won’t eat them. What action by the nurse is best?
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a.
b.
c.
d.
Explain the pathophysiologic reasons behind the client not eating.
Help the family show other ways to demonstrate love and caring.
Suggest foods and liquids the client might be willing to try to eat.
Tell the family the client isn’t able to eat now no matter what they bring.
ANS: B
Families often become distressed when their loved ones won’t eat. Providing food is a
universal sign of caring, and to some people the refusal to eat signifies worsening of the
condition. The best option for the nurse is to help the family find other ways to demonstrate
caring and love, because with treatment-related anorexia and mucositis, the client is not likely
to eat anything right now. Explaining the rationale for the problem is a good idea but does not
suggest to the family anything that they can do for the client. Simply telling the family the
client is not able to eat does not give them useful information and is dismissive of their
concerns.
KEY: Cancer, Nutrition
m
DIF: Applying
TOP: Integrated Process: Caring
MSC: Client Needs Category: Psychosocial Integrity
25. A client in the emergency department reports difficulty breathing. The nurse assesses the
ba
nk
s.
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client’s appearance as depicted below:
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ANS: A
st
What action by the nurse is most important?
a. Assess blood pressure and pulse.
b. Attach the client to a pulse oximeter.
c. Have the client rate his or her pain.
d. Facilitate urgent radiation therapy.
This client has superior vena cava syndrome, in which venous return from the head, neck, and
trunk is blocked. Decreased cardiac output can occur. The nurse would assess indicators of
cardiac output, including blood pressure and pulse, as the priority. The other actions are also
appropriate but are not as important. The ED nurse may or may not be able to facilitate
radiation therapy.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cancer, Oncologic emergencies
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
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1. The nurse caring for clients who have cancer understands that the general consequences of
cancer include which client problems? (Select all that apply.)
a. Clotting abnormalities from thrombocythemia
b. Increased risk of infection from white blood cell deficits
c. Nutritional deficits such as early satiety and cachexia
d. Potential for reduced gas exchange
e. Various motor and sensory deficits
f. Increased risk of bone fractures
ANS: A, B, C, D, E, F
The general consequences of cancer include reduced immunity and blood-producing
functions, altered GI structure and function, decreased respiratory function, and motor and
sensory deficits. Clotting problems often occur due to thrombocytopenia (not enough
platelets), not thrombocythemia (too many platelets).
m
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Cancer
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
ANS: A, B, C, F
s.
nk
(Select all that apply.)
a. “Chemo” gloves
b. Face mask
c. Impervious gown
d. N95 respirator
e. Shoe covers
f. Eye protection
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2. A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need?
ba
The Occupational Safety and Health Administration (OSHA) and the Oncology Nurses
Society have developed safety guidelines for those preparing or administering IV
chemotherapy. These include double gloves (or “chemo” gloves), eye protection, a face mask,
and a gown. An N95 respirator and shoe covers are not required.
st
DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Cancer, Medication safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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3. A client receiving radiation therapy reports severe skin itching and irritation. What actions
does the nurse delegate to assistive personnel (AP)? (Select all that apply.)
a. Apply approved moisturizers to dry skin.
b. Apply steroid creams to the skin.
c. Bathe the client using mild soap.
d. Help the client pat skin dry after a bath.
e. Teach the client to avoid sunlight.
f. Make sure no clothing is rubbing the site.
ANS: A, C, D, F
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The nurse can delegate applying moisturizer approved by the radiation oncologist using mild
soap for bathing, and helping the client pat wet skin dry after bathing. Any clothing worn over
the site should be soft and not create friction. Steroid creams are not used for this condition.
Hot water will worsen the irritation. Client teaching is a nursing function.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Cancer, Skin care, Delegation
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
4. A client has thrombocytopenia. What actions does the nurse delegate to assistive personnel
m
(AP)? (Select all that apply.)
a. Apply the client’s shoes before getting the client out of bed.
b. Assist the client with ambulation.
c. Shave the client with a safety razor only.
d. Use a lift sheet to move the client up in bed.
e. Use a water pressure device be set on low for oral care.
ANS: A, B, D
s.
co
Clients with thrombocytopenia are at risk of significant bleeding even with minor injuries.
The nurse instructs the AP to put the client’s shoes on before getting the client out of bed,
assist with ambulation, shave the client with an electric razor, use a lift sheet when needed to
reposition the client, and use a soft-bristled toothbrush for oral care. All of these measures
help prevent client injury.
nk
DIF: Understanding
TOP: Integrated Process: Communication and Documentation
KEY: Cancer, Client safety, Delegation
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
5. A client has mucositis. What actions by the nurse will improve the client’s nutrition? (Select
st
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all that apply.)
a. Assist with rinsing the mouth with saline frequently.
b. Encourage the client to eat room-temperature foods.
c. Give the client hot liquids to hold in the mouth.
d. Provide local anesthetic medications to swish and spit.
e. Remind the client to brush teeth gently after each meal.
f. Offer the client fluids to drink each hour.
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e
ANS: A, B, D, F
Mucositis can interfere with nutrition. The nurse can help with rinsing the mouth frequently
with water or saline; encouraging the client to eat cool, slightly warm, or room-temperature
foods; providing swish-and-spit anesthetics; and reminding the client to keep the mouth clean
by brushing gently after each meal. Drinking plenty of fluids (unless contraindicated for
another condition) is another beneficial measure. Hot liquids would be painful for the client.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Cancer, Oral care, Delegation
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
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6. A client’s family members are concerned that telling the client about a new finding of cancer
will cause extreme emotional distress. They approach the nurse and ask if this can be kept
from the client. What actions by the nurse are most appropriate? (Select all that apply.)
a. Ask the family to describe their concerns more fully.
b. Consult with a social worker, chaplain, or ethics committee.
c. Explain the client’s right to know and ask for their assistance.
d. Have the unit manager take over the care of this client and family.
e. Tell the family that this secret will not be kept from the client.
ANS: A, B, C
co
m
The client’s right of autonomy means that the client must be fully informed as to his or her
diagnosis and treatment options. The nurse cannot ethically keep this information from the
client. The nurse can ask the family to explain their concerns more fully so everyone
understands them. A social worker, chaplain, or ethics committee can become involved to
assist the nurse, client, and family. The nurse would explain the client’s right to know and ask
the family how best to proceed. Enlisting their help might reduce their reluctance for the client
to be informed. The nurse would not abdicate responsibility for this difficult situation by
transferring care to another nurse. Simply telling the family that he or she will not keep this
secret sets up an adversarial relationship. Explaining this fact along with the concept of
autonomy would be acceptable, but this by itself is not.
s.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Cancer, Ethical principles
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A client receiving chemotherapy has a white blood cell count of 1000/mm3 (1  109/L). What
ANS: A, C, D, E
ba
nk
actions by the nurse are most appropriate? (Select all that apply.)
a. Assess all mucous membranes every 4 to 8 hours.
b. Do not allow the client to eat meat or poultry.
c. Listen to lung sounds and monitor for cough.
d. Monitor the venous access device appearance hourly.
e. Take and record vital signs every 4 to 8 hours.
f. Encourage activity the client can tolerate.
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st
Depending on facility protocol, the nurse would assess this client for infection every 4 to 8
hours by assessing all mucous membranes, listening to lung sounds, monitoring for cough,
monitoring the appearance of the venous access device, and recording vital signs. Assisting
the client with mobilization will also help prevent infection. Eating meat and poultry is
allowed.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cancer, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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Chapter 21: Concepts of Care for Patients With Infection
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse learning about infection discovers that which factor is the best and most important
barrier to infection?
a. Colonization by host bacteria
b. Gastrointestinal secretions
c. Inflammatory processes
d. Skin and mucous membranes
ANS: D
m
The skin and mucous membranes are two of the most important barriers against infection. The
other options are also barriers, but are considered secondary to skin and mucous membranes.
co
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Infection
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nursing manager is concerned about the number of infections on the hospital unit. What
nk
s.
action by the manager would best help prevent these infections?
a. Auditing staff members’ hand hygiene practices
b. Ensuring clients are placed in appropriate isolation
c. Establishing a policy to remove urinary catheters quickly
d. Teaching staff members about infection control methods
ANS: A
ba
All methods will help prevent infection; however, health care workers’ lack of hand hygiene
is the biggest cause of health care–associated infections. The manager can start with a hand
hygiene audit to see if this is a contributing cause.
st
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Infection, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. An assistive personnel asks why brushing client s’ teeth with a toothbrush in the intensive care
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unit is important to infection control. What response by the registered nurse is best?
a. “It mechanically removes biofilm on teeth.”
b. “It’s easier to clean all surfaces with a brush.”
c. “Oral care is important to all our clients.”
d. “Toothbrushes last longer than oral swabs.”
ANS: A
Biofilms are a complex group of bacteria that function within a slimy gel on surfaces such as
teeth. Mechanical disruption (i.e., toothbrushing with friction) is the best way to control them.
The other answers are not accurate.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Infection, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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4. A client is admitted with possible sepsis. Which action will the nurse perform first?
a. Administer antibiotics.
b. Give an antipyretic.
c. Place the client in isolation.
d. Obtain specified cultures.
ANS: D
Prior to administering antibiotics, the nurse obtains the prescribed cultures. Broad-spectrum
antibiotics will be administered until the culture and sensitivity results are known.
Antipyretics are given if the client is uncomfortable; fever is a defense mechanism. Giving
antipyretics does not occur before obtaining cultures. The client may or may not need
isolation.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection, Medication administration
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
5. A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea.
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What action by the nurse is most important?
a. Consult with the primary health care provider about obtaining stool cultures.
b. Delegate frequent perianal care to assistive personnel.
c. Place the client on NPO status until the diarrhea resolves.
d. Request a prescription for an antidiarrheal medication.
ANS: A
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Hospitalized clients who have three or more stools a day for 2 or more days are suspected of
having infection with Clostridium difficile. The nurse will inform the primary health care
provider and request stool cultures. Frequent perianal care is important and can be delegated
but is not the most important action. The client does not necessarily need to be NPO; if the
client is NPO, the nurse ensures he or she is getting appropriate IV fluids to prevent
dehydration. Antidiarrheal medication may or may not be appropriate as the diarrhea serves as
the portal of exit for the infection.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Infection, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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6. A nurse is observing as an assistive personnel (AP) performs hygiene and provides comfort
measures to a client with an infection. What action by the AP requires intervention by the
nurse?
a. Not using gloves while combing the client’s hair
b. Rinsing the client’s commode pan after use
c. Ordering an oscillating fan for the client
d. Wearing gloves when providing perianal care
ANS: C
Fans in client care areas are discouraged because they can disperse airborne or droplet-borne
pathogens. The other actions are appropriate. If the client has a scalp infection or infestation,
the AP will wear gloves; otherwise, it is not required for grooming the hair.
DIF: Analyzing
TOP: Integrated Process: Communication and Documentation
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KEY: Infection, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
7. A client is to receive a fecal microbiota transplantation tomorrow (FMT). What action by the
nurse is best?
a. Administer bowel cleansing as prescribed.
b. Educate the client on immunosuppressive drugs.
c. Inform the client he/she will drink a thick liquid.
d. Place a nasogastric tube to intermittent suction.
ANS: A
The usual route of delivering an FMT is via colonoscopy, so the client would have a bowel
cleansing as prescribed for that procedure. The client will not need immunosuppressant drugs,
to drink the material, or have an NG tube inserted.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
8. A nurse manager is preparing an educational session for floor nurses on drug-resistant
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organisms. Which statement below indicates the need to review this information?
a. “Methicillin-resistant Staphylococcus aureus can be hospital- or
community-acquired.”
b. “Vancomycin-resistant Enterococcus can live on surfaces and be infectious for
weeks.”
c. Carbapenem-resistant Enterobacteriaceae is hard to treat due to enzymes that
break down antibiotics.”
d. “If you leave work wearing your scrubs, go directly home and wash them right
away.”
ANS: D
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To help prevent the transmission of an MDRO, wear scrubs and change clothes before leaving
work. Keep work clothes separate from personal clothes. The nursing manager would need to
correct his or her knowledge if he or she is letting staff know that wearing scrubs home is
alright. The other statements are correct about multi-drug resistant organisms.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
9. The nurse caring for clients admitted for infectious diseases understands what information
about emerging global diseases and bioterrorism?
a. Many infections are or could be spread by international travel.
b. Safer food preparation practices have decreased foodborne illnesses.
c. The majority of Americans have adequate innate immunity to smallpox.
d. Plague produces a mild illness and generally has a low mortality rate.
ANS: A
Increased global travel has resulted in the spread of many emerging diseases and has the
potential to spread diseases caused by bioterrorism. Foodborne illnesses are on the increase.
Many people in the United States have never been vaccinated against smallpox, and those
who have are not guaranteed life-long protection. Plague can be fatal.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection, Infection control
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. A client has been placed on Contact Precautions. The client’s family is very afraid to visit for
fear of being “contaminated” by the client. What action by the nurse is best?
a. Explain to them that these precautions are mandated by law.
b. Show the family how to avoid spreading the disease.
c. Reassure the family that they will not get the infection.
d. Tell the family it is important that they visit the client.
ANS: B
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Visitors may be apprehensive about visiting a client in Transmission-Based Precautions. The
nurse would reassure the visitors that taking appropriate precautions will minimize their risks.
The nurse would then demonstrate what precautions were needed. The other options do
nothing to ease the family’s fears.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Infection, Transmission-based precautions
MSC: Client Needs Category: Psychosocial Integrity
11. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA)
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infection cultured from the urine. What action by the nurse is most appropriate?
a. Prepare to administer vancomycin.
b. Strictly limit visitors to immediate family only.
c. Wash hands only after taking off gloves after care.
d. Wear a respirator when handling urine output.
ANS: A
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Vancomycin is one of a few drugs approved to treat MRSA. The others include linezolid and
ceftaroline fosamil. Delafloxacin is a new antibiotic approved to treat MRSA. Visitation does
not need to be limited to immediate family only. Hand hygiene is performed before and after
wearing gloves. A respirator is not needed, but if splashing is anticipated, a face shield can be
used.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection, Antibiotics
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
12. A hospitalized client is placed on Contact Precautions. The client needs to have a computed
tomography (CT) scan. What action by the nurse is most appropriate?
a. Ensure that the radiology department is aware of the Isolation Precautions.
b. Plan to travel with the client to ensure appropriate precautions are used.
c. No special precautions are needed when this client leaves the unit.
d. Notify the primary health care provider that the client cannot leave the room.
ANS: A
Clients in isolation will leave their rooms only when necessary, such as for a CT scan that
cannot be done portably in the room. The nurse will ensure that the receiving department is
aware of the Isolation Precautions needed to care for the client. The other options are not
needed.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Infection, Transmission-based precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
13. A nurse receives report from the laboratory on a client who was admitted for fever. The
laboratory technician states that the client has “a shift to the left” on the white blood cell
count. What action by the nurse is most important?
a. Document findings and continue monitoring.
b. Notify the primary health care provider and request antibiotics.
c. Place the client in protective isolation.
d. Tell the client this signifies inflammation.
ANS: B
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A shift to the left indicates an increase in immature neutrophils and is often seen in infections,
especially those caused by bacteria. The nurse will notify the primary health care provider and
request antibiotics (and cultures). Documentation and teaching need to be done, but the nurse
needs to do more. The client does not need protective isolation.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Infection, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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MULTIPLE RESPONSE
1. The nurse caring for clients understands that which factors must be present to transmit
ANS: B, C, D, E
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infection? (Select all that apply.)
a. Colonization
b. Host
c. Mode of transmission
d. Portal of entry
e. Reservoir
f. Poor hygiene
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Factors that must be present in order to transmit an infection include a host with a portal of
entry, a mode of transmission, and a reservoir. Colonization is not one of these factors. Poor
hygiene may or may not contribute to infection.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Infection
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. Which statements are true regarding Standard Precautions? (Select all that apply.)
a. Always wear a gown when performing hygiene on clients.
b. Sneeze into your sleeve or into a tissue that you throw away.
c. Remain 3 feet (1 m) away from any client who has an infection.
d. Use personal protective equipment as needed for client care.
e. Wear gloves when touching clients’ excretions or secretions.
f. Cohorting clients who have infections caused by the same organism.
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ANS: D, E
Standard Precautions implies that contact with bodily secretions, excretions, and moist
mucous membranes and tissues (excluding perspiration) is potentially infectious. Always wear
gloves when coming into contact with such material. Other personal protective equipment is
used based on the care being given. For example, if face splashing is expected, you will also
wear a mask. Wearing a gown for hygiene is not required. Sneezing into your sleeve or tissue
is part of respiratory etiquette. Remaining 3 feet (1 m) away from client is also not part of
Standard Precautions. Cohorting infectious clients can be used for deciding room/bed
placement, but is not part of Standard Precautions.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection, Standard precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. The nurse learns that effective antimicrobial therapy requires which factors to be present?
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(Select all that apply.)
a. Appropriate drug
b. Proper route of administration
c. Standardized peak levels
d. Sufficient dose
e. Sufficient length of treatment
f. Appropriate trough levels
ANS: A, B, D, E
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In order to be effective, antimicrobial therapy must use the appropriate drug in a sufficient
dose, for a sufficient length of time, and given via the appropriate route. Some antimicrobials
do require monitoring for peak and trough levels, but not all.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Infection, Antibiotics
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are
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best? (Select all that apply.)
a. Admit the client to a negative-airflow room.
b. Maintain a distance of 3 feet (1 m) from the client at all times.
c. Obtain specialized respirators for caregiving.
d. Other than wearing gloves, no special actions are needed.
e. Wash hands with chlorhexidine after providing care.
f. Assure client has a respirator for moving between departments.
ANS: A, C
A client with suspected TB is admitted to Airborne Precautions, which includes a
negative-airflow room and special N95 or PAPR masks to be worn when providing care. A
3-foot (1 m) distance without a mask is required for Droplet Precautions (a nurse providing
direct care cannot ensure that he or she will never need to be within 3 feet of the client).
Chlorhexidine is used for clients with a high risk of infection. When moving between
departments, the client wears a surgical mask.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
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KEY: Infection, Transmission-based precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5. A nurse asks the supervisor why older adults are more prone to infection than other adults.
What reasons does the supervisor give? (Select all that apply.)
a. Age-related decrease in immune function
b. Decreased cough and gag reflexes
c. Diminished acidity of gastric secretions
d. Increased lymphocytes and antibodies
e. Thinning skin that is less protective
f. Higher rates of chronic illness
ANS: A, B, C, E, F
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Older adults have several age-related changes making them more susceptible to infection,
including decreased immune function, decreased cough and gag reflex, decreased acidity of
gastric secretions, thinning skin, fewer lymphocytes and antibodies, and higher rates of
chronic illness.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Infection, Older adult
MSC: Client Needs Category: Health Promotion and Maintenance
6. A client with an infection has a fever. What actions by the nurse help increase the client’s
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ANS: B, C, F
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comfort? (Select all that apply.)
a. Administer antipyretics around the clock.
b. Change the client’s gown and linens when damp.
c. Offer cool fluids to the client frequently.
d. Place ice bags in the armpits and groin.
e. Provide a fan to help cool the client.
f. Sponging the client with tepid water.
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Comfort measures appropriate for this client include offering frequent cool drinks, and
changing linens or the gown when damp. Fever is a defense mechanism, and antipyretics will
be administered only when the client is uncomfortable. Ice bags can help cool the client
quickly but are not comfort measures. Fans are discouraged because they can disperse
microbes. Sponging the client’s body with tepid water is also helpful.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection, Comfort measures
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
7. A nurse plans care for a client who is at risk for infection. Which interventions will the nurse
implement to prevent infection? (Select all that apply.)
a. Administer prophylactic antibiotics.
b. Monitor white blood cell count and differential.
c. Screen all visitors for infections.
d. Implement Transmission-Based Precautions.
e. Promote sufficient nutritional intake.
ANS: B, C, E
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Nursing interventions for clients at risk for infection include monitoring white blood cell
count and differential, screening visitors for infections and infectious disease, and promoting
sufficient nutritional intake. Standard Precautions are required but not Transmission-Based
Precautions. Prophylactic antibiotics are not generally used to prevent infections.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection, Infection control
MSC: Client Needs Category: Health Promotion and Maintenance
8. A nurse cares for several clients on an inpatient unit. Which infection control measures will
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the nurse implement? (Select all that apply.)
a. Wear a gown when contact of clothing with body fluids is anticipated.
b. Teach clients and visitors respiratory hygiene techniques.
c. Obtain powered air purifying respirators for all staff members.
d. Do not use alcohol-based hand rub between client contacts.
e. Disinfect frequently touched surfaces in client-care areas.
ANS: A, B, E
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Infection control measures appropriate to all clients include hand hygiene with alcohol-based
hand rub or soap between client contact, procedures for routine care, cleaning and disinfection
of frequently contaminated surfaces, and wearing personal protective equipment when
contamination is anticipated. Client and visitors would be instructed on appropriate
respiratory hygiene and cough etiquette. No information in the stem indicates the clients need
anything more than Standard Precautions.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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Chapter 22: Assessment of the Skin, Hair, and Nails
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. While assessing a client, a nurse detects a bluish tinge to the client’s palms, soles, and mucous
membranes. Which action will the nurse take next?
a. Ask the client about current medications he or she is taking.
b. Use pulse oximetry to assess the patient’s oxygen saturation.
c. Auscultate the patient’s lung fields for adventitious sounds.
d. Palpate the patient’s bilateral radial and pedal pulses.
ANS: B
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Cyanosis can be present when impaired gas exchange occurs. In a client with dark skin,
cyanosis can be seen because the palms, soles, and mucous membranes have a bluish tinge.
The nurse will assess for systemic oxygenation before continuing with other assessments.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Skin, hair, and nail, Assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
2. A nurse assesses a client who has inflamed soft-tissue folds around the nail plates. Which
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question will the nurse ask to elicit useful information about the possible condition?
a. “What do you do for a living?”
b. “Are your nails professionally manicured?”
c. “Do you have diabetes mellitus?”
d. “Have you had a recent fungal infection?”
ANS: A
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The condition chronic paronychia is common in people with frequent intermittent exposure to
water, such as homemakers, bartenders, and laundry workers. The other questions would not
provide information specifically related to this assessment finding.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Analysis
KEY: Skin, hair, and nail, Assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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3. A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question
will the nurse ask first?
a. “Are you using lotion on your skin?”
b. “Do you have a family history of this?”
c. “Do your arms itch?”
d. “What medications are you taking?”
ANS: D
Certain drugs such as aspirin, warfarin, and corticosteroids can lead to easy or excessive
bruising, which can result in ecchymosis. The other options would not provide information
about bruising.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Skin, hair, and nail, Assessment, Medication side effects
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MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. After teaching a client who expressed concern about a rash located beneath her breast, a nurse
assesses the client’s understanding. Which statement indicates the client has a good
understanding of this condition?
a. “This rash is probably due to fluid overload.”
b. “I need to wash this daily with antibacterial soap.”
c. “I can use powder to keep this area dry.”
d. “I will schedule a mammogram as soon as I can.”
ANS: C
Rashes limited to skinfold areas (e.g., on the axillae, beneath the breasts, in the groin) may
reflect problems related to excessive moisture. The client needs to keep the area dry; one
option is to use powder. Good hygiene is important, but the rash does not need an antibacterial
soap. Fluid overload and breast cancer are not related to rashes in skinfolds.
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DIF: Analyzing
TOP: Integrated Process: Teaching/Learning
KEY: Skin, hair, and nail, Assessment
MSC: Client Needs Category: Health Promotion and Maintenance
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5. A nurse assesses an older client who has two skin lesions on the chest. Each lesion is the size
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of a nickel, flat, and darker in color than the rest of the client’s skin. What does the nurse tell
the client regarding these lesions?
a. “Monitor these spots for any changes.”
b. “You don’t need to worry about these.”
c. “I will ask for a dermatology referral for you.”
d. “We need to schedule you for a skin biopsy.”
ANS: A
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Because of melanocyte hyperplasia, the older adult frequently has “age spots,” or darker spots
on the skin. The nurse would teach the client to monitor the spots and report any changes
indicative of cancer. Stating the client does not need to worry is inaccurate and dismissive.
The client does not necessarily need a dermatology referral and does not need a skin biopsy at
this point.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Skin, hair, and nail, Assessment
MSC: Client Needs Category: Health Promotion and Maintenance
6. A nurse cares for an older adult client who has a chronic skin disorder. The client states, “I
have not been to church in several weeks because of the discoloration of my skin.” How will
the nurse respond?
a. “I will consult the chaplain to provide you with spiritual support.”
b. “You do not need to go to church; God is everywhere.”
c. “Tell me more about your concerns related to your skin.”
d. “Religious people are nonjudgmental and will accept you.”
ANS: C
Clients with chronic skin disorders often become socially isolated related to the fear of
rejection by others. Nurses will assess how the client’s skin changes are affecting his or her
body image and encourage the client to express feelings about a change in appearance. The
other statements are dismissive of the client’s concerns.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Skin, hair, and nail, Assessment, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
7. A nurse assesses a client who has open skin lesions. Which action by the nurse is most
important?
a. Put on gloves.
b. Ask the client about his or her occupation.
c. Assess the client’s pain.
d. Obtain vital signs.
ANS: A
Nurses wear gloves as part of Standard Precautions when examining skin that is not intact.
The other options are part of the full assessment but adhering to Standard Precautions is
important for safety and infection control.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Skin, hair, and nail, Assessment, Standard Precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
8. The nurse reads on a chart that a client has lichenification. What assessment finding confirms
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this description?
a. Increased skin thickness
b. Excessive facial hair
c. Purple skin patches
d. Tightly stretched skin
ANS: A
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Lichenification is increased skin thickness as the result of scarring. Excessive facial hair (or
body hair) is hirsutism. Purple patches on the skin are purpura. Tightly stretched skin is from
edema.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Skin, hair, and nail, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. A nurse assesses a client and identifies that the client has pale conjunctivae. Which focused
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assessment will the nurse complete next?
a. Partial thromboplastin time
b. Hemoglobin and hematocrit
c. Liver enzymes
d. Basic metabolic panel
ANS: B
Pale conjunctivae signify anemia. The nurse will assess the client’s hemoglobin and
hematocrit to confirm anemia. The other laboratory results do not relate to this client’s
potential anemia.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Skin, hair, and nail, Assessment, Laboratory results
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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10. During skin inspection, the nurse observes lesions with wavy borders that are widespread
across the client’s chest. Which descriptors will the nurse use to document these observations?
a. Clustered and annular
b. Linear and circinate
c. Diffuse and serpiginous
d. Coalesced and circumscribed
ANS: C
“Diffuse” is used to describe lesions that are widespread. “Serpiginous” describes lesions with
wavy borders. “Clustered” describes lesions grouped together. “Linear” describes lesions
occurring in a straight line. Annular lesions are ring like with raised borders, circinate lesions
are circular, and circumscribed lesions have well-defined sharp borders. “Coalesced”
describes lesions that merge with one another and appear confluent.
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DIF: Remembering
TOP: Integrated Process: Communication and Documentation
KEY: Skin, hair, and nail, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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11. A nurse assesses an older adult client with the skin disorder shown below:
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How will the nurse document this finding?
a. Petechiae
b. Ecchymoses
c. Actinic lentigo
d. Senile angiomas
ANS: A
Petechiae, or small, reddish purple nonraised lesions that do not fade or blanch with pressure,
are pictured here. Ecchymoses are larger areas of hemorrhaging, commonly known as
bruising. Actinic lentigo presents as paper-thin, transparent skin. Senile angiomas, also known
as cherry angiomas, are red raised lesions.
DIF: Remembering
TOP: Integrated Process: Communication and Documentation
KEY: Skin, hair, and nail, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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MULTIPLE RESPONSE
1. A nurse assesses an older adult’s skin. Which findings require immediate referral? (Select all
that apply.)
Excessive moisture under axilla
Increased hair thinning
Presence of toenail fungus
Lesion with various colors
Spider veins on legs
Asymmetric 6-mm dark lesion on forehead
a.
b.
c.
d.
e.
f.
ANS: D, F
The lesion with various colors, as well as the asymmetric 6-mm dark lesion, fits two of the
Skin Cancer Foundation’s hallmark signs for cancer according to the ABCDE method. Other
signs and symptoms, while not normal, are not cause for concern.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Skin, hair, and nail, Assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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2. A nurse plans care for a client who has a wound that is not healing. Which focused
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assessments will the nurse complete to develop the patient’s plan of care? (Select all that
apply.)
a. Height
b. Allergies
c. Alcohol use
d. Prealbumin laboratory results
e. Liver enzyme laboratory results
f. Weight
ANS: A, C, D, E
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Nutritional status can have a significant impact on skin health and wound healing. The care
plan for a client with poor nutritional status will include a high-protein, high-calorie diet. To
determine the patient’s nutritional status, the nurse will assess height and weight, alcohol use,
and prealbumin laboratory results. These data will provide information related to vitamin and
protein deficiencies, and body mass. Allergies and liver enzyme laboratory results will not
provide information about nutrition status or wound healing.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Skin, hair, and nail, Assessment, Nutrition
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A client has multiple lesions all over the body and a family history of skin cancer. The nurse
teaches the client to perform a total skin self-examinations on a monthly basis. Which
statements will the nurse include in this patient’s teaching? (Select all that apply.)
a. “Look for asymmetry of shape and irregular borders.”
b. “Assess for color variation within each lesion.”
c. “Examine the distribution of lesions over a section of the body.”
d. “Monitor for edema or swelling of tissues.”
e. “Focus your assessment on skin areas that itch.”
f. “Report any lesions that change over time in any way.”
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ANS: A, B, F
Patients will be taught to examine each lesion following the ABCDE features associated with
skin cancer: asymmetry of shape, border irregularity, color variation within one lesion,
diameter greater than 6 mm, and evolving or changing in any feature.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Skin, hair, and nail, Assessment, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
4. A nurse assesses a client who presents with early koilonychias. Which assessments will the
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nurse complete next? (Select all that apply.)
a. Review the client’s health history for a diagnosis of iron deficiency anemia.
b. Palpate the client’s nail base for potential edemata and sponginess.
c. Ask the client about prolonged contact with chemical irritants.
d. Assess the client for signs of chronic obstructive pulmonary disease.
e. Request a prescription to assess the client’s hemoglobin A1C.
ANS: A, E
s.
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Early koilonychias manifests as flattening of the nail plate with an increased smoothness of
the nail. This is caused by iron deficiency with or without anemia, poorly controlled diabetes,
and local injury. Nails with visible edema and sponginess when palpated are associated with
clubbing. Chronic obstructive pulmonary disease may cause clubbing of the nails and
chemical irritants are associated with late koilonychias.
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ba
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Skin, hair, and nail, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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Chapter 23: Concepts of Care for Patients With Skin Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse teaches a client who has pruritus. Which statement by the client shows a need to
review the information?
a. “I will shower daily using a super-fatted soap.”
b. “I can try taking a bath with colloidal oatmeal.”
c. “I will pat my skin dry instead of rubbing it with a towel.”
d. “I will be careful to keep my nails filed smoothly.”
ANS: D
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The client with pruritus should shower only every other day, although super-fatted soap is an
appropriate choice. Colloidal oatmeal baths are very soothing. Patting the skin dry avoids
trauma and injury. Keeping nails filed smoothly also prevents injury.
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DIF: Analyzing
TOP: Integrated Process: Teaching/Learning
KEY: Skin disorders, Health teaching
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
2. A nurse assesses clients on a medical-surgical unit. Which client is at greatest risk for pressure
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s.
injury development?
a. A 44 year old prescribed IV antibiotics for pneumonia
b. A 26 year old who is bedridden with a fractured leg
c. A 65 year old with hemiparesis and incontinence
d. A 78 year old requiring assistance to ambulate with a walker
ANS: C
st
ba
Risk factors for development of a pressure injury include lack of mobility, exposure of skin to
excessive moisture (e.g., urinary or fecal incontinence), malnourishment, and aging skin. The
client with hemiparesis and incontinence has two risk factors. The client with pneumonia has
no identified risk factors. The other two are at lower risk if they are not very mobile, but
having two risk factors is a higher risk.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Pressure injuries, Risk factors
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A nurse is caring for a client with an electrical burn. The client has entrance wounds on the
hands and exit wounds on the feet. What information is most important to include when
planning care?
a. The client may have memory and cognitive issues postburn.
b. Everything between the entry and exit wounds can be damaged.
c. The respiratory system requires close monitoring for signs of swelling.
d. Electrical burns increase the risk of developing future cancers.
ANS: B
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As the electricity enters the body, travels through various tissues, and exits, it damages all the
tissue it flows through. There may be severe internal injury that is not yet apparent. The client
may have cognitive issues postburn but this is not as important as vigilant monitoring for
complications. Respiratory system swelling is associated with thermal burns and smoke
inhalation. Exposure to radiation increases cancer risk.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: Burns
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. A nurse cares for a client who has a stage 3 pressure injury with copious exudate. What type
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of dressing does the nurse use on this wound?
a. Wet-to-damp saline moistened gauze
b. None, the wound is left open to the air
c. A transparent film
d. Multi-fiber superabsorbent dressing
ANS: D
co
This pressure injury requires a superabsorbent dressing that will collect the exudate but not
stick to the wound itself. A wet-to-damp gauze dressing provides mechanical removal of
necrotic tissue. A draining wound would not be left open. A transparent film is a good choice
for a noninfected stage 2 pressure injury.
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Pressure injuries, Wound care
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
nk
5. A nurse is caring for a client who has a nonhealing pressure injury on the right ankle. Which
ANS: D
ba
action would the nurse take first?
a. Draw blood for albumin, prealbumin, and total protein.
b. Prepare for and assist with obtaining a wound culture.
c. Instruct the client to elevate the foot.
d. Assess the right leg for pulses, skin color, and temperature.
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A client with an ulcer on the foot would be assessed for interruption in arterial flow to the
area. This begins with the assessment of pulses and color and temperature of the skin. The
nurse can also assess for pulses noninvasively with a Doppler flowmeter if unable to palpate
with his or her fingers. Tests to determine nutritional status and risk assessment would be
completed after the initial assessment is done. Wound cultures are done after it has been
determined that drainage, odor, and other risks for infection are present. Elevation of the foot
would impair the ability of arterial blood to flow to the area.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Pressure injuries, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A client has been brought to the emergency department after being covered in fertilizer after
an explosion and fire at a warehouse. What action by the nurse is best?
a. Assess the client’s airway.
b. Irrigate the client’s skin.
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c. Brush any visible dust off the skin.
d. Call poison control for guidance
ANS: A
With any burn client, assessing and maintaining the airway is paramount. Airway tissues can
swell quickly, cutting off the airway. The fertilizer would then be brushed off before
irrigation. Poison control may or may not need to be called.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Burns
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. After teaching a client who has a stage 2 pressure injury, a nurse assesses the client’s
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understanding. Which dietary choice by the client indicates a good understanding of the
teaching?
a. Green salad, a banana, whole wheat dinner roll, coffee
b. Chicken breast, broccoli, baked potato, ice water
c. Vegetable lasagna and green salad, iced tea
d. Hamburger, fruit cup, cookie, diet pop
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ANS: B
s.
Successful healing of pressure injuries depends on adequate intake of calories, protein,
vitamins, minerals, and water. The dinner with the chicken breast meets all these criteria. The
other dinners while having some healthy items each, are not as nutritious.
nk
DIF: Evaluating
TOP: Integrated Process: Teaching/Learning
KEY: Pressure injuries, Nutrition
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. A nurse assesses clients on a medical-surgical unit, all of whom have stage 2 or 3 pressure
st
ANS: B
ba
injuries. Which client would the nurse evaluate further for a wound infection?
a. WBC 9200 mm/L3 (9.2  109)
b. Boggy feel to granulation tissue
c. Increased size after debridement
d. Requesting pain medication
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Wound infection may or may not occur in the presence of signs of systemic infection, but a
change in the appearance, texture, color, drainage, or size of a wound (except after
debridement) is indicative of possible infection. The nurse would assess the client with boggy
granulation tissue further. The WBC is normal. After debridement, the wound may look
larger. If the client needs a sudden increase in the amount or frequency of pain medication that
would be another indicator, but there is no evidence this client has more pain than usual.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Pressure injuries, Infection
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
9. A nurse is teaching a client and family about self-care at home for the client’s wound infected
with methicillin-resistant Staphylococcus aureus. What statement by the client indicates a
need to review the information?
a. “I will keep dry bandages on the wound and change them when drainage appears.”
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b. “I will shower instead of taking a bath in the bathtub each day.”
c. “If the dressing is dry, I can sit or sleep anywhere in the house.”
d. “I will clean exposed household surfaces with a bleach and water mixture.”
ANS: C
The client should not sit on upholstered furniture or sleep in the same bed as another person
until the infection has cleared. The other statements show good understanding.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Skin disorders, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. A nurse is assessing a client who has a recent diagnosis of melanoma for understanding of
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treatment choices. What statement by the client indicates good understanding of the
information?
a. “Dermabrasion or chemical peels can be done in the office.”
b. “I may need lymph node resection during Mohs surgery.”
c. “This needs only a small excision with local anesthetic.”
d. “After surgery I will need 8 weeks of radiation therapy.”
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ANS: B
s.
Melanoma is usually treated with Mohs micrographic surgery, in which tissue is sectioned
horizontally in layers and examined histologically, layer by layer, to assess for cancer cells.
Dermabrasion and chemical peels can be used on actinic keratoses. Local anesthetic for small
excisions is generally used on basal or squamous cell carcinomas. Radiation is usually not
used with melanoma.
nk
DIF: Analyzing
TOP: Integrated Process: Teaching/Learning
KEY: Skin cancer
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
ba
11. A nurse assesses an older client who is scratching and rubbing white ridges on the skin
ANS: A
st
between the fingers and on the wrists. Which action would the nurse take?
a. Request a prescription for permethrin.
b. Administer an antihistamine.
c. Assess the client’s airway.
d. Apply gloves to minimize friction.
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The client’s presentation is most likely to be scabies, a contagious mite infestation. The drugs
used to treat this infestation are ivermectin and permethrin. The nurse would contact the
primary care provider to request a prescription for one of the medications. Secondary
interventions may include medication to decrease the itching. The client’s airway is not at risk
with this skin disorder. Applying gloves will help prevent transmission.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Skin disorders, Medications
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
12. A client contacts the clinic to report a life-long mole has developed a crust with occasional
bleeding. What instruction by the nurse is most appropriate?
a. “Take monthly photographs of it so you can document any changes.”
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b. “Wash daily with warm water and gentle soap to prevent infection.”
c. “Keep the lesion covered with a bandage and triple antibiotic ointment.”
d. “Please make an appointment to be seen here as soon as possible.”
ANS: D
A lesion demonstrating a change in characteristics, such as oozing, crusting, bleeding, or
scaling, is suspicious for skin cancer. The nurse would instruct the client to come in for
evaluation. Monthly photographs are a good way to document skin changes, but the client
needs an assessment for skin cancer. The lesion can be washed and covered with a bandage
and ointment, but again, the client needs an evaluation for skin cancer.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Skin cancer
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
13. A nurse is teaching a client who has itchy, raised red patches covered with a silvery white
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scale how to care for this disorder. What statement by the client shows a need for further
information?
a. “At the next family reunion, I’m going to ask my relatives if they have anything
similar.”
b. “I have to make sure I keep my lesions covered, so I do not spread this to others.”
c. “I must avoid large crowds and sick people while I am taking adalimumab.”
d. “I will buy a good quality emollient to put on my skin each day.”
s.
ANS: B
ba
nk
This client has plaque psoriasis which is not a contagious disorder. The client does not have to
worry about spreading the condition to others. It is a condition that has hereditary links so it
would be correct for the client to inquire about other family members who are affects.
Adalimumab is a drug used to treat psoriasis and it has a black box warning about serious
infection risk and cancer risk, so the client needs to take precautions to avoid infectious
individuals. Emollients help keep the plaques soft and reduce itching.
st
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Skin disorders, Psoriasis
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
14. A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion
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does the nurse evaluate first?
a. Beige freckles on the backs of both hands.
b. Irregular mole with multiple colors on the leg.
c. Large cluster of pustules in the right axilla.
d. Thick, reddened papules covered by white scales.
ANS: B
This mole fits two of the criteria for being cancerous or precancerous: variation of color
within one lesion, and an indistinct or irregular border. Freckles are a benign condition.
Pustules could mean an infection, but it is more important to assess the potentially cancerous
lesion first. Psoriasis vulgaris manifests as thick reddened papules covered by white scales.
This is a chronic disorder and is not the priority.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Skin cancer, Nursing assessment
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MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
15. A nurse assesses a young female client who is prescribed tazarotene. Which question should
the nurse ask prior to starting this therapy?
a. “Do you spend a great deal of time in the sun?”
b. “Have you or any family members ever had skin cancer?”
c. “Which method of contraception are you using?”
d. “Do you drink alcoholic beverages?”
ANS: C
Tazarotene has many side effects. It is a known teratogen and can cause severe birth defects.
Strict birth control measures must be used during therapy. The other questions are not directly
related to this medication.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Skin disorders, Medications
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
16. A nurse is assessing clients with pressure injuries. Which wound description is correctly
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matched to its description?
a. Suspected deep tissue injury: nonblanchable deep purple or maroon.
b. Stage 2: may have visible adipose tissue and slough.
c. Stage 3: may have a pink or red wound bed.
d. Stage 4: wound bed is obscured with eschar or slough.
ANS: A
ba
nk
A suspected deep tissue injury is characterized by persistent, nonblanchable purple or maroon
discoloration. A stage 2 wound may have a pink of red would bed with granulation tissue. The
stage 3 wound may have visible adipose tissue and slough. A stage 4 wound is full-thickness
skin loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or bone. An
unstageable wound is obscured by eschar or slough making assessment impossible.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Pressure injuries, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
17. A new nurse reads a client has a wound “healing by second intention” and asks what that
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means. Which description by the charge nurse is most accurate?
a. “The wound edges have been approximated and stitched together.”
b. “The wound was stapled together after an infection was cleared up.”
c. “The wound is an open cavity that will fill in with granulation tissue.”
d. “The wound was contaminated by debris and can’t be closed at all.”
ANS: C
Wounds healing by second intention are deeper wounds that leave open cavities. These
wounds heal as connective tissue fills in the dead space. A wound that has its edges brought
together (approximated) and sutured or stapled together is said to be healing by first intention.
A wound that was left open while an infection healed and then is closed is an example of
healing by third intention. A wound that cannot be closed at all would be left to heal by
second intention.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
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KEY: Skin disorders, Wounds
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
18. A nurse assesses a client who has psoriasis. Which action would the nurse take first?
a. Don gloves and an isolation gown.
b. Shake the client’s hand and introduce self.
c. Assess for signs and symptoms of infections.
d. Ask the client if she might be pregnant.
ANS: B
Clients with psoriatic lesions are often self-conscious of their skin. The nurse would first
provide direct contact and touch without gloves to establish a good report with the client.
Psoriasis is not an infectious disease, nor is it contagious. The nurse would not need to wear
gloves or an isolation gown. Obtaining a health history and assessing for an infection and
pregnancy would be completed after establishing a report with the client.
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DIF: Applying
TOP: Integrated Process: Caring
KEY: Skin lesions, Wounds psoriasis
MSC: Client Needs Category: Psychosocial Integrity
19. A nurse is caring for a client whose Braden Scale score is 9. What intervention demonstrates a
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lack of evidence-based knowledge?
a. Requests a referral to a registered dietitian nutritionist.
b. Raises the head of the bed no more than 45 degrees.
c. Performs perineal cleansing every 2 hours.
d. Assesses the client’s entire skin surface daily.
ANS: B
ba
nk
A client with a Braden Scale score of 9 is at high risk for skin breakdown and requires
moderate to maximum assistance to prevent further breakdown. The nurse needs to keep the
head of the bed elevated to no more than 30 degrees to prevent shearing. An RDN
consultation, frequent perineal cleaning, and assessing the client’s entire skin surface are all
appropriate actions.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Pressure injuries
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
20. A nurse evaluates the following data in a client’s chart:
Laboratory Results
Wound Care Note
White blood cell count: 8000/mm3 Sacral ulcer: 4  2 
(8  109/L)
1.5 cm
Prealbumin: 15.2 mg/dL (152
mg/L)
Albumin: 4.2 mg/dL (42 mg/L)
Lymphocyte count: 2000/mm3 (2 
109/L)
Based on this information, which action would the nurse take?
a. Perform a neuromuscular assessment.
b. Request a dietary consult.
c. Initiate Contact Precautions.
d. Assess the client’s vital signs.
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Admission Note
A 66-year-old male with a
health history of a cerebral
vascular accident and
left-side paralysis
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ANS: B
The white blood cell count is not directly related to nutritional status. Albumin, prealbumin,
and lymphocyte counts all give information related to nutritional status. The prealbumin count
is a more specific indicator of nutritional status than is the albumin count. The albumin and
lymphocyte counts given are normal, but the prealbumin count is low. This puts the client at
risk for inadequate wound healing, so the nurse would request a dietary consult. The other
interventions do not address the information provided.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Pressure injuries, Nutrition
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
21. A nurse evaluates the following data in a client’s chart:
s.
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Admission Note
Prescriptions
Wound Care
A 78-year-old male with Warfarin sodium
Negative-pressure wound
a past medical history of (Coumadin)
therapy (NPWT) to leg
atrial fibrillation is
Sotalol (Betapace)
wound
admitted with a chronic
leg wound
Based on this information, which action would the nurse take first?
a. Assess the client’s vital signs and initiate continuous telemetry monitoring.
b. Contact the primary health care provider to discuss the treatment
c. Consult the wound care nurse to apply the VAC device.
d. Obtain a prescription for a low-fat, high-protein diet with vitamin supplements.
ANS: B
st
ba
nk
A client on anticoagulants is not a candidate for NPWT because of the incidence of bleeding
complications. The health care primary health care provider needs this information quickly to
plan other therapy for the client’s wound. The nurse would contact the wound care nurse after
alternative orders for wound care are prescribed. Vital signs and telemetry monitoring are
appropriate for a client who has a history of atrial fibrillation and would be implemented as
routine care for this client. A low-fat, high-protein diet with vitamin supplements will provide
the client with necessary nutrients for wound healing but can be implemented after wound
care, vital signs, and telemetry monitoring.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Wounds, Negative-pressure therapy
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
MULTIPLE RESPONSE
1. A nurse plans care for a client who is immobile. Which interventions would the nurse include
in this client’s plan of care to prevent pressure sores? (Select all that apply.)
a. Place a small pillow between bony surfaces.
b. Elevate the head of the bed to 45 degrees.
c. Limit fluids and proteins in the diet.
d. Use a lift sheet to assist with re-positioning.
e. Re-position the client who is in a chair every 2 hours.
f. Keep the client’s heels off the bed surfaces.
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g. Use a rubber ring to decrease sacral pressure when up in the chair.
ANS: A, D, F
A small pillow decreases the risk for pressure between bony prominences, a lift sheet
decreases friction and shear, and heels have poor circulation and are at high risk for pressure
sores, so they would be kept off hard surfaces. Head-of-the-bed elevation greater than 30
degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for
maintaining tissue integrity. Clients would be repositioned every hour while sitting in a chair.
A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Pressure injuries
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
2. A nurse is working with a client who has a painful rash consisting of grouped weeping and
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crusting lesions in distinct lines. What actions by the nurse are most appropriate? (Select all
that apply.)
a. Instruct the client to report lesions near the eyes.
b. Have the client take long, hot baths to soak the lesions.
c. Show the client how to make a baking soda compress.
d. Advise the client to avoid exposure to UV light rays.
e. Demonstrate proper use of antifungal medications.
f. Review appropriate hygiene measures.
s.
ANS: A, C
nk
This client has herpes zoster (shingles). Eye infection is possible, so the client should be
taught to report any lesions erupting near the eyes. Comfort measures can include compresses,
calamine lotions, and baking soda. Long hot baths are not recommended. Avoiding UV
lighting is important for herpes simplex. Herpes zoster is a viral disorder, so antifungal
medications are not used. Hygiene is not an issue causing an outbreak.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Skin disorders, Herpes zoster
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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3. The nurse learns that which age-related changes increase the potential for complications of
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burns? (Select all that apply.)
a. Thinner skin
b. Slower healing time
c. Decreased mobility
d. Hyperresponsive immune response
e. Increased risk of unnoticed sepsis
f. Pre-existing conditions
ANS: A, B, C, E, F
Age-related differences that can increase the risk of burns and complications of burns include
thinner skin, slower healing, decreased mobility, increased risk of infection that goes
unnoticed, and pre-existing conditions that can complicate recovery. The older adult has
decreased inflammatory and immune responses.
DIF: Understanding
KEY: Burns, Age-related differences
TOP: Integrated Process: Nursing Process: Planning
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MSC: Client Needs Category: Health Promotion and Maintenance
4. A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions
would the nurse ask to identify a possible trigger for worsening of this client’s psoriatic
lesions? (Select all that apply.)
a. “Have you eaten a large amount of chocolate lately?”
b. “Have you been under a lot of stress lately?”
c. “Have you recently used a public shower?”
d. “Have you been out of the country recently?”
e. “Have you recently had any other health problems?”
f. “Have you changed any medications recently?”
ANS: B, E, F
m
Outbreaks of psoriasis can be induced by stress, environmental triggers, certain medications,
skin injuries, infections, smoking, alcohol use, and obesity. Psoriatic lesions are not triggered
by chocolate, public showers, or international travel.
co
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Skin disorders, Psoriasis
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse cares for many clients with pressure injuries. What actions by the nurse are
ANS: A, B, D, E, F
nk
s.
considered best practice? (Select all that apply.)
a. Conduct ongoing assessments that include pain.
b. Use normal saline to cleanse around the pressure injury.
c. Soak eschar daily until it softens and can be removed.
d. Consult with a registered dietitian nutritionist.
e. Use antimicrobial agents to clean wounds that are infected.
f. Consider the use of adjuvant therapies for nonhealing wounds.
st
ba
Best practice for pressure injury wound management includes ongoing assessments that
include pain, using normal saline to clean gently around the wound, ensuring optimal nutrition
by involving a registered dietitian nutritionist, using an antimicrobial agent to clean wounds
that are anticipated to become infected, and considering the use of adjuvant therapies such as
stimulation, negative-pressure wound therapy, ultrasound, hyperbaric oxygen, and topical
growth factors. The nurse would not disturb stable eschar.
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e
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Pressure injuries, Assistive personnel (AP)
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A nurse cares for a client who reports discomfort related to eczematous dermatitis. Which
nonpharmacologic comfort measures would the nurse implement? (Select all that apply.)
a. Cool, moist compresses
b. Topical corticosteroids
c. Heating pad
d. Tepid bath with colloidal oatmeal
e. Back rub with baby oil
ANS: A, D
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For a client with eczematous dermatitis, the goal of comfort measures is to decrease
inflammation and help débride crusts and scales. The nurse would implement cool, moist
compresses and tepid baths with additives such as colloidal oatmeal. Topical corticosteroids
are a pharmacologic intervention. A heating pad and a back rub with baby oil are not
appropriate for this client and could increase inflammation and discomfort.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Skin disorders, Comfort measures
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
7. The nurse in the emergency department would arrange to transfer which burned clients to a
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burn center? (Select all that apply.)
a. 15% partial-thickness burn
b. Lightening injury
c. 7% partial-thickness burn
d. History of pulmonary edema
e. Healthy 67 year old
f. 4% partial-thickness burn to perineum
ANS: A, B, D, E, F
nk
s.
co
Clients with major burns are transferred to a burn center for specialized care. These include
any partial-thickness burn over 10% TBSA; any lightening injury; a burn injury in a client
with a history of pre-existing conditions that could complicate care or prolong recovery;
adults over the age of 60; and burns to the face, hands, feet, genitalia, perineum, or major
joints. The client with a 7% partial-thickness burn could be cared for in a hospital or a burn
center.
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st
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: Burns
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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Chapter 24: Assessment of the Respiratory System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse obtains the health history of a client who is recently diagnosed with lung cancer and
identifies that the client has a 60–pack-year smoking history. Which action is most important
for the nurse to take when interviewing this client?
a. Tell the client that he or she needs to quit smoking to stop further cancer
development.
b. Encourage the client to be completely honest about both tobacco and marijuana
use.
c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
d. Avoid giving the client false hope regarding cancer treatment and prognosis.
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ANS: C
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Smoking assessments and cessation information can be an uncomfortable and sensitive topic
among both clients and health care providers. The nurse would maintain a nonjudgmental
attitude in order to foster trust with the client. Telling the client he or she needs to quit
smoking is paternalistic and threatening. Assessing exposure to smoke includes more than
tobacco and marijuana. The nurse would avoid giving the client false hope but when taking a
history, it is most important to get accurate information.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Respiratory assessment
MSC: Client Needs Category: Psychosocial Integrity
2. A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with
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ANS: C
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the correct intervention?
a. Client reports being dizzy—nurse calls the Rapid Response Team.
b. Client’s heart rate is 55 beats/min—nurse withholds pain medication.
c. Client has reduced breath sounds—nurse calls primary health care provider
immediately.
d. Client’s respiratory rate is 18 breaths/min—nurse decreases oxygen flow rate.
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A potentially serious complication after biopsy is pneumothorax, which is indicated by
decreased or absent breath sounds. The primary health care provider needs to be notified
immediately. Dizziness without other data would not lead the nurse to call the RRT. If the
client’s heart rate is 55 beats/min, no reason is known to withhold pain medication. A
respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the
oxygen flow rate.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory assessment, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse assesses a client’s respiratory status. Which information is most important for the
nurse to obtain?
a. Average daily fluid intake.
b. Neck circumference.
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c. Height and weight.
d. Occupation and hobbies.
ANS: D
Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in
a client’s occupation and hobbies. Although it will be important for the nurse to assess the
client’s fluid intake, height, and weight, these will not be as important as determining his
occupation and hobbies. This is part of the I-PREPARE assessment model for particulate
matter exposure. Determining the client’s neck circumference will not be an important part of
a respiratory assessment.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A nurse observes that a client’s anteroposterior (AP) chest diameter is the same as the lateral
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chest diameter. Which question would the nurse ask the client in response to this finding?
a. “Are you taking any medications or herbal supplements?”
b. “Do you have any chronic breathing problems?”
c. “How often do you perform aerobic exercise?”
d. “What is your occupation and what are your hobbies?”
ANS: B
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The normal chest has an anteroposterior (AP or front-to-back) diameter ratio with the lateral
(side-to-side) diameter. This ratio normally is about 1:1.5. When the AP diameter approaches
the lateral diameter, and the ratio is 1:1, the client is said to have a barrel chest. Most
commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem,
such as chronic emphysema. It can also be seen in people who have lived at a high altitude for
many years. Medications, herbal supplements, and aerobic exercise are not associated with a
barrel chest. Although occupation and hobbies may expose a client to irritants that can cause
chronic lung disorders and barrel chest, asking about chronic breathing problems is more
direct and would be asked first.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse is assessing a client who is recovering from a lung biopsy. The client’s breath sounds
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are absent. While another nurse calls the Rapid Response Team, what action by the nurse
takes is most important?
a. Take a full set of vital signs.
b. Obtain pulse oximetry reading.
c. Ask the patient about hemoptysis.
d. Inspect the biopsy site.
ANS: B
Absent breath sounds may indicate that the client has a pneumothorax, a serious complication
after a needle biopsy or open lung biopsy. The nurse would first obtain a pulse oximetry
reading and perform other respiratory assessments. Temperature is not a priority. The nurse
can ask about other symptoms while conducting the assessment. The nurse would assess the
biopsy site and/or dressings, but this is not the first action.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory assessment, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention
would the nurse complete prior to the procedure?
a. Measure oxygen saturation before and after a 12-minute walk.
b. Verify that the client understands all possible complications.
c. Explain the procedure in detail to the client and the family.
d. Validate that informed consent has been given by the client.
ANS: D
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A thoracentesis is an invasive procedure with many potentially serious complications. The
nurse would ensure signed informed consent has been obtained. Verifying that the client
understands complications and explaining the procedure to be performed will be done by the
primary health care provider, not the nurse. Measurement of oxygen saturation before and
after a 12-minute walk is not a procedure unique to a thoracentesis.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Respiratory assessment, Diagnostic testing
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate
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action?
a. The client rates pain as a 5/10 at the site of the procedure.
b. A small amount of drainage from the site is noted.
c. Pulse oximetry is 93% on 2 L of oxygen.
d. The trachea is shifted toward the opposite side of the neck.
ANS: D
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A shift of central thoracic structures toward one side is a sign of a tension pneumothorax,
which is a medical emergency. The other findings are normal or near normal. The nurse
would report this finding immediately or call the Rapid Response Team.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory assessment, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
8. A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of
water. What action would the nurse take next?
a. Call the primary health care provider and request food and water for the client.
b. Provide the client with ice chips instead of a drink of water.
c. Assess the client’s gag reflex before giving any food or water.
d. Let the client have a small sip to see whether he or she can swallow.
ANS: C
The topical anesthetic used during the procedure will have affected the client’s gag reflex.
Before allowing the client anything to eat or drink, the nurse must check for the return of this
reflex.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
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KEY: Respiratory assessment, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
9. A nurse plans care for a client who is experiencing dyspnea and must stop multiple times
when climbing a flight of stairs. Which intervention would the nurse include in this client’s
plan of care?
a. Assistance with activities of daily living
b. Physical therapy activities every day
c. Oxygen therapy at 2 L per nasal cannula
d. Complete bedrest with frequent repositioning
ANS: A
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A client with dyspnea and the inability to complete activities such as climbing a flight of stairs
without pausing has class IV dyspnea. The nurse would provide assistance with activities of
daily living. These clients would be encouraged to participate in activities as tolerated. They
would not be on complete bedrest, may not be able to tolerate daily physical therapy, and only
need oxygen if hypoxia is present.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory assessment, Functional ability
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
10. A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement
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would the nurse include in this client’s teaching?
a. “Make a list of reasons why smoking is a bad habit.”
b. “Rise slowly when getting out of bed in the morning.”
c. “Smoking while taking this medication will increase your risk of a stroke.”
d. “Stopping this medication suddenly increases your risk for a heart attack.”
ANS: C
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Clients who smoke while using drugs for nicotine replacement therapy increase the risk of
stroke and heart attack. Nurses would teach clients not to smoke while taking these drugs. The
nurse would encourage the client to make a list of reasons for stopping the habit but would not
phrase it so judgmentally. Orthostatic hypotension is not a risk with nicotine replacement
therapy. Stopping suddenly does not increase the risk of heart attack.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory assessment, Smoking cessation
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
11. A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy.
The client presents with continuous cyanosis even with oxygen therapy. What action would
the nurse take next?
a. Administer an albuterol treatment.
b. Notify the Rapid Response Team.
c. Assess the client’s peripheral pulses.
d. Obtain blood and sputum cultures.
ANS: B
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Cyanosis unresponsive to oxygen therapy is a sign of methemoglobinemia, which is an
adverse effect of benzocaine spray. This condition can lead to death. The nurse would notify
the Rapid Response Team to provide advanced care. An albuterol treatment would not address
the client’s oxygenation problem. Assessment of pulses and cultures will not provide data
necessary to treat the client.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory assessment, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
12. A nurse auscultates a harsh hollow sound over a client’s trachea and larynx. What action
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would the nurse take first?
a. Document the findings.
b. Administer oxygen therapy.
c. Position the client in high-Fowler position.
d. Administer prescribed albuterol.
ANS: A
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Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal
finding over the trachea and larynx. The nurse would document this finding. There is no need
to implement oxygen therapy, administer albuterol, or change the client’s position because the
finding is normal.
MULTIPLE RESPONSE
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DIF: Understanding
TOP: Integrated Process: Communication and Documentation KEY: Respiratory assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
1. A nurse assesses a client who is prescribed varenicline for smoking cessation. Which signs or
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symptoms would the nurse identify as adverse effects of this medication? (Select all that
apply.)
a. Visual hallucinations
b. Tachycardia
c. Decreased cravings
d. Manic behavior
e. Increased thirst
f. Orangish urine
ANS: A, D
Varenicline has a black box warning stating that the drug can cause manic behavior and
hallucinations. The nurse would assess for changes in behavior and thought processes,
including manic behaviors and visual hallucinations. Tachycardia, increased thirst, and
orange-colored urine are not adverse effects of this medication. Decreased cravings are a
therapeutic response to this medication.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Medication administration, Medication side effects
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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2. While obtaining a client’s health history, the client states, “I am allergic to avocados, molds,
and grass.” Which responses by the nurse are best? (Select all that apply.)
a. “What happens when you are exposed to those things?
b. “How do you treat these allergies?”
c. “When was the last time you ate foods containing avocados?”
d. “I will document this in your record so all so everyone knows.”
e. “Have you ever been in the hospital after an allergic response?”
f. “How do manage to avoid grass and mold?”
ANS: A, B, D, E
Nurses would assess clients who have allergies for the specific cause, treatment, and response
to treatment. The nurse would also document the allergies in a prominent place in the client’s
medical record. Asking about the last time the client ate avocados does not provide any
pertinent information for the client’s plan of care. Asking how a client manages to avoid
environmental allergies in this fashion also does not provide any pertinent information.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Respiratory assessment, Allergies
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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3. A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs)
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for a client. Which statements would the nurse include in communications with the respiratory
therapist prior to the tests? (Select all that apply.)
a. “I held the client’s morning bronchodilator medication.”
b. “The client is ready to go down to radiology for this examination.”
c. “Physical therapy states the client can run on a treadmill.”
d. “I advised the client not to smoke for 6 hours prior to the test.”
e. “The client is alert and can follow your commands.”
ANS: A, D, E
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To ensure that the PFTs are accurate, the therapist needs to know that no bronchodilators have
been administered in the past 4 to 6 hours (depending on the suspected cause), the client did
not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands,
including different breathing maneuvers. The respiratory therapist can perform PFTs at the
bedside or the respiratory lab. A treadmill is not used for this test.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Respiratory assessment, Diagnostic testing
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A nurse teaches a client who is interested in smoking cessation. Which statements would the
nurse include in this client’s teaching? (Select all that apply.)
a. “Find an activity that you enjoy and will keep your hands busy.”
b. “Keep snacks like potato chips on hand to nibble on.”
c. “Identify a consequence for yourself in case you backslide.”
d. “Drink at least eight glasses of water each day.”
e. “Make a list of reasons you want to stop smoking.”
f. “Set a quit date and stick to it.”
ANS: A, D, E, F
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The nurse would teach a client who is interested in smoking cessation to find an activity that
keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least eight
glasses of water each day, to make a list of reasons for quitting smoking, and to set a firm quit
date and stick to it. The nurse would also encourage the client not to be upset if he or she
backslides and has a cigarette but to try to determine what conditions caused him or her to
smoke.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Smoking cessation, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
5. A nurse is assessing a client’s history of particular matter exposure. What questions are
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consistent with the I PREPARE tool? (Select all that apply.)
a. Investigate all history of known exposures.
b. Determine if breathing problems are worse at work.
c. Ask the client what type of heating is in the home.
d. Gather details about the geographic location of the client’s home.
e. Have client list all previous jobs and work experiences.
f. Assess what hobbies the client and family enjoy.
ANS: A, B, C, D, E, F
s.
All questions are appropriate for the I PREPARE model of particulate matter exposure. The R
and final E stands for resources/referrals and educate.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory assessment, Smoking cessation
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A nurse assesses a client who is recovering from a thoracentesis. Which assessment findings
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would alert the nurse to a potential pneumothorax? (Select all that apply.)
a. Bradycardia
b. New-onset cough
c. Purulent sputum
d. Tachypnea
e. Pain with respirations
f. Rapid, shallow respirations
ANS: B, D, E
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Symptoms of a pneumothorax include tachycardia, tachypnea, new-onset “nagging” cough,
and pain that is worse at the end of inhalation and the end of exhalation on the affected side.
Additional symptoms include trachea slanted to the unaffected side, cyanosis, and the affected
side of the chest that does not move in and out with respirations. Purulent sputum is a
symptom of infection.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory assessment, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy
procedure at 9:00 AM (0900). What actions would the nurse take? (Select all that apply.)
a. Provide a clear liquid breakfast.
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b.
c.
d.
e.
f.
Verify that the informed consent was obtained.
Document the client’s allergies.
Review laboratory results.
Hold the client’s bronchodilator.
Monitor the client for at least 24 hours afterwards.
ANS: B, C, D, F
Prior to a bronchoscopy, the nurse would verify that the informed consent was obtained, keep
the client NPO for 4 to 8 hours prior to the procedure or per agency policy to prevent
aspiration, document allergies, and review laboratory results including complete blood count
and bleeding times. There is no reason to hold the client’s bronchodilator prior to this
procedure. The nurse will monitor the client at least every 4 hours for 24 hours.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory assessment, Diagnostic testing
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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Chapter 25: Concepts of Care for Patients Requiring Oxygen Therapy or
Tracheostomy
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse caring for a client removes the client’s oxygen as prescribed. The client is now
breathing what percentage of oxygen in the room air?
a. 14%
b. 21%
c. 28%
d. 31%
ANS: B
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Oxygen content of atmospheric or “room air” is about 21%.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Oxygen, Physiology
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is
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the priority?
a. Administer prescribed anxiolytic medication.
b. Ensure that informed consent is on the chart.
c. Reinforce any teaching done previously.
d. Start the preoperative antibiotic infusion.
ANS: B
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Since this is an operative procedure, the client must sign an informed consent, which must be
on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required
but do not take priority.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Informed consent, Autonomy
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the
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client’s face is puffy and the eyelids are swollen. What action by the nurse takes best?
a. Assess the client’s oxygen saturation.
b. Notify the Rapid Response Team.
c. Oxygenate the client with a bag-valve-mask.
d. Palpate the skin of the upper chest.
ANS: A
This client may have subcutaneous emphysema, which is air that leaks into the tissues
surrounding the tracheostomy. The nurse would first assess the client’s oxygen saturation and
other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the
upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response
Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
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KEY: Oxygenation, Tracheostomy, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A client has a tracheostomy tube in place. When the nurse suctions the client, food particles
are noted. What action by the nurse is best?
a. Elevate the head of the client’s bed.
b. Measure and compare cuff pressures.
c. Place the client on NPO status.
d. Request that the client have a swallow study.
ANS: B
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Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to
dilation of the tracheal passage. This can be manifested by food particles seen in secretions or
by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff
inflated. The nurse would measure the pressures and compare them to previous ones to detect
a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a
swallow study will not correct this situation.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Tracheostomy, Client safety
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the
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UAP reports that the client had a coughing spell during the meal. What action by the nurse is
best?
a. Assess the client’s lung sounds.
b. Assign a different AP to the client.
c. Report the AP to the manager.
d. Request thicker liquids for meals.
ANS: A
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The best action is to check the client’s oxygenation because he or she may have aspirated.
Once the client has been assessed, the nurse would notify the primary health care provider of
possible aspiration and would consult with the registered dietitian about appropriately
thickened liquids. The UAP should have reported the incident immediately, but addressing
that issue is not the immediate priority.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Aspiration, Tracheostomy
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A nurse is providing tracheostomy care. What action by the nurse requires intervention by
the charge nurse?
Holding the device securely when changing ties
Suctioning the client first if secretions are present
Tying a square knot at the back of the neck
Using half-strength peroxide for cleansing
a.
b.
c.
d.
ANS: C
To prevent pressure injuries and for client safety, when ties are used that must be knotted, the
knot would be placed at the side of the client’s neck, not in back. The other actions are
appropriate.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Tracheostomy care, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
7. A nurse is demonstrating suctioning a tracheostomy during the annual skills review. What
action by the student demonstrates that more teaching is needed?
a. Applying suction while inserting the catheter
b. Preoxygenating the client prior to suctioning
c. Suctioning for a total of three times if needed
d. Suctioning for only 10 to 15 seconds each time
ANS: A
Suction would only be applied while withdrawing the catheter. The other actions are
appropriate.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Tracheostomy, Suctioning
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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8. A nurse is caring for a client using oxygen while in the hospital. What assessment finding
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indicates that outcomes for client safety with oxygen therapy are being met?
a. 100% of meals being eaten by the client
b. Intact skin behind the ears
c. The client understanding the need for oxygen
d. Unchanged weight for the past 3 days
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ANS: B
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Oxygen tubing can cause pressure injuries, so clients using oxygen have a high risk of skin
breakdown. Intact skin behind the ears indicates that goals for maintaining client safety with
oxygen therapy are being met. Nutrition and weight are not related to using oxygen.
Understanding the need for oxygen is important but would not take priority over a physical
problem.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Oxygen therapy, Skin integrity
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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9. A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy
tube is pulsing with the heartbeat as the client’s pulse is being taken. No other abnormal
findings are noted. What action by the nurse is most appropriate?
a. Call the operating room to inform them of a pending emergency case.
b. No action is needed at this time; this is a normal finding in some clients.
c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask.
d. Stay with the client and have someone else call the primary health care provider
immediately.
ANS: D
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This client may have a tracheoinnominate artery fistula, which can be a life-threatening
emergency if the artery is breached and the client begins to hemorrhage. Since no bleeding is
yet present, the nurse stays with the client and asks someone else to notify the primary health
care provider. If the client begins hemorrhaging, the nurse removes the tracheostomy and
applies pressure at the bleeding site. The client will need to be prepared for surgery.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Tracheostomy, Medical emergencies
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. A client with a new tracheostomy is being seen in the oncology clinic. What finding by the
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nurse best indicates that goals for the client’s decrease in self-esteem are being met?
a. The client demonstrates good understanding of stoma care.
b. The client has joined a book club that meets at the library.
c. Family members take turns assisting with stoma care.
d. Skin around the stoma is intact without signs of infection.
ANS: B
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The client joining a book club that meets outside the home and requires him or her to go out in
public is the best sign that goals for disrupted self-esteem are being met. The other findings
are all positive signs but do not relate to this client problem.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Tracheostomy, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
11. A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse
ANS: A
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delegate to assistive personnel (AP)?
a. Apply water-soluble ointment to nares and lips.
b. Periodically turn the oxygen down or off.
c. Replaces the oxygen tubing with a different type.
d. Turn the client every 2 hours or as needed.
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Oxygen can be drying, so the UAP can apply water-soluble lubricant to the client’s lips and
nares. The AP would not adjust the oxygen flow rate or replace the tubing. Turning the client
is not related to comfort measures for oxygen.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Oxygen, Comfort measures, Delegation
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
12. A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What
action by the nurse is best?
a. Assess the client’s oxygen saturation and, if normal, turn off the oxygen.
b. Determine if the client can switch to a nasal cannula during the meal.
c. Have the client lift the mask off the face when taking bites of food.
d. Turn the oxygen off while the client eats the meal and then restart it.
ANS: B
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Oxygen is a drug that needs to be delivered constantly. The nurse would determine if the
primary health care provider has approved switching to a nasal cannula during meals. If not,
the nurse would consult with the primary health care provider about this issue. The primary
health care provider would need to prescribe discontinuing oxygen if the client’s oxygen
saturation is normal. The oxygen would not be turned off. Lifting the mask to eat will alter the
FiO2 delivered.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Oxygen therapy, Oxygen
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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13. The nurse assesses the client using the device pictured below to deliver 50% O2:
ANS: C
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The nurse finds that the mask fits snugly, the skin under the mask and straps is intact, and the
flow rate of the oxygen is 3 L/min. What action by the nurse is best?
a. Assess the client’s oxygen saturation.
b. Document these findings in the chart.
c. Immediately increase the flow rate.
d. Turn the flow rate down to 2 L/min.
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For the venturi mask to deliver high flow of oxygen, the flow rate must be set correctly,
usually between 4 and 10 L/min. The client’s flow rate is too low and the nurse would
increase it. After increasing the flow rate, the nurse assesses the oxygen saturation and
documents the findings.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Oxygen therapy, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
MULTIPLE RESPONSE
1. A home health nurse is visiting a new client who uses oxygen in the home. For which factors
does the nurse assess when determining if the client is using the oxygen safely? (Select all
that apply.)
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a.
b.
c.
d.
e.
f.
The client does not allow smoking in the house.
Electrical cords are in good working order.
Flammable liquids are stored in the garage.
Household light bulbs are the fluorescent type.
The client does not have pets inside the home.
No alcohol-based hand sanitizers are present.
ANS: A, B, C
Oxygen it enhances combustion, so precautions are needed whenever using it. The nurse
would assess if the client allows smoking in the house, whether electrical cords are in good
shape or are frayed, and if flammable liquids are stored (and used) in the garage away from
the oxygen. Light bulbs and pets are not related to oxygen safety. Alcohol-based hand
sanitizers are permitted.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Oxygen therapy, Home safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
2. A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse
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delegate to assistive personnel (AP)? (Select all that apply.)
a. Applying water-soluble lip balm to the client’s lips
b. Ensuring that the humidification provided is adequate
c. Performing oral care with alcohol-based mouthwash
d. Reminding the client to cough and deep breathe often
e. Suctioning excess secretions through the tracheostomy
f. Holding the new tracheostomy tube while the RN changes the ties
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ANS: A, D
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The AP can perform hygiene measures such as applying lip balm and reinforce teaching such
as reminding the client to perform coughing and deep-breathing exercises. Oral care can be
accomplished with normal saline, not products that dry the mouth. Ensuring that the humidity
is adequate and suctioning through the tracheostomy are nursing functions. When needed, a
second licensed person assists with holding the tracheostomy tube during tie changes; some
hospitals require a second licensed person during the first 72 hours after placement.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Tracheostomy, Delegation
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A client is being discharged home after having a tracheostomy placed. What suggestions does
the nurse offer to help the client maintain self-esteem? (Select all that apply.)
a. Create a communication system.
b. Don’t go out in public alone.
c. Find hobbies to enjoy at home.
d. Try loose-fitting shirts with collars.
e. Wear fashionable scarves.
ANS: A, D, E
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The client with a tracheostomy may be shy and hesitant to go out in public. The client needs
to have a sound communication method to ease frustration. The nurse can also suggest ways
of enhancing appearance so the client is willing to leave the house. These can include wearing
scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound is not good
advice.
DIF: Understanding
TOP: Integrated Process: Caring
KEY: Tracheostomy, Psychosocial response, Client education
MSC: Client Needs Category: Psychosocial Integrity
4. A nurse is planning discharge teaching on tracheostomy care for an older client. What factors
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does the nurse need to assess before teaching this particular client? (Select all that apply.)
a. Cognition
b. Dexterity
c. Hydration
d. Range of motion
e. Vision
f. Upper arm range of motion
ANS: A, B, D, E, F
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The older adult is at risk for having impairments in cognition, dexterity, range of motion, and
vision that could limit the ability to perform tracheostomy care and would be assessed. Upper
arm mobility is required to perform tracheostomy self-care. Hydration is not directly related to
the ability to perform self-care.
nk
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Tracheostomy, Older adult
MSC: Client Needs Category: Health Promotion and Maintenance
5. A nurse is teaching a client about possible complications and hazards of home oxygen
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therapy. About which complications does the nurse plan to teach the client? (Select all that
apply.)
a. Absorptive atelectasis
b. Combustion
c. Dried mucous membranes
d. Alveolar recruitment
e. Toxicity
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ANS: A, B, C, E
Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous
membranes, and oxygen toxicity. Alveolar recruitment may be a benefit of high-flow nasal
cannulas such as Vapotherm, which both humidifies and warms the oxygen.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Oxygen therapy, Health teaching
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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Chapter 26: Concepts of Care for Patients With Noninfectious Upper Respiratory
Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the
nurse perform first?
a. Facial pain
b. Vital signs
c. Bone displacement
d. Airway patency
ANS: D
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A patent airway is the priority. The nurse first would make sure that the airway is patent and
then would determine whether the client is in pain and whether bone displacement or blood
loss has occurred.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Trauma, Medical emergencies
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
s.
2. A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a
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headache, and difficulty with vision. What action would the nurse take next?
a. Collect the nasal drainage on a piece of filter paper.
b. Encourage the client to blow his or her nose.
c. Perform a test focused on a neurologic examination.
d. Palpate the nose, face, and neck.
ANS: A
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The client with nasal drainage after facial trauma could have a skull fracture resulting in
leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the
fact that it forms a halo when dripped on filter paper and tests positive for glucose. The other
actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak
would increase the patient’s risk for infection.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Trauma, Medical emergencies
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A nurse teaches a client who had a supraglottic laryngectomy. Which technique would the
nurse teach the client to prevent aspiration?
a. Tilt the head back as far as possible when swallowing.
b. Swallow twice while bearing down.
c. Breathe slowly and deeply while swallowing.
d. Keep the head very still and straight while swallowing.
ANS: B
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The client post supraglottic laryngectomy has a high risk for aspiration. The nurse or speech
language pathologist teaches the client the supraglottic method of swallowing. This includes
placing a small amount of food in the mouth, performing the Valsalva maneuver, then
swallowing twice. The client sits upright. The client holds the breath while swallowing twice.
Keeping the head still and straight will not decrease the risk of aspiration.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Aspiration Precautions
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for
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development of obstructive sleep apnea?
a. A 26-year-old woman who is 8 months pregnant.
b. A 42-year-old man with gastroesophageal reflux disease.
c. A 55-year-old woman who is 50 lb (23 kg) overweight.
d. A 73-year-old man with type 2 diabetes mellitus.
ANS: C
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The client at highest risk would be the one who is extremely overweight. None of the other
clients have risk factors for sleep apnea. Clients with sleep apnea may develop
gastroesophageal reflux.
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Obstructive sleep apnea, Risk factors
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse cares for a client who has hypertension that has not responded well to several
ANS: A
ba
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medications. The client states compliance is not an issue. What action would the nurse take
next?
a. Assess the client for obstructive sleep apnea.
b. Arrange a home sleep apnea test.
c. Encourage the client to begin exercising.
d. Schedule a polysomnography
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Hypertension not responding to medications can be a sign of obstructive sleep apnea (OSA).
The nurse would assess the client using an evidence-based tool, such as the STOP-Bang Sleep
Apnea Questionnaire, the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index, and
the Multiple Sleep Latency Test. If the results of the assessment indicate OSA may be a
problem, the nurse would consult the primary health care provider for further testing. An
at-home sleep-study is often done prior to a polysomnography. Excessive weight can
contribute to OSA so exercising is always encouraged, but this is not specific to assessing for
OSA.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Obstructive sleep apnea, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
6. A nurse cares for a client after radiation therapy for neck cancer. The client reports extreme
dry mouth. What action by the nurse is most appropriate?
a. Ask the client to gargle with mouthwash containing lidocaine.
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b. Administer IV fluid boluses every 2 hours.
c. Explain that xerostomia may be a permanent side effect.
d. Assess the client’s neck for redness and swelling.
ANS: C
Xerostomia, or dry mouth, is a potential side effect of radiation, particularly if the salivary
glands were in the radiation zone. Unfortunately, this may be long term or even permanent.
Gargling with lidocaine would not help. Increasing fluids is somewhat helpful, but the client
would be encouraged to drink. The client’s neck may have redness and swelling, but this
finding is not related to the reported dry mouth.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Cancer, Surgical complications
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
7. A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that
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all food tastes bland. How would the nurse respond?
a. “I will consult the speech therapist to ensure you are swallowing properly.”
b. “This is normal after surgery. What types of food do you like to eat?”
c. “I will ask the dietitian to change the consistency of the food in your diet.”
d. “Replacement of protein, calories, and water is very important after surgery.”
ANS: B
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s.
Many clients experience changes in taste after surgery. The nurse would identify foods that
the client wants to eat to ensure that the client maintains necessary nutrition. Although the
nurse would collaborate with the speech therapist and dietitian to ensure appropriate
replacement of protein, calories, and water, the other responses do not address the patient’s
concerns.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Surgical care, Nutrition
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
8. A nurse cares for a client who is scheduled for a total laryngectomy. What action would the
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nurse take prior to surgery?
a. Assess airway patency, breathing, and circulation.
b. Administer prescribed intravenous pain medication.
c. Assist the client to choose a communication method.
d. Ambulate the client in the hallway to assess gait.
ANS: C
The client will not be able to speak after surgery. The nurse would assist the client to choose a
communication method that he or she would like to use after surgery. Assessing the patient’s
airway and administering IV pain medication are done after the procedure. Although
ambulation promotes health and decreases the complications of any surgery, this patient’s gait
would not be impacted by a total laryngectomy and therefore is not a priority.
DIF: Applying
TOP: Integrated Process: Caring
KEY: Surgical care, Communication
MSC: Client Needs Category: Psychosocial Integrity
9. While assessing a client who has facial trauma, the nurse auscultates stridor. The client is
anxious and restless. What action would the nurse take first?
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a.
b.
c.
d.
Contact the primary health care provider and prepare for intubation.
Administer prescribed albuterol nebulizer therapy.
Place the client in high-Fowler position.
Ask the client to perform deep-breathing exercises.
ANS: A
Facial and neck tissue edema can occur in clients with facial trauma. Airway patency is the
highest priority. Clients who experience stridor and hypoxia, manifested by anxiety and
restlessness, would be immediately intubated to ensure airway patency. Albuterol decreases
bronchi and bronchiole inflammation, not facial and neck edema. Although putting the client
in high-Fowler position and asking the client to perform breathing exercises may temporarily
improve the patient’s comfort, these actions will not decrease the underlying problem or
improve airway patency.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Trauma, Airway
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action
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would the nurse take first?
a. Assess the client’s pain level.
b. Keep the client’s head elevated.
c. Teach the client about the causes of nasal bleeding.
d. Assess the client’s airway.
ANS: D
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If the packing slips out of place, it may obstruct the client’s airway. The other options are
good interventions, but ensuring that the airway is patent in the priority objective.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Epistaxis, Airway
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
11. A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement
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would the nurse include in this patient’s teaching?
a. “Add peppermint oil to the humidifier to relax the airway.”
b. “Make sure you clean the humidifier to prevent infection.”
c. “Keep the humidifier filled with water at all times.”
d. “Use the humidifier when you sleep, even during daytime naps.”
ANS: B
Priority teaching related to the use of a room humidifier focuses on infection control. Clients
would be taught to meticulously clean the humidifier to prevent the spread of mold or other
sources of infection. Peppermint oil would not be added to a humidifier. The humidifier
would be refilled with water as needed and would be used while awake and asleep.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Laryngectomy, Health teaching
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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12. A nurse is caring for a client who had a modified uvulopalatopharyngoplasty (modUPPP)
earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a
priority goal has been met?
a. Client reports pain is controlled satisfactorily with analgesic regime.
b. Client does not have foul odor to the breath or beefy red mucus membranes.
c. Client is able to swallow own secretions without drooling.
d. Client’s vital signs are within normal parameters.
ANS: C
The priority after a modUPPP is maintaining a patent airway. The client who has a patent
airway can swallow his or her own secretions without drooling. Controlled pain is important,
but not the priority. Foul breath odor and beefy red mucus membranes indicate possible
infection, which probably would not occur this soon after surgery, but preventing infection
does not take priority over airway. Vital signs “within normal parameters” are vague.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Obstructive sleep apnea, Airway
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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MULTIPLE RESPONSE
1. A nurse assesses a client who is 6 hours postsurgery for a nasal fracture and has nasal packing
ba
ANS: A, B, C, D
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s.
in place. What actions would the nurse take? (Select all that apply.)
a. Observe for clear drainage.
b. Assess for signs of bleeding.
c. Watch the client for frequent swallowing.
d. Ask the client to open his or her mouth.
e. Administer a nasal steroid to decrease edema.
f. Change the nasal packing.
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The nurse would observe for clear drainage because of the risk for cerebrospinal fluid leakage.
The nurse would assess for signs of bleeding by asking the client to open his or her mouth and
observing the back of the throat for bleeding. The nurse would also note whether the client is
swallowing frequently because this could indicate postnasal bleeding. A nasal steroid would
increase the risk for infection. It is too soon to change the packing, which would be changed
by the surgeon the first time.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Surgical care, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
2. The nurse is teaching a client with obstructive sleep apnea (OSA) about the prescribed CPAP.
What information does the nurse include? (Select all that apply.)
a. Insurance will cover the cost if you wear it at least 4 hours a day.
b. Once the delivery mask is adjusted, do not loosen the straps.
c. The CPAP provides pressure that holds your upper airways open.
d. You need to clean the mask at least once a week to prevent infection.
e. The humidification increases the risk of fungal infections.
f. Be patient when first using the system, it can be frustrating at first.
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ANS: B, C, E, F
A CPAP for OSA provides pressure that keeps the upper airway open. A properly fitting mask
or nasal pillows is necessary to provide the pressure. Humidification in the system leads to an
increased risk for fungal infections. Patients may have anxiety about using the equipment and
worry about it being disruptive; most clients have a period of adjustment when first starting to
use a CPAP. Medicare will usually cover the cost if the client wears the CPAP at least 6 hours
a day. The mask or pillows should be cleaned daily.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Obstructive sleep apnea, Health teaching
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
ANS: A, D
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immediate intervention? (Select all that apply.)
a. Stridor
b. Nasal stuffiness
c. Edema of the cheek
d. Ecchymosis behind the ear
e. Eye pain
f. Swollen chin
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3. A nurse assesses a client who has facial trauma. Which assessment findings require
nk
s.
Stridor is a sign of airway obstruction and requires immediate intervention. Ecchymosis, or
bruising, behind the ear is called “battle sign” and indicates basilar skull fracture.
Nasal stuffiness, edema of the cheek or chin, and eye pain do not interfere with respirations or
neurologic function, and therefore are not priorities for immediate intervention.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Trauma, Medical emergencies
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
ba
4. A nurse teaches a client who is being discharged after a jaw wiring for a mandibular fracture.
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Which statements would the nurse include in this patient’s teaching? (Select all that apply.)
a. “You will need to cut the wires if you start vomiting.”
b. “Eat six soft or liquid meals each day while recovering.”
c. “Use a Waterpik for dental hygiene until you can brush again.
d. “Sleep in a semi-Fowler position after the surgery.”
e. “Gargle with mouthwash that contains hydrogen peroxide once a day.”
ANS: A, B, C, D
The client needs to know how to cut the wires in case of emergency. If the client vomits, he or
she may aspirate. The client would also be taught to eat soft or liquid meals multiple times a
day, irrigate the mouth with a Waterpik to prevent infection, and sleep in a semi-Fowler
position to assist in avoiding aspiration. Mouthwash with hydrogen peroxide is not a
recommendation.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Surgical care, Health teaching
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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5. A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for
airway loss related to aspirated oral and nasopharyngeal secretions? (Select all that apply.)
a. A 24 year old with a traumatic brain injury
b. A 36 year old who fractured his left femur
c. A 58 year old getting radiation therapy
d. A 66 year old who is a quadriplegic
e. An 80-year-old who is aphasic
ANS: A, C, D, E
Thickly crusted, dry secretions that potentially can cause asphyxiation and airway obstruction
(inspissated secretions or mucoid impaction) are seen most often in clients who have an
altered mental status and level of consciousness (brain injury), are dehydrated, are unable to
communicate (aphasic), are unable to cough effectively (quadriplegic), or are at risk for
aspiration. The clients with the femur fracture and receiving radiation therapy are not as high
of a risk. The location of the radiation is not known.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Medical emergencies
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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6. A nurse assesses a client who is at risk for neck cancer. Which symptoms would the nurse
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s.
assess for? (Select all that apply.)
a. Oral mucosa is gray or dark brown
b. Pain when drinking grapefruit juice
c. Persistent weight gain over the past 2 months
d. Oral lesions that are over 2 weeks old
e. Changes in the patient’s voice quality
ANS: A, B, D, E
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Symptoms of head and neck cancer include color changes in the mouth or tongue to gray or
dark brown; pain in the mouth, neck, and throat; burning sensation when drinking citrus
juices; weight loss; oral lesions or soars that do not heal in 2 weeks; and hoarseness or
changes in voice quality.
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DIF: Knowing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cancer, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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7. A nurse teaches a client who has epistaxis and recently had his nasal packing removed. Which
statements indicate that the client correctly understood the teaching? (Select all that apply.)
a. “I will vigorously blow my nose multiple times each day.”
b. “Nasal saline sprays will help to prevent rebleeding.”
c. “I will wait at least 1 month before resuming weight lifting.”
d. “Ibuprofen will decrease nasal swelling and pain.”
e. “I will apply a small amount of petroleum jelly to my nares.”
ANS: B, C, E
A nurse would teach a client to avoid vigorous nose blowing, the use of aspirin or other
NSAIDs, and strenuous activities such as heavy lifting for at least 1 month. The nurse would
also teach the client to apply petroleum jelly sparingly to the nares for lubrication and
comfort, and to use nasal saline sprays and humidification to prevent rebleeding.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Epistaxis, Home care
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. A nurse is teaching a community group about the long-term effects of untreated sleep apnea.
What information does the nurse include? (Select all that apply.)
a. Hypertension
b. Stroke
c. Weight gain
d. Diabetes
e. Cognitive deficits
f. Pulmonary disease
ANS: A, B, C, D, E, F
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The long-term effects of untreated sleep apnea include increased risk for hypertension, stroke,
cognitive deficits, weight gain, diabetes, and pulmonary and cardiovascular disease.
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ba
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Obstructive sleep apnea, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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Chapter 27: Concepts of Care for Patients With Noninfectious Lower Respiratory
Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse assesses several clients who have a history of respiratory disorders. Which client
would the nurse assess first?
a. A 66-year-old client with a barrel chest and clubbed fingernails
b. A 48-year-old client with an oxygen saturation level of 92% at rest
c. A 35-year-old client who reports orthopnea in bed
d. A 27-year-old client with a heart rate of 120 beats/min
ANS: D
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Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available.
A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not
considered an acute finding. Orthopnea at night in bed is breathlessness when lying down but
is not an acute finding at this moment.
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory distress, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
2. A nurse cares for a client with arthritis who reports frequent asthma attacks. What action
ba
ANS: B
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would the nurse take first?
a. Review the client’s pulmonary function test results.
b. Ask about medications the client is currently taking.
c. Assess how frequently the client uses a bronchodilator.
d. Consult the primary health care provider and request arterial blood gases.
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Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some
people. This results from increased production of leukotriene when aspirin or NSAIDs
suppress other inflammatory pathways and is a likely culprit given the client’s history.
Reviewing pulmonary function test results will not address the immediate problem of frequent
asthma attacks. This is a good time to review response to bronchodilators, but assessing
triggers is more important. Questioning the client about the use of bronchodilators will
address interventions for the attacks but not their cause. Reviewing arterial blood gas results
would not be of use in a client between attacks because many clients are asymptomatic when
not having attacks.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory distress, Adverse medication effects
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
3. After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse
assesses the client’s understanding. Which statement indicates that the client comprehends
the teaching?
a. “I will carry this medication with me at all times in case I need it.”
b. “I will take this medication when I start to experience an asthma attack.”
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c. “I will take this medication every morning to help prevent an acute attack.”
d. “I will be weaned off this medication when I no longer need it.”
ANS: C
Long-acting beta2 agonist medications will help prevent an acute asthma attack because they
are long acting. The client will take this medication every day for best effect. The client does
not have to always keep this medication with him or her because it is not used as a rescue
medication. This is not the medication the client will use during an acute asthma attack
because it does not have an immediate onset of action. The client will not be weaned off this
medication because this is likely to be one of his or her daily medications.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory disorders, Medications, Health teaching
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client’s
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understanding. Which action demonstrates that the client correctly understands the teaching?
a. The client lies on his or her side with knees bent.
b. The client places his or her hands on the abdomen.
c. The client lies in a prone position with straight.
d. The client places his or her hands above the head.
ANS: B
nk
s.
To perform diaphragmatic breathing correctly, the client would place his or her hands on the
abdomen to create resistance. This type of breathing cannot be performed effectively while
lying on the side or with hands over the head. This type of breathing would not be as effective
lying prone.
ba
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory disorders, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse cares for a client who has developed esophagitis after undergoing radiation therapy
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for lung cancer. Which diet selection would the nurse provide for this client?
a. Spaghetti with meat sauce, ice cream
b. Chicken soup, grilled cheese sandwich
c. Omelet, soft whole-wheat bread
d. Pasta salad, custard, orange juice
ANS: C
Side effects of radiation therapy may include inflammation of the esophagus. Clients would
be taught that bland, soft, high-calorie foods are best, along with liquid nutritional
supplements. Tomato sauce may prove too spicy for a client with esophagitis. A grilled cheese
sandwich is too difficult to swallow with this condition, and orange juice and other foods with
citric acid are too caustic.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Cancer, Nutrition
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
6. After teaching a client who is prescribed salmeterol, the nurse assesses the client’s
understanding. Which statement by the client indicates a need for additional teaching?
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a.
b.
c.
d.
“I will be certain to shake the inhaler well before I use it.”
“It may take a while before I notice a change in my asthma.”
“I will use the drug when I have an asthma attack.”
“I will be careful not to let the drug escape out of my nose and mouth.”
ANS: C
Salmeterol is a long-acting beta2 agonist designed to prevent an asthma attack; it does not
relieve or reverse symptoms. Salmeterol has a slow onset of action; therefore, it would not be
used as a rescue drug. The drug must be shaken well because it has a tendency to separate
easily. Poor technique on the client’s part allows the drug to escape through the nose and
mouth.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Medication, Client education
MSC: Client Needs Category: Health Promotion and Maintenance
m
7. A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client
co
states that going out with friends is no longer enjoyable. How would the nurse respond?
a. “There are a variety of support groups for people who have COPD.”
b. “I will ask your primary health care provider to prescribe an antianxiety agent.”
c. “I’d like to hear about thoughts and feelings causing you to limit social activities.”
d. “Friends can be a good support system for clients with chronic disorders.”
ANS: C
ba
nk
s.
Many clients with moderate to severe COPD become socially isolated because they are
embarrassed by frequent coughing and mucus production. They also can experience fatigue,
which limits their activities. The nurse needs to encourage the client to verbalize thoughts and
feelings so that appropriate interventions can be selected. Joining a support group would not
decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety
agents will not help the client with social isolation. While friends can be good sources of
support, the client specifically is discussing going out of the home.
st
DIF: Applying
TOP: Integrated Process: Caring
KEY: Respiratory disorders, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
8. A nurse is teaching a client who has cystic fibrosis (CF). Which statement would the nurse
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include in this client’s teaching?
a. “Take an antibiotic each day.”
b. “You should get genetic screening.”
c. “Eat a well-balanced, nutritious diet.”
d. “Plan to exercise for 30 minutes every day.”
ANS: C
Clients with CF often are malnourished due to vitamin deficiency and pancreatic malfunction.
Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions.
Genetic screening might be an option; however, the nurse would not just tell the client to do
something like that.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory disorders, Nutrition, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
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9. While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a
nurse notices that the chest tube is dislodged. Which action by the nurse is best?
a. Assess for drainage from the site.
b. Cover the insertion site with sterile gauze.
c. Contact the primary health care provider.
d. Reinsert the tube using sterile technique.
ANS: B
Immediately covering the insertion site helps prevent air from entering the pleural space and
causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering
the chest. The nurse would not leave the client to obtain a suture kit. An occlusive dressing
may cause a tension pneumothorax. The nurse does not need to assess the site at this moment.
The primary health care provider would be called to reinsert the chest tube or prescribe other
treatment options.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory disorders, Chest tubes
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
co
10. A nurse assesses a client who is prescribed fluticasone and notes oral lesions. What action
s.
would the nurse take?
a. Encourage oral rinsing after fluticasone administration.
b. Obtain an oral specimen for culture and sensitivity.
c. Start the client on a broad-spectrum antibiotic.
d. Document the finding as a known side effect.
nk
ANS: A
ba
The drug reduces local immunity and increases the risk for local infection, especially Candida
albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this
infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation.
The nurse would document the finding, but the best action to take is to have the client start
rinsing his or her mouth after using fluticasone. An oral specimen for culture and sensitivity is
not necessary to care for this client.
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e
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory disorders, Medication side effects
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
11. A nurse cares for a client who is infected with Burkholderia cepacia. What action would the
nurse take first when admitting this client to a pulmonary care unit?
a. Instruct the client to wash his or her hands after contact with other people.
b. Implement Droplet Precautions and don a surgical mask.
c. Keep the client separated from other clients with cystic fibrosis.
d. Obtain blood, sputum, and urine culture specimens.
ANS: C
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B. cepacia infection is spread through casual contact between cystic fibrosis clients, thus the
need for infected clients to be separated from noninfected clients. Strict isolation measures
will not be necessary. Although the client would wash his or her hands frequently, the most
important measure that can be implemented on the unit is isolation of the client from other
clients with cystic fibrosis. There is no need to implement Droplet Precautions or don a
surgical mask when caring for this client. Obtaining blood, sputum, and urine culture
specimens will not provide information necessary to care for a client with B. cepacia
infection.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory disorders, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
12. A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep
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breaths because of the pain. What action would the nurse take?
a. Ambulate the client in the hallway to promote deep breathing.
b. Auscultate the client’s anterior and posterior lung fields.
c. Encourage the client to take shallow breaths to help with the pain.
d. Administer pain medication and encourage the client to take deep breaths.
ANS: D
s.
A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse
would provide pain medication to minimize discomfort and encourage the client to take deep
breaths. The other responses do not address the client’s discomfort and need to take deep
breaths to prevent complications.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory disorders, Pharmacologic pain management
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
13. The nurse is caring for a client who has cystic fibrosis (CF). The client asks for information
ANS: C
st
ba
about gene therapy. What response by the nurse is best?
a. “Unfortunately, gene therapy is only provided to children upon diagnosis.”
b. “Do you know that you will have to have genetic testing?”
c. “There is a good treatment for the most common genetic defect in CF.”
d. “Gene therapy will only help improve your pulmonary symptoms.”
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The drug ivacaftor/lumacaftor is effective as therapy for patients whose CF is caused by the
F508del (also known as the Phe508del) mutation, the most common mutation involved in CF,
even in patients who are homozygous for the mutation with both alleles being affected. The
nurse would provide that information as the best response. Asking if the client understands he
or she will have to undergo genetic testing is a correct statement, but is a yes/no question
which is not therapeutic and might sound paternalistic. It also does not provide any
information on the therapy itself. The drug is not limited to children and helps move chloride
closer to the membrane surfaces so it would have an effect on any organ compromised by CF.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory disorders, Gene therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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14. A nurse cares for a client with a 40-year smoking history who is experiencing distended neck
veins and dependent edema. Which physiologic process would the nurse correlate with this
client’s history and clinical signs and symptoms?
a. Increased pulmonary pressure creating a higher workload on the right side of the
heart
b. Exposure to irritants resulting in increased inflammation of the bronchi and
bronchioles
c. Increased number and size of mucous glands producing large amounts of thick
mucus
d. Left ventricular hypertrophy creating a decrease in cardiac output
ANS: A
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Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart
failure. Increased pressures in the lungs make it more difficult for blood to flow through the
lungs. Blood backs up into the right side of the heart and then into the peripheral venous
system, creating distended neck veins and dependent edema. Inflammation in bronchi and
bronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in the
lungs has no impact on distended neck veins and edema. Left ventricular hypertrophy is
associated with left-heart failure and is not directly caused by a 40-year smoking history.
s.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory disorders, Cor pulmonale
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
15. A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears
ba
ANS: C
nk
thin and disheveled. Which question would the nurse ask first?
a. “Do you have a strong support system?”
b. “What do you understand about your disease?”
c. “Do you experience shortness of breath with basic activities?”
d. “What medications are you prescribed to take each day?”
st
Clients with severe COPD may not be able to perform daily activities, including bathing and
eating, because of excessive shortness of breath. The nurse would ask the client if shortness of
breath is interfering with basic activities. Although the nurse would need to know about the
client’s support systems, current knowledge, and medications, these questions do not address
the client’s appearance.
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e
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory disorders, Functional ability
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
16. A clinic nurse is reviewing care measures with a client who has asthma, Step 3. What
statement by the client indicates the need to review the information?
a. “I still will use my rapid-acting inhaler for an asthma attack.”
b. “I will always use the spacer with my dry powder inhaler.”
c. “If I am stable for 3 months, I might be able to reduce my drugs.”
d. “My inhaled corticosteroid must be taken regularly to work well.”
ANS: B
Dry powder inhalers are not used with a spacer. The other statements are accurate.
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DIF: Analyzing
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory disorders, Medications, Health teaching
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
17. A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease
(COPD). Which client would the nurse assess first?
a. A 46 year old with a 30–pack-year history of smoking
b. A 52 year old in a tripod position using accessory muscles to breathe
c. A 68 year old who has dependent edema and clubbed fingers
d. A 74 year old with a chronic cough and thick, tenacious secretions
ANS: B
The client who is in a tripod position and using accessory muscles is working to breathe. This
client must be assessed first to establish how effectively the client is breathing and provide
interventions to minimize respiratory distress. The other clients are not in acute distress.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory disorders, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
18. A nurse cares for a client who has a pleural chest tube. What action would the nurse take to
nk
s.
ensure safe use of this equipment?
a. Strip the tubing to minimize clot formation and ensure patency.
b. Secure tubing junctions with clamps to prevent accidental disconnections.
c. Connect the chest tube to wall suction as prescribed by the primary health care
provider.
d. Keep padded clamps at the bedside for use if the drainage system is interrupted.
ANS: D
ba
Padded clamps would be kept at the bedside for use if the drainage system becomes dislodged
or is interrupted. The nurse would never strip the tubing. Tubing junctions would be taped, not
clamped. Wall suction would be set at the level indicated by the device’s manufacturer, not
the primary health care provider.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory disorders, Chest tubes
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
19. A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The
client asks, “What does this mean?” How would the nurse respond?
a. “Your children will be at high risk for chronic obstructive pulmonary disease.”
b. “I will contact a genetic counselor to discuss your condition.”
c. “Your risk for chronic obstructive pulmonary disease is higher, especially if you
smoke.”
d. “This is a recessive gene and would have no impact on your health.”
ANS: C
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Alpha1-antitrypsin deficiency is an important risk factor for COPD. The gene for AAT is a
recessive gene. Clients with only one allele produce enough AAT to prevent COPD unless the
client smokes or there is sufficient exposure to other inhalants. A client with two alleles is at
high risk for COPD even if not exposed to smoke or other irritants. The client is a carrier, and
children may or may not be at high risk depending on the partner’s AAT levels. Contacting a
genetic counselor may be helpful but does not address the client’s current question.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory disorders, Genetic disorders
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
20. A nurse cares for a client who has a family history of cystic fibrosis. The client asks, “Will my
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children have cystic fibrosis?” How would the nurse respond?
a. “Since many of your family members are carriers, your children will also be
carriers of the gene.”
b. “Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your
children will have the disorder.”
c. “Since you have a family history of cystic fibrosis, I would encourage you and
your partner to be tested.”
d. “Cystic fibrosis is caused by a protein that controls the movement of chloride.
Adjusting your diet will decrease the spread of this disorder.”
ANS: C
nk
s.
Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated
for the disorder to be expressed. The nurse would encourage both the client and partner to be
tested for the abnormal gene. The other statements are not true.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory disorders, Genetic disorders
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
ba
21. A nurse administers medications to a client who has asthma. Which medication classification
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is paired correctly with its physiologic action?
a. Bronchodilator—stabilizes the membranes of mast cells and prevents the release of
inflammatory mediators.
b. Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic
nervous system.
c. Corticosteroid—relaxes bronchiolar smooth muscles by binding to and activating
pulmonary beta2 receptors.
d. Cromone—disrupts the production of pathways of inflammatory mediators.
ANS: B
Cholinergic antagonist drugs cause bronchodilation by inhibiting the parasympathetic nervous
system. This allows the sympathetic nervous system to dominate and release norepinephrine
that activates beta2 receptors. Bronchodilators relax bronchiolar smooth muscles by binding to
and activating pulmonary beta2 receptors. Corticosteroids disrupt the production of pathways
of inflammatory mediators. Cromones stabilize the membranes of mast cells and prevent the
release of inflammatory mediators.
DIF: Remembering
KEY: Respiratory disorders, Medications
TOP: Integrated Process: Nursing Process: Analysis
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MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
22. A nurse evaluates the following arterial blood gas and vital sign results for a client with
chronic obstructive pulmonary disease (COPD):
Arterial Blood Gas Results
Vital Signs
Heart rate = 110 beats/min
pH = 7.32
Respiratory rate = 12 breaths/min
PaCO2 = 62 mm Hg
Blood pressure = 145/65 mm Hg
PaO2 = 46 mm Hg
Oxygen saturation = 76%
HCO3 = 28 mEq/L (28 mmol/L)
What action would the nurse take first?
a. Administer a short-acting beta2 agonist inhaler.
b. Document the findings as normal for a client with COPD.
c. Teach the client diaphragmatic breathing techniques.
d. Initiate oxygenation therapy to increase saturation to 88% to 92%.
ANS: D
co
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Oxygen would be administered to a client who is hypoxic even if the client has COPD and is a
carbon dioxide retainer. The other interventions do not address the client’s hypoxia, which is
the major issue. There is no indication the client needs an inhaler. Diaphragmatic breathing
techniques would not be taught to a client in distress. These findings are not normal for all
clients with COPD.
nk
MULTIPLE RESPONSE
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory disorders, Respiratory distress
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
1. A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen
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st
ba
saturation, and suprasternal retraction on inhalation. What actions by the nurse are best?
(Select all that apply.)
a. Administer prescribed salmeterol inhaler.
b. Assess the client for a tracheal deviation.
c. Administer oxygen and place client on an oximeter.
d. Perform peak expiratory flow readings.
e. Administer prescribed albuterol inhaler.
f. Assess the client’s lung sounds after administering the inhaler.
ANS: C, E, F
Suprasternal retraction caused by inhalation usually indicates that the client is using accessory
muscles and is having difficulty moving air into the respiratory passages because of airway
narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also
supports this finding. The asthma is becoming unstable, and intervention is needed.
Administration of a rescue inhaler is indicated, probably along with administration of oxygen.
The nurse would reassess the lung sounds after the rescue inhaler. The nurse would not do a
peak flow reading at this time, nor would a code be called. The nurse could assess for tracheal
deviation after administering oxygen and albuterol.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory disorders, Respiratory distress
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MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the
nurse’s immediate intervention? (Select all that apply.)
a. Production of pink sputum
b. Tracheal deviation
c. Pain at insertion site
d. Sudden onset of shortness of breath
e. Drainage greater than 70 mL/hr
f. Disconnection at Y site
ANS: B, D, E, F
m
Immediate intervention is warranted if the client has tracheal deviation because this could
indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of
the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could
indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing.
Production of pink sputum and pain at the insertion site are not signs/symptoms that would
require immediate intervention.
co
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Drain, Respiratory distress, Failure
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements
ba
nk
s.
related to nutrition would the nurse include in this client’s teaching? (Select all that apply.)
a. “Avoid drinking fluids just before and during meals.”
b. “Rest before meals if you have dyspnea.”
c. “Have about six small meals a day.”
d. “Eat high-fiber foods to promote gastric emptying.”
e. “Use pursed-lip breathing during meals.”
f. “Choose soft, high-calorie, high-protein foods.”
ANS: A, B, C, E, F
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st
Clients with COPD often are malnourished for several reasons. The nurse would teach the
client not to drink fluids before and with meals to avoid early satiety. The client needs to rest
before eating, and eat smaller frequent meals: 4 to 6 a day. Pursed-lip breathing will help
control dyspnea. Food that is easy to eat will be less tiring and the client should choose
high-calorie, high-protein foods.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory disorders, Nutrition, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
4. A nurse assesses a client with chronic obstructive pulmonary disease. Which questions would
the nurse ask to determine the client’s activity tolerance? (Select all that apply.)
a. “What color is your sputum?”
b. “Do you have any difficulty sleeping?”
c. “How long does it take to perform your morning routine?”
d. “Do you walk upstairs every day?”
e. “Have you lost any weight lately?”
f. “How does your activity compare to this time last year?”
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ANS: B, C, E, F
Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform
activities of daily living. Weight loss could mean increased dyspnea as the client becomes too
fatigued to eat. The color of the client’s sputum would not assist in determining activity
tolerance. Asking whether the client walks upstairs every day is not as pertinent as
determining if the client becomes short of breath on walking upstairs, or if the client goes
upstairs less often than previously. The nurse would ask the client to compare his or her
current level of activity with that of a month or even a year ago.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory disorders, Functional ability
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A client, who has become increasingly dyspneic over a year, has been diagnosed with
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pulmonary fibrosis. What information would the nurse plan to include in teaching this client?
(Select all that apply.)
a. The need to avoid large crowds and people who are ill
b. Safety measures to take if home oxygen is needed
c. Information about appropriate use of the drug nintedanib
d. Genetic therapy to stop the progression of the disease
e. Measures to avoid fatigue during the day
f. The possibility of receiving a lung transplant if infection-free for a year
s.
ANS: A, B, C, E
ba
nk
Pulmonary fibrosis is a progressive disorder with no cure. Therapy focuses on slowing
progression and managing dyspnea. Clients need to avoid contracting infections so should be
taught to stay away from large crowds and sick people. Home oxygen is needed and the nurse
would teach safety measures related to oxygen. The drug nintedanib has shown to improve
cellular regulation and slow progression of the disease. Gene therapy is not available. Energy
conservation measures are also an important topic. Lung transplantation is an unlikely option
due to selection criteria.
st
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory disorders, Pulmonary fibrosis, Health teaching
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A nurse plans care for a client who has chronic obstructive pulmonary disease and thick,
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tenacious secretions. Which interventions would the nurse include in this client’s plan of care?
(Select all that apply.)
a. Ask the client to drink 2 L of fluids daily.
b. Add humidity to the prescribed oxygen.
c. Suction the client every 2 to 3 hours.
d. Use a vibrating chest physiotherapy device.
e. Encourage diaphragmatic breathing.
f. Administer the ordered mucolytic agent.
ANS: A, B, D, F
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Interventions to decrease thick tenacious secretions include maintaining adequate hydration
and providing humidified oxygen. These actions will help to thin secretions, making them
easier to remove by coughing. The use of a vibrating chest physiotherapy device can also help
clients remove thick secretions but is usually used in clients with cystic fibrosis. Mucolytic
agents help thin secretions, making them easier to bring up. Although suctioning may assist
with the removal of secretions, frequent suctioning can cause airway trauma and does not
support the client’s ability to successfully remove secretions through normal coughing.
Diaphragmatic breathing is not used to improve the removal of thick secretions.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory disorders, COPD
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
7. A nurse cares for a client who is prescribed an intravenous prostacyclin agent for pulmonary
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artery hypertension. What actions would the nurse take to ensure the client’s safety while on
this medication? (Select all that apply.)
a. Keep an intravenous line dedicated strictly to the infusion.
b. Teach the client that this medication increases pulmonary pressures.
c. Ensure that there is always a backup drug cassette available.
d. Start a large-bore peripheral intravenous line.
e. Use strict aseptic technique when using the drug delivery system.
ANS: A, C, E
nk
s.
Intravenous prostacyclin agents would be administered to a client with pulmonary artery
hypertension through a central venous catheter with a dedicated intravenous line for this
medication. Death has been reported when the drug delivery system is interrupted even
briefly; therefore, a backup drug cassette would also be available. The nurse would use strict
aseptic technique when using the drug delivery system. The nurse would teach the client that
this medication decreases pulmonary pressures and increases lung blood flow.
ba
DIF: Understanding
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory disorders, Medication administration
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
st
8. A home health nurse evaluates a client who has chronic obstructive pulmonary disease. Which
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assessments would the nurse include in this client’s evaluation? (Select all that apply.)
a. Examination of mucous membranes and nail beds
b. Measurement of rate, depth, and rhythm of respirations
c. Auscultation of bowel sounds for abnormal sounds
d. Check peripheral veins for distention while at rest
e. Determine the client’s need and use of oxygen
f. Ability to perform activities of daily living
ANS: A, B, E, F
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A home health nurse would assess the client’s respiratory status and adequacy of ventilation
including an examination of mucous membranes and nail beds for evidence of hypoxia,
measurement of rate, depth and rhythm of respirations, auscultation of lung fields for
abnormal breath sounds, checking neck veins for distention with the client in a sitting
position, and determining the client’s needs and use of supplemental oxygen. The home health
nurse would also determine the client’s ability to perform his or her own ADLs. Auscultation
of bowel sounds and assessment of peripheral veins are not part of a focused assessment for a
client with COPD.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory disorders, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. A nurse is teaching a client how to perform pursed-lip breathing. Which instructions would
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the nurse include in this teaching? (Select all that apply.)
a. “Open your mouth and breathe deeply.”
b. “Use your abdominal muscles to squeeze air out of your lungs.”
c. “Breath out slowly without puffing your cheeks.”
d. “Focus on inhaling and holding your breath as long as you can.”
e. “Exhale at least twice the amount of time it took to breathe in.”
f. “Lie on your back with your knees bent.”
ANS: B, C, E
nk
s.
A nurse would teach a client to close his or her mouth and breathe in through his or her nose,
purse his or her lips and breathe out slowly without puffing his or her cheeks, and use his or
her abdominal muscles to squeeze out every bit of air. The nurse would also remind the client
to use pursed-lip breathing during any physical activity, to focus on exhaling, and to never
hold his or her breath. Lying on the back with bent knees is the preferred position for
diaphragmatic breathing.
ba
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory disorders, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
10. A nurse is assessing a client with lung cancer. What nonpulmonary signs and symptoms
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would the nurse be aware of? (Select all that apply.)
a. Gynecomastia in male patients
b. Frequent shaking and sweating relieved by eating
c. Positive Chvostek and Trousseau signs
d. “Moon” face and “buffalo” hump
e. Expectorating purulent sputum
f. General edema
ANS: A, B, D, F
Lung cancer often is associated with paraneoplastic syndromes. Symptoms of these include
gynecomastia from ectopic follicle-stimulating hormone release, hypoglycemia from ectopic
insulin production (shaking and sweating relieved by eating), and Cushing syndrome (moon
facies and buffalo hump) from ectopic adrenocorticotropic hormone. General edema can be
caused by antidiuretic hormone.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
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KEY: Respiratory disorders, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
11. The nurse is preparing to teach a community group about warning signs of lung cancer. What
information does the nurse include? (Select all that apply.)
a. Over 10–pack-year history of smoking
b. Persistent coughing
c. Rusty or blood-tinged sputum
d. Dyspnea
e. Hoarseness
f. Fatigue
ANS: B, C, D, E
m
Some common signs of lung cancer include persistent cough, rusty or blood-tinged sputum,
dyspnea, and hoarseness. Fatigue is common to many conditions. Smoking history is a risk
factor for lung cancer.
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ba
nk
s.
co
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory disorders, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
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Chapter 28: Concepts of Care for Patients With Infectious Respiratory Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse working in a geriatric clinic sees clients with “cold” symptoms and rhinitis. The
primary health care provider (PHCP) often leaves a prescription for diphenhydramine. What
action by the nurse is best?
a. Teach the client about possible drowsiness.
b. Instruct the client to drink plenty of water.
c. Consult with the PHCP about the medication.
d. Encourage the client to take the medication with food.
ANS: C
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First-generation antihistamines are not appropriate for use in the older population. These
drugs include chlorpheniramine, diphenhydramine, and hydroxyzine. The nurse would consult
with the PHCP and request a different medication. Diphenhydramine does cause drowsiness,
but the nurse would request a different medication. Drinking plenty of fluids is appropriate for
the condition and is not related to the medication. Antihistamines can be taken without regard
to food.
s.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Antihistamines, Older adults
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
nk
2. A nurse in a family practice clinic is preparing discharge instructions for a client reporting
ANS: C
ba
facial pain that is worse when bending over, tenderness across the cheeks, and postnasal
discharge. What instruction will be most helpful?
a. “Ice packs may help with the facial pain.”
b. “Limit fluids to dry out your sinuses.”
c. “Try warm, moist heat packs on your face.”
d. “We will schedule a computed tomography scan this week.”
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This client has rhinosinusitis. Comfort measures for this condition include humidification, hot
packs, nasal saline irrigations, sleeping with the head elevated, increased fluids, and avoiding
cigarette smoke. The client does not need a CT scan.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Infectious respiratory problems, Nonpharmacologic comfort interventions
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
3. Which teaching point is most important for the client with a peritonsillar abscess?
a. Gargle with warm salt water.
b. Take all antibiotics as directed.
c. Let us know if you want liquid medications.
d. Wash hands frequently.
ANS: B
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Any client on antibiotics must be instructed to complete the entire course of antibiotics. Not
completing them can lead to complications or drug-resistant strains of bacteria. The other
instructions are appropriate, just not the most important.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Antibiotics, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A client is in the family practice clinic reporting a severe “cold” that started 4 days ago. On
examination, the nurse notes that the client also has a severe headache and muscle aches.
What action by the nurse is best?
a. Educate the client on oseltamivir.
b. Facilitate admission to the hospital.
c. Instruct the client to have a flu vaccine.
d. Teach the client to sneeze in the upper sleeve.
m
ANS: D
s.
co
Sneezing and coughing into one’s sleeve helps prevent the spread of upper respiratory
infections. The client does have symptoms of the flu (influenza), but it is too late to start
antiviral medications; to be effective, they must be started within 24 to 48 hours of symptom
onset. The client does not need hospital admission. The client would be instructed to have a
flu vaccination, but now that he or she has the flu, vaccination will have to wait until next
year.
nk
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Influenza, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
5. The charge nurse on a medical unit is preparing to admit several “clients” who have possible
st
ANS: B
ba
pandemic flu during a preparedness drill. What action by the nurse is best?
a. Admit the “clients” on Contact Precautions.
b. Inquire as to recent travel outside the United States.
c. Do not allow pregnant caregivers to care for these “clients.”
d. Place the “clients” on enhanced Droplet Precautions.
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Preventing the spread of pandemic flu is equally important as caring for the clients who have
it. Preventing the spread of disease is vital. The nurse would ask the “clients” about recent
overseas travel to assess the risk of a pandemic flu. Clients with possible pandemic flu need to
be in Contact and Airborne Precautions the infectious organism is identified and routes of
transmission known. There is no specific danger to pregnant caregivers. Droplet Precautions
are not appropriate.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection control, Transmission-based precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
6. A client admitted for pneumonia has been tachypneic for several days. When the nurse starts
an IV to give fluids, the client questions this action, saying “I have been drinking tons of
water. How am I dehydrated?” What response by the nurse is best?
a. “Breathing so quickly can be dehydrating.”
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b. “Everyone with pneumonia is dehydrated.”
c. “This is really just to administer your antibiotics.”
d. “Why do you think you are so dehydrated?”
ANS: A
Tachypnea and mouth breathing (from increased work of breathing), both seen in pneumonia,
increase insensible water loss and can lead to a degree of dehydration. The other options do
not give the client useful information that addresses this specific concern.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Pneumonia, Fluid and electrolyte imbalances
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. An older adult is brought to the emergency department by a family member, who reports a
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moderate change in mental status and mild cough. The client is afebrile. The primary health
care provider orders a chest x-ray. The family member questions why this is needed since the
symptoms seem so vague. What response by the nurse is best?
a. “Chest x-rays are always ordered when we suspect pneumonia.”
b. “Older people often have vague symptoms, so an x-ray is essential.”
c. “The x-ray can be done and read before laboratory work is reported.”
d. “We are testing for any possible source of infection in the client.”
ANS: B
ba
nk
s.
It is essential to obtain an early chest x-ray in older adults suspected of having pneumonia
because symptoms are often vague. Waiting until definitive signs and symptoms are present to
obtain the x-ray leads to a costly delay in treatment. Stating that chest x-rays are always
ordered does not give the family definitive information. The x-ray can be done while
laboratory values are still pending, but this also does not provide specific information about
the importance of a chest x-ray in this client. The client has symptoms of pneumonia, so the
staff is not testing for any possible source of infection but rather is testing for a suspected
disorder.
st
DIF: Understanding
TOP: Integrated Process: Communication and Documentation KEY: Older adult, Pneumonia
MSC: Client Needs Category: Health Promotion and Maintenance
8. A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest
priority?
Educating the client on adherence to the treatment regimen
Encouraging the client to eat a well-balanced diet
Informing the client about follow-up sputum cultures
Teaching the client ways to balance rest with activity
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a.
b.
c.
d.
ANS: A
The treatment regimen for TB often ranges from 26 weeks, but can be up to 2 years, making
adherence problematic for many people. The nurse would stress the absolute importance of
following the treatment plan for the entire duration of prescribed therapy. The other options
are appropriate topics to educate this client on but do not take priority.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Tuberculosis, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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9. A client has been admitted for suspected inhalation anthrax infection. What question by the
nurse is most important?
a. “Are any family members also ill?”
b. “Have you traveled recently?”
c. “How long have you been ill?”
d. “What is your occupation?”
ANS: D
Inhalation anthrax is rare and is an occupational hazard among people who work with animal
wool, bone meal, hides, and skin, such as taxidermists and veterinarians. Inhalation anthrax
seen in someone without an occupational risk is considered a bioterrorism event and must be
reported to authorities immediately. The other questions are appropriate for anyone with an
infection.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Infection, Anthrax
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
10. A charge nurse is rounding on several older clients on ventilators in the Intensive Care Unit
s.
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whom the nurse identifies as being at high risk for ventilator-associated pneumonia. To reduce
this risk, what activity would the nurse delegate to the assistive personnel (AP)?
a. Encourage between-meal snacks.
b. Monitor temperature every 4 hours.
c. Provide oral care every 4 hours.
d. Report any new onset of cough.
nk
ANS: C
ba
Oral colonization by gram-negative bacteria is a risk factor for health care–associated
pneumonia. Good, frequent oral care can help prevent this from developing and is a task that
can be delegated to the AP. Encouraging good nutrition is important, but this will not prevent
pneumonia. Monitoring temperature and reporting new cough in clients are important to
detect the onset of possible pneumonia but do not prevent it.
st
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Pneumonia, Oral care
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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11. The emergency department (ED) manager is reviewing client charts to determine how well the
staff perform when treating clients with community-acquired pneumonia. What outcome
demonstrates that goals for this client type have been met?
a. Antibiotics started before admission.
b. Blood cultures obtained within 20 minutes.
c. Chest x-ray obtained within 30 minutes.
d. Pulse oximetry obtained on all clients.
ANS: A
Goals for treatment of community-acquired pneumonia include initiating antibiotics prior to
inclient admission or within 6 hours of presentation to the ED. Timely collection of blood
cultures, chest x-ray, and pulse oximetry are important as well but do not coincide with
established goals.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Infection, Pneumonia
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
12. A nurse has educated a client on isoniazid. What statement by the client indicates that
teaching has been effective?
a. “I need to take extra vitamin C while on isoniazid.”
b. “I should take this medicine with milk or juice.”
c. “I will take this medication on an empty stomach.”
d. “My contact lenses will be permanently stained.”
ANS: C
Isoniazid needs to be taken on an empty stomach, either 1 hour before or 2 hours after meals.
Extra vitamin B needs to be taken while on the drug. Staining of contact lenses commonly
occurs while taking rifampin.
m
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Tuberculosis, Medications, Health teaching
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
co
13. A client has been taking isoniazid for tuberculosis for 3 weeks. What laboratory results need
s.
to be reported to the primary health care provider immediately?
a. Albumin: 5.1 g/dL (7.4 mcmol/L)
b. Alanine aminotransferase (ALT): 180 U/L
c. Red blood cell (RBC) count: 5.2/million/µL (5.2  1012/L)
d. White blood cell (WBC) count: 12,500/mm3 (12.5  109/L)
nk
ANS: B
ba
INH can cause liver damage, especially if the client drinks alcohol. The ALT (one of the liver
enzymes) is extremely high and needs to be reported immediately. The albumin and RBCs are
normal. The WBCs are slightly high, but that would be an expected finding in a client with an
infection.
st
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Tuberculosis, Medication side effects
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
14. A client seen in the emergency department reports fever, fatigue, and dry cough but no other
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upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the
nurse is best?
a. Collect a sputum sample for culture by deep suctioning.
b. Inform the client that oral antibiotics will be needed for 60 days.
c. Place the client on Airborne Precautions immediately.
d. Tell the client that directly observed therapy is needed.
ANS: B
This client has signs and symptoms of early inhalation anthrax. For treatment, after IV
antibiotics are finished, oral antibiotics are continued for at least 60 days. Sputum cultures are
not needed. Anthrax is not transmissible from person to person, so Standard Precautions are
adequate. Directly observed therapy is often used for tuberculosis.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
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KEY: Anthrax, Antibiotics
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
15. A client has been hospitalized with tuberculosis (TB). The client’s spouse is fearful of
entering the room where the client is in isolation and refuses to visit. What action by the nurse
is best?
a. Ask the spouse to explain the fear of visiting in further detail.
b. Inform the spouse that the precautions are meant to keep other clients safe.
c. Show the spouse how to follow the Isolation Precautions to avoid illness.
d. Tell the spouse that he or she has already been exposed, so it’s safe to visit.
ANS: A
co
DIF: Applying
TOP: Integrated Process: Caring
KEY: Tuberculosis, Therapeutic communication
MSC: Client Needs Category: Psychosocial Integrity
m
The nurse needs to obtain further information about the spouse’s specific fears so they can be
addressed. This will decrease stress and permit visitation, which will be beneficial for both
client and spouse. Precautions for TB prevent transmission to all who come into contact with
the client. Explaining Isolation Precautions and what to do when entering the room will be
helpful, but this is too narrow in scope to be the best answer. Telling the spouse that it’s safe
to visit is demeaning of the spouse’s feelings.
16. A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the
nk
s.
nurse is most appropriate?
a. Community social worker for Meals on Wheels
b. Occupational therapy for job retraining
c. Physical therapy for homebound therapy services
d. Visiting nurses for directly observed therapy
ANS: D
ba
Directly observed therapy is often utilized for managing clients with TB in the community.
Meals on Wheels, job retraining, and home therapy may or may not be appropriate.
st
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Tuberculosis, Referrals
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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17. A client is admitted with suspected pneumonia from the emergency department. The client
went to the primary health care provider a “few days ago” and shows the nurse the results of
what the client calls “an allergy test,” as shown below:
The reddened area is firm. What action by the nurse is best?
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a.
b.
c.
d.
Assess the client for possible items to which he or she is allergic.
Call the primary health care provider’s office to request records.
Immediately place the client on Airborne Precautions.
Prepare to begin administration of intravenous antibiotics.
ANS: C
This “allergy test” is actually a positive tuberculosis test. The client would be placed on
Airborne Precautions immediately. The other options do not take priority over preventing the
spread of the disease.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Tuberculosis, Transmission-based precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
18. A nurse admits a client from the emergency department. Client data are listed below:
Laboratory Values
° WBC 5,200/mm3 (5.2 
109/L)
° PaO2 on room air 85 mm
Hg
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Physical Assessment
° Crackles and rhonchi heard
throughout the lungs
° Dullness to percussion
LLL
° Afebrile
° Oriented to person only
s.
History
° 70 years of age
° History of diabetes
° On insulin twice a day
° Reports new onset dyspnea
and productive cough
nk
What action by the nurse is the priority?
a. Administer oxygen at 4 L per nasal cannula.
b. Begin broad-spectrum antibiotics.
c. Collect a sputum sample for culture.
d. Start an IV of normal saline at 50 mL/hr.
ANS: A
st
ba
All actions are appropriate for this client who has signs and symptoms of pneumonia.
However, airway and breathing come first, so begin oxygen administration and titrate it to
maintain saturations greater than 95%. Start the IV and collect a sputum culture, and then
begin antibiotics.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Pneumonia, Oxygen therapy
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances,
the event organizers must limit giving the vaccination to priority groups. What clients would
be considered a priority when administering the pneumonia vaccination? (Select all that
apply.)
a. A 22-year-old client with asthma
b. Client who had a cholecystectomy last year
c. Client with well-controlled diabetes
d. Healthy 72-year-old client
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e. Client who is taking medication for hypertension
ANS: A, C, D, E
Clients over 65 years of age and any client (no matter what age) with a chronic health
condition would be considered a priority for a pneumonia vaccination. Having a
cholecystectomy a year ago does not qualify as a chronic health condition.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Implementation
KEY: Vaccinations, Health promotion
MSC: Client Needs Category: Health Promotion and Maintenance
2. A hospital nurse is participating in a drill during which many “clients” with inhalation anthrax
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are being admitted. What drugs would the nurse anticipate administering? (Select all that
apply.)
a. Vancomycin
b. Ciprofloxacin
c. Doxycycline
d. Ethambutol
e. Sulfamethoxazole-trimethoprim (SMX-TMP)
ANS: A, B, C
s.
Vancomycin, ciprofloxacin, and doxycycline are all possible treatments for inhalation anthrax.
Ethambutol is used for tuberculosis. SMX-TMP is commonly used for urinary tract infections
and other common infections.
nk
DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Anthrax, Emergency preparedness plan
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
ba
3. A client in the emergency department is taking rifampin for tuberculosis. The client reports
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yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results
correlate to this condition? (Select all that apply.)
a. Blood urea nitrogen (BUN): 19 mg/dL (6.7 mmol/L)
b. International normalized ratio (INR): 6.3
c. Prothrombin time: 35 seconds
d. Serum sodium: 130 mEq/L (130 mmol/L)
e. White blood cell (WBC) count: 72,000/mm3 (72  109/L)
ANS: B, C
Rifampin can cause liver damage, evidenced by the client’s high INR and prothrombin time.
The BUN and WBC count are normal. The sodium level is low, but that is not related to this
client’s problem.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Tuberculosis, Adverse medication effects
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. A client has been diagnosed with an empyema. What interventions would the nurse anticipate
providing to this client? (Select all that apply.)
a. Assisting with chest tube insertion
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b.
c.
d.
e.
Facilitating pleural fluid sampling
Performing frequent respiratory assessment
Providing antipyretics as needed
Suctioning deeply every 4 hours
ANS: A, B, C, D
The client with an empyema is often treated with chest tube insertion, which facilitates
obtaining samples of the pleural fluid for analysis and re-expands the lungs. The nurse would
perform frequent respiratory system assessments. Antipyretic medications are also used.
Suction is only used when needed and is not done deeply to prevent tissue injury.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory system, Chest tubes, Infection, Respiratory assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. The emergency department nurse is participating in a bioterrorism drill in which several
s.
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“clients” are suspected to have inhalation anthrax. Which “clients” would the nurse see as the
priorities? (Select all that apply.)
a. Widened mediastinum on chest x-ray
b. Dry cough
c. Stridor
d. Oxygen saturation of 91%
e. Diaphoresis
f. Oral temperature of 99.9° F (37.7° C)
ANS: C, D, E
nk
Clients with fulminant anthrax may exhibit stridor, hypoxia, and diaphoresis. Although an
oxygen saturation of 91% is not critical, it is abnormally low. These clients would be seen as
the priority. A widened mediastinum and dry cough are usually seen in the prodromal phase
when the temperature elevation is not as severe.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Anthrax, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
st
6. A client is taking ethambutol for tuberculosis. What instructions does the nurse provide the
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client regarding this drug? (Select all that apply.)
a. Contact the primary health care provider if preexisting gout becomes worse.
b. Report any changes in vision immediately to the health care provider.
c. Avoid drinking alcoholic beverages due to the chance of liver damage.
d. Do not take antacids or eat within 2 hours after taking this medication.
e. You will take this medication along with some others for 8 weeks.
f. Take this medicine with a full glass of water.
ANS: A, B, E, F
The nurse would teach the client that preexisting gout may get worse and the client should
report this as medications for gout may need to be adjusted. The nurse would also inform the
client about the multi-drug routine used for TB. Optic neuritis can occur with this drug so the
client needs to report visual changes right away. The medication should be taken with a full
glass of water. Drinking while taking ethambutol causes severe nausea and vomiting.
Avoiding antacids and food (within 2 hours) is a precaution with isoniazid.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Tuberculosis, Health teaching
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
7. The nurse is learning about endemic pulmonary diseases. Which diseases are matched with
correct information? (Select all that apply.)
a. Hanta virus: found in urine, droppings, and saliva of infected rodents.
b. Aspergillosis: requires a prolonged course of antibiotics.
c. Histoplasmosis: sources include soil containing bird and bat droppings.
d. Blastomycosis: requires strict adherence to multi-antibiotic regimen.
e. Cryptococcosis: has been eradicated due to strategic deforestation.
f. Coccidioidomycosis: found in the southwest and far west of the United States.
ANS: A, C, F
s.
co
m
Hanta virus is often seen in the southwest United States and is found in the urine, droppings,
and saliva of infected rodents. Histoplasmosis is found in soil containing bird and bat
droppings and on surfaces covered with bird droppings. Apergillosis is a common mold found
both indoors and outdoors and is treated with a long course of antifungal drugs. Blastomycosis
is a fungal disease requiring a prolonged course of antifungal medications. Cryptococcosis is a
fungus found on trees and in the soil beneath trees, but has not been eradicated with strategic
deforestation. Coccidioidomycosis is found in the southwest and far west of the United States,
plus Mexico, and Central and South America.
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st
ba
nk
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory system, Infection, Respiratory assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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Chapter 29: Critical Care of Patients With Respiratory Emergencies
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain,
and has a blood pressure of 88/52 mm Hg. What action by the nurse takes priority?
a. Assess the client’s lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs.
ANS: B
m
This client has signs and symptoms of a pulmonary embolism, and the most critical action is
to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are
appropriate also but are not the priority.
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DIF: Remembering
TOP: Integrated Process: Communication and Documentation
KEY: Pulmonary embolism, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active
nk
s.
and has no known risk factors for PE. What action by the nurse is most appropriate?
a. Encourage the client to walk 5 minutes each hour.
b. Refer the client to smoking cessation classes.
c. Teach the client about factor V Leiden testing.
d. Tell the client that sometimes no cause for disease is found.
ANS: C
st
ba
Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events,
including PE. A client with no known risk factors for this disorder would be asked about
family history and referred for testing. Encouraging the client to walk is healthy, but is not
related to the development of a PE in this case, nor is smoking. Although there are cases of
disease where no cause is ever found, this assumption is premature.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Pulmonary embolism, Genetic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge
nurse why the client’s oxygen saturation has not significantly improved. What response by the
nurse is best?
a. “Breathing so rapidly interferes with oxygenation.”
b. “Maybe the client has respiratory distress syndrome.”
c. “The blood clot interferes with perfusion in the lungs.”
d. “The client needs immediate intubation and mechanical ventilation.”
ANS: C
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A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless
the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with
oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating,
and this is also not the most precise physiologic answer. Acute respiratory distress syndrome
can occur, but this is not as likely soon after the client starts on oxygen plus there is no
indication of how much oxygen the client is on. The client may need to be mechanically
ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Pulmonary embolism, Respiratory system
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A client is on intravenous heparin to treat a pulmonary embolism. The client’s most recent
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partial thromboplastin time (PTT) was 25 seconds. What order would the nurse anticipate?
a. Decrease the heparin rate.
b. Increase the heparin rate.
c. No change to the heparin rate.
d. Stop heparin; start warfarin.
ANS: B
s.
co
For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate
that the heparin is working. A normal PTT is 25 to 35 seconds, so this client’s PTT value is
too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Analysis
KEY: Pulmonary embolism, Anticoagulants, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic
ANS: B
st
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testing reveals that the client has an alteration in the gene CYP2C19. What action by the nurse
is best?
a. Instruct the client to eliminate all vitamin K from the diet.
b. Prepare preoperative teaching for an inferior vena cava (IVC) filter.
c. Refer the client to a chronic illness support group.
d. Teach the client to use a soft-bristled toothbrush.
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e
Often clients are discharged from the hospital on warfarin after a PE. However, clients with a
variation in the CYP2C19 gene do not metabolize warfarin well and have much higher blood
levels and more side effects. This client is a poor candidate for warfarin therapy, and the
prescriber will most likely order an IVC filter device to be implanted. The other option is to
lower the dose of warfarin. The nurse would prepare to do preoperative teaching on this
procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness
support group may be needed, but this is not the best intervention as it is not as specific to the
client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on
anticoagulation therapy.
DIF: Applying
TOP: Integrated Process: Nursing Process: Analysis
KEY: Pulmonary embolism, Genetic alterations
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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6. A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value
possibly indicates that a serious side effect has occurred?
a. Hemoglobin: 14.2 g/dL (142 g/L)
b. Platelet count: 82,000/L (82  109/L)
c. Red blood cell count: 4.8/mm3 (4.8  1012/L)
d. White blood cell count: 8700/mm3 (8.7  109/L)
ANS: B
This platelet count is low and could indicate heparin-induced thrombocytopenia. The other
values are normal for either gender.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Anticoagulants, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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7. A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
a. Assess for other signs of hypoxia.
b. Change the sensor on the pulse oximeter.
c. Obtain a new oximeter from central supply.
d. Tell the client to take slow, deep breaths.
ANS: A
s.
Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors
can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse
would conduct a more thorough assessment. The other actions are not appropriate for a
hypoxic client.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory assessment, Hypoxia
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
ba
8. A nurse is assisting the primary health care provider (PHCP) who is intubating a client. The
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ANS: C
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PHCP has been attempting to intubate for 40 seconds. What action by the nurse is best?
a. Ensure that the client has adequate sedation.
b. Find another qualified provider to intubate.
c. Interrupt the procedure to give oxygen.
d. Monitor the client’s oxygen saturation.
Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia.
The nurse would interrupt the intubation attempt and give the client oxygen. The nurse would
also have adequate sedation during the procedure and monitor the client’s oxygen saturation,
but these do not take priority. Finding another qualified provider to intubate the client is not
appropriate at this time.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory system, Intubation
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
9. An intubated client’s oxygen saturation has dropped to 88%. What action by the nurse takes
priority?
a. Determine if the tube is kinked.
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b. Ensure that all connections are patent.
c. Listen to the client’s lung sounds.
d. Suction the endotracheal tube.
ANS: C
When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most
common cause), obstruction (often by secretions), pneumothorax, and equipment problems.
The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube
is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic
and perform suction if needed, assess for pneumothorax, and finally check the equipment.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Mechanical ventilation, Respiratory assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
ANS: C
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nurse delegate to the assistive personnel AP)?
a. Assess the client for sedation needs.
b. Get family permission for restraints.
c. Provide frequent oral care per protocol.
d. Use nonverbal pain assessment tools.
m
10. A client with acute respiratory failure is on a ventilator and is sedated. What care may the
s.
The client on mechanical ventilation needs frequent oral care, which can be delegated to the
AP. The other actions fall within the scope of practice of the nurse.
nk
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Mechanical ventilation, Oral care, Delegation
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
11. A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator
ANS: D
st
ba
settings with the respiratory therapist, what would the nurse ensure?
a. The client is able to initiate spontaneous breaths.
b. The inspired oxygen has adequate humidification.
c. The upper peak airway pressure limit alarm is off.
d. The upper peak airway pressure limit alarm is on.
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The upper peak airway pressure limit alarm will sound when the airway pressure reaches a
preset maximum. This is critical to prevent barotrauma to the lungs. Alarms are never be
turned off. Initiating spontaneous breathing is important for some modes of ventilation but not
others. Adequate humidification is important but does not take priority over preventing injury.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Mechanical ventilation, Equipment safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
12. A nurse is caring for a client on mechanical ventilation and finds the client agitated and
thrashing about. What action by the nurse is most appropriate?
a. Assess the cause of the agitation.
b. Reassure the client that he or she is safe.
c. Restrain the client’s hands.
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d. Sedate the client immediately.
ANS: A
The nurse needs to determine the cause of the agitation. The inability to communicate often
makes clients anxious, even to the point of panic. Pain, confusion, and hypoxia can also cause
agitation. Once the nurse determines the cause of the agitation, he or she can implement
measures to relieve the underlying cause. Reassurance is also important but may not address
the etiology of the agitation. Restraints and more sedation may be necessary but not as a first
step. Ensuring the client is adequately oxygenated is the priority.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Mechanical ventilation, Anxiety
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
13. A nurse is preparing to admit a client on mechanical ventilation for acute respiratory failure
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from the emergency department. What action does the nurse take first?
a. Assessing that the ventilator settings are correct
b. Ensuring that there is a bag-valve-mask in the room
c. Obtaining personal protective equipment
d. Planning to suction the client upon arrival to the room
ANS: B
nk
s.
Having a bag-valve-mask device is critical in case the client needs manual breathing. The
respiratory therapist is usually primarily responsible for setting up the ventilator, although the
nurse would know and check the settings. Personal protective equipment is important, but
ensuring client safety is the most important action. The client may or may not need suctioning
on arrival.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Mechanical ventilation, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
14. A client is on mechanical ventilation and the client’s spouse wonders why ranitidine is needed
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since the client “only has lung problems.” What response by the nurse is best?
a. “It will increase the motility of the gastrointestinal tract.”
b. “It will keep the gastrointestinal tract functioning normally.”
c. “It will prepare the gastrointestinal tract for enteral feedings.”
d. “It will prevent ulcers from the stress of mechanical ventilation.”
ANS: D
Stress ulcers can occur in many clients who are receiving mechanical ventilation, and often
prophylactic medications are used to prevent them and possible subsequent aspiration.
Frequently used medications include antacids, histamine blockers, and proton pump
inhibitors. Ranitidine is a histamine-blocking agent.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Mechanical ventilation, Histamine blocker
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
15. A client has been brought to the emergency department with a life-threatening chest injury.
What action by the nurse takes priority?
a. Apply oxygen at 100%.
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b. Assess the respiratory rate.
c. Ensure a patent airway.
d. Start two large-bore IV lines.
ANS: C
The priority for any chest trauma client is airway, breathing, and circulation. The nurse first
ensures that the client has a patent airway. Assessing respiratory rate and applying oxygen are
next, followed by inserting IVs.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Emergency nursing, Primary survey, Trauma
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
16. A client with ARDS is receiving minimal amounts of IV fluids. The new nurse notes the client
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is scheduled to receive a diuretic at this time. The nurse consults the Staff Development Nurse
to determine the best course of action. What will the new nurse do?
a. Contact the primary health care provider.
b. Give the ordered diuretic as scheduled.
c. Request an increase in the IV rate.
d. Calculate the client’s 24-hour fluid balance.
ANS: B
nk
s.
Research has shown that clients with ARDS may benefit from conservative fluid therapy
along with diuretics to maintain fluid balance. The nurse will give the ordered diuretic as
scheduled. There is no reason to contact the provider or request an increased IV rate. The
nurse can calculate the 24-hour fluid balance, but this will not influence the administration of
the medication.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: ARDS, Medication
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
17. A nurse is assessing a client who is suspected of having ARDS. The nurse is confused that
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st
although the client appears dyspneic and the oxygen saturation is 88% on 6 L/min of oxygen,
the client’s lungs are clear. What explanation does the more senior nurse provide?
a. “The client is too dehydrated for moist-sounding lungs.”
b. “The client hasn’t started having any bronchospasm yet.”
c. “Lung edema is in the interstitial tissues, not the airways.”
d. “Clients with ARDS usually have clear lung sounds.”
ANS: C
The clear lung sounds are due to the fact that the edema is found in the lung interstitial tissues,
where it can’t be auscultated, instead of in the airways. It is not related to the client being
dehydrated or having bronchospasm. The statement about all clients with ARDS having clear
lung sounds does not provide any information.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: ARDS, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
18. A client in the emergency department has several broken ribs and reports severe pain. What
care measure will best promote comfort?
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a.
b.
c.
d.
Prepare to assist with intercostal nerve block.
Humidify the supplemental oxygen.
Splint the chest with a large ACE wrap.
Provide warmed blankets and warmed IV fluids.
ANS: A
Uncomplicated rib fractures generally are simple to manage; however, opioids may be needed
for pain. For severe pain, an intercostal nerve block is beneficial. The client needs to be able
to breathe deeply and cough so as not to get atelectasis and/or pneumonia. Humidifying the
oxygen will not help with the pain. Rib fractures are not wrapped or splinted in any way
because this inhibits chest movement. Warmed blankets and warm IV fluids are nice comfort
measures, but do not help with severe pain.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory system, Pharmacological pain management
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
19. A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping
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blood pressure. What medication would the nurse being most beneficial?
a. Alteplase
b. Enoxaparin
c. Unfractionated heparin
d. Warfarin sodium
s.
ANS: A
nk
Alteplase is a “clot-busting” agent indicated in large PEs in the setting of hemodynamic
instability. The nurse knows that this drug is the priority, although heparin may be started
initially. Enoxaparin and warfarin are not indicated in this setting.
ba
DIF: Remembering
TOP: Integrated Process: Nursing Process: Analysis
KEY: Pulmonary embolism, Anticoagulants
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
20. A client is brought to the emergency department after sustaining injuries in a severe car crash.
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The client’s chest wall does not appear to be moving normally with respirations, oxygen
saturation is 82%, and the client is cyanotic. What action does the nurse take first?
a. Administer oxygen and reassess.
b. Auscultate the client’s lung sounds.
c. Facilitate a portable chest x-ray.
d. Prepare to assist with intubation.
ANS: D
This client has signs and symptoms of flail chest and, with the other signs, needs to be
intubated and mechanically ventilated immediately. The nurse does not have time to
administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken
after the client is intubated.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Trauma, Respiratory system
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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21. A new nurse asks for an explanation of “refractory hypoxemia.” What answer by the staff
development nurse is best?
a. “It is chronic hypoxemia that accompanies restrictive airway disease.”
b. “It is hypoxemia from lung damage due to mechanical ventilation.”
c. “It is hypoxemia that continues even after the client is weaned from oxygen.”
d. “It is hypoxemia that persists even with 100% oxygen administration.”
ANS: D
Refractory hypoxemia is hypoxemia that persists even with the administration of 100%
oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany
restrictive airway disease and is not caused by the use of mechanical ventilation or by being
weaned from oxygen.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Respiratory disorders, Pathophysiology
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
22. A nurse is caring for a client on the medical stepdown unit. The following data are related to
this client:
Subjective Information
Shortness of breath for 20
minutes
Reports feeling frightened
“Can’t catch my breath”
Physical Assessment
Pulse: 120 beats/min
Respiratory rate: 34
breaths/min
Blood pressure 158/92 mm
Hg
Lungs have crackles
s.
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Laboratory Analysis
pH: 7.32
PaCO2: 28 mm Hg
PaO2: 78 mm Hg
SaO2: 88%
ANS: B
ba
nk
What action by the nurse is most appropriate?
a. Call respiratory therapy for a breathing treatment.
b. Facilitate a STAT pulmonary angiography.
c. Prepare for immediate endotracheal intubation.
d. Prepare to administer intravenous anticoagulants.
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e
st
This client has signs and symptoms of pulmonary embolism (PE); however, many conditions
can cause the client’s presentation. The gold standard for diagnosing a PE is pulmonary
angiography. The nurse would facilitate this test as soon as possible. The client does not have
wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need
intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of
PE.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Pulmonary embolism
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. A nurse is caring for five clients. For which clients would the nurse assess a high risk for
developing a pulmonary embolism (PE)? (Select all that apply.)
a. Client who had a reaction to contrast dye yesterday
b. Client with a new spinal cord injury on a rotating bed
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c.
d.
e.
f.
Middle-age client with an exacerbation of asthma
Older client who is 1 day post-hip replacement surgery
Young obese client with a fractured femur
Middle-age adult with a history of deep vein thrombosis
ANS: B, D, E
Conditions that place clients at higher risk of developing PE include prolonged immobility,
central venous catheters, surgery, obesity, advancing age, conditions that increase blood
clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure,
stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma
pose no risk for PE.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Pulmonary embolism, Risk factors
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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2. When working with women who are taking hormonal birth control, what health promotion
s.
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measures does the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that
apply.)
a. Avoid drinking alcohol.
b. Eat more omega-3 fatty acids.
c. Exercise on a regular basis.
d. Maintain a healthy weight.
e. Stop smoking cigarettes.
ANS: C, D, E
nk
Health promotion measures for clients to prevent thromboembolic events such as PE include
maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding
alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do
not relate to the prevention of PE.
ba
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Pulmonary embolism, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
st
3. A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most
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appropriate? (Select all that apply.)
a. Acknowledge the frightening nature of the illness.
b. Delegate a back rub to the assistive personnel (AP).
c. Give simple explanations of what is happening.
d. Request a prescription for antianxiety medication.
e. Stay with the client and speak in a quiet, calm voice.
ANS: A, B, C, E
Clients with PEs are often anxious. The nurse can acknowledge the client’s fears, delegate
comfort measures, give simple explanations the client will understand, and stay with the
client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are
not used routinely because they can contribute to hypoxia. If the client’s anxiety is interfering
with diagnostic testing or treatment, they can be used, but there is no evidence that this is the
case.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
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KEY: Pulmonary embolism, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
4. The nurse caring for mechanically ventilated clients uses best practices to prevent
ventilator-associated pneumonia. What actions are included in this practice? (Select all that
apply.)
a. Adherence to proper hand hygiene
b. Administering antiulcer medication
c. Elevating the head of the bed
d. Providing oral care per protocol
e. Suctioning the client on a regular schedule
f. Turning and positioning the client at least every 2 hours
ANS: A, B, C, D, F
co
m
The “ventilator bundle” is a group of care measures to prevent ventilator-associated
pneumonia. Actions in the bundle include using proper hand hygiene, giving antiulcer
medications, elevating the head of the bed, providing frequent oral care per policy, preventing
aspiration, turning and positioning, and providing pulmonary hygiene measures. Suctioning is
done as needed.
s.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Mechanical ventilation, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5. A nurse is caring for a client in acute respiratory failure who is on mechanical ventilation.
ANS: A, B, D, E
ba
nk
What actions will promote comfort in this client? (Select all that apply.)
a. Allow visitors at the client’s bedside.
b. Ensure that the client can communicate if awake.
c. Keep the television tuned to a favorite channel.
d. Provide back and hand massages when turning.
e. Turn the client every 2 hours or more.
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e
st
There are many basic care measures that can be employed for the client who is on a ventilator.
Allowing visitation, providing a means of communication, massaging the client’s skin, and
routinely turning and repositioning the client are some of them. Keeping the TV on will
interfere with sleep and rest.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Mechanical ventilation, Comfort measures
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
6. The nurse caring for mechanically ventilated clients knows that older adults are at higher risk
for weaning failure. What age-related changes contribute to this? (Select all that apply.)
a. Chest wall stiffness
b. Decreased muscle strength
c. Inability to cooperate
d. Less lung elasticity
e. Poor vision and hearing
f. Chronic anemia
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ANS: A, B, D
Age-related changes that increase the difficulty of weaning older adults from mechanical
ventilation include increased stiffness of the chest wall, decreased muscle strength, and less
elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory
acuity. Anemia can make it difficult to wean a client, but this is not a normal age-related
change.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Analysis
KEY: Mechanical ventilation, Older adult
MSC: Client Needs Category: Health Promotion and Maintenance
7. A 100-kg client has developed ARDS and needs mechanical ventilation. Which of the
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following are potentially correct ventilator management choices? (Select all that apply.)
a. Tidal volume: 600 mL
b. Volume-controlled ventilation
c. PEEP based on oxygen saturation
d. Suctioning every hour
e. High-frequency oscillatory ventilation
f. Limited turning for ventilator pressures
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ANS: A, C, E
nk
s.
The client with ARDS who needs mechanical ventilation benefits from “open lung” and lung
protective strategies, such as using low tidal volumes (6 mL/kg body weight).
Pressure-controlled ventilation is preferred due to the high pressures often required in these
clients. PEEP usually starts at 5 cm H2O and adjusted to keep oxygen saturations in an
acceptable range. Suctioning may need to be frequent due to secretions, but is not scheduled
hourly. High-frequency oscillatory ventilation is an alternative to traditional modes of
ventilation. Early mobility is encouraged as is turning and positioning the client.
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ba
DIF: Understanding
TOP: Integrated Process: Nursing Process: Implementation
KEY: Mechanical ventilation, ARDS
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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Chapter 30: Assessment of the Cardiovascular System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58
mm Hg. Which additional assessment finding would the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min
ANS: A
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When a client experiences hypotension, baroreceptors in the aortic arch sense a pressure
decrease in the vessels. The parasympathetic system responds by lessening the inhibitory
effect on the sinoatrial node. This results in an increase in heart rate and respiratory rate. This
tachycardia is an early response and is seen even when blood pressure is not critically low. An
increased heart rate and respiratory rate will compensate for the low blood pressure and
maintain oxygen saturation and perfusion. The client may not be able to compensate for long
and decreased oxygenation and cool, clammy skin will occur later.
s.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Coronary perfusion, Hemodynamics
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
nk
2. A nurse assesses a client after administering a prescribed beta blocker. Which assessment
ANS: D
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would the nurse expect to find?
a. Blood pressure increased from 98/42 to 132/60 mm Hg.
b. Respiratory rate decreased from 25 to 14 breaths/min.
c. Oxygen saturation increased from 88% to 96%.
d. Pulse decreased from 100 to 80 beats/min.
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st
Beta blockers block the stimulation of beta1-adrenergic receptors. They block the sympathetic
(fight-or-flight) response and decrease the heart rate (HR). The beta blocker will decrease HR
and blood pressure, increasing ventricular filling time. It usually does not have effects on
beta2-adrenergic receptor sites. Cardiac output may drop because of decreased HR, but
slowing the rate may allow for better filling and better cardiac output.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Beta blocker, Medication
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
3. A nurse assesses clients on a medical-surgical unit. Which client would the nurse identify as
having the greatest risk for cardiovascular disease?
a. An 86-year-old man with a history of asthma.
b. A 32-year-old man with colorectal cancer.
c. A 65-year-old woman with diabetes mellitus.
d. A 53-year-old postmenopausal woman who takes bisphosphonates.
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ANS: C
Of the options, the client with diabetes has a two- to four-fold increase in risk for death due to
cardiovascular disease. Advancing age also increases risk, but not as much. Asthma,
colorectal cancer, and bisphosphonate therapy do not increase the risk for cardiovascular
disease.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Health screening
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A nurse assesses an older adult client who has multiple chronic diseases. The client’s heart
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rate is 48 beats/min. What action would the nurse take first?
a. Document the finding in the chart.
b. Initiate external pacing.
c. Assess the client’s medications.
d. Administer 1 mg of atropine.
ANS: C
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Pacemaker cells in the conduction system decrease in number as a person ages, potentially
resulting in bradycardia. However, the nurse would first check the medication reconciliation
for medications that might cause such a drop in heart rate, and then would inform the primary
health care provider. Documentation is important, but it is not the first action. The heart rate is
not low enough for atropine or an external pacemaker to be needed unless the client is
symptomatic, which is not apparent.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Medication, Assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
5. An emergency department nurse obtains the health history of a client. Which statement by the
ANS: A
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client would alert the nurse to the occurrence of heart failure?
a. “I get short of breath when I climb stairs.”
b. “I see halos floating around my head.”
c. “I have trouble remembering things.”
d. “I have lost weight over the past month.”
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Dyspnea on exertion is an early manifestation of heart failure and is associated with an
activity such as stair climbing. The other findings are not specific to early occurrence of heart
failure.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cardiovascular assessment, Heart failure
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A nurse obtains the health history of a client who is newly admitted to the medical unit.
Which statement by the client would alert the nurse to the presence of edema?
a. “I wake up to go to the bathroom at night.”
b. “My shoes fit tighter by the end of the day.”
c. “I seem to be feeling more anxious lately.”
d. “I drink at least eight glasses of water a day.”
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ANS: B
Weight gain can result from fluid accumulation in the interstitial spaces. This is known as
edema. The nurse would note whether the client feels that his or her shoes or rings are tight,
and would observe, when present, an indentation around the leg where the socks end. The
other answers do not describe edema.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Heart failure, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. A nurse assesses female client who is experiencing a myocardial infarction. Which clinical
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manifestation would the nurse expect?
a. Excruciating pain on inspiration
b. Left lateral chest wall pain
c. Fatigue and shortness of breath
d. Numbness and tingling of the arm
ANS: C
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In women, fatigue, shortness of breath, and indigestion may be the major symptoms of
myocardial infarction caused by poor cardiac output. Chest pain is the classic symptom of
myocardial infarction and can be present in women. Pain on inspiration may be related to a
pleuropulmonary cause. Numbness and tingling of the arm could also be related to the
myocardial infarction, but are not known to be specific symptoms for women having and MI.
nk
s.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Coronary perfusion, Gender differences
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The
st
ANS: C
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nurse notes that the left pedal pulse is weak. What action would the nurse take next?
a. Elevate the leg and apply a sandbag to the entrance site.
b. Increase the flow rate of intravenous fluids.
c. Assess the color and temperature of the left leg.
d. Document the finding as “left pedal pulse of +1/4.”
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Loss of a pulse distal to an angiography entry site is serious, indicating a possible arterial
obstruction. The left pulse would be compared with the right, and pulses would be compared
with previous assessments, especially before the procedure. Assessing color (pale, cyanosis)
and temperature (cool, cold) will identify a decrease in circulation. Once all peripheral and
vascular assessment data are acquired, the primary health care provider would be notified.
Simply documenting the findings is inappropriate. The leg would be positioned below the
level of the heart to increase blood flow to the distal portion of the leg. Increasing intravenous
fluids will not address the client’s problem.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cardiovascular assessment, Complications
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which
assessment finding requires immediate intervention?
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a.
b.
c.
d.
Urinary output less than intake
Bruising at the insertion site
Slurred speech and confusion
Discomfort in the left leg
ANS: C
A left-sided cardiac catheterization specifically increases the risk for a cerebral vascular
accident. A change in neurologic status needs to be acted on immediately. Discomfort and
bruising are not unexpected at the site. Urinary output less than intake may or may not be
significant.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cardiovascular assessment, Diagnostic examination, Critical rescue
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
10. A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment
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would the nurse complete as the priority prior to this procedure?
a. Client’s level of anxiety
b. Ability to turn self in bed
c. Cardiac rhythm and heart rate
d. Allergies to iodine-based agents
ANS: D
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Before the procedure, the nurse would ascertain whether the client has an allergy to
iodine-containing preparations, such as seafood or local anesthetics. The contrast medium
used during the procedure is iodine based. This allergy can cause a life-threatening reaction,
so it is a high priority. It is important for the nurse to assess anxiety, mobility, and baseline
cardiac status, but allergies take priority for client safety.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Diagnostic examination, Client safety
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
11. A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart.
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The client’s health history includes a previous myocardial infarction and pacemaker
implantation. What action would the nurse take?
a. Schedule an electrocardiogram just before the MRI.
b. Notify the primary health care provider before scheduling the MRI.
c. Request lab for cardiac enzymes from the primary health care provider.
d. Instruct the client to increase fluid intake the day before the MRI.
ANS: B
The magnetic fields of the MRI can deactivate the pacemaker. The nurse would call the
primary health care provider and report that the client has a pacemaker so that he or she can
order other diagnostic tests. The client does not need an electrocardiogram, cardiac enzymes,
or increased fluids. Some newer MRI scanners have eliminated the possibility of
complications due to implants, but the nurse needs to notify the primary health care provider.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: Diagnostic examination, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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12. A nurse assesses a client who is recovering from a myocardial infarction. The client’s blood
pressure is 140/88 mm Hg. What action would the nurse take first?
a. Compare the results with previous blood pressure readings.
b. Increase the intravenous fluid rate because these readings are low.
c. Immediately notify the primary health care provider of the elevated blood pressure.
d. Document the finding in the client’s chart as the only action.
ANS: A
The most recent range for normal blood pressure is less than 140 mm Hg systolic and less
than 90mm Hg diastolic. This client’s blood pressure is at the upper range of acceptable, so
the nurse would compare the client’s current reading with those previously recorded before
doing anything else. The reading is not low, so the nurse would not increase IV fluids, nor
would the nurse necessarily notify the primary health care provider. Documentation is
important, but the nurse first checks previous readings.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Blood pressure, Assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
13. A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is
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scheduled for bypass surgery. Which intervention would the nurse be prepared to implement
while this client waits for surgery?
a. Administration of IV furosemide
b. Initiation of an external pacemaker
c. Assistance with endotracheal intubation
d. Placement of central venous access
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ANS: B
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The RCA supplies the right atrium, right ventricle, inferior portion of the left ventricle, and
atrioventricular (AV) node. It also supplies the sinoatrial node in 50% of people. If the client
totally occludes the RCA, the AV node would not function and the client would go into heart
block, so emergency pacing would be available for the client. Furosemide, intubation, and
central venous access will not address the primary complication of RCA occlusion, which is
AV node (and possibly SA node) malfunction.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Planning
KEY: Coronary perfusion
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
14. A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk
for coronary artery disease. Which statement related to nutrition would the nurse include in
this client’s teaching?
a. “The best way to lose weight is a high-protein, low-carbohydrate diet.”
b. “You should balance weight loss with consuming necessary nutrients.”
c. “A nutritionist will provide you with information about your new diet.”
d. “If you exercise more frequently, you won’t need to change your diet.”
ANS: B
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Clients at risk for cardiovascular diseases should follow the American Heart Association
guidelines to combat obesity and improve cardiac health. The nurse would encourage the
client to eat vegetables, fruits, unrefined whole-grain products, and fat-free dairy products
while losing weight. High-protein food items are often high in fat and calories. Although the
nutritionist can assist with client education, the nurse would include nutrition education and
assist the client to make healthy decisions. Exercising and eating nutrient-rich foods are both
important components in reducing cardiovascular risk.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Nutrition, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
15. A nurse cares for a client who has advanced cardiac disease and states, “I am having trouble
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breathing while I’m sleeping at night.” What is the nurse’s best response?
a. “I will consult your primary health care provider to prescribe a sleep study.”
b. “You become hypoxic while sleeping; oxygen therapy via nasal cannula will
help.”
c. “A continuous positive airway pressure, or CPAP, breathing mask will help you
breathe at night.”
d. “Use pillows to elevate your head and chest while you are sleeping.”
ANS: D
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s.
The client is experiencing orthopnea (shortness of breath while lying flat). The nurse would
teach the client to elevate the head and chest with pillows or sleep in a recliner. A sleep study
is not necessary to diagnose this client. Oxygen and CPAP will not help a client with
orthopnea.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Heart failure, Orthopnea, Health teaching
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
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16. A nurse cares for a client who is recovering from a myocardial infarction. The client states, “I
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will need to stop eating so much chili to keep that indigestion pain from returning.” What is
the nurse’s best response?
a. “Chili is high in fat and calories; it would be a good idea to stop eating it.”
b. “The primary health care provider has prescribed an antacid every morning.”
c. “What do you understand about what happened to you?”
d. “When did you start experiencing this indigestion?”
ANS: C
Clients who experience myocardial infarction often respond with denial, which is a defense
mechanism. The nurse would ask the client what he or she thinks happened, or what the
illness means to him or her. The other responses do not address the client’s misconception
about recent pain and the cause of that pain.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Coronary perfusion, Coping
MSC: Client Needs Category: Psychosocial Integrity
17. A nurse prepares a client for cardiac catheterization. The client states, “I am afraid I might
die.” What is the nurse’s best response?
a. “This is a routine test and the risk of death is very low.”
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b. “Would you like to speak with a chaplain prior to test?”
c. “Tell me more about your concerns about the test.”
d. “What support systems do you have to assist you?”
ANS: C
The nurse would discuss the client’s feelings and concerns related to the cardiac
catheterization. The nurse would not provide false hope or push the client’s concerns off on
the chaplain. The nurse would address support systems after addressing the client’s current
issue.
DIF: Applying
TOP: Integrated Process: Caring
KEY: Diagnostic examination, Anxiety
MSC: Client Needs Category: Psychosocial Integrity
18. An emergency department nurse triages clients who present with chest discomfort. Which
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client would the nurse plan to assess first?
a. Client who describes pain as a dull ache.
b. Client who reports moderate pain that is worse on inspiration.
c. Client who reports cramping substernal pain.
d. Client who describes intense squeezing pressure across the chest.
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ANS: D
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s.
All clients who have chest pain would be assessed more thoroughly. To determine which
client would be seen first, the nurse must understand common differences in pain descriptions.
Intense stabbing and viselike (squeezing) substernal pain or pressure that spreads through the
client ’s chest, arms, jaw, back, or neck are indicatives of a myocardial infarction. The nurse
would plan to see this client first to prevent cardiac cell death. A dull ache, pain that gets
worse with inspiration, and cramping pain are not usually associated with myocardial
infarction.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: Cardiovascular disease, Assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
19. A nurse assesses a client who has aortic regurgitation. In which location in the illustration
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shown below would the nurse auscultate to best hear a cardiac murmur related to aortic
regurgitation?
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a.
b.
c.
d.
Location A
Location B
Location C
Location D
ANS: A
The aortic valve is auscultated in the second intercostal space just to the right of the sternum.
The pulmonic valve would be heard in location B located in the second intercostal space just
left of the sternum. The mitral valve would be heard in location D located in the fifth
intercostal space at the apex of the heart. The tricuspid valve would be heard in location C
located in the fifth intercostal space at the lower left of the sternal border.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cardiovascular assessment, Physical assessment
MSC: Client Needs Category: Health Promotion and Maintenance
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MULTIPLE RESPONSE
1. A nurse is caring for a client with a history of renal insufficiency who is scheduled for a
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cardiac catheterization. What actions would the nurse take prior to the catheterization? (Select
all that apply.)
a. Assess for allergies to iodine.
b. Administer intravenous fluids.
c. Assess blood urea nitrogen (BUN) and creatinine results.
d. Insert a Foley catheter.
e. Administer a prophylactic antibiotic.
f. Insert a central venous catheter.
ANS: A, B, C
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If the client has kidney disease, fluids may be given 12 to 24 hours before the procedure for
renal protection. Hydration would continue after the procedure. The client would be assessed
for allergies to iodine, including shellfish; the contrast medium used during the catheterization
contains iodine. Baseline renal labs would be assessed. A Foley catheter and central venous
catheter are not required for the procedure and would only increase the client’s risk for
infection. Prophylactic antibiotics are not administered prior to a cardiac catheterization.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Cardiovascular assessment, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
2. An emergency department nurse assesses a female client. Which assessment findings would
alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.)
a. Hypertension
b. Fatigue despite adequate rest
c. Indigestion
d. Abdominal pain
e. Shortness of breath
ANS: B, C, E
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Women may not have chest pain with myocardial infarction, but may feel discomfort or
indigestion. They often present with a triad of symptoms—indigestion or feeling of abdominal
fullness, feeling of chronic fatigue despite adequate rest, and feeling unable to catch their
breath. Frequently, women are not diagnosed and therefore are not treated adequately.
Hypertension and abdominal pain are not associated with acute coronary syndrome.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cardiac electrical conduction, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse assesses a client who is recovering after a coronary catheterization. Which assessment
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findings in the first few hours after the procedure require immediate action by the nurse?
(Select all that apply.)
a. Blood pressure of 140/88 mm Hg
b. Serum potassium of 2.9 mEq/L (2.9 mmol/L)
c. Warmth and redness at the site
d. Expanding groin hematoma
e. Rhythm changes on the cardiac monitor
f. Oxygen saturation 93% on room air
ANS: B, D, E
nk
s.
After a cardiac catheterization, the nurse monitors vital signs, entry site, cardiac function, and
distal circulation. The potassium is very low which can lead to dysrhythmias. An expanding
hematoma signifies bleeding. Rhythm changes on the monitor are a known complication.
These findings would require prompt action. The client’s blood pressure is slightly elevated
but does not need immediate action. Warmth and redness at the site would indicate an
infection, but this would not be present in the first few hours. The oxygen saturation is slightly
low but not critical and there is no baseline to compare it to.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cardiovascular assessment, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. A nurse reviews a client’s laboratory results. Which findings would alert the nurse to the
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possibility of atherosclerosis? (Select all that apply.)
a. Total cholesterol: 280 mg/dL (7.3 mmol/L)
b. High-density lipoprotein cholesterol: 50 mg/dL (1.3 mmol/L)
c. Triglycerides: 200 mg/dL (2.3 mmol/L)
d. Serum albumin: 4 g/dL (5.8 mcmol/L)
e. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L)
ANS: A, C, E
A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides,
and low-density lipoprotein cholesterol levels are all high, indicating higher risk for
cardiovascular disease. High-density lipoprotein cholesterol is within the normal range for
both males and females. Serum albumin is not assessed for atherosclerosis.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cardiovascular assessment, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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5. A nurse prepares a client for a pharmacologic stress echocardiogram. What actions would the
nurse take when preparing this client for the procedure? (Select all that apply.)
a. Assist the primary health care provider to place a central venous access device.
b. Prepare for continuous blood pressure and pulse monitoring.
c. Administer the client’s prescribed beta blocker.
d. Give the client nothing by mouth 3 to 6 hours before the procedure.
e. Explain to the client that dobutamine will simulate exercise for this examination.
ANS: B, D, E
Clients receiving a pharmacologic stress echocardiogram will need peripheral venous access
and continuous blood pressure and pulse monitoring. The client must be NPO 3 to 6 hours
prior to the procedure. Education about dobutamine, which will be administered during the
procedure, would be performed. Beta blockers are often held prior to the procedure as they
lower the heart rate and may result in inaccurate results.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Planning
KEY: Cardiovascular assessment, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A nurse cares for a client who is recovering from a right-sided heart catheterization. For which
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complications of this procedure would the nurse assess? (Select all that apply.)
a. Thrombophlebitis
b. Stroke
c. Pulmonary embolism
d. Myocardial infarction
e. Cardiac tamponade
f. Dysrhythmias
ANS: A, C, E
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Complications from a right-sided heart catheterization include thrombophlebitis, pulmonary
embolism, and vagal response. Cardiac tamponade is a risk of both right- and left-sided heart
catheterizations. Stroke, myocardial infarction, and dysrhythmias are complications of
left-sided heart catheterizations.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Assessment, Diagnostic examination
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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Chapter 31: Concepts of Care for Patients With Dysrhythmias
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse assesses a client’s electrocardiograph tracing and observes that not all QRS
complexes are preceded by a P wave. How would the nurse interpret this observation?
a. The client has hyperkalemia causing irregular QRS complexes.
b. Ventricular tachycardia is overriding the normal atrial rhythm.
c. The client’s chest leads are not making sufficient contact with the skin.
d. Ventricular and atrial depolarizations are initiated from different sites.
ANS: D
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Normal rhythm shows one P wave preceding each QRS complex, indicating that all
depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a
different source of initiation of depolarization. This finding on an electrocardiograph tracing is
not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Analysis
KEY: Cardiac electrical conduction
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
s.
2. A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse
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ANS: B
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symptoms. Which activity modification would the nurse suggest to avoid further slowing of
the heart rate?
a. “Make certain that your bath water is warm.”
b. “Avoid straining while having a bowel movement.”
c. “Limit your intake of caffeinated drinks to one a day.”
d. “Avoid strenuous exercise such as running.”
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Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which
stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not
desirable in a person who has bradycardia. The other instructions are not appropriate for this
condition.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Cardiac electrical conduction, Health education
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A nurse is assessing clients on a medical-surgical unit. Which client would the nurse identify
as being at greatest risk for atrial fibrillation?
a. A 45-year-old who takes an aspirin daily.
b. A 50-year-old who is post coronary artery bypass graft surgery.
c. A 78-year-old who had a carotid endarterectomy.
d. An 80-year-old with chronic obstructive pulmonary disease.
ANS: B
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Atrial fibrillation occurs commonly in clients with cardiac disease. Other risk factors include
hypertension (HTN), previous ischemic stroke, transient ischemic attack (TIA) or other
thromboembolic event, diabetes mellitus, heart failure, obesity, hyperthyroidism, chronic
kidney disease, excessive alcohol use, and mitral valve disease. The other conditions do not
place these clients at higher risk for atrial fibrillation.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cardiac electrical conduction, Risk factors
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. A nurse assesses a client with atrial fibrillation. Which manifestation would alert the nurse to
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the possibility of a serious complication from this condition?
a. Sinus tachycardia
b. Speech alterations
c. Fatigue
d. Dyspnea with activity
ANS: B
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Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events
includes changes in mentation, speech, sensory function, and motor function. Clients with
atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific
complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased
cardiac output caused by the rhythm disturbance.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cardiac electrical conduction, Vascular perfusion
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication
ANS: B
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would the nurse expect to find on this client’s medication administration record to prevent a
common complication of this condition?
a. Sotalol
b. Warfarin
c. Atropine
d. Lidocaine
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Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are
treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and
lidocaine are not appropriate for preventing this complication.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Analysis
KEY: Cardiac electrical conduction, Medication
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
6. A nurse administers prescribed adenosine to a client. Which response would the nurse assess
for as the expected therapeutic response?
a. Decreased intraocular pressure
b. Increased heart rate
c. Short period of asystole
d. Hypertensive crisis
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ANS: C
Clients usually respond to adenosine with a short period of asystole, bradycardia with long
pauses, nausea, or vomiting. Adenosine has no impact on intraocular pressure nor does it
cause increased heart rate or hypertensive crisis.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Analysis
KEY: Cardiac electrical conduction, Medication
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
7. A telemetry nurse assesses a client who has a heart rate of 35 beats/min on the cardiac
monitor. Which assessment would the nurse complete next?
a. Pulmonary auscultation
b. Pulse strength and amplitude
c. Level of consciousness
d. Mobility and gait stability
ANS: C
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A heart rate of 40 beats/min or less could have hemodynamic consequences. The client is at
risk for inadequate cerebral perfusion. The nurse would assess for level of consciousness,
dizziness, confusion, syncope, chest pain, shortness of breath. Although the other assessments
would be completed, the nurse would assess the client’s neurologic status next.
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cardiac electrical conduction, Vascular perfusion
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
8. A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The
ANS: B
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nurse observes the presence of a pacing spike but no QRS complex on the client’s
electrocardiogram. What action would the nurse take next?
a. Administer intravenous diltiazem.
b. Assess vital signs and level of consciousness.
c. Administer sublingual nitroglycerin.
d. Assess capillary refill and temperature.
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In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit
through the chest wall. The pacemaker spike would be followed immediately by a QRS
complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If
there is no capture, then there is no ventricular depolarization and contraction. The nurse
would assess for cardiac output via vital signs and level of consciousness. The other
interventions would not determine if the client is tolerating the loss of capture.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cardiac electrical conduction
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
9. A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which intervention is
appropriate for the nurse to perform prior to defibrillating this client?
a. Make sure that the defibrillator is set to the synchronous mode.
b. Administer 1 mg of intravenous epinephrine.
c. Test the equipment by delivering a smaller shock at 100 J.
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d. Ensure that everyone is clear of contact with the client and the bed.
ANS: D
To avoid injury, the rescuer commands that all personnel clear contact with the client or the
bed and ensures their compliance before delivery of the shock. Defibrillation is done in
asynchronous mode. Equipment would not be tested before a client is defibrillated because
this is an emergency procedure; equipment would be checked on a routine basis.
Defibrillation takes priority over any medications.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Cardiac electrical conduction, Safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
10. After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse
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assesses the client’s understanding. Which statement by the client indicates correct
understanding of the teaching?
a. “I would wear a snug-fitting shirt over the ICD.”
b. “I will avoid sources of strong electromagnetic fields.”
c. “I would participate in a strenuous exercise program.”
d. “Now I can discontinue my antidysrhythmic medication.”
ANS: B
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s.
The client being discharged with an ICD is instructed to avoid strong sources of
electromagnetic fields, such as devices emitting microwaves (not microwave ovens);
transformers; radio, television, and radar transmitters; large electrical generators; metal
detectors, including handheld security devices at airports; antitheft devices; arc welding
equipment; and sources of 60-cycle (Hz) interference. Also avoid leaning directly over the
alternator of a running motor of a car or boat. Clients would avoid tight clothing, which could
cause irritation over the ICD generator. The client would be encouraged to exercise but would
not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff
point because the ICD can discharge inappropriately. The client would continue all prescribed
medications.
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DIF: Analyzing
TOP: Integrated Process: Teaching/Learning
KEY: Cardiac electrical conduction, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
11. A nurse cares for a client with atrial fibrillation who reports fatigue when completing
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activities of daily living. What intervention would the nurse implement to address this client’s
concerns?
a. Administer oxygen therapy at 2 L per nasal cannula.
b. Provide the client with a sleeping pill to stimulate rest.
c. Schedule periods of exercise and rest during the day.
d. Ask assistive personnel (AP) to help bathe the client.
ANS: C
Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when
completing activities of daily living. The nurse would schedule periods of exercise and rest
during the day to decrease fatigue. The other interventions will not assist the client with
performing self-care activities and there is no indication for oxygen.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
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KEY: Cardiac electrical conduction
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
12. A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. What
action would the nurse take prior to the cardioversion?
a. Administer intravenous adenosine.
b. Turn off oxygen therapy.
c. Ensure that a tongue blade is available.
d. Position the client on the left side.
ANS: B
For safety during cardioversion, the nurse would turn off any oxygen therapy to prevent fire.
The other interventions are not appropriate for a cardioversion. The client would be placed in
a supine position.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Cardiac electrical conduction, Safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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13. A nurse prepares to discharge a client with a cardiac dysrhythmia who is prescribed home
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s.
health care services. Which priority information would be communicated to the home health
nurse upon discharge?
a. Medication orders for home
b. Immunization history
c. Religious beliefs
d. Nutrition preferences
ANS: A
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The home health nurse needs to know current medications the client is taking to ensure
assessment, evaluation, and further education related to these medications. The other
information might be used to plan care, but not as the priority.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Hand-off communication, Safety
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
14. A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate
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intervention by the nurse?
a. Midsternal chest pain
b. Increased urine output
c. Mild orthostatic hypotension
d. P wave touching the T wave
ANS: A
Chest pain, possibly angina, indicates that tachycardia may be increasing the client’s
myocardial workload and oxygen demand to such an extent that normal oxygen delivery
cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and
mild orthostatic hypotension are not life-threatening conditions and therefore do not require
immediate intervention. The P wave touching the T wave indicates significant tachycardia and
would be assessed to determine the underlying rhythm and cause; this is an important
assessment but is not as critical as chest pain, which indicates cardiac cell death.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cardiac electrical conduction
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
15. A nurse teaches a client who experiences occasional premature atrial contractions (PACs)
accompanied by palpitations that resolve spontaneously without treatment. Which statement
would the nurse include in this client’s teaching?
a. “Minimize or abstain from caffeine.”
b. “Lie on your side until the attack subsides.”
c. “Use your oxygen when you experience PACs.”
d. “Take amiodarone daily to prevent PACs.”
ANS: A
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PACs usually have no hemodynamic consequences. For a client experiencing infrequent
PACs, the nurse would explore possible lifestyle causes, such as excessive caffeine intake and
stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although
medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the
client first would try lifestyle changes to control them.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Cardiac electrical conduction, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
s.
16. The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse.
ANS: C
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The client asks, “Why do you want to know if I use cocaine?” What is the nurse’s best
response?
a. “Substance abuse puts clients at risk for many health issues.”
b. “The hospital requires that I ask you about cocaine use.”
c. “Clients who use cocaine are at risk for fatal dysrhythmias.”
d. “We can provide services for cessation of substance abuse.”
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Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal
dysrhythmias. The other responses do not adequately address the client’s question.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cardiac electrical conduction, Substance abuse
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
17. A nurse supervises an assistive personnel (AP) applying electrocardiographic monitoring.
Which statement would the nurse provide to the AP related to this procedure?
a. “Clean the skin and clip hairs if needed.”
b. “Add gel to the electrodes prior to applying them.”
c. “Place the electrodes on the posterior chest.”
d. “Turn off oxygen prior to monitoring the client.”
ANS: A
To ensure the best signal transmission, the skin would be clean and hairs clipped. Electrodes
would be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact
on electrocardiographic monitoring.
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DIF: Understanding
TOP: Integrated Process: Communication and Documentation
KEY: Cardiac electrical conduction, Delegation
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
18. A nurse assesses a client’s electrocardiogram (ECG) and observes the reading shown below:
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How would the nurse document this client’s ECG strip?
a. Ventricular tachycardia
b. Ventricular fibrillation
c. Sinus rhythm with premature atrial contractions (PACs)
d. Sinus rhythm with premature ventricular contractions (PVCs)
ANS: D
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s.
Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular
depolarization that sometimes precede atrial depolarization. The PVC would exhibit as a
widened QRS without a preceding p wave. Ventricular tachycardia and ventricular fibrillation
rhythms would not have sinus beats present. Premature atrial contractions are atrial
contractions initiated from another region of the atria before the sinus node initiates atrial
depolarization.
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DIF: Analyzing
TOP: Integrated Process: Communication and Documentation
KEY: Cardiac electrical conduction, Documentation
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
19. A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm
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shown below:
What action would the nurse take first?
a. Assess airway, breathing, and circulation.
b. Administer an amiodarone bolus followed by a drip.
c. Cardiovert the client with a biphasic defibrillator.
d. Begin cardiopulmonary resuscitation (CPR).
ANS: A
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Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus,
usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a potentially
lethal dysrhythmia. The nurse would first assess if the client is alert, breathing, and has a
pulse. If this client is pulseless, then the nurse would call a Code Blue and begin CPR. The
treatment of choice for pulseless ventricular tachycardia is defibrillation. If the client has a
pulse, then cardioversion would be indicated. Amiodarone is an appropriate antidysrhythmic,
but it is not the first action.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Cardiac electrical conduction, Medical emergency
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
20. A nurse performs an admission assessment on a 75-year-old client with multiple chronic
s.
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diseases. The client’s blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 L
per nasal cannula. The nurse assesses the client’s rhythm on the cardiac monitor and observes
the reading shown below:
ANS: C
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What action would the nurse take first?
a. Begin external temporary pacing.
b. Assess peripheral pulse strength.
c. Ask the client what medications he or she takes.
d. Administer 1 mg of atropine.
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This client is stable and therefore does not require any intervention except to determine the
cause of the bradycardia. Bradycardia is often caused by medications. Clients who have
multiple chronic diseases are often on multiple medications that can interact with each other.
The nurse would assess the client’s current medications first. Pacing is not necessary.
Peripheral pulses are assessed with a full assessment since this client is stable. Atropine is not
needed.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cardiac electrical conduction, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
21. The nurse is caring for a client on the medical-surgical unit who suddenly becomes
unresponsive and has no pulse. The cardiac monitor shows the rhythm below:
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After calling for assistance and a defibrillator, what action would the nurse take next?
Perform a pericardial thump.
Initiate cardiopulmonary resuscitation (CPR).
Start an 18-gauge intravenous line.
Ask the client’s family about code status.
a.
b.
c.
d.
ANS: B
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The client’s rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with
immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse
would start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the
client does not already have an IV, other members of the team can insert one after
defibrillation. The client’s code status would already be known by the nurse prior to this
event.
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s.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cardiac electrical conduction, Medical emergency
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
22. After assessing a client who is receiving an amiodarone intravenous infusion for unstable
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ventricular tachycardia, the nurse documents the findings and compares these with the
previous assessment findings:
Vital Signs
Nursing Assessment
Time: 08:00
Time: 08:00
Temperature: 98° F (36.7° C)
Client alert and oriented.
Heart rate: 68 beats/min
Cardiac rhythm: normal sinus rhythm.
Blood pressure: 135/60 mm Hg
Skin: warm, dry, and appropriate for
Respiratory rate: 14 breaths/min
race.
Oxygen saturation: 96%
Respirations equal and unlabored.
Oxygen therapy: 2 L nasal cannula Client denies shortness of breath and
chest pain.
Time: 10:00
Temperature: 98.2° F (36.8° C)
Heart rate: 50 beats/min
Blood pressure: 132/57 mm Hg
Respiratory rate: 16 breaths/min
Oxygen saturation: 95%
Oxygen therapy: 2 L nasal cannula
Time: 10:00
Client alert and oriented.
Cardiac rhythm: sinus bradycardia.
Skin: warm, dry, and appropriate for
race.
Respirations equal and unlabored.
Client denies shortness of breath and
chest pain.
Client voids 420 mL of clear yellow
urine.
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Based on the assessments, what action would the nurse take?
Stop the infusion and flush the IV.
Slow the amiodarone infusion rate.
Administer IV normal saline.
Ask the client to cough and deep breathe.
a.
b.
c.
d.
ANS: B
Amiodarone lengthens the absolute refractory period and prolongs repolarization and the
action potential duration (and heart rate), so IV administration of amiodarone may cause
bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this
time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV
block that might require pacing. Abruptly ceasing the medication could allow fatal
dysrhythmias to occur. The administration of IV fluids and encouragement of coughing and
deep-breathing exercises are not indicated, and will not increase the client’s heart rate.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Cardiac electrical conduction, Medication
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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MULTIPLE RESPONSE
1. A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of
ANS: A, C, E
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128 beats/min. For which physiologic alterations would the nurse assess? (Select all that
apply.)
a. Decrease in cardiac output
b. Increase in cardiac output
c. Decrease in blood pressure
d. Increase in blood pressure
e. Decrease in urine output
f. Increase in urine output
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Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to
increase. However, in a client who has congestive heart failure or a client with long-term
tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease.
As cardiac output and blood pressure decrease, urine output will fall.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cardiac electrical conduction, Heart failure
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse teaches a client with a new permanent pacemaker. Which instructions would the
nurse include in this client’s teaching? (Select all that apply.)
a. “Until your incision is healed, do not submerge your pacemaker. Only take
showers.”
b. “Report any pulse rates lower than your pacemaker settings.”
c. “If you feel weak, apply pressure over your generator.”
d. “Have your pacemaker turned off before having magnetic resonance imaging
(MRI).”
e. “Do not lift your left arm above the level of your shoulder for 8 weeks.”
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ANS: A, B, E
The client would not submerge in water until the site has healed; after the incision is healed,
the client may take showers or baths without concern for the pacemaker. The client would be
instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker
setting or greater than 100 beats/min. The client would be advised of restrictions on physical
activity for 8 weeks to allow the pacemaker to settle in place. The client would never apply
pressure over the generator and would avoid tight clothing. The client would never have MRI
because, whether turned on or off, the pacemaker contains metal. The client would be advised
to inform all health care providers that he or she has a pacemaker.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Cardiac electrical conduction, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
3. A nurse is teaching a client who has premature ectopic beats. Which education would the
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nurse include in this client’s teaching? (Select all that apply.)
a. Smoking cessation
b. Stress reduction and management
c. Avoiding vagal stimulation
d. Adverse effects of medications
e. Foods high in potassium
f. Types of aerobic exercise
s.
ANS: A, B, D
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A client who has premature beats or ectopic rhythms would be taught to stop smoking,
manage stress, take medications as prescribed, and report adverse effects of medications.
Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.
While exercise is beneficial, aerobic exercise is not specifically linked to this client’s
educational needs.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
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Chapter 32: Concepts of Care for Patients With Cardiac Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse assesses clients on a cardiac unit. Which client would the nurse identify as being at
greatest risk for the development of left-sided heart failure?
a. A 36-year-old woman with aortic stenosis
b. A 42-year-old man with pulmonary hypertension
c. A 59-year-old woman who smokes cigarettes daily
d. A 70-year-old man who had a cerebral vascular accident
ANS: A
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Causes of left ventricular failure include mitral or aortic valve disease, coronary artery
disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk
factors for right ventricular failure. A cerebral vascular accident does not increase the risk of
heart failure.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Heart failure, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
s.
2. A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the
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possibility of left-sided heart failure?
a. “I have been drinking more water than usual.”
b. “I am awakened by the need to urinate at night.”
c. “I must stop halfway up the stairs to catch my breath.”
d. “I have experienced blurred vision on several occasions.”
ANS: C
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Clients with left-sided heart failure report weakness or fatigue while performing normal
activities of daily living, as well as difficulty breathing, or “catching their breath.” This occurs
as fluid moves into the alveoli. Nocturia is often seen with right-sided heart failure. Thirst and
blurred vision are not related to heart failure.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Heart failure, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the
nurse to the possibility of right-sided heart failure?
a. “I sleep with four pillows at night.”
b. “My shoes fit really tight lately.”
c. “I wake up coughing every night.”
d. “I have trouble catching my breath.”
ANS: B
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Signs of systemic congestion occur with right-sided heart failure. Fluid is retained, pressure
builds in the venous system, and peripheral edema develops. Left-sided heart failure
symptoms include respiratory symptoms. Orthopnea, coughing, and difficulty breathing all
could be results of left-sided heart failure.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Heart failure, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. What
action would the nurse take next?
a. Assess for symptoms of left-sided heart failure.
b. Document this as a normal finding.
c. Call the primary health care provider immediately.
d. Transfer the client to the intensive care unit.
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ANS: A
The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left
ventricular pressure and left ventricular failure. The other actions are not warranted.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Heart failure, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
s.
5. A nurse cares for a client with right-sided heart failure. The client asks, “Why do I need to
ba
ANS: A
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weigh myself every day?” How would the nurse respond?
a. “Weight is the best indication that you are gaining or losing fluid.”
b. “Daily weights will help us make sure that you’re eating properly.”
c. “The hospital requires that all clients be weighed daily.”
d. “You need to lose weight to decrease the incidence of heart failure.”
st
Daily weights are needed to document fluid retention or fluid loss. One liter of fluid equals
2.2 lb (1 kg). Weight changes are the most reliable indicator of fluid loss or gain. The other
responses do not address the importance of monitoring fluid retention or loss.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Heart failure, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A nurse is teaching a client with heart failure who has been prescribed enalapril. Which
statement would the nurse include in this client’s teaching?
a. “Avoid using salt substitutes.”
b. “Take your medication with food.”
c. “Avoid using aspirin-containing products.”
d. “Check your pulse daily.”
ANS: A
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Angiotensin-converting enzyme (ACE) inhibitors such as enalapril inhibit the excretion of
potassium. Hyperkalemia can be a life-threatening side effect, and clients should be taught to
limit potassium intake. Salt substitutes are composed of potassium chloride. ACE inhibitors
do not need to be taken with food and have no impact on the client’s pulse rate. Aspirin is
often prescribed in conjunction with ACE inhibitors and is not contraindicated.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Angiotensin-converting enzyme (ACE) inhibitor, Health teaching
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
7. After administering the first dose of captopril to a client with heart failure, the nurse
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implements interventions to decrease complications. Which intervention is most important for
the nurse to implement?
a. Provide food to decrease nausea and aid in absorption.
b. Instruct the client to ask for assistance when rising from bed.
c. Collaborate with assistive personnel to bathe the client.
d. Monitor potassium levels and check for symptoms of hypokalemia.
ANS: B
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s.
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Hypotension is a side effect of ACE inhibitors such as captopril. Clients with a fluid volume
deficit should have their volume replaced or start at a lower dose of the drug to minimize this
effect. The nurse would instruct the client to seek assistance before arising from bed to
prevent injury from postural hypotension. ACE inhibitors do not need to be taken with food.
Collaboration with assistive personnel to provide hygiene is not a priority. The client would
be encouraged to complete activities of daily living as independently as possible. The nurse
would monitor for hyperkalemia, not hypokalemia, especially if the client has renal
insufficiency secondary to heart failure.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Angiotensin-converting enzyme (ACE) inhibitor, Client safety
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
8. A nurse assesses a client after administering the first dose of a nitrate. The client reports a
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headache. What action would the nurse take?
a. Initiate oxygen therapy.
b. Hold the next dose.
c. Instruct the client to drink water.
d. Administer PRN acetaminophen.
ANS: D
The vasodilating effects of nitrates frequently cause clients to have headaches during the
initial period of therapy. The nurse would inform the client about this side effect and offer a
mild analgesic, such as acetaminophen. The client’s headache is not related to hypoxia or
dehydration; therefore, applying oxygen and drinking water would not help. The client needs
to take the medication as prescribed to prevent angina; the medication would not be held.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Nitroglycerin, Nitrates, Side effects
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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9. A nurse teaches a client who is prescribed digoxin therapy. Which statement would the nurse
include in this client’s teaching?
a. “Avoid taking aspirin or aspirin-containing products.”
b. “Increase your intake of foods that are high in potassium.”
c. “Hold this medication if your pulse rate is below 80 beats/min.”
d. “Do not take this medication within 1 hour of taking an antacid.”
ANS: D
Gastrointestinal absorption of digoxin is erratic. Many medications, especially antacids,
interfere with its absorption. Clients are taught to hold their digoxin for bradycardia; a heart
rate of 80 beats/min is too high for this cutoff. Potassium and aspirin have no impact on
digoxin absorption.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Digoxin, Health teaching
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
10. A nurse teaches a client who has a history of heart failure. Which statement would the nurse
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include in this client’s discharge teaching?
a. “Avoid drinking more than 3 quarts (3 L) of liquids each day.”
b. “Eat six small meals daily instead of three larger meals.”
c. “When you feel short of breath, take an additional diuretic.”
d. “Weigh yourself daily while wearing the same amount of clothing.”
s.
ANS: D
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Clients with heart failure are instructed to weigh themselves daily to detect worsening heart
failure early, and thus avoid complications. Other signs of worsening heart failure include
increasing dyspnea, exercise intolerance, cold symptoms, and nocturia. Fluid overload
increases symptoms of heart failure. The client would be taught to eat a heart-healthy diet,
balance intake and output to prevent dehydration and overload, and take medications as
prescribed. The most important discharge teaching is daily weights as this provides the best
data related to fluid retention.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Heart failure, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
11. A nurse admits a client who is experiencing an exacerbation of heart failure. What action
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would the nurse take first?
a. Assess the client’s respiratory status.
b. Draw blood to assess the client’s serum electrolytes.
c. Administer intravenous furosemide.
d. Ask the client about current medications.
ANS: A
Assessment of respiratory and oxygenation status is the most important nursing intervention
for the prevention of complications. Monitoring electrolytes, administering diuretics, and
asking about current medications are important but do not take precedence over assessing
respiratory status.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Heart failure, Nursing assessment
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MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
12. A nurse assesses a client with mitral valve stenosis. What clinical sign or symptom would
alert the nurse to the possibility that the client’s stenosis has progressed?
a. Oxygen saturation of 92%
b. Dyspnea on exertion
c. Muted systolic murmur
d. Upper extremity weakness
ANS: B
Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs
increases. The other signs and symptoms do not relate to the progression of mitral valve
stenosis.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Valvular disorders, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
13. A nurse cares for a client recovering from prosthetic valve replacement surgery. The client
s.
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asks, “Why will I need to take anticoagulants for the rest of my life?” What is the best
response by the nurse?
a. “The prosthetic valve places you at greater risk for a heart attack.”
b. “Blood clots form more easily in artificial replacement valves.”
c. “The vein taken from your leg reduces circulation in the leg.”
d. “The surgery left a lot of small clots in your heart and lungs.”
ANS: B
nk
Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate
easily and initiate the formation of blood clots. The other responses are inaccurate.
ba
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Valvular disorders, Anticoagulants
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
14. After teaching a client who is being discharged home after mitral valve replacement surgery,
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the nurse assesses the client’s understanding. Which client statement indicates a need for
additional teaching?
a. “I’ll be able to carry heavy loads after 6 months of rest.”
b. “I will have my teeth cleaned by my dentist in 2 weeks.”
c. “I must avoid eating foods high in vitamin K, like spinach.”
d. “I must use an electric razor instead of a straight razor to shave.”
ANS: B
Clients who have defective or repaired valves are at high risk for endocarditis. The client who
has had valve surgery should avoid dental procedures for 6 months because of the risk for
endocarditis. When undergoing a mitral valve replacement surgery, the client needs to be
placed on anticoagulant therapy to prevent vegetation forming on the new valve. Clients on
anticoagulant therapy would be instructed on bleeding precautions, including using an electric
razor. If the client is prescribed warfarin, the client should avoid foods high in vitamin K.
Clients recovering from open-heart valve replacements should not carry anything heavy for 6
months while the chest incision and muscle heal.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Valvular disorders, Health teaching
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
15. A nurse cares for a client with infective endocarditis. Which infection control precautions
would the nurse use?
a. Standard Precautions
b. Bleeding Precautions
c. Reverse isolation
d. Contact isolation
ANS: A
The client with infective endocarditis does not pose any specific threat of transmitting the
causative organism. Standard Precautions would be used. Bleeding Precautions, reverse
isolation, or Contact Precautions are not necessary.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection, Standard precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
s.
to find?
a. Heart rate that speeds up and slows down.
b. Friction rub at the left lower sternal border.
c. Presence of a regular gallop rhythm.
d. Coarse crackles in bilateral lung bases.
co
16. A nurse assesses a client with pericarditis. Which assessment finding would the nurse expect
nk
ANS: B
ba
The client with pericarditis may present with a pericardial friction rub at the left lower sternal
border. This sound is the result of friction from inflamed pericardial layers when they rub
together. The other assessments are not related.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Inflammatory response, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
st
17. After teaching a client who is recovering from a heart transplant to change positions slowly,
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the client asks, “Why is this important?” How would the nurse respond?
a. “Rapid position changes can create shear and friction forces, which can tear out
your internal vascular sutures.”
b. “Your new vascular connections are more sensitive to position changes, leading to
increased intravascular pressure and dizziness.”
c. “Your new heart is not connected to the nervous system and is unable to respond to
decreases in blood pressure caused by position changes.”
d. “While your heart is recovering, blood flow is diverted away from the brain,
increasing the risk for stroke when you stand up.”
ANS: C
Because the new heart is denervated, the baroreceptor and other mechanisms that compensate
for blood pressure drops caused by position changes do not function. This allows orthostatic
hypotension to persist in the postoperative period. The other options are false statements and
do not correctly address the client’s question.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Implementation
KEY: Transplant, Health teaching
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
18. A nurse is providing discharge teaching to a client recovering from a heart transplant. Which
statement would the nurse include?
a. “Use a soft-bristled toothbrush and avoid flossing.”
b. “Avoid large crowds and people who are sick.”
c. “Change positions slowly to avoid hypotension.”
d. “Check your heart rate before taking the medication.”
ANS: B
m
Clients who have had heart transplants must take immunosuppressant therapy for the rest of
their lives. The nurse would teach this client to avoid crowds and sick people to reduce the
risk of becoming ill him- or herself. These medications do not place clients at risk for
bleeding, orthostatic hypotension, or changes in heart rate. Orthostatic hypotension from the
denervated heart is generally only a problem in the immediate postoperative period.
co
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Transplant, Health teaching
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
19. A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client
ba
ANS: D
nk
s.
appears depressed and states, “I know a transplant is my last chance, but I don’t want to
become a vegetable.” How would the nurse respond?
a. “Would you like to speak with a priest or chaplain?”
b. “I will arrange for a psychiatrist to speak with you.”
c. “Do you want to come off the transplant list?”
d. “Would you like information about advance directives?”
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The client is verbalizing a real concern or fear about negative outcomes of the surgery. This
anxiety itself can have a negative effect on the outcome of the surgery because of sympathetic
stimulation. The best action is to allow the client to verbalize the concern and work toward a
positive outcome without making the client feel as though the concerns are not valid. The
client needs to feel that he or she has some control over the future. The nurse personally
provides care to address the client’s concerns instead of immediately calling for the chaplain
or psychiatrist. The nurse would not jump to conclusions and suggest taking the client off the
transplant list, which is the best treatment option.
DIF: Applying
TOP: Integrated Process: Caring
KEY: Transplant, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity
20. A nurse assesses a client who has a history of heart failure. Which question would the nurse
ask to assess the extent of the client’s heart failure?
a. “Do you have trouble breathing or chest pain?”
b. “Are you still able to walk upstairs without fatigue?”
c. “Do you awake with breathlessness during the night?”
d. “Do you have new-onset heaviness in your legs?”
ANS: B
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Clients with a history of heart failure generally have negative findings, such as shortness of
breath and fatigue. The nurse needs to determine whether the client’s activity is the same or
worse, or whether the client identifies a decrease in activity level. Trouble breathing, chest
pain, breathlessness at night, and peripheral edema are symptoms of heart failure, but do not
provide data that can determine the extent of the client’s heart failure.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Heart failure, Functional ability
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
21. A nurse cares for an older adult client with heart failure. The client states, “I don’t know what
m
to do. I don’t want to be a burden to my daughter, but I can’t do it alone. Maybe I should die.”
What is the best response by the nurse?
a. “I can stay if you would you like to talk more about this.”
b. “You are lucky to have such a devoted daughter.”
c. “It is normal to feel as though you are a burden.”
d. “Would you like to meet with the chaplain?”
ANS: A
s.
co
Depression can occur in clients with heart failure, especially older adults. Having the client
talk about his or her feelings will help the nurse focus on the actual problem. Open-ended
statements allow the client to respond safely and honestly. The other options minimize the
client’s concerns and do not allow the nurse to obtain more information to provide
client-centered care.
nk
DIF: Applying
TOP: Integrated Process: Caring
KEY: Heart failure, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
22. A nurse teaches a client with heart failure about energy conservation. Which statement would
ANS: B
st
ba
the nurse include in this client’s teaching?
a. “Walk until you become short of breath, and then walk back home.”
b. “Begin walking 200 feet a day three times a week.”
c. “Do not lift heavy weights for 6 months.”
d. “Eat plenty of protein to build your strength.”
Bt
e
A client who has heart failure would be taught to conserve energy and given an exercise plan.
The client should begin walking 200-400 feet a day at home three times a week. The client
should not walk until becoming short of breath because he or she may not make it back home.
The lifting restriction is specifically for clients after valve replacements. Protein does help
build strength, but this direction is not specific to heart failure.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Heart failure, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
23. A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that
radiates to the left side of the neck. Which nonpharmacologic comfort measure would the
nurse implement?
a. Apply an ice pack to the client’s chest.
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b. Provide a neck rub, especially on the left side.
c. Allow the client to lie in bed with the lights down.
d. Sit the client up with a pillow to lean forward on.
ANS: D
Pain from acute pericarditis may worsen when the client lays supine. The nurse would
position the client in a comfortable position, which usually is upright and leaning slightly
forward. An ice pack and neck rub will not relieve this pain. Dimming the lights will also not
help the pain.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Nonpharmacologic pain management
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
24. A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia
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would the nurse assess?
a. Preventricular contractions
b. Atrial fibrillation
c. Symptomatic bradycardia
d. Sinus tachycardia
ANS: B
nk
s.
Atrial fibrillation is a clinical manifestation of mitral valve regurgitation and stenosis.
Preventricular contractions and bradycardia are not associated with valvular problems. These
are usually identified in clients with electrolyte imbalances, myocardial infarction, and sinus
node problems. Sinus tachycardia is a manifestation of aortic regurgitation due to a decrease
in cardiac output.
ba
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Valve disorder, Cardiac dysrhythmia
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. A nurse is assessing a client with left-sided heart failure. For which clinical manifestations
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would the nurse assess? (Select all that apply.)
a. Pulmonary crackles
b. Confusion
c. Pulmonary hypertension
d. Dependent edema
e. Cough that worsens at night
f. Jugular venous distention
ANS: A, B, E
Left-sided heart failure occurs with a decrease in contractility of the heart or an increase in
afterload. Most of the signs will be noted in the respiratory system. These include crackles,
confusion (due to decreased oxygenation), and cough. Right ventricular failure is associated
with pulmonary hypertension, edema, and jugular venous distention.
DIF: Remembering
KEY: Heart failure, Nursing assessment
TOP: Integrated Process: Nursing Process: Assessment
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MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse evaluates laboratory results for a client with heart failure. Which results would the
nurse expect? (Select all that apply.)
a. Hematocrit: 32.8%
b. Serum sodium: 130 mEq/L (130 mmol/L)
c. Serum potassium: 4.0 mEq/L (4.0 mmol/L)
d. Serum creatinine: 1.0 mg/dL (88.4 mcmol/L)
e. Proteinuria
f. Microalbuminuria
ANS: A, B, E, F
m
A hematocrit of 32.8% is low (should be 42.6%), indicating a dilutional ratio of red blood
cells to fluid. A serum sodium of 130 mEq/L (130 mmol/L) is low because of hemodilution.
Microalbuminuria and proteinuria are present, indicating a decrease in renal filtration. These
are early warning signs of decreased compliance of the heart. The potassium level is normal
and the serum creatinine level is normal.
co
DIF: Applying
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Heart failure, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A nurse assesses clients on a cardiac unit. Which clients would the nurse identify as at
nk
s.
greatest risk for the development of acute pericarditis? (Select all that apply.)
a. A 36-year-old woman with systemic lupus erythematosus (SLE)
b. A 42-year-old man recovering from coronary artery bypass graft surgery
c. A 59-year-old woman recovering from a hysterectomy
d. An 80-year-old man with a bacterial infection of the respiratory tract
e. An 88-year-old woman with a stage III sacral ulcer
ANS: A, B, D
st
ba
Acute pericarditis is most commonly associated with acute exacerbations of systemic
connective tissue disease, including SLE; with Dressler syndrome, or inflammation of the
cardiac sac after cardiac surgery or a myocardial infarction; and with infective organisms,
including bacterial, viral, and fungal infections. Abdominal and reproductive surgeries and
pressure injuries do not increase clients’ risk for acute pericarditis.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Inflammatory response, Pericarditis
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. After teaching a client with congestive heart failure (CHF), the nurse assesses the client’s
understanding. Which client statements indicate a correct understanding of the teaching
related to nutritional intake? (Select all that apply.)
a. “I’ll read the nutritional labels on food items for salt content.”
b. “I will drink at least 3 L of water each day.”
c. “Using salt in moderation will reduce the workload of my heart.”
d. “I will eat oatmeal for breakfast instead of ham and eggs.”
e. “Substituting fresh vegetables for canned ones will lower my salt intake.”
f. “Salt substitutes are a good way to cut down on sodium in my diet.”
ANS: A, D, E
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Nutritional therapy for a client with CHF is focused on decreasing sodium and water retention
to decrease the workload of the heart. The client would be taught to read nutritional labels on
all food items, omit table salt and foods high in sodium (e.g., ham and canned foods), and
limit water intake to a normal 2 L/day. Salt substitutes typically contain potassium, so
although they are not strictly banned, clients would have to have their renal function and
serum potassium monitored while using them. It would be safer to avoid them.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Heart failure, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse collaborates with assistive personnel (AP) to provide care for a client with congestive
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heart failure. Which instructions would the nurse provide to the AP when delegating care for
this client? (Select all that apply.)
a. “Reposition the client every 2 hours.”
b. “Teach the client to perform deep-breathing exercises.”
c. “Accurately record intake and output.”
d. “Use the same scale to weigh the client each morning.”
e. “Place the client on oxygen if the client becomes short of breath.”
ANS: A, C, D
s.
The AP should reposition the client every 2 hours to improve oxygenation and prevent
atelectasis. The AP can also accurately record intake and output, and use the same scale to
weigh the client each morning before breakfast. APs are not qualified to teach clients or assess
the need for and provide oxygen therapy.
nk
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Heart failure, Delegation, Interdisciplinary team
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
6. A nurse prepares to discharge a client who has heart failure. Based on national quality
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measures, what actions would the nurse complete prior to discharging this client? (Select all
that apply.)
a. Teach the client about energy conservation techniques.
b. Ensure that the client is prescribed a beta blocker.
c. Document a discussion about advanced directives.
d. Confirm that a postdischarge nurse visit has been scheduled.
e. Consult a social worker for additional resources.
f. Care transition record transmitted to next level of care within 7 days of discharge.
ANS: B, C, D, F
National quality measures aim to decrease heart failure readmission by proper preparation for
discharge. These measures include :(1) beta blocker prescribed for left ventricular dysfunction
at discharge, (2) postdischarge follow-up appointment scheduled within 7 days of discharge
with documentation of location, date, and time. (3) care transition record transmitted to next
level of care within 7 days of discharge. (4) documentation of discussion of advance
directives/advance care planning with a health care provider, (5) documentation of execution
of advance directives within the medical record, and (6) postdischarge evaluation of patient
for symptom assessment and treatment adherence within 72 hours of discharge (this can occur
by phone, scheduled office visit, or home visit)
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Analysis
KEY: Heart failure, Core measures
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A nurse prepares to discharge a client who has heart failure. Which questions would the nurse
ask to ensure this client’s safety prior to discharging home? (Select all that apply.)
a. “Are your bedroom and bathroom on the first floor?”
b. “What social support do you have at home?”
c. “Will you be able to afford your oxygen therapy?”
d. “What spiritual beliefs may impact your recovery?”
e. “Are you able to accurately weigh yourself at home?”
ANS: A, B, D
m
To ensure safety upon discharge, the nurse would assess for structural barriers to functional
ability, such as stairs. The nurse would also assess the client’s available social support, which
may include family, friends, and home health services. The client’s beliefs about and ability to
adhere to medication and treatments, including daily weights, would also be reviewed. The
other questions do not specifically address the client’s safety upon discharge.
co
DIF: Applying
TOP: Integrated Process: Nursing Process: Analysis
KEY: Heart failure, Discharge, Safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
8. A nurse assesses a client who is recovering from a heart transplant. Which assessment
ANS: A, B, C, F
ba
nk
s.
findings would alert the nurse to the possibility of heart transplant rejection? (Select all that
apply.)
a. Shortness of breath
b. Abdominal bloating
c. New-onset bradycardia
d. Increased ejection fraction
e. Hypertension
f. Fatigue
st
Clinical findings of heart transplant rejection include shortness of breath, fatigue, fluid gain,
abdominal bloating, new-onset bradycardia, hypotension, atrial fibrillation or flutter,
decreased activity tolerance, and decreased ejection fraction.
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e
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Transplant, Rejection
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
9. A nurse is caring for a client who was admitted with hypertrophic cardiomyopathy (HCM).
What interprofessional care does the nurse anticipate providing? (Select all that apply.)
a. Administering beta blockers
b. Administering high-dose furosemide
c. Preparing for a cardiac catheterization
d. Loading the client on digitalis
e. Instructing the client to avoid strenuous exercise
f. Teaching the client how to use the CardioMEMS™
ANS: A, C, E
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Management of obstructive HCM includes administering negative inotropic agents such as
beta-adrenergic blocking agents (carvedilol) and calcium antagonists (verapamil).
Vasodilators, diuretics, nitrates, and cardiac glycosides are contraindicated in patients with
obstructive HCM. Strenuous exercise is also prohibited. Echocardiography, radionuclide
imaging, and angiocardiography during cardiac catheterization are performed to diagnose and
differentiate cardiomyopathies. The CardioMEMS™ device is used with clients who have
heart failure.
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ba
nk
s.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Implementation
KEY: Cardiomyopathy, Intraprofessional care
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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Chapter 33: Concepts of Care for Patients With Vascular Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is assessing the peripheral vascular system of an older adult. What action by the nurse
would cause the supervising nurse to intervene?
a. Assessing blood pressure in both upper extremities
b. Auscultating the carotid arteries for any bruits
c. Classifying capillary filling of 4 seconds as normal
d. Palpating both carotid arteries at the same time
ANS: D
m
The nurse would not compress both carotid arteries at the same time to avoid brain ischemia.
Blood pressure would be taken and compared in both arms. Prolonged capillary filling is
considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as
normal would not require intervention. Bruits would be auscultated.
co
DIF: Remembering
TOP: Integrated Process: Communication and Documentation
KEY: Vascular system, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
s.
2. The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel.
ba
ANS: B
nk
What meal selection indicates that the client is managing this condition well with diet?
a. A 4-ounce steak, French fries, iceberg lettuce
b. Baked chicken breast, broccoli, tomatoes
c. Fried catfish, cornbread, peas
d. Spaghetti with meat sauce, garlic bread
st
The diet recommended for this client would be low in saturated fats and red meat, high in
vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the
chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg
lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no
vegetables.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Nutrition, Self-care
MSC: Client Needs Category: Health Promotion and Maintenance
3. A nurse is working with a client who takes clopidogrel. The client’s recent laboratory results
include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action
by the nurse is best?
a. Ask if the client eats grapefruit.
b. Assess the client for dehydration.
c. Facilitate admission to the hospital.
d. Obtain a random urinalysis.
ANS: A
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There is a drug–food interaction between clopidogrel and grapefruit that can lead to acute
kidney failure. This client has elevated renal laboratory results, indicating some degree of
kidney involvement. The nurse would assess if the client eats grapefruit or drinks grapefruit
juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more
specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis
may or may not be ordered.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Medication-food interactions, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A client has been diagnosed with hypertension but does not take the antihypertensive
m
medications because of a lack of symptoms. What response by the nurse is best?
a. “Do you have trouble affording your medications?”
b. “Most people with hypertension do not have symptoms.”
c. “You are lucky; most people get severe morning headaches.”
d. “You need to take your medicine or you will get kidney failure.”
ANS: B
s.
co
Most people with hypertension are asymptomatic, although a small percentage do have
symptoms such as headache. The nurse would explain this to the client. Asking about paying
for medications utilizes closed-ended questioning and is not therapeutic. Threatening the
client with possible complications will not increase compliance.
nk
DIF: Understanding
TOP: Integrated Process: Communication and Documentation
KEY: Hypertension, Medication adherence
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
st
ANS: C
ba
5. A client asks what “essential hypertension” is. What response by the registered nurse is best?
a. “It means it is caused by another disease.”
b. “It means it is ‘essential’ that it be treated.”
c. “It is hypertension with no specific cause.”
d. “It refers to severe and life-threatening hypertension.”
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e
Essential hypertension is the most common type of hypertension and has no specific cause
such as an underlying disease process. Hypertension that is due to another disease process is
called secondary hypertension. A severe, life-threatening form of hypertension is malignant
hypertension.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Hypertension, Pathophysiology
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A nurse is interested in providing community education and screening on hypertension. In
order to reach a priority population, to what target audience would the nurse provide this
service?
a. African-American churches
b. Asian-American groceries
c. High school sports camps
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d. Women’s health clinics
ANS: A
African Americans in the United States have one of the highest rates of hypertension in the
world. The nurse has the potential to reach this priority population by providing services at
African-American churches. Although hypertension education and screening are important for
all groups, African Americans are the priority population for this intervention.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Analysis
KEY: Hypertension, Primary prevention
MSC: Client Needs Category: Health Promotion and Maintenance
7. A client has hypertension and high risk factors for cardiovascular disease. The client is
m
overwhelmed with the recommended lifestyle changes. What action by the nurse is best?
a. Assess the client’s support system.
b. Assist in finding one change the client can control.
c. Determine what stressors the client faces in daily life.
d. Inquire about delegating some of the client’s obligations.
ANS: B
s.
co
All options are appropriate when assessing stress and responses to stress. However, this client
feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed
changes, the nurse would assist the client in choosing one the client feels optimistic about
controlling. Once the client has mastered that change, he or she can move forward with
another change. Determining support systems, daily stressors, and delegation opportunities
does not directly impact the client’s feelings of control.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Hypertension, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
ba
8. The nurse is caring for four hypertensive clients. Which drug–laboratory value combination
ANS: A
st
would the nurse report immediately to the health care provider?
a. Furosemide/potassium: 2.1 mEq/L
b. Hydrochlorothiazide/potassium: 4.2 mEq/L
c. Spironolactone/potassium: 5.1 mEq/L
d. Torsemide/sodium: 142 mEq/L
Bt
e
Furosemide is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is
quite low and would be reported immediately. Spironolactone is a potassium-sparing diuretic
that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not
as critical as the low potassium with furosemide. The other two laboratory values are normal.
DIF: Applying
TOP: Integrated Process: Nursing Process: Analysis
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
9. A nurse is assessing a client with peripheral artery disease (PAD). The client states that
walking five blocks is possible without pain. What question asked next by the nurse will give
the best information?
a. “Could you walk further than that a few months ago?”
b. “Do you walk mostly uphill, downhill, or on flat surfaces?”
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c. “Have you ever considered swimming instead of walking?”
d. “How much pain medication do you take each day?”
ANS: A
As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on
activity to be pain free indicates that the client’s disease is worsening. The other questions are
useful, but not as important.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Peripheral artery disease, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. An older client with peripheral vascular disease (PVD) is explaining the daily foot care
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regimen to the family practice clinic nurse. What statement by the client may indicate a
barrier to proper foot care?
a. “I nearly always wear comfy sweatpants and house shoes.”
b. “I’m glad I get energy assistance so my house isn’t so cold.”
c. “My daughter makes sure I have plenty of lotion for my feet.”
d. “My hands shake when I try to do things requiring coordination.”
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ANS: D
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s.
Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and
cut straight across. The client whose hands shake may cause injury when trimming toenails.
The nurse would refer this client to a podiatrist. Comfy sweatpants and house shoes are
generally loose and not restrictive, which is important for clients with PVD. Keeping the
house at a comfortable temperature makes it less likely the client will use alternative heat
sources, such as heating pads, to stay warm. The client should keep the feet moist and soft
with lotion.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Peripheral vascular disease, Home safety
MSC: Client Needs Category: Health Promotion and Maintenance
11. A client is taking warfarin and asks the nurse if taking St. John’s wort is acceptable. What
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response by the nurse is best?
a. “No, it may interfere with the warfarin.”
b. “There isn’t any information about that.”
c. “Why would you want to take that?”
d. “Yes, it is a good supplement for you.”
ANS: A
Many foods and drugs interfere with warfarin, St. John’s wort being one of them. The nurse
would advise the client against taking it. The other answers are not accurate.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Anticoagulants, Medication-food interactions
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
12. A nurse is teaching a female client about alcohol intake and how it affects hypertension. The
client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is
best?
a. “No, women should only have one beer a day as a general rule.”
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b. “No, you should not drink any alcohol with hypertension.”
c. “Yes, since you are larger, you can have more alcohol.”
d. “Yes, two beers per day is an acceptable amount of alcohol.”
ANS: A
Alcohol intake should be limited to two drinks a day for men and one drink a day for women.
A “drink” is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited
alcohol intake is acceptable with hypertension. The woman’s size does not matter.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Hypertension, Lifestyle choices
MSC: Client Needs Category: Health Promotion and Maintenance
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13. A nurse is caring for four clients. Which one would the nurse see first?
a. Client who needs a beta blocker, and has a blood pressure of 98/58 mm Hg.
b. Client who had a first dose of captopril and needs to use the bathroom.
c. Hypertensive client with a blood pressure of 188/92 mm Hg.
d. Client who needs pain medication prior to a dressing change of a surgical wound.
ANS: B
nk
s.
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Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially
after the first dose. The nurse would see this client first to prevent falling if the client decides
to get up without assistance. The two blood pressure readings are abnormal but not critical.
The nurse would check on the client with higher blood pressure next to assess for problems
related to the reading. The nurse can administer the beta blocker as standards state to hold it if
the systolic blood pressure is below 90 to 100 mm Hg. The client who needs pain medication
prior to the dressing change is not a priority over client safety and assisting the other client to
the bathroom.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Hypertension, Angiotensin-converting enzyme (ACE) inhibitors
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
14. A client had a percutaneous angioplasty for renovascular hypertension 3 months ago. What
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assessment finding by the nurse indicates that an important outcome for this client has been
met?
a. Client is able to decrease blood pressure medications.
b. Insertion site has healed without redness or tenderness.
c. Most recent lab data show BUN: 19 mg/dL and creatinine 1.1 mg/dL.
d. Verbalizes understanding of postprocedure lifestyle changes.
ANS: A
Hypertension can be caused by renovascular disease. Opening up a constricted renal artery
can lead to decreased blood pressure, manifested by the need for less blood pressure
medication. The other findings are normal and desired, but not specifically related to
hypertension caused by renal disease.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Hypertension, Perfusion
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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15. A client is 4 hours postoperative after a femoral-popliteal bypass. The client reports throbbing
leg pain on the affected side, rated as 7/10. What action by the nurse is most important?
a. Administer pain medication as ordered.
b. Assess distal pulses and skin color.
c. Document the findings in the client’s chart.
d. Notify the surgeon immediately.
ANS: B
Once perfusion has been restored or improved to an extremity, clients can often feel a
throbbing pain due to the increased blood flow. However, it is important to differentiate this
pain from ischemia. The nurse would assess for other signs of perfusion, such as distal pulses
and skin color/temperature. Administering pain medication is done once the nurse determines
that the client’s perfusion status is normal. Documentation needs to be thorough. Notifying the
surgeon is not necessary.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Peripheral vascular disease, Nursing process assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
16. A client had a femoral-popliteal bypass graft with a synthetic graft. What action by the nurse
s.
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is most important to prevent wound infection?
a. Appropriate hand hygiene before giving care
b. Assessing the client’s temperature every 4 hours
c. Clean technique when changing dressings
d. Monitoring the client’s daily white blood cell count
ANS: A
nk
Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes
would be done with sterile technique. Assessing vital signs and white blood cell count will not
prevent infection.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection control, Hand hygiene
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
st
17. A client is receiving an infusion of alteplase for an intra-arterial clot. The client begins to
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mumble and is disoriented. What action by the nurse is most important?
a. Assess the client’s neurologic status.
b. Notify the Rapid Response Team.
c. Prepare to administer vitamin K.
d. Turn down the infusion rate.
ANS: B
Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic
signs may indicate that the client is having a hemorrhagic stroke. The nurse does need to
complete a thorough neurologic examination, but would first call the Rapid Response Team
based on the client’s manifestations. Vitamin K is not the antidote for this drug. Turning down
the infusion rate will not be helpful if the client is still receiving any of the drug.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Critical rescue, Fibrinolytic agents
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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18. A new nurse is caring for a client with an abdominal aneurysm. What action by the new nurse
requires the nurse’s mentor to intervene?
a. Assesses the client for back pain.
b. Auscultates over abdominal bruit.
c. Measures the abdominal girth.
d. Palpates the abdomen in four quadrants.
ANS: D
Abdominal aneurysms should never be palpated as this increases the risk of rupture. The nurse
mentoring the new nurse would intervene when the new nurse attempts to do this. The other
actions are appropriate.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Aneurysms, Abdominal assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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indicates that an important outcome has been met?
a. Ambulates with assistance
b. Oxygen saturation of 98%
c. Pain of 2/10 after medication
d. Verbalizing risk factors
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19. A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment
s.
ANS: B
nk
A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates
that this has not occurred. The other assessments are also positive, but not as important.
ba
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Pulmonary embolism, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
20. A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to
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ANS: B
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the assistive personnel (AP)?
a. Ambulate the client.
b. Apply a warm moist pack.
c. Massage the client’s leg.
d. Provide an ice pack.
Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure.
Massaging the client’s legs is contraindicated to prevent complications such as pulmonary
embolism. Ice packs are not recommended for DVT.
DIF: Understanding
TOP: Integrated Process: Communication and Documentation
KEY: Thromboembolic event, Comfort measures
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
21. A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein
thrombosis. The client has lost 20 lb (9.09 Kg) since the last visit. What action by the nurse is
best?
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a.
b.
c.
d.
Ask if the weight loss was intended.
Encourage a high-protein, high-fiber diet.
Measure for new compression stockings.
Review a 3-day food recall diary.
ANS: C
Compression stockings must fit correctly in order to work. After losing a significant amount
of weight, the client would be remeasured and new stockings ordered if needed. The other
options are appropriate, but not the most important.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Thromboembolic event, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
22. A nurse wants to provide community service that helps meet the goals of Healthy People 2020
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(HP2020) related to cardiovascular disease and stroke. What activity would best meet this
goal?
a. Teach high school students heart-healthy living.
b. Participate in blood pressure screenings at the mall.
c. Provide pamphlets on heart disease at the grocery store.
d. Set up an “Ask the nurse” booth at the pet store.
ANS: B
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s.
An important goal of HP2020 is to increase the proportion of adults who have had their blood
pressure measured within the preceding 2 years and can state whether their blood pressure
was normal or high. Participating in blood pressure screening in a public spot will best help
meet that goal. The other options are all appropriate but do not specifically help meet a goal.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Hypertension, Primary prevention
MSC: Client Needs Category: Health Promotion and Maintenance
23. A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin.
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The client is adamant about refusing the drug because “it’s dangerous.” What action by the
nurse is best?
a. Assess the reason behind the client’s fear.
b. Remind the client about laboratory monitoring.
c. Tell the client that drugs are safer today than before.
d. Warn the client about consequences of noncompliance.
ANS: A
The first step is to assess the reason behind the client’s fear, which may be related to the
experience of someone the client knows who took warfarin or misinformation. If the nurse
cannot address the specific rationale, teaching will likely be unsuccessful. Laboratory
monitoring once every few weeks may not make the client perceive the drug to be safe.
General statements like “drugs are safer today” do not address the root cause of the problem.
Warning the client about possible consequences of not taking the drug is not therapeutic and is
likely to lead to an adversarial relationship.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Psychosocial response, Therapeutic communication
MSC: Client Needs Category: Psychosocial Integrity
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24. A client with a history of heart failure and hypertension is in the clinic for a follow-up visit.
The client is on lisinopril and warfarin. The client reports new-onset cough. What action by
the nurse is most appropriate?
a. Assess the client’s lung sounds and oxygenation.
b. Instruct the client on another antihypertensive.
c. Obtain a set of vital signs and document them.
d. Remind the client that cough is a side effect of lisinopril.
ANS: A
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This client could be having an exacerbation of heart failure or experiencing a side effect of
lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse would assess the
client’s lung sounds and other signs of oxygenation first. The client may or may not need to
switch antihypertensive medications. Vital signs and documentation are important, but the
nurse would assess the respiratory system first. If the cough turns out to be a side effect,
reminding the client is appropriate, but then more action needs to be taken.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Angiotensin-converting enzyme (ACE) inhibitors, Adverse effects
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
25. A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the
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s.
nurse is best?
a. Consult with the wound care nurse.
b. Give pain medication prior to dressing changes.
c. Maintain sterile technique for dressing changes.
d. Prepare the client for eventual amputation.
ANS: A
ba
A nonhealing wound needs the expertise of the wound care nurse. Premedicating prior to
painful procedures and maintaining sterile technique are helpful, but if the wound is not
healing, more needs to be done. The client may need an amputation, but other options need to
be tried first.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Peripheral arterial disease, Wound care
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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26. A client has peripheral arterial disease (PAD). What statement by the client indicates
misunderstanding about self-management activities?
“I can use a heating pad on my legs if it’s set on low.”
“I should not cross my legs when sitting or lying down.”
“I will go out and buy some warm, heavy socks to wear.”
“It’s going to be really hard but I will stop smoking.”
a.
b.
c.
d.
ANS: A
Clients with PAD should never use heating pads as skin sensitivity is diminished and burns
can result. The other statements show good understanding of self-management.
DIF: Evaluating
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Peripheral arterial disease, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
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27. The nurse is assessing a client on admission to the hospital. The client’s leg appears as shown
s.
What action by the nurse is best?
a. Assess the client’s ankle-brachial index.
b. Elevate the client’s leg above the heart.
c. Obtain an ice pack to provide comfort.
d. Prepare to teach about heparin sodium.
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below:
ANS: A
ba
nk
This client has dependent rubor, a classic finding in peripheral arterial disease. The nurse
would measure the client’s ankle-brachial index. Elevating the leg above the heart will further
impede arterial blood flow. Ice will cause vasoconstriction, also impeding circulation and
perhaps causing tissue injury. Heparin sodium is not the drug of choice for this condition.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Peripheral vascular disease, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
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1. What nonpharmacologic comfort measures would the nurse include in the plan of care for a
client with severe varicose veins? (Select all that apply.)
a. Administering mild analgesics for pain
b. Applying elastic compression stockings
c. Elevating the legs when sitting or lying
d. Reminding the client to do leg exercises
e. Teaching the client about surgical options
f. Encouraging participation in high impact aerobic activity
ANS: B, C, D
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The three Es of care for varicose veins include elastic compression hose, exercise, and
elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical
options is not a comfort measure. High impact aerobics is not encouraged and is not a comfort
measure.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Implementation
KEY: Peripheral vascular disease, Nonpharmacologic comfort measures
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
2. A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the
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nurse delegate to the assistive personnel (AP)? (Select all that apply.)
a. Administering preoperative medication
b. Ensuring that the consent is signed
c. Marking pulses with a pen
d. Raising the side rails on the bed
e. Recording baseline vital signs
ANS: D, E
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The AP can raise the side rails of the bed for client safety and take and record the vital signs.
Administering medications, ensuring that a consent is on the chart, and marking the pulses for
later comparison would be done by the registered nurse. This is also often done by the
postanesthesia care nurse and is part of the hand-off report.
nk
s.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Delegation, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A client has been bedridden for several days after major abdominal surgery. What action does
st
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the nurse delegate to the assistive personnel (AP) for deep vein thrombosis (DVT) prevention?
(Select all that apply.)
a. Apply compression stockings.
b. Assist with ambulation.
c. Encourage coughing and deep breathing.
d. Offer fluids frequently.
e. Teach leg exercises.
ANS: A, B, D
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The AP can apply compression stockings, assist with ambulation, and offer fluids frequently
to help prevent DVT. The AP can also encourage the client to do pulmonary exercises, but
these do not decrease the risk of DVT. Teaching is a nursing function.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Deep vein thrombosis, Delegation
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include
in the client’s plan of care? (Select all that apply.)
a. Assess the client for bleeding.
b. Monitor the daily activated partial thromboplastin time (aPTT) results.
c. Stop the IV for aPTT above baseline.
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d. Use an IV pump for the infusion.
e. Weigh the client daily on the same scale.
ANS: A, B, D
Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all
important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be
1.5 to 2.5 times normal in order to demonstrate that the heparin is therapeutic. Weighing the
client is not related.
DIF: Applying
TOP: Integrated Process: Nursing Process: Intervention
KEY: Anticoagulants, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
ANS: A, C, D, E
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required to provide? (Select all that apply.)
a. Dietary restrictions
b. Driving restrictions
c. Follow-up laboratory monitoring
d. Possible drug–drug interactions
e. Reason to take medication
f. Wearing a Medic Alert bracelet
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5. A client is being discharged on warfarin therapy. What discharge instruction is the nurse
s.
Best practices state that clients being discharged on warfarin need instruction on follow-up
monitoring, dietary restrictions, drug–drug interactions, using a Medic Alert bracelet or
necklace, and reason for compliance. Driving is typically not restricted.
nk
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Anticoagulants, Health teaching
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
ba
6. Which statements by the client indicate good understanding of foot care in peripheral vascular
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disease? (Select all that apply.)
a. “A good abrasive pumice stone will keep my feet soft.”
b. “I’ll always wear shoes if I can buy cheap flip-flops.”
c. “I will keep my feet dry, especially between the toes.”
d. “Lotion is important to keep my feet smooth and soft.”
e. “Washing my feet in room-temperature water is best.”
f. “I will inspect my feet daily.”
ANS: C, D, E
Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry;
wearing good, comfortable shoes; using lotion; washing the feet in room-temperature water;
cutting the nails straight across; and inspecting the feet daily are all important measures.
Abrasive material such as pumice stones would not be used. Cheap flip-flops may not fit well
and won’t offer much protection against injury.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Peripheral vascular disease, Health teaching
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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7. A nurse is caring for a client with a nonhealing arterial ulcer. The primary health care provider
has informed the client about possibly needing to amputate the client’s leg. The client is
crying and upset. What actions by the nurse are best? (Select all that apply.)
a. Ask the client to describe his or her current emotions.
b. Assess the client for support systems and family.
c. Offer to stay with the client if he or she desires.
d. Relate how smoking contributed to this situation.
e. Tell the client that many people have amputations.
f. Arrange for an amputee to come visit the client.
ANS: A, B, C
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DIF: Applying
TOP: Integrated Process: Caring
KEY: Psychosocial response, Therapeutic communication
MSC: Client Needs Category: Psychosocial Integrity
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When a client is upset, the nurse would offer self by remaining with the client if desired.
Other helpful measures include determining what and whom the client has for support systems
and asking the client to describe what he or she is feeling. Telling the client how smoking has
led to this situation will only upset the client further and will damage the therapeutic
relationship. Telling the client that many people have amputations belittles the client’s
feelings. It is too early to send an amputee to visit the client as the decision to amputate has
not yet been made.
s.
8. The nurse working in the emergency department knows that which factors are commonly
ANS: A, D, E, F
ba
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related to aneurysm formation? (Select all that apply.)
a. Atherosclerosis
b. Down syndrome
c. Frequent heartburn
d. History of hypertension
e. History of smoking
f. Hyperlipidemia
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Atherosclerosis, hypertension, hyperlipidemia, hyperlipidemia, and smoking are the most
commonly related factors. Down syndrome and heartburn have no relation to aneurysm
formation.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Peripheral vascular disorders, Pathophysiology
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal
pain. The nurse assesses the client’s blood pressure at 82/40 mm Hg. What actions by the
nurse are most important? (Select all that apply.)
a. Administer pain medication.
b. Assess distal pulses every 10 minutes.
c. Have the client sign a surgical consent.
d. Notify the Rapid Response Team.
e. Take vital signs every 10 minutes.
ANS: B, D, E
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This client may have a ruptured/rupturing aneurysm. The nurse would notify the Rapid
Response team and perform frequent client assessments. Giving pain medication will lower
the client’s blood pressure even further. The nurse cannot have the client sign a consent until
the surgeon has explained the procedure.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Aneurysm, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. A client presents to the emergency department with a thoracic aortic aneurysm. Which
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findings are most consistent with this condition? (Select all that apply.)
a. Abdominal tenderness
b. Difficulty swallowing
c. Changes in bowel habits
d. Shortness of breath
e. Hoarseness
ANS: B, E
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Signs of a thoracic aortic aneurysm include shortness of breath, hoarseness, and difficulty
swallowing. Pain is often rated as a 10 on a 10-point scale. Bowel habits are not related.
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Aortic aneurysm, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
11. The nurse is reviewing risk factors in a client who has atherosclerosis. Which findings are
ANS: A, B, D
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most concerning? (Select all that apply.)
a. Elevated low-density lipoprotein (LDL-C)
b. Decreased levels of high-density lipoprotein cholesterol (HDL-C)
c. Asian ethnicity
d. History of smoking
e. Blood pressure: 142/92 mm Hg on one occasion
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Elevated levels of lipids (fats) such as low-density lipoprotein cholesterol (LDL-C) and
decreased levels of high-density lipoprotein cholesterol can cause chemical damage to blood
vessel walls. Smoking can cause endothelial damage in addition to increasing a client’s
carbon monoxide levels. African American and Hispanic ethnicities carry an increased risk for
atherosclerosis. Hypertension does increase atherosclerosis risk, but an elevated reading on
one occasion is not classified as hypertension.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Atherosclerosis, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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Chapter 34: Critical Care of Patients With Shock
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is caring for a client who suffered massive blood loss after trauma. How does the
nurse correlate the blood loss with the client’s mean arterial pressure (MAP)?
a. It causes vasoconstriction and increased MAP.
b. Lower blood volume lowers MAP.
c. There is no direct correlation to MAP.
d. It raises cardiac output and MAP.
ANS: B
Lower blood volume will decrease MAP. The other answers are not accurate.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Mean arterial blood pressure, Shock
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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2. A nurse is caring for a client after surgery. The client’s respiratory rate has increased from 12
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s.
to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since the client was last
assessed 4 hours ago. What action by the nurse is best?
a. Ask if the client needs pain medication.
b. Assess using the MEWS score.
c. Document the findings in the client’s chart.
d. Increase the rate of the client’s IV infusion.
ANS: B
st
ba
Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart
rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal
range, the nurse would conduct a thorough assessment of the patient, focusing on indicators of
perfusion. The MEWS score (Modified Early Warning Score) was developed to identify
clients at risk for deterioration. The client may need pain medication, but this is not the
priority at this time. Documentation would be done thoroughly but would be done after the
assessment. The nurse would not increase the rate of the IV infusion without an order.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Shock, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. The nurse gets the hand-off report on four clients. Which client would the nurse assess first?
a. Client with a blood pressure change of 128/74 to 110/88 mm Hg
b. Client with oxygen saturation unchanged at 94%
c. Client with a pulse change of 100 to 88 beats/min
d. Client with urine output of 40 mL/hr for the last 2 hours
ANS: A
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This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing
pulse pressure, all of which may be indications of worsening perfusion status and possible
shock. The nurse would assess this client first. The client with the unchanged oxygen
saturation is stable at this point. Although the client with a change in pulse has a slower rate, it
is not an indicator of shock since the pulse is still within the normal range; it may indicate that
the client’s pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine
output of 40 mL/hr is above the normal range, which is 30 mL/hr.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Shock, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A nurse is caring for a client after surgery who is restless and apprehensive. The assistive
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personnel (AP) reports the vital signs and the nurse sees that they are only slightly different
from previous readings. What action does the nurse delegate next to the AP?
a. Assess the client for pain or discomfort.
b. Measure urine output from the catheter.
c. Reposition the client to the side.
d. Stay with the client and reassure him or her.
ANS: B
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Urine output changes are a sensitive early indicator of shock. The nurse would delegate
emptying the urinary catheter and measuring output to the AP as a baseline for hourly urine
output measurements. The AP cannot assess for pain. Repositioning may or may not be
effective for decreasing restlessness, but does not take priority over physical assessments.
Reassurance is a therapeutic nursing action, but the nurse needs to do more in this situation.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Shock, Delegation
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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5. A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of
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208 mg/dL (11.6 mmol/L). The spouse asks why the client needs insulin as the client is not a
diabetic. What response by the nurse is best?
a. “High glucose is common in shock and needs to be treated.”
b. “Some of the medications we are giving are to raise blood sugar.”
c. “The IV solution has lots of glucose, which raises blood sugar.”
d. “The stress of this illness has made your spouse a diabetic.”
ANS: A
High glucose readings are common in shock, and best outcomes are the result of treating them
and maintaining glucose readings in the range of 140 to 180 mg/dL (7.7 to 10 mmol/L.
Medications and IV solutions may raise blood glucose levels, but this is not the most accurate
answer. The stress of the illness has not “made” the client diabetic.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Shock, Insulin
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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6. A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3
(3.8  109/L), blood glucose level 198 mg/dL (11 mmol/L), and temperature 96.2° F (35.6°
C). What action by the nurse takes priority?
a. Document the findings in the client’s chart.
b. Give the client warmed blankets for comfort.
c. Notify the primary health care provider immediately.
d. Prepare to administer insulin per sliding scale.
ANS: C
This client has several indicators of sepsis with systemic inflammatory response. The nurse
would notify the primary health care provider immediately. Documentation needs to be
thorough but does not take priority. The client may appreciate warm blankets, but comfort
measures do not take priority. The client may need insulin if blood glucose is being regulated
tightly.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Shock, Critical rescue
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
s.
nurse teach the clients to prevent shock?
a. Do not get dehydrated in warm weather.
b. Drink fluids on a regular schedule.
c. Seek attention for any lacerations.
d. Take medications as prescribed.
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7. A nurse works at a community center for older adults. What self-management measure can the
ANS: B
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Preventing dehydration in older adults is important because the age-related decrease in the
thirst mechanism makes them prone to dehydration. Having older adults drink fluids on a
regular schedule will help keep them hydrated without the influence of thirst (or lack of
thirst). Telling clients not to get dehydrated is important, but not the best answer because it
doesn’t give them the tools to prevent it from occurring. Older adults should seek attention for
lacerations, but this is not as important an issue as staying hydrated. Taking medications as
prescribed may or may not be related to hydration.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Older adult, Fluid and electrolyte imbalance
MSC: Client Needs Category: Health Promotion and Maintenance
8. A client arrives in the emergency department after being in a car crash with fatalities. The
client has a nearly amputated leg that is bleeding profusely. What action by the nurse takes
priority?
a. Apply direct pressure to the bleeding.
b. Ensure the client has a patent airway.
c. Obtain a pulse oximetry reading
d. Start two large-bore IV catheters.
ANS: B
Airway is the priority, followed by breathing (pulse oximetry) and circulation (IVs and direct
pressure).
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Critical rescue, Shock
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
9. A client is receiving norepinephrine for shock. What assessment finding best indicates a
therapeutic effect from this drug?
a. Alert and oriented, answering questions
b. Client denies chest pain or chest pressure
c. IV site without redness or swelling
d. Urine output of 30 mL/hr for 2 hours
ANS: A
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Normal cognitive function is a good indicator that the client is receiving the benefits of
norepinephrine. The brain is very sensitive to changes in oxygenation and perfusion.
Norepinephrine can cause chest pain as an adverse reaction, so the absence of chest pain is
good but does not indicate therapeutic effect. The IV site is normal. The urine output is
normal, but only minimally so.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Shock, Vasoconstrictors
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
10. A nurse is caring for a client who has a diagnosis of multiple organ dysfunction syndrome
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(MODS) who will be receiving sodium nitroprusside via IV infusion. What action by the
nurse causes the charge nurse to intervene?
a. Assessing the IV site before giving the drug
b. Obtaining a programmable (“smart”) IV pump
c. Removing the IV bag from the brown plastic cover
d. Taking and recording a baseline set of vital signs
ANS: C
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Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the
original brown plastic bag when infusing. The other actions are correct
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Shock, Vasoconstrictors
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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11. A nurse on the general medical-surgical unit is caring for a client in shock and assesses the
following:
Respiratory rate: 10 breaths/min
Pulse: 136 beats/min
Blood pressure: 92/78 mm Hg
Level of consciousness: responds to voice
Temperature: 101.5° F (38.5° C)
Urine output for the last 2 hours: 40 mL/hr.
What action by the nurse is best?
a. Transfer the client to the Intensive Care Unit.
b. Continue monitoring every 30 minutes.
c. Notify the unit charge nurse immediately.
d. Call the Rapid Response Team.
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ANS: D
This client has a MEWS score of 7 (RR: 0, P: 3, SBP: 1, LOC: 1, Temperature: 1, UO: 1).
Scores above 5 are associated with a high risk of death and ICU admission. The most
important action for the nurse is to notify the Rapid Response Team so that timely
interventions can be initiated. The client most likely will be transferred to the ICU, but an
order is required. Monitoring the client every 30 minutes is appropriate, but the nurse needs to
obtain care for the client. The charge nurse is a valuable resource, but the best action is to
notify the Rapid Response Team.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Sepsis, Critical rescue
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
12. A nurse is caring for several clients at risk for shock. Which laboratory value requires the
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nurse to communicate with the primary health care provider?
a. Creatinine: 0.9 mg/dL (68.6 mcmol/L)
b. Lactate: 5.4 mg/dL (6 mmol/L)
c. Sodium: 150 mEq/L (150 mmol/L)
d. White blood cell count: 11,000/mm3 (11  109/L)
ANS: B
s.
A lactate level of 5.4 mg/dL (6 mmol/L) is high and is indicative of possible shock. A
creatinine level of 0.9 mg/dL (68.6 mcmol/L) is normal. A sodium level of 150 mEq/L (150
mmol/L) is slightly high but does not need to be communicated. A white blood cell count of
11,000/mm3 (11  109/L) is slightly high but is not as critical as the lactate level.
nk
DIF: Analyzing
TOP: Integrated Process: Communication and Documentation
KEY: Shock, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
13. A nurse receives hand-off report from the emergency department on a new admission
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ANS: A
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suspected of having septic shock. The client’s qSOFA score is 3. What action by the nurse is
best?
a. Plan to calculate a full SOFA score on arrival.
b. Contact respiratory therapy about ventilator setup.
c. Arrange protective precautions to be implemented.
d. Call the hospital chaplain to support the family.
The qSOFA score is an abbreviated Sequential Organ Failure Assessment (or “quick”). A
score of 3 is high and requires the nurse to assess the client further for organ impairment. The
client may or may not need a ventilator, but that in not specified in the score. The client does
not need protective precautions. The client’s family may well need support, but the nurse
would assess their needs and wishes prior to calling the chaplain.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Shock, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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14. A client is being discharged home after a large myocardial infarction and subsequent coronary
artery bypass grafting surgery. The client’s sternal wound has not yet healed. What statement
by the client most indicates a higher risk of developing sepsis after discharge?
a. “All my friends and neighbors are planning a party for me.”
b. “I hope I can get my water turned back on when I get home.”
c. “I am going to have my daughter scoop the cat litter box.”
d. “My grandkids are so excited to have me coming home!”
ANS: B
All these statements indicate a potential for leading to infection once the client gets back
home. A large party might include individuals who are themselves ill and contagious. Having
litter boxes in the home can expose the client to microbes that can lead to infection. Small
children often have upper respiratory infections and poor hand hygiene that spread germs.
However, the most worrisome statement is the lack of running water for handwashing and
general hygiene and cleaning purposes.
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DIF: Analyzing
TOP: Integrated Process: Communication and Documentation
KEY: Shock, Infection control
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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15. A client with MODS has been started on dobutamine. What assessment finding requires the
s.
nurse to communicate with the primary health care provider immediately?
a. Blood pressure of 98/68 mm Hg
b. Pedal pulses 1+/4+ bilaterally
c. Report of chest heaviness
d. Urine output of 32 mL/hr
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ANS: C
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Chest heaviness or pain indicates myocardial ischemia, a possible adverse effect of
dobutamine. While taking dobutamine, the oxygen requirements of the heart are increased due
to increased myocardial workload, and may cause ischemia. Without knowing the client’s
previous blood pressure or pedal pulses, there is not enough information to determine if these
are an improvement or not. A urine output of 32 mL/hr is acceptable.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Shock, Vasoconstrictors
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
MULTIPLE RESPONSE
1. The nurse studying shock understands that the common signs and symptoms of this condition
are directly related to which problems? (Select all that apply.)
a. Anaerobic metabolism
b. Hyperglycemia
c. Hypotension
d. Impaired renal perfusion
e. Increased systemic perfusion
ANS: A, C
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The common signs and symptoms of shock, no matter the cause, are directly related to the
effects of anaerobic metabolism and hypotension. Hyperglycemia, impaired renal function,
and increased perfusion are not the cause of common signs and symptoms of shock.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Shock, Pathophysiology
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. The nurse caring for hospitalized clients includes which actions on their care plans to reduce
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the possibility of the clients developing shock? (Select all that apply.)
a. Assessing and identifying clients at risk
b. Monitoring the daily white blood cell count
c. Performing proper hand hygiene
d. Removing invasive lines as soon as possible
e. Using aseptic technique during procedures
f. Limiting the client’s visitors until more stable
ANS: A, C, D, E
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Assessing and identifying clients at risk for shock is probably the most critical action the
nurse can take to prevent shock from occurring. Proper hand hygiene, using aseptic technique,
and removing IV lines and catheters are also important actions to prevent shock. Monitoring
laboratory values does not prevent shock but can indicate a change. Limiting the client’s
visitors is not a caring action. The nurse would ensure they perform proper hand hygiene on
entering and leaving the room and that visitors are not ill themselves.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Shock, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
3. The nurse caring frequently for older adults in the hospital is aware of risk factors that place
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them at a higher risk for shock. For what factors would the nurse assess? (Select all that
apply.)
a. Altered mobility/immobility
b. Decreased thirst response
c. Diminished immune response
d. Malnutrition
e. Overhydration
f. Use of diuretics
ANS: A, B, C, D, F
Immobility, decreased thirst response, diminished immune response, malnutrition, and use of
diuretics can place the older adult at higher risk of developing shock. Overhydration is not a
common risk factor for shock.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Shock, Older adult
MSC: Client Needs Category: Health Promotion and Maintenance
4. A client is in the early stages of shock and is restless. What comfort measures does the nurse
delegate to the assistive personnel (AP)? (Select all that apply.)
a. Bringing the client warm blankets
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b.
c.
d.
e.
Giving the client hot tea to drink
Massaging the client’s painful legs
Reorienting the client as needed
Sitting with the client for reassurance
ANS: A, B, D, E
The AP can bring the client warm blankets, reorient the client as needed to decrease anxiety,
and sit with the client for reassurance. If the nurse assesses the client is safely able to swallow,
small amounts of fluids would be allowed. Massaging the legs is not recommended as this can
dislodge any clots present, which may lead to pulmonary embolism.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Shock, Nonpharmacologic comfort interventions
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
5. The nurse is caring for a client with suspected septic shock. What does the nurse prepare to do
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within 1 hour of the client being identified as possibly having sepsis? (Select all that apply.)
a. Administer antibiotics.
b. Draw serum lactate levels.
c. Infuse vasopressors.
d. Measure central venous pressure.
e. Obtain blood cultures.
f. Administer rapid bolus of IV crystalloids.
s.
ANS: A, B, C, E, F
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Within the first hour of suspecting severe sepsis, the nurse would draw (or facilitate) serum
lactate levels, obtain blood cultures (or other cultures), administer antibiotics (after the
cultures have been obtained), begin rapid administration of 30 mL/kg crystalloid for
hypotension or lactate 4 mmol/L. and administer vasopressors if hypotensive during or after
fluid resuscitation to maintain a mean arterial pressure 65 mm Hg. Initiating hemodynamic
monitoring would be done after these “bundle” measures have been accomplished.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Shock, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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Chapter 35: Critical Care of Patients With Acute Coronary Syndromes
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A client is receiving an infusion of tissue plasminogen activator (tPA). The nurse assesses the
client to be disoriented to person, place, and time. What action by the nurse is best?
a. Assess the client’s pupillary responses.
b. Request a neurologic consultation.
c. Call the primary health care provider immediately.
d. Take and document a full set of vital signs.
ANS: C
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A change in neurologic status in a client receiving t-PA could indicate intracranial
hemorrhage. The nurse would notify the primary health care provider immediately. A full
assessment, including pupillary responses and vital signs, occurs next. The nurse may or may
not need to call a neurologist.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Coronary artery disease, Thrombolytic agents, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
s.
2. A client received tissue plasminogen activator (tPA) after a myocardial infarction and now is
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ANS: B
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on an intravenous infusion of heparin. The client’s spouse asks why the client needs this
medication. What response by the nurse is best?
a. “The t-PA didn’t dissolve the entire coronary clot.”
b. “The heparin keeps that artery from getting blocked again.”
c. “Heparin keeps the blood as thin as possible for a longer time.”
d. “The heparin prevents a stroke from occurring as the t-PA wears off.”
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After the original intracoronary clot has dissolved, large amounts of thrombin are released
into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are
not accurate. Heparin is not a “blood thinner,” although laypeople may refer to it as such.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Coronary artery disease, Anticoagulants
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
3. A client is in the hospital after suffering a myocardial infarction and has bathroom privileges.
The nurse assists the client to the bathroom and notes the client’s O2 saturation to be 95%,
pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by
the nurse is best?
a. Administer oxygen at 2 L/min.
b. Allow continued bathroom privileges.
c. Obtain a bedside commode.
d. Suggest the client use a bedpan.
ANS: B
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This client’s physiologic parameters did not exceed normal during and after activity, so it is
safe for the client to continue using the bathroom. There is no indication that the client needs
oxygen, a commode, or a bedpan.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Coronary artery disease, Activity tolerance
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. A nurse is caring for a client who had a myocardial infarction. The nurse is confused because
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the client states that nothing is wrong and yet listens attentively while the nurse provides
education on lifestyle changes and healthy menu choices. What response by the charge nurse
is best?
a. “Continue to educate the client on possible healthy changes.”
b. “Emphasize complications that can occur with noncompliance.”
c. “Tell the client that denial is normal and will soon go away.”
d. “You need to make sure the client understands this illness.”
ANS: A
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Clients are often in denial after a coronary event. The client who seems to be in denial but is
compliant with treatment may be using a healthy form of coping that allows time to process
the event and start to use problem-focused coping. The nurse would not discourage this type
of denial and coping, but rather continue providing education in a positive manner.
Emphasizing complications may make the client defensive and more anxious. Telling the
client that denial is normal is placing too much attention on the process. Forcing the client to
verbalize understanding of the illness is also potentially threatening to the client.
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DIF: Understanding
TOP: Integrated Process: Communication and Documentation
KEY: Coronary artery disease, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
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5. A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial
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ANS: D
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pressure of 0.5 mm Hg. What action by the nurse is most appropriate?
a. Level the transducer at the phlebostatic axis.
b. Lay the client in the supine position.
c. Prepare to administer diuretics.
d. Prepare to administer a fluid bolus.
Normal right atrial pressures are from 0 to 8 mm Hg. This pressure is at the extreme lower
end, which indicates hypovolemia, so the nurse would prepare to administer a fluid bolus. The
transducer would remain leveled at the phlebostatic axis. Positioning may or may not
influence readings but a reading this low is definitive for volume depletion. Diuretics would
be contraindicated.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Hemodynamic monitoring, Fluid and electrolyte imbalance
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A client has hemodynamic monitoring after a myocardial infarction. What safety precaution
does the nurse implement for this client?
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a. Document pulmonary artery occlusion pressure (PAOP) readings and assess their
trends.
b. Ensure that the balloon does not remain wedged.
c. Keep the client on strict NPO status.
d. Maintain the client in a semi-Fowler position.
ANS: B
If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse would
ensure that the balloon remains deflated between PAOP readings. Documenting PAOP
readings and assessing trends are important nursing actions related to hemodynamic
monitoring, but are not specifically related to safety. The client does not have to be NPO
while undergoing hemodynamic monitoring. Positioning is not related to safety with
hemodynamic monitoring.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Hemodynamic monitoring, Equipment safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
7. A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse
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notes that the client’s heart rate has increased from 88 to 110 beats/min, and the blood
pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most
appropriate?
a. Allow the client to rest quietly.
b. Assess the client for bleeding.
c. Document the findings in the chart.
d. Medicate the client for pain.
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ANS: B
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A major complication related to intra-arterial blood pressure monitoring is hemorrhage from
the insertion site. Since these vital signs are out of the normal range, are a change, and are
consistent with blood loss, the nurse would assess the client for any bleeding associated with
the arterial line. The nurse would document the findings after a full assessment. The client
may or may not need pain medication and rest; the nurse first needs to rule out any emergent
bleeding.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Intra-arterial blood pressure monitoring, Equipment safety
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
8. A client is in the preoperative holding area prior to an emergency coronary artery bypass graft
(CABG). The client is yelling at family members and tells the doctor to “just get this over
with” when asked to sign the consent form. What action by the nurse is best?
a. Ask the family members to wait in the waiting area.
b. Inform the client that this behavior is unacceptable.
c. Stay out of the room to decrease the client’s stress levels.
d. Tell the client that anxiety is common and that you can help.
ANS: D
Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent
situations. The client is exhibiting anxiety, and the nurse would reassure the client that fear is
common and offer to help. The other actions will not reduce the client’s anxiety.
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DIF: Applying
TOP: Integrated Process: Caring
KEY: Coronary artery disease, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
9. A client is in the clinic a month after having a myocardial infarction. The client reports
sleeping well since moving into the guest bedroom. What response by the nurse is best?
a. “Do you have any concerns about sexuality?”
b. “I’m glad to hear you are sleeping well now.”
c. “Sleep near your spouse in case of emergency.”
d. “Why would you move into the guest room?”
ANS: A
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Concerns about resuming sexual activity are common after cardiac events. The nurse would
gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse
would investigate the reason for the move. The other two responses are likely to cause the
client to be defensive.
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DIF: Applying
TOP: Integrated Process: Caring
KEY: Coronary artery disease, Sexuality MSC: Client Needs Category: Psychosocial Integrity
10. A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by
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nausea and vomiting. What action by the nurse takes priority?
a. Administer an aspirin.
b. Call for an electrocardiogram (ECG).
c. Maintain airway patency.
d. Notify the provider.
ANS: C
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Airway always is the priority. The other actions are important in this situation as well, but the
nurse would stay with the client and ensure that the airway remains patent (especially if
vomiting occurs) while another person calls the primary health care provider (or Rapid
Response Team) and facilitates getting an ECG done. Aspirin will probably be administered,
depending on the primary health care provider’s prescription and the client’s current
medications.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Coronary artery disease, Critical rescue
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
11. An older adult is on cardiac monitoring after a myocardial infarction. The client shows
frequent dysrhythmias. What action by the nurse is most appropriate?
a. Assess for any hemodynamic effects of the rhythm.
b. Prepare to administer antidysrhythmic medication.
c. Notify the primary health care provider or call the Rapid Response Team.
d. Turn the alarms off on the cardiac monitor.
ANS: A
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Older clients may have dysrhythmias due to age-related changes in the cardiac conduction
system. Or this client’s dysrhythmias could be a consequence of the myocardial infarction.
They may or may not have significant hemodynamic effects. The nurse would first assess for
the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor
would never be shut off. The other two actions may or may not be needed.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Coronary artery disease, Dysrhythmias
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
12. The nurse is preparing to change a client’s sternal dressing. What action by the nurse is most
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important?
a. Assess vital signs.
b. Don a mask and gown.
c. Gather needed supplies.
d. Perform hand hygiene.
ANS: D
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To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a
priority and uses sterile technique when changing the dressing. Vital signs do not necessarily
need to be assessed beforehand. A mask and gown are not needed. The nurse would gather
needed supplies, but this is not the priority.
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Coronary artery disease, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
nk
13. A client has progressed to Killip class III heart failure after a myocardial infarction. What
ANS: D
ba
does the nurse anticipate the client’s care to include?
a. Diuretics
b. Nitrates
c. Clopidogrel
d. Dobutamine
Bt
e
st
The client in class III heart failure would benefit from a positive inotrope such as dobutamine.
Clients in class I typically respond well to diuretics and nitrates so this client would already be
on these medications. Clopidogrel is a platelet inhibitor that will be prescribed for anyone
having acute coronary syndrome for at least 12 months.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Heart failure, Inotropic medications
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
14. A nurse is in charge of the coronary intensive care unit. Which client would the nurse see
first?
a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours
b. Client who is 1-day post coronary artery bypass graft, with blood pressure 88/64
mm Hg
c. Client who is 1-day post percutaneous coronary intervention, going home this
morning
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d. Client who is 2-day post coronary artery bypass graft, who became dizzy this
morning while walking
ANS: B
Hypotension after coronary artery bypass graft surgery can be dangerous because it can lead
to collapse of the graft. The charge nurse would see this client first. The client who became
dizzy earlier would be seen next. The client on the nitroglycerin drip is stable. The client
going home can wait until the other clients are cared for.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Coronary artery disease, Coronary artery bypass graft
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
15. A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements.
m
What response by the nurse is best?
a. “Fish oil is contraindicated with most drugs for CAD.”
b. “The best source is fish, but pills have benefits too.”
c. “There is no evidence to support fish oil use with CAD.”
d. “You can reverse CAD totally with diet and supplements.”
co
ANS: B
s.
Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of
sudden cardiac death, and for stabilizing atherosclerotic plaque. The preferred source of
omega-3 acids is from fish rich in long-chain n-3 polyunsaturated fatty acids two times a week
or a daily fish oil nutritional supplement (1 to 2 g/day). The other options are not accurate.
nk
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Coronary artery disease, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
16. A client has presented to the emergency department with an acute myocardial infarction (MI).
ANS: B
st
ba
What action by the nurse is best for optimal client outcomes?
a. Obtain an electrocardiogram (ECG) within 20 minutes.
b. Give the client a nonenteric coated aspirin.
c. Notify the Rapid Response Team immediately.
d. Prepare to administer thrombolytics within 30 minutes.
Bt
e
Best practice recommendations for acute MI require that aspirin is administered when a client
with MI presents to the emergency department or when an MI occurs in the hospital. A rapid
ECG (within 10 minutes) is vital for best outcomes. The Rapid Response Team is not needed
if an emergency department provider is available. Thrombolytics may or may not be needed
depending on the type of myocardial infarction the client has.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Coronary artery disease, Best practice
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
17. A nurse is caring for four client s. Which client would the nurse assess first?
a. Client with an acute myocardial infarction, pulse 102 beats/min
b. Client who is 1 hour post-angioplasty, and has tongue swelling and anxiety
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c. Client who is post coronary artery bypass, with chest tube drained 100 mL/hr
d. Client who is post coronary artery bypass, with potassium 4.2 mEq/L (4.2 mmol/L)
ANS: B
The post-angioplasty client with tongue swelling and anxiety is exhibiting signs and
symptoms of an allergic reaction (perhaps to the contrast medium) that could progress to
anaphylaxis. The nurse would assess this client first. The client with a heart rate of 102
beats/min may have increased oxygen demands but is just over the normal limit for heart rate.
The two post coronary artery bypass clients are stable.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Coronary artery disease, Critical rescue
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
18. A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client
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is restless and agitated. What action would the nurse perform first for comfort?
a. Allow family members to remain at the bedside.
b. Ask the family if the client would like a fan in the room.
c. Keep the television tuned to the client’s favorite channel.
d. Speak loudly to the client in case of hearing problems.
ANS: A
s.
Allowing the family to remain at the bedside can help calm the client with familiar voices
(and faces if the client wakes up). A fan might be helpful but may also spread germs through
air movement or may agitate the client further. The TV would not be kept on all the time to
allow for rest. Speaking loudly may agitate the client more.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Intra-aortic balloon pump, Nonpharmacologic comfort measures
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
ba
19. The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The
ANS: B
st
drainage stops suddenly. What action by the nurse is most important?
a. Increase the setting on the suction.
b. Notify the primary health care provider immediately.
c. Reposition the chest tube.
d. Take the tubing apart to assess for clots.
Bt
e
If the drainage in the chest tube decreases significantly and dramatically, the tube may be
blocked by a clot. This could lead to cardiac tamponade. The nurse would notify the primary
health care provider immediately. The nurse would not independently increase the suction,
reposition the chest tube, or take the tubing apart.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Coronary artery bypass graft, Chest tubes
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
20. A client is to receive a dopamine infusion. What does the nurse do to prepare for this
infusion?
a. Gather central line supplies.
b. Mark the client’s pedal pulses.
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c. Monitor the client’s vital signs.
d. Ensure an accurate weight is charted.
ANS: A
Dopamine should be infused through a central line to prevent extravasation and necrosis of
tissue. The nurse would gather supplies for the primary health care provider to insert a central
line. Monitoring vital signs is important for any client who has an acute cardiac problem, but
this doesn’t give the frequency of evaluation. Marking the client’s pedal pulses and ensuring a
weight is documented are not related to this infusion.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Inotropic agents, Medication safety
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
co
that a significant complication has occurred?
a. Blood pressure that is 20 mm Hg below baseline
b. Oxygen saturation of 94% on room air
c. Poor peripheral pulses and cool skin
d. Urine output of 1.2 mL/kg/hr for 4 hours
m
21. A client had an acute myocardial infarction. What assessment finding indicates to the nurse
ANS: C
s.
Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and would
be reported immediately. A blood pressure drop of 20 mm Hg may not be worrisome. An
oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4
hours is normal.
nk
DIF: Remembering
TOP: Integrated Process: Nursing Process: Analysis
KEY: Coronary artery disease, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
ba
22. A client presents to the emergency department with an acute myocardial infarction (MI) at
Bt
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st
15:00 (3:00 p.m.). The facility has 24-hour catheterization laboratory abilities. To improve
client outcomes, by what time would the client have a percutaneous coronary intervention
performed?
a. 15:30 (3:30 p.m.)
b. 16:00 (4:00 p.m.)
c. 16:30 (4:30 p.m.)
d. 17:00 (5:00 p.m.)
ANS: C
Percutaneous coronary intervention would be performed within 90 minutes of diagnosis of
myocardial infarction. Therefore, the client would have a percutaneous coronary intervention
performed no later than 16:30 (4:30 p.m.).
DIF: Remembering
TOP: Integrated Process: Communication and Documentation
KEY: Coronary artery disease, Percutaneous coronary intervention
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
23. The primary health care provider requests the nurse start an infusion of milrinone on a client.
How does the nurse explain the action of this drug to the client and spouse?
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a.
b.
c.
d.
“It constricts vessels, improving blood flow.”
“It dilates vessels, which lessens the work of the heart.”
“It increases the force of the heart’s contractions.”
“It slows the heart rate down for better filling.”
ANS: C
Milrinone, is a positive inotrope, is a medication that increases the strength of the heart’s
contractions. It is not a vasoconstrictor, a vasodilator, nor does it slow the heart rate.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Coronary artery disease, Inotropic agents
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
24. A client had an inferior wall myocardial infarction (MI). The nurse notes the client’s cardiac
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rhythm as shown below:
nk
s.
What action by the nurse is most important?
a. Assess the client’s blood pressure and level of consciousness.
b. Call the primary health care provider or the Rapid Response Team.
c. Obtain a permit for an emergency temporary pacemaker insertion.
d. Prepare to administer antidysrhythmic medication.
ANS: A
st
ba
Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased
perfusion, as seen in this ECG strip. The nurse would first assess the client’s hemodynamic
status, including vital signs and level of consciousness. The client may or may not need the
Rapid Response Team, a temporary pacemaker, or medication; there is no indication of this in
the question.
Bt
e
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Coronary artery disease, Dysrhythmias
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
25. A nurse prepares a client for coronary artery bypass graft surgery. The client states, “I am
afraid I might die.” What is the nurse’s best response?
a. “This is a routine surgery and the risk of death is very low.”
b. “Would you like to speak with a chaplain prior to surgery?”
c. “Tell me more about your concerns about the surgery.”
d. “What support systems do you have to assist you?”
ANS: C
The nurse would discuss the client’s feelings and concerns related to the surgery. The nurse
would not provide false hope or simply call the chaplain. The nurse would address support
systems after addressing the client’s current issue.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Coping, Anxiety
MSC: Client Needs Category: Psychosocial Integrity
MULTIPLE RESPONSE
1. A nurse learns about modifiable risk factors for coronary artery disease. Which factors does
this include? (Select all that apply.)
a. Age
b. Hypertension
c. Obesity
d. Smoking
e. Stress
f. Gender
ANS: B, C, D, E
m
Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for
coronary artery disease. Age and gender are not nonmodifiable risk factors.
co
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Coronary artery disease, Lifestyle factors
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse is caring for a client who had coronary artery bypass grafting 2 days ago. What
nk
s.
actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.)
a. Assist the client to the chair for meals and to the commode.
b. Encourage the client to use the spirometer every 4 hours.
c. Ensure that the client wears TED hose or sequential compression devices.
d. Have the client rate pain on a 0-10 scale and report to the nurse.
e. Take and record a full set of vital signs per hospital protocol.
ba
ANS: A, C, E
st
The nurse can delegate assisting the client to get up in the chair or commode (if the nurse has
evaluated the client as being stable), applying TEDs or sequential compression devices, and
taking/recording vital signs. The spirometer would be used every hour the day after surgery.
Assessing pain using a 0-10 scale is a nursing assessment, although if the client reports pain,
the AP would inform the nurse so a more detailed assessment is done.
Bt
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Coronary artery disease, Delegation
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A nurse studying acute coronary syndromes learns that the pain of a myocardial infarction
(MI) differs from stable angina in what ways? (Select all that apply.)
a. Accompanied by shortness of breath
b. Feelings of fear or anxiety
c. Lasts less than 15 minutes
d. No relief from taking nitroglycerin
e. Pain occurs without known cause
f. Can be precipitated by exertion or stress
ANS: A, B, D, E
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The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts
longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause
such as exertion or stress.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Coronary artery disease, Pathophysiology
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A client is 1-day postoperative after a coronary artery bypass graft. What nonpharmacologic
comfort measures does the nurse include when caring for this client? (Select all that apply.)
a. Administer pain medication before ambulating.
b. Assist the client into a position of comfort in bed.
c. Encourage high-protein diet selections.
d. Provide complementary therapies such as music.
e. Remind the client to splint the incision when coughing.
m
ANS: B, D, E
co
Nonpharmacologic comfort measures can include positioning, complementary therapies, and
splinting the chest incision. Medications are not nonpharmacologic. Food choices are not
comfort measures.
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Coronary artery disease, Nonpharmacologic comfort measures
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
5. Prior to discharge, a client who had an acute myocardial infarction and coronary artery bypass
st
ANS: B, C, F
ba
nk
graft asks the nurse about sexual activity. What information does the nurse provide? (Select
all that apply.)
a. “You will need to wait at least 6 weeks before intercourse.’
b. “Your usual sexual activity is not likely to damage your heart.”
c. “Start having sex when you are most rested, like in the morning.”
d. “When you can climb four flights of stairs, you can tolerate sex.”
e. “Don’t eat for three hours before engaging in sexual activity.”
f. “Use a comfortable position that doesn’t stress your incision.”
Bt
e
Clients have many concerns about resuming sexual activity after an acute coronary event.
Generally, once the client can walk one block or climb two flights of stairs, he or she can
tolerate sex. The client should start after a period of rest and at least 11/2 hours after a heavy
meal or exercise. Clients should be taught to choose a position that is comfortable for both
parties and does not place undue stress on their incisions or on their hearts.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Coronary artery disease, Health teaching
MSC: Client Needs Category: Psychosocial Integrity
6. A nurse is studying hemodynamic monitoring. Which measurements are correctly matched
with the physiologic cause? (Select all that apply.)
a. Right atrial pressure 12 mm Hg: right ventricular failure
b. Right atrial pressure 4 mm Hg: hypovolemia
c. Pulmonary artery pressure 20/10 mm Hg: normal finding
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d. Pulmonary artery occlusion pressure 20 mm Hg: mitral regurgitation
e. Pulmonary artery occlusion pressure 2 mm Hg: afterload reduction
ANS: A, C, D, E
Normal right atrial pressure is 0 to 8 mm Hg; high readings can indicate right ventricular
failure; low readings often signify hypovolemia. Normal pulmonary artery pressure ranges
from 15 to 30 mm Hg systolic to 3 to 12 mm Hg diastolic. Pulmonary artery occlusion
pressure ranges from 5 to 12 mm Hg; high values may indicate left ventricular failure,
hypervolemia, mitral regurgitation, or intracardiac shunting. A decreased PAOP is seen with
hypovolemia or afterload reduction.
Bt
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ba
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s.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Hemodynamic monitoring
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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Chapter 36: Assessment of the Hematologic System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is assessing an older client for any potential hematologic health problem. Which
assessment finding is the most significant and would be reported to the primary health care
provider?
a. Poor skin turgor on both forearms
b. Multiple petechiae and large bruises
c. Dry, flaky skin on arms and legs
d. Decreased body hair distribution
ANS: B
co
m
The presence of multiple petechiae and large bruises indicate a possible problem with blood
clotting. Older adults typically have poor skin turgor and dry, flaky skin due to decreased
body fluid as a result of aging. They also lose body hair or have thinning hair as a normal
change of aging.
s.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Hematologic system, Nursing assessment, Older adult
MSC: Client Needs Category: Health Promotion and Maintenance
2. A nurse is assessing a dark-skinned client for pallor. What nursing assessment is best to
ba
ANS: A
nk
assess for pallor in this client?
a. Assess the conjunctiva of the eye.
b. Have the patient open the hand widely.
c. Look at the roof of the patient’s mouth.
d. Palpate for areas of mild swelling.
st
To assess pallor in dark-skinned people, assess the conjunctiva of the eye or the mucous
membranes. Looking at the roof of the mouth can reveal jaundice. Opening the hand widely is
not related to pallor, nor is palpating for mild swelling.
Bt
e
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Hematologic system, Nursing assessment, Anemia
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A hospitalized client has a platelet count of 58,000/mm3 (58  109/L). What action by the
nurse is most appropriate?
a. Encourage high-protein foods.
b. Institute neutropenic precautions.
c. Limit visitors to healthy adults.
d. Place the client on safety precautions.
ANS: D
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With a platelet count between 40,000 and 80,000/mm3 (40 and 80  109/L), clients are at risk
of prolonged bleeding even after minor trauma. The nurse would place the client on safety or
bleeding precautions as the most appropriate action. High-protein foods, while healthy, are not
the priority. Neutropenic precautions are not needed as the patient’s white blood cell count is
not low. Limiting visitors would also be more likely related to a low white blood cell count.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Hematologic system, Patient safety, Laboratory values
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
4. A client is having a bone marrow aspiration and biopsy. What action by the nurse takes
m
priority?
a. Administer pain medication first.
b. Ensure that valid consent is in the medical record.
c. Have the client shower in the morning.
d. Premedicate the client with sedatives.
ANS: B
co
A bone marrow aspiration and biopsy is an invasive procedure that requires informed consent.
Pain medication and sedation are important components of care for this client but do not take
priority. The client may or may not need or be able to shower.
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Hematologic system, Informed consent
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
5. What is the nurse’s priority when caring for a client who just completed a bone marrow
ANS: C
ba
nk
aspiration and biopsy?
a. Teach the client to avoid activity for 24 to 48 hours to prevent infection.
b. Administer a nonsteroidal anti-inflammatory drug (NSAID) to promote comfort.
c. Check the pressure dressing frequently for signs of excessive or active bleeding.
d. Report the laboratory results to the primary health care provider.
Bt
e
st
The client having a bone marrow aspiration and biopsy has a puncture wound from the large
needle used to extract the bone marrow. Therefore, the client is at risk for bleeding. A NSAID
should not be given because it can cause bleeding. Avoiding activity helps to prevent
bleeding, not infection, and reporting the results of the biopsy is not the responsibility of the
nurse.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Hematologic system, Patient safety, Diagnostic testing
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
6. A nurse is caring for four clients. After reviewing today’s laboratory results, which client
would the nurse assess first?
a. Client with an international normalized ratio of 2.8
b. Client with a platelet count of 128,000/mm3 (128  109/L).
c. Client with a prothrombin time (PT) of 28 seconds
d. Client with a red blood cell count of 5.1 million/mcL (5.1  1012/L)
ANS: C
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A normal PT is 11 to 12.5 seconds. This client is at high risk of bleeding with a PT of 28
seconds. The other values are within normal limits.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Hematologic system, Laboratory values
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A client is having a bone marrow aspiration and biopsy and is extremely anxious. What action
by the nurse is the most appropriate?
a. Assess the client’s fears and coping mechanisms.
b. Reassure the client that this is a common test.
c. Sedate the client prior to the procedure.
d. Tell the client that he or she will be asleep.
ANS: A
m
Assessing the client’s specific fears and coping mechanisms helps guide the nurse in
providing holistic care that best meets the client’s needs. Reassurance will be helpful but is
not the best option. Sedation is usually used. The client may or may not be totally asleep
during the procedure.
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DIF: Applying
TOP: Integrated Process: Caring
KEY: Hematologic system, Psychosocial response, Anxiety, Support
MSC: Client Needs Category: Psychosocial Integrity
nk
s.
8. A client is having a radioisotopic imaging scan. What action by the nurse is most important?
a. Assess the client for shellfish allergies.
b. Place the client on radiation precautions.
c. Sedate the client before the scan.
d. Teach the client about the procedure.
ANS: D
ba
The nurse should ensure that teaching is done and the client understands the procedure.
Contrast dye is not used, so shellfish/iodine allergies are not related. The client will not be
radioactive and does not need radiation precautions. Sedation is not used in this procedure.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Hematologic system, Patient education
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. While taking a client history, which factor(s) that place the client at risk for a hematologic
health problem will the nurse document? (Select all that apply.)
a. Family history of bleeding problems
b. Diet low in iron and protein
c. Excessive alcohol consumption
d. Family history of allergies
e. Diet high in saturated fats
f. Diet high in Vitamin K
ANS: A, C, F
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A family history of bleeding problems places the client at risk for having a similar problem.
Excessive alcohol can damage the liver where prothrombin is produced. A diet high in
Vitamin K can cause excessive clotting because it is a major clotting factor.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Hematologic system, Nursing assessment
MSC: Client Needs Category: Health Promotion and Maintenance
2. An older client asks the nurse why “people my age” have weaker immune systems than
younger people. What responses by the nurse are best? (Select all that apply.)
a. “Bone marrow produces fewer blood cells as you age.”
b. “You may have decreased levels of circulating platelets.”
c. “You have lower levels of plasma proteins in the blood.”
d. “Lymphocytes become more reactive to antigens.”
e. “Spleen function declines after age 60.”
m
ANS: A, C
co
The aging adult has bone marrow that produces fewer cells and decreased blood volume with
fewer plasma proteins. Platelet numbers remain unchanged, lymphocytes become less
reactive, and spleen function stays the same.
s.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Hematologic system
MSC: Client Needs Category: Health Promotion and Maintenance
3. The nurse is assessing a client experiencing anemia. Which laboratory findings will the nurse
ANS: B, C, D
ba
nk
expect for this client? (Select all that apply.)
a. Increased hematocrit
b. Decreased red blood cell count
c. Decreased serum iron
d. Decreased hemoglobin
e. Increased platelet count
f. Decreased white blood cell count
Bt
e
st
Clients experiencing anemia have a decreased red blood cell count which leads to a decreased
hemoglobin and hematocrit. For some clients, serum iron levels are also decreased. Anemia is
not a problem involving platelets or white blood cells.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Lab Profile Box
MSC: Client Needs Category: Physiological Integrity
4. A nurse works in a gerontology clinic. What age-related change(s) related to the hematologic
system will the nurse expect during health assessment? (Select all that apply.)
a. Dentition deteriorates with more cavities.
b. Nail beds may be thickened or discolored.
c. Progressive loss or thinning of hair occurs.
d. Sclerae begin to turn yellow or pale.
e. Skin becomes more oily.
ANS: B, C
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Common findings in older adults include thickened or discolored nail beds, dry (not oily)
skin, and thinning hair. The nurse adapts to these changes by altering assessment techniques.
Having more dental caries and changes in the sclerae are not normal age-related changes.
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ba
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Hematologic system, Older adult, Nursing assessment
MSC: Client Needs Category: Health Promotion and Maintenance
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Chapter 37: Concepts of Care for Patients With Hematologic Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse caring for a client with sickle cell disease (SCD) reviews the client’s laboratory test
results. Which finding would the nurse report to the primary health care provider?
a. Creatinine: 2.9 mg/dL (256 mcmol/L)
b. Hematocrit: 30%
c. Sodium: 146 mEq/L (146 mmol/L)
d. White blood cell count: 12,000/mm3 (12  109/L)
ANS: A
m
An elevated creatinine indicates kidney damage, which occurs in SCD. A hematocrit level of
30% is an expected finding, as is a slightly elevated white blood cell count due to chronic
inflammation. A sodium level of 146 mEq/L (146 mmol/L), although slightly high, is not
concerning.
co
DIF: Analyzing
TOP: Integrated Process: Communication and Documentation
KEY: Hematologic system, Laboratory values, Anemias
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
s.
2. The nurse is assessing a client in sickle cell disease (SCD) crisis. What priority client
problem will the nurse expect?
Infection
Pallor
Pain
Fatigue
nk
a.
b.
c.
d.
ANS: C
st
ba
The priority expected client problem for clients experiencing sickle cell disease crisis is pain,
often concentrated in the legs, arms, and joints. Clients may also be fatigued and pale but
these symptoms are not a priority for care. Infection is not expected but can occur in clients
who have SCD crisis.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Hematologic system, Physical assessment, Sickle cell disease
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
3. A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans
to start an IV. Which fluid choice is best?
a. 0.45% normal saline
b. 0.9% normal saline
c. Dextrose 50% (D50)
d. Lactated Ringer’s solution
ANS: A
Because clients in sickle cell crisis are often dehydrated, the fluid of choice is a hypotonic
solution such as 0.45% normal saline. 0.9% normal saline and lactated Ringer’s solution are
isotonic. D50 is hypertonic and not used for hydration.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Hematologic system, Anemias, Fluid and electrolyte imbalance, IV fluids, Hydration
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A client presents to the emergency department in sickle cell disease crisis. What intervention
by the nurse takes priority?
a. Administer oxygen.
b. Initiate pulse oximetry.
c. Give pain medication.
d. Start an IV line.
ANS: A
All actions are appropriate, but remembering the ABCs, oxygen would come first. The main
problem in a sickle cell crisis is tissue and organ hypoxia, so providing oxygen helps halt the
process.
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m
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Hematologic system, Anemias, Oxygen, Oxygen therapy
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
5. A client hospitalized with sickle cell disease crisis frequently asks for opioid pain
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s.
medications, often shortly after receiving a dose. The nurses on the unit believe that the client
is drug seeking. When the client requests pain medication, what action by the nurse is best?
a. Give the client pain medication if it is time for another dose.
b. Instruct the client not to request pain medication too early.
c. Request the primary health care provider leave a prescription for a placebo.
d. Tell the client that it is too early to have more pain medication.
ANS: A
st
ba
Clients with sickle cell crisis often have severe pain that is managed with up to 48 hours of IV
opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme
pain. If the client can receive another dose of medication, the nurse would provide it. The
other options are judgmental and do not address the client’s pain. Giving a placebo is
unethical.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Hematologic system, Anemias, Pain, Caring
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. The nurse is caring for a client experiencing sickle cell disease crisis. Which priority action
would help prevent infection?
Administering prophylactic antibiotics
Monitoring the client’s temperature
Checking the client’s white blood cell count
Performing frequent handwashing
a.
b.
c.
d.
ANS: D
Frequent and thorough handwashing is the most important intervention that helps prevent
infection. Antibiotics are not usually used to prevent infection. Monitoring the client’s
temperature or white blood cell count helps to detect the presence of infection, but prevent it.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Hematologic system, Sickle cell disease
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
7. A nurse in a hematology clinic is working with four clients who have polycythemia vera.
Which client would the nurse assess first?
a. Client with a blood pressure of 180/98 mm Hg
b. Client who reports shortness of breath
c. Client who reports calf tenderness and swelling
d. Client with a swollen and painful left great toe
ANS: B
m
Clients with polycythemia vera often have clotting abnormalities due to the hyperviscous
blood with sluggish flow. The client reporting shortness of breath may have a pulmonary
embolism and should be seen first. The client with a swollen calf may have a deep vein
thrombosis and should be seen next. High blood pressure and gout symptoms are common
findings with this disorder.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Hematologic system, Polycythemia vera, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
8. The nurse is teaching a client who has pernicious anemia about necessary dietary changes.
nk
s.
Which statement by the client indicates understanding about those changes?
a. “I’ll increase animal proteins like fish and meat.”
b. “I’ll work on increasing my fats and carbohydrates.”
c. “I’ll avoid eating green leafy vegetables.
d. “I’ll limit my intake of citrus fruits.”
ANS: A
ba
Clients who have pernicious anemia have a Vitamin B12 deficiency and need to consume
foods high in Vitamin B12, such as animal and plant proteins, citrus fruits, green leafy
vegetables, and dairy products. While carbohydrates and fats can provide sources of energy,
they do not supply the necessary nutrient to improve anemia.
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st
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Hematologic system, Anemia
MSC: Client Needs Category: Health Promotion and Maintenance
9. An assistive personnel is caring for a client with leukemia and asks why the client is still at
risk for infection when the white blood cell count (WBC) is high. What response by the nurse
is correct?
a. “If the WBCs are high, there already is an infection present.”
b. “The client is in a blast crisis and has too many WBCs.”
c. “There must be a mistake; the WBCs should be very low.”
d. “Those WBCs are abnormal and don’t provide protection.”
ANS: D
In leukemia, the WBCs are abnormal and do not provide protection to the client against
infection. The other statements are not accurate.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
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KEY: Leukemia, Infection, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. The family of a neutropenic client reports that the client “is not acting right.” What action by
the nurse is the priority?
a. Ask the client about pain.
b. Assess the client for infection.
c. Take a set of vital signs.
d. Review today’s laboratory results.
ANS: B
Neutropenic clients often do not have classic manifestations of infection, but infection is the
most common cause of death in neutropenic clients. The nurse would definitely assess for
infection. The nurse would assess for pain but this is not the priority.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Hematologic system, Neutropenia, Infection
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
11. A nurse is caring for a client who is about to receive a bone marrow transplant. To best help
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the client cope with the long recovery period, what action by the nurse is best?
a. Arrange a visitation schedule among friends and family.
b. Explain that this process is difficult but must be endured.
c. Help the client find things to hope for each day of recovery.
d. Provide plenty of diversionary activities for this time.
ANS: C
ba
nk
Providing hope is an essential nursing function during treatment for any disease process, but
especially during the recovery period after bone marrow transplantation, which can take up to
3 weeks. The nurse can help the client look ahead to the recovery period and identify things to
hope for during this time. Visitors are important to clients, but may pose an infection risk.
Telling the client that the recovery period must be endured does not acknowledge his or her
feelings. Diversionary activities are important, but not as important as instilling hope.
st
DIF: Applying
TOP: Integrated Process: Caring
KEY: Psychosocial response, Caring, Hematologic system, Bone marrow transplant
MSC: Client Needs Category: Psychosocial Integrity
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12. A client asks about the process of graft-versus-host disease. What explanation by the nurse is
correct?
a. “Because of immunosuppression, the donor cells take over.”
b. “It’s like a transfusion reaction because no perfect matches exist.”
c. “The patient’s cells are fighting donor cells for dominance.”
d. “The donor’s cells are actually attacking the patient’s cells.”
ANS: D
Graft-versus-host disease is an autoimmune-type process in which the donor cells recognize
the client’s cells as foreign and begin attacking them. The other answers are not accurate.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Hematologic system, Bone marrow transplant
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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13. The nurse is caring for a patient with leukemia who has severe fatigue. What action by the
client best indicates that an important outcome to manage this problem has been met?
a. Doing activities of daily living (ADLs) using rest periods
b. Helping plan a daily activity schedule
c. Requesting a sleeping pill at night
d. Telling visitors to leave when fatigued
ANS: A
Fatigue is a common problem for clients with leukemia. This client is managing his or her
own ADLs using rest periods, which indicates an understanding of fatigue and how to control
it. Helping to plan an activity schedule is a lesser indicator. Requesting a sleeping pill does
not help control fatigue during the day. Asking visitors to leave when tired is another lesser
indicator. Managing ADLs using rest periods demonstrates the most comprehensive
management strategy.
m
DIF: Evaluating
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Hematologic system, Leukemia, Sleep and rest, Activity
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
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14. A nurse is caring for a young male client with lymphoma who is to begin treatment. What
nk
ANS: C
s.
teaching topic is a priority?
a. Genetic testing
b. Infection prevention
c. Sperm banking
d. Treatment options
ba
All teaching topics are important to the client with lymphoma, but for a young male, sperm
banking is of particular concern if the client is going to have radiation to the lower abdomen
or pelvis.
st
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Lymphoma, Hematologic system, Caring, Reproductive problems
MSC: Client Needs Category: Health Promotion and Maintenance
15. A client has been admitted after sustaining a humerus fracture that occurred when picking up
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the family cat. What test result would the nurse correlate to this condition?
a. Bence-Jones protein in urine
b. Epstein-Barr virus: positive
c. Hemoglobin: 18 mg/dL (180 mmol/L)
d. Red blood cell count: 8.2 million/mcL (8.2  1012/L)
ANS: A
This client has possible multiple myeloma. A positive Bence-Jones protein finding would
correlate with this condition. The Epstein-Barr virus is a herpesvirus that causes infectious
mononucleosis and some cancers. A hemoglobin of 18 mg/dL (180 mmol/L) is slightly high
for a male and somewhat high for a female; this can be caused by several conditions, and
further information would be needed to correlate this value with a specific medical condition.
A red blood cell count of 8.2 million/mcL (8.2  1012/L) is also high, but again, more
information would be needed to correlate this finding with a specific medical condition.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Hematologic system, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
16. A client with multiple myeloma demonstrates worsening bone density on diagnostic scans.
About what drug does the nurse plan to teach this client?
a. Bortezomib
b. Dexamethasone
c. Thalidomide
d. Zoledronic acid
ANS: D
All the options are drugs used to treat multiple myeloma, but the drug used specifically for
bone manifestations is zoledronic acid, which is a bisphosphonate. This drug class inhibits
bone resorption and is used to treat osteoporosis as well.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Hematologic system, Bisphosphonates, Patient education
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
17. A client has a platelet count of 9000/mm3 (9  109/L). The nurse finds the client confused and
mumbling. What nursing action takes priority at this time?
Call the Rapid Response Team.
Take a set of vital signs.
Institute bleeding precautions.
Place the client on bedrest.
nk
s.
a.
b.
c.
d.
ANS: A
ba
With a platelet count this low, the client is at high risk of spontaneous bleeding. The most
disastrous complication would be intracranial bleeding. The nurse needs to call the Rapid
Response Team as this client has manifestations of a sudden neurologic change. Bleeding
precautions will not address the immediate situation. Placing the client on bedrest is
important, but the critical action is to call for immediate medical attention.
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st
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Hematologic system, Laboratory values, Critical rescue, Neurologic system
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
18. A nurse is preparing to administer a blood transfusion. What action is most important?
a. Correctly identify client using two identifiers.
b. Ensure that informed consent is obtained.
c. Hang the blood product with Ringer’s lactate.
d. Stay with the client for the entire transfusion.
ANS: B
If the facility requires informed consent for transfusions, this action is most important because
it precedes the other actions taken during the transfusion. Correctly identifying the client and
blood product is a National Patient Safety Goal, and is the most important action after
obtaining informed consent. Ringer’s lactate is not used to transfuse blood. The nurse does not
need to stay with the client for the duration of the transfusion.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Informed consent, Blood transfusions, Hematologic system
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
19. A nurse is preparing to administer a blood transfusion. Which action is most important?
a. Document the transfusion.
b. Place the client on NPO status.
c. Place the client in isolation.
d. Put on a pair of gloves.
ANS: D
To prevent bloodborne illness, the nurse should don a pair of gloves prior to hanging the
blood. Documentation is important but not the priority at this point. NPO status and isolation
are not needed.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Blood transfusion, Standard Precautions, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
20. A client receiving a blood transfusion develops anxiety and low back pain. After stopping the
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transfusion, what action by the nurse is most important?
a. Document the events in the client’s medical record.
b. Double-check the client and blood product identification.
c. Place the client on strict bedrest until the pain subsides.
d. Review the client’s medical record for known allergies.
ANS: B
ba
nk
This client most likely had a hemolytic transfusion reaction, most commonly caused by blood
type or Rh incompatibility. The nurse should double-check all identifying information for
both the client and blood type. Documentation occurs after the client is stable. Bedrest may or
may not be needed. Allergies to medications or environmental items are not related.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Implementation
KEY: Blood transfusion, Core measures, Transfusion reaction
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
st
21. A client has thrombocytopenia. What statement indicates that the client understands
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self-management of this condition?
a. “I brush and use dental floss every day.”
b. “I chew hard candy for my dry mouth.”
c. “I usually put ice on bumps or bruises.”
d. “Nonslip socks are best when I walk.”
ANS: C
The client should be taught to apply ice to areas of minor trauma. Flossing is not
recommended. Hard foods should be avoided. The client should wear well-fitting shoes when
ambulating.
DIF: Evaluating
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Hematologic system, Patient safety, Patient education
MSC: Client Needs Category: Health Promotion and Maintenance
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22. A nurse is caring for four clients with leukemia. After hand-off report, which client would the
nurse assess first?
a. Client who had two bloody diarrhea stools this morning.
b. Client who has been premedicated for nausea prior to chemotherapy.
c. Client with a respiratory rate change from 18 to 22 breaths/min.
d. Client with an unchanged lesion to the lower right lateral malleolus.
ANS: A
The client who had two bloody diarrhea stools that morning may be hemorrhaging in the
gastrointestinal (GI) tract and should be assessed first to monitor for or avoid the client from
going into hypovolemic shock. The client with the slight change in respiratory rate may have
an infection or worsening anemia and should be seen next. If the client’s respiratory rate was
greater than 28 to 30 breaths/min, the client may need the initial assessment. Marked
tachypnea is an early sign of a deteriorating client condition. The other two clients are not a
priority at this time.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Hematologic system, Anemias, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
s.
23. Which statement by a client with leukemia indicates a need for further teaching by the nurse?
a. “I will use a soft-bristled toothbrush and avoid flossing.”
b. “I will not take aspirin or any aspirin product.”
c. “I will use an electric shaver instead of my manual one.”
d. “I will take a daily laxative to prevent constipation.”
ANS: D
ba
nk
The client experiencing leukemia needs to prevent injury to prevent bleeding, including
avoiding hard-bristled toothbrushes, floss, aspirin, and straight or manual safety razors.
However, although constipation can cause hemorrhoids or rectal bleeding, laxatives can cause
fluid and electrolyte imbalances and abdominal cramping. Stool softeners would be a better
option to allow the passage of soft stool.
st
DIF: Analyzing
TOP: Integrated Process: Teaching/Learning
KEY: Leukemia, Risk for bleeding, Bleeding Precautions
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
24. The nurse is assessing a client who has probable lymphoma. What is the most common early
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assessment finding for clients with this disorder?
a. Weight gain
b. Enlarged painless lymph node(s)
c. Fever at night
d. Nausea and vomiting
ANS: B
The first change that is noted for clients with probable lymphoma is one or more enlarged
lymph nodes. The other findings are either not common in clients with lymphoma or later
findings.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Hematologic system, Lymphoma, Physical assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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25. The nurse assesses a client’s oral cavity as seen in the photo below:
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What action by the nurse is most appropriate?
a. Encourage the client to have genetic testing.
b. Instruct the client on high-fiber foods.
c. Place the client in protective precautions.
d. Teach the client about cobalamin therapy.
ANS: D
s.
This condition is known as glossitis, and is characteristic of B12 anemia. If the anemia is a
pernicious anemia, it is treated with cobalamin. Genetic testing is not a priority for this
condition. The client does not need high-fiber foods or protective precautions.
ba
MULTIPLE RESPONSE
nk
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Hematologic system, Anemias, Patient education, Medications
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
1. A nurse working with clients diagnosed with sickle cell disease (SCD) teaches about
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self-management to prevent exacerbations and sickle cell crises. What factor(s) should clients
be taught to avoid? (Select all that apply.)
a. Dehydration
b. Exercise
c. Extreme stress
d. High altitudes
e. Pregnancy
ANS: A, C, D, E
Several factors cause red blood cells to sickle in SCD, including dehydration, extreme stress,
high altitudes, and pregnancy. Strenuous exercise can also cause sickling, but not unless it is
very vigorous.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Hematologic system, Patient education, Genetic alterations, Anemias
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. Which risk factor(s) places a client at risk for leukemia? (Select all that apply.)
a. Chemical exposure
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b.
c.
d.
e.
Genetically modified foods
Ionizing radiation exposure
Vaccinations
Viral infections
ANS: A, C, E
Chemical and ionizing radiation exposure and viral infections are known risk factors for
developing leukemia. Eating genetically modified food and receiving vaccinations are not
known risk factors.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Hematologic System, Leukemia, Pathophysiology
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
ANS: A, B, C, D
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expected for this client? (Select all that apply.)
a. Decreased hematocrit
b. Abnormal white blood cell count
c. Low platelet count
d. Decreased hemoglobin
e. Increased albumin
m
3. The nurse is assessing a client with chronic leukemia. Which laboratory test result(s) is (are)
nk
s.
Chronic leukemia affects all types of blood cells causing a decrease is red blood cells (RBCs)
and platelets. When the number of RBCs decreases, the client’s hemoglobin and hematocrit
also decrease. White blood cell counts are also abnormal depending on disease progression
and management.
ba
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Hematologic system, Chronic leukemia, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. The nurse is caring for a client being treated for Hodgkin lymphoma. For which side effect(s)
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of treatment will the nurse assess? (Select all that apply.)
a. Severe nausea and vomiting
b. Low platelet count
c. Skin irritation at radiation site
d. Low red blood cell count
e. High white blood cell count
ANS: A, B, C, D
Drug and radiation therapy for Hodgkin lymphoma cause many side and adverse effects,
including all of the choices except for a high white blood cell (WBC) count. Instead, most
clients experience a low WBC count making them very susceptible to infections.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Hematologic system, Hodgkin lymphoma, Collaborative management
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
5. The nurse is preparing to administer a blood transfusion. Which action(s) by the nurse is (are)
most appropriate? (Select all that apply.)
a. Hang the blood product using normal saline and a filtered tubing set.
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b.
c.
d.
e.
Take a full set of vital signs prior to starting the blood transfusion.
Tell the client that someone will remain at the bedside for the first 5 minutes.
Use gloves to start the client’s IV if needed and to handle the blood product.
Verify the client’s identity, and checking blood compatibility and expiration time.
ANS: A, B, D
Correct actions prior to beginning a blood transfusion include hanging the product with saline
and the correct filtered blood tubing, taking a full set of vital signs prior to starting, and using
gloves. Someone stays with the client for the first 15 to 20 minutes of the transfusion. Two
registered nurses must verify the client’s identity and blood compatibility.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Blood transfusions, Patient safety, Core measures
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
6. Which statement(s) about blood transfusion compatibilities is (are) correct? (Select all that
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apply.)
a. Donor blood type A can donate to recipient blood type AB.
b. Donor blood type B can donate to recipient blood type O.
c. Donor blood type AB can donate to anyone.
d. Donor blood type O can donate to anyone.
e. Donor blood type A can donate to recipient blood type B.
ANS: A, D
nk
s.
Blood type A can be donated to people who have blood types A or AB. Blood type O can be
given to anyone. Blood type B can be donated to people who have blood types B or AB.
Blood type AB can only go to recipients with blood type AB.
ba
DIF: Remembering
REF: Table 37-5
TOP: Integrated Process: Teaching/Learning
KEY: Blood transfusions, Patient safety
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
7. The nurse is caring for a client receiving a unit of whole blood. Which nursing action(s) is
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(are) appropriate regarding infusion administration. (Select all that apply.)
a. Use a dedicated filtered blood administration set.
b. Stay with the client for the first 15 to 20 minutes of the infusion.
c. Infuse the blood over a 30-minute period of time.
d. Monitor and document vital signs per agency policy.
e. Use a 21-gauge or smaller catheter to administer the blood.
f. Infuse the transfusion with intravenous normal saline.
ANS: A, B, D, F
Blood administration requires a dedicated and filtered intravenous set and a larger catheter or
needle due to the viscosity of the infusion. Normal saline is the only IV fluid that is
compatible with blood. Vital signs are frequently monitored and documented while the client
is carefully assesses for signs and symptoms of a blood transfusion reaction, usually within
the first 15 to 20 minutes. One unit of blood is administered in no less than 60 minutes.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Blood transfusion, Patient safety
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MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
8. A nurse is preparing to administer a packed red blood cell transfusion to an older adult.
Understanding age-related changes, what alteration(s) in the usual protocol is (are) necessary
for the nurse to implement? (Select all that apply.)
a. Assess vital signs at least every 15 minutes.
b. Avoid giving other IV fluids.
c. Premedicate to prevent transfusion reaction.
d. Transfuse smaller bags of blood.
e. Transfuse each unit over 8 hours.
f. Assess the client for fluid overload.
ANS: A, B, F
m
The older adult needs vital signs monitored as often as every 15 minutes for the duration of
the transfusion because vital sign changes may be the only indication of a transfusion-related
problem. To prevent fluid overload, the nurse obtains a prescription to hold other running IV
fluids during the transfusion and assesses the client frequently for signs and symptoms of
overload. The other options are not correct.
co
DIF: Understanding
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Anemias, Blood transfusions, Older adults
MSC: Client Needs Category: Health Promotion and Maintenance
s.
9. Which assessment finding(s) may indicate that a client may be experiencing a blood
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transfusion reaction? (Select all that apply.)
a. Tachycardia
b. Fever
c. Bronchospasm
d. Tachypnea
e. Urticaria
f. Hypotension
ANS: A, B, C, D, E, F
st
Several types of blood transfusion reactions can occur and cause all of the findings listed.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Blood transfusions, Transfusion reactions
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
10. A client has received a bone marrow transplant and is waiting for engraftment. What action(s)
by the nurse are most appropriate? (Select all that apply.)
a. Not allowing any visitors until engraftment
b. Limiting the protein in the client’s diet
c. Placing the client in protective precautions
d. Teaching visitors appropriate hand hygiene
e. Telling visitors not to bring live flowers or plants
ANS: C, D, E
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The client waiting for engraftment after bone marrow transplant has no white cells to protect
him or her against infection. The client is on protective precautions and visitors are taught
hand hygiene. No fresh flowers or plants are allowed due to the standing water in the vase or
container that may harbor organisms; clients are also told not to work with houseplants in the
home. Limiting protein is not a healthy option and will not promote engraftment.
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Anemias, Protective precautions, Infection control
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
11. A nurse is caring for an older adult receiving multiple packed red blood cell transfusions.
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Which assessment finding(s) indicate(s) possible transfusion circulatory overload? (Select all
that apply.)
a. Acute confusion
b. Dyspnea
c. Depression
d. Hypertension
e. Bradycardia
f. Bounding pulse
ANS: A, B, D, F
s.
Circulatory overload is the result of excessive body fluid which can cause signs and
symptoms of heart failure including dyspnea, increased blood pressure, tachycardia (not
bradycardia), and a bounding pulse. Dyspnea is caused by hypoxia which in older adults can
cause acute confusion. Depression is not a common finding resulting from fluid overload.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Blood transfusions, Transfusion reactions
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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Chapter 38: Assessment of the Nervous System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse teaches an 80-year-old client with diminished peripheral sensation. Which
statement would the nurse include in this client’s teaching?
a. “Place soft rugs in your bathroom to decrease pain in your feet.”
b. “Bathe in warm water to increase your circulation.”
c. “Look at the placement of your feet when walking.”
d. “Walk barefoot to decrease pressure injuries from your shoes.”
ANS: C
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Older clients with decreased sensation are at risk of injury from the inability to sense changes
in terrain when walking. To compensate for this loss, the client is instructed to look at the
placement of his or her feet when walking. Throw rugs can slip and increase fall risk. Bath
water that is too warm places the client at risk for thermal injury.
co
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Neurologic assessment, Changes associated with aging, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
s.
2. The nurse assesses a client’s recent memory. Which statement by the client confirms that
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recent memory is intact?
a. “A young girl wrapped in a shroud fell asleep on a bed of clouds.”
b. “I was born on April 3, 1967, in Johnstown Community Hospital.”
c. “Apple, chair, and pencil are the words you just stated.”
d. “I ate oatmeal with wheat toast and orange juice for breakfast.”
ANS: D
st
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Asking clients about recent events that can be verified, such as what the client ate for
breakfast, assesses recent memory. Asking clients about certain facts from the past that can be
verified assesses remote or long-term memory. Asking the client to repeat words assesses
immediate memory.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Memory
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A client is admitted to the emergency department with a probable traumatic brain injury.
Which assessment finding would be the priority for the nurse to report to the primary health
care provider?
a. Mild temporal headache
b. Pupils equal and react to light
c. Alert and oriented  3
d. Decreasing level of consciousness
ANS: D
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A decreasing level of consciousness is the first sign of increasing intracranial pressure, a
potentially severe and possibly fatal complication of a traumatic brain injury (TBI). A mild
headache would be expected for a client having a TBI. Equal reactive pupils and being alert
and oriented are normal assessment findings.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Level of consciousness
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. A nurse asks a client to take deep breaths during an electroencephalography. The client asks,
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“Why are you asking me to do this?” How would the nurse respond?
a. “Hyperventilation causes vascular dilation of cerebral arteries, which decreases
electoral activity in the brain.”
b. “Deep breathing helps you to relax and allows the electroencephalograph to obtain
a better waveform.”
c. “Hyperventilation causes cerebral vasoconstriction and increases the likelihood of
seizure activity.”
d. “Deep breathing will help you to blow off carbon dioxide and decreases
intracranial pressures.”
ANS: C
s.
Hyperventilation produces cerebral vasoconstriction and alkalosis, which increase the
likelihood of seizure activity. The client is asked to breathe deeply 20 times for 3 minutes.
The other responses are not accurate.
nk
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Assessment, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A nurse assesses a client recovering from a cerebral angiography via the right femoral artery.
ANS: A
st
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Which assessment would the nurse complete?
a. Palpate bilateral lower extremity pulses.
b. Obtain orthostatic blood pressure readings.
c. Perform a funduscopic examination.
d. Assess the gag reflex prior to eating.
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Cerebral angiography is performed by threading a catheter through the femoral or brachial
artery. The extremity is kept immobilized after the procedure. The nurse checks the extremity
for adequate circulation by noting skin color and temperature, presence and quality of pulses
distal to the injection site, and capillary refill. Clients usually are on bedrest; therefore,
orthostatic blood pressure readings cannot be performed. The funduscopic (eye) examination
would not be affected by cerebral angiography. The client is not given general anesthesia;
therefore, the client’s gag reflex would not be compromised.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Assessment, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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6. When assessing a client who had a traumatic brain injury, the nurse notes that the client is
drowsy but easily aroused. What level of consciousness will the nurse document to describe
this client’s current level of consciousness?
a. Alert
b. Lethargic
c. Stuporous
d. Comatose
ANS: B
The client is categorized as being lethargic because he or she can be easily aroused even
though drowsy. The nurse would carefully monitor the client to determine any decrease in the
level of consciousness (LOC).
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Level of consciousness
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
7. The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V.
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What assessment findings will the nurse expect for this client?
a. Expressive aphasia
b. Ptosis (eyelid drooping)
c. Slurred speech
d. Severe facial pain
s.
ANS: D
ba
nk
Cranial nerve (CN) V is the Trigeminal Nerve which has both a motor and sensory function in
the face. When affected by a health problem, the client experiences severely facial pain.
Expressive aphasia results from damage to the Broca speech area in the frontal lobe of the
brain. Ptosis can result from damage to CN III and slurred speech often occurs from either
damage to several cranial nerves or from damage to the motor strip in the frontal lobe of the
brain.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Cranial nerve assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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8. The nurse is performing an assessment of cranial nerve III. Which testing is appropriate?
a. Pupil constriction
b. Deep tendon reflexes
c. Upper muscle strength
d. Speech and language
ANS: A
CN III is the oculomotor nerve which controls eye movement, pupil constriction, and eyelid
movement.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Cranial nerve assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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9. A nurse cares for a client who is experiencing deteriorating neurologic functions. The client
states, “I am worried I will not be able to care for my young children.” How would the nurse
respond?
a. “Caring for your children is a priority. You may not want to ask for help, but you
really have to.”
b. “Our community has resources that may help you with some household tasks so
you have energy to care for your children.”
c. “You seem distressed. Would you like to talk to a psychologist about adjusting to
your changing status?”
d. “Can you tell me more about what worries you, so we can see if we can do
something to make adjustments?”
ANS: D
m
Investigate specific concerns about situational or role changes before providing additional
information. The nurse would not tell the client what is or is not a priority for him or her.
Although community resources may be available, they may not be appropriate for the patient.
Consulting a psychologist would not be appropriate without obtaining further information
from the client related to current concerns.
co
DIF: Applying TOP: Integrated Process: Communication and Documentation
KEY: Neurologic assessment, Therapeutic communication, Psychosocial assessment
MSC: Client Needs Category: Psychosocial Integrity
s.
10. A nurse plans care for a 77-year-old client who is experiencing age-related
ba
ANS: C
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peripheral sensory perception changes. Which intervention would the nurse include in this
client’s plan of care?
a. Provide a call button that requires only minimal pressure to activate.
b. Write the date on the client’s white board to promote orientation.
c. Ensure that the path to the bathroom is free from clutter.
d. Encourage the client to season food to stimulate nutritional intake.
st
Dementia and confusion are not common phenomena in older adults. However, physical
impairment related to illness can be expected. Providing opportunities for hazard-free
ambulation will maintain strength and mobility (and ensure safety). Providing a call button,
providing the date, and seasoning food do not address the client’s impaired sensory
perception.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Neurologic assessment, Client safety, Changes associated with aging
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
11. After teaching a patient who is scheduled for magnetic resonance imaging (MRI), the nurse
assesses the client’s understanding. Which statement indicates client understanding of the
teaching?
a. “I must increase my fluids because of the dye used for the MRI.”
b. “My urine will be radioactive so I should not share a bathroom.”
c. “My gag reflex will be tested before I can eat or drink anything.”
d. “I can return to my usual activities immediately after the MRI.”
ANS: D
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No postprocedure restrictions are imposed after MRI. The client can return to normal
activities after the test is complete. There are no dyes or radioactive materials used for the
MRI; therefore, increased fluids are not needed and the client’s urine would not be
radioactive. The procedure does not impact the client’s gag reflex.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Neurologic assessment, Diagnostic testing, Client education
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
12. A nurse performs an assessment of pain discrimination on an older adult. The client correctly
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identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin.
Which action would the nurse take next?
a. Touch the pin on the same area of the left hand.
b. Contact the primary health care provider with the assessment results.
c. Ask the client about current and past medications.
d. Continue the assessment on the client’s feet and legs.
ANS: A
s.
co
If testing is begun on the right hand and the client correctly identifies the pain stimulus, the
nurse would continue the assessment on the left hand. This is a normal finding and does not
need to be reported to the provider, but instead documented in the client’s medical record.
Medications do not need to be assessed in response to this finding. The nurse would assess the
left hand prior to assessing the feet.
nk
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Motor, Sensory impairment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
13. A nurse is teaching a client with cerebellar function impairment. Which statement would the
st
ANS: C
ba
nurse include in this client’s discharge teaching?
a. “Connect a light to flash when your door bell rings.”
b. “Label your faucet knobs with hot and cold signs.”
c. “Ask a friend to drive you to your follow-up appointments.”
d. “Use a natural gas detector with an audible alarm.”
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Cerebellar function enables the client to predict distance or gauge the speed with which one is
approaching an object, control voluntary movement, maintain equilibrium, and shift from one
skilled movement to another in an orderly sequence. A client who has cerebellar function
impairment should not be driving. The client would not have difficulty hearing, distinguishing
between hot and cold, or smelling.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Neurologic assessment, Client safety, Brain function
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
14. Which statement would the nurse include when teaching the assistive personnel (AP) about
how to care for a client with cranial nerve II impairment?
a. “Tell the client where food items are on the breakfast tray.”
b. “Place the client in a high-Fowler position for all meals.”
c. “Make sure the client’s food is visually appetizing.”
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d. “Assist the client by placing the fork in the left hand.”
ANS: A
Cranial nerve II, the optic nerve, provides central and peripheral vision. A patient who has
cranial nerve II impairment will have decreased visual acuity, so the AP would tell the client
where different food items are on the meal tray. The other options are not appropriate for
client with cranial nerve II impairment.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Neurologic assessment, Cranial nerve assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
nurse to contact the primary health care provider?
a. Shingles infection on the client’s back
b. Client is claustrophobic
c. Absence of intravenous access
d. Paroxysmal nocturnal dyspnea
ANS: A
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15. A nurse prepares a client for lumbar puncture (LP). Which assessment finding would alert the
s.
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An LP would not be performed if the client has a skin infection at or near the puncture site
because of the risk of cerebrospinal fluid infection. A nurse would want to notify the primary
health care provider if shingles were identified on the client’s back. If a client has shortness of
breath when lying flat, the LP can be adapted to meet the client’s needs. Claustrophobia,
absence of IV access, and paroxysmal nocturnal dyspnea have no impact on whether an LP
can be performed.
nk
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Neurologic assessment, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
ba
16. A nurse assesses a patient who is recovering from a lumbar puncture (LP). Which
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complication of this procedure would alert the nurse to urgently contact the primary health
care provider?
a. Weak pedal pulses
b. Nausea and vomiting
c. Increased thirst
d. Hives on the chest
ANS: B
The nurse would immediately contact the provider if the client experiences a severe headache,
nausea, vomiting, photophobia, or a change in level of consciousness after an LP, which are
all signs of increased intracranial pressure. Weak pedal pulses, increased thirst, and hives are
not complications of an LP.
DIF: Remembering
TOP: Integrated Process: Communication and Documentation
KEY: Neurologic assessment, Diagnostic testing
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
17. A nurse assesses a client and notes the client’s position as indicated in the illustration below:
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How would the nurse document this finding?
Decorticate posturing
Decerebrate posturing
Atypical hyperreflexia
Spinal cord degeneration
a.
b.
c.
d.
ANS: A
co
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The client is demonstrating decorticate posturing, which is seen with interruption in the
corticospinal pathway. This finding is abnormal and is a sign that the client’s condition has
deteriorated. The primary health care provider, the charge nurse/team leader, and other health
care team members would be notified immediately of this change in status. Decerebrate
posturing consists of external rotation and extension of the extremities. Hyperreflexes present
as increased reflex responses. Spinal cord degeneration presents frequently with pain and
discomfort.
nk
s.
DIF: Remembering
TOP: Integrated Process: Communication and Documentation
KEY: Neurologic assessment, Diagnostic testing, Documentation
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
18. A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his
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name, mumbles in response to questions, and follows simple commands. How would the
nurse document this client’s assessment using the Glasgow Coma Scale shown below?
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8
10
12
14
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a.
b.
c.
d.
s.
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ANS: C
st
ba
The client opens his eyes to speech (Eye Opening: To sound = 3), mumbles in response to
questions (Verbal Response: Inappropriate words = 3), and follows simple commands (Motor
Response: Obeys commands = 6). Therefore, the client’s Glasgow Coma Scale score is 3 + 3
+ 6 = 12.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Neurologic assessment, Glasgow Coma scale
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. A nurse assesses a client with an injury to the medulla. Which clinical manifestations would
the nurse expect to find? (Select all that apply.)
Decreased respiratory rate
Impaired swallowing
Visual changes
Inability to shrug shoulders
Loss of gag reflex
a.
b.
c.
d.
e.
ANS: A, B, D, E
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Cranial nerves IX (glossopharyngeal), X (vagus), XI (accessory), and XII (hypoglossal)
emerge from the medulla, as do portions of cranial nerves VII (facial) and VIII (acoustic).
Damage to these nerves causes decreased respirations, impaired swallowing, inability to shrug
shoulders, and loss of the gag reflex. The other manifestations are not associated with damage
to the medulla.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Brain function
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. An 84-year-old client who is usually alert and oriented experiences an acute cognitive decline.
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Which of the following factors would the nurse anticipate as contributing to this neurologic
change? (Select all that apply.)
a. Chronic hearing loss
b. Infection
c. Drug toxicity
d. Dementia
e. Hypoxia
f. Aging
ANS: B, C, E
nk
s.
Acute client conditions that occur in older adults often cause acute confusion and associated
emotional behaviors. Infection, drug toxicity, and hypoxia are all acute health problems that
can contribute to the client’s cognitive decline. Aging does not cause changes in cognition. If
the client had dementia, he or she would not be alert and oriented. Having a chronic hearing
loss is not a change in the client’s condition.
DIF: Applying
TOP: Integrated Process: Culture and Spirituality
KEY: Neurologic assessment, Changes associated with aging
MSC: Client Needs Category: Health Promotion and Maintenance
ba
3. A nurse assesses a client with a brain tumor. Which newly identified assessment findings
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would alert the nurse to urgently communicate with the primary health care provider? (Select
all that apply.)
a. Glasgow Coma Scale score of 8
b. Decerebrate posturing
c. Reactive pupils
d. Uninhibited speech
e. Decreasing level of consciousness
ANS: A, B, E
The nurse would urgently communicate changes in a patient’s neurologic status, including a
decrease in the Glasgow Coma Scale score; abnormal flexion or extension; changes in
cognition or level of consciousness; and pinpointed, dilated, and nonreactive pupils.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Neurologic assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A nurse assesses an older client. Which assessment findings would the nurse identify as
normal changes in the nervous system related to aging? (Select all that apply.)
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a.
b.
c.
d.
e.
Long-term memory loss
Slower processing time
Increased sensory perception
Decreased risk for infection
Change in sleep patterns
ANS: B, E
Normal changes in the nervous system related to aging include recent memory loss, slower
processing time, decreased sensory perception, an increased risk for infection, changes in
sleep patterns, changes in perception of pain, and altered balance and/or decreased
coordination.
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ba
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s.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Changes associated with aging
MSC: Client Needs Category: Health Promotion and Maintenance
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Chapter 39: Concepts of Care for Patients With Problems of the Central Nervous
System: The Brain
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is teaching the daughter of a client who has middle-stage Alzheimer disease. The
daughter asks, “Will the sertraline my mother is taking improve her dementia?” How would
the nurse respond about the purpose of the drug?
a. “It will allow your mother to live independently for several more years.”
b. “It is used to halt the advancement of Alzheimer disease but will not cure it.”
c. “It will not improve her dementia but can help control emotional responses.”
d. “It is used to improve short-term memory but will not improve problem solving.”
ANS: C
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Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer
disease. However, certain psychoactive drugs may help suppress emotional disturbances and
manage depression, psychoses, or anxiety. Drug therapy will not allow the client with
middle-stage dementia to safely live independently.
s.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Alzheimer disease, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
2. A client with early-stage Alzheimer disease is admitted to the hospital with chest pain. Which
ANS: B
ba
nk
nursing action is most appropriate to manage this client’s dementia?
a. Provide animal-assisted therapy as needed.
b. Ensure a structured and consistent environment.
c. Assist the client with activities of daily living (ADLs).
d. Use validation therapy when communicating with the client.
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The client who has early Alzheimer disease (AD) does not require assistance with ADLs or
validation therapy. While animal-assisted therapy may be helpful, some health care agencies
do not allow this intervention. Therefore, the most appropriate action is to provide a structured
and consistent environment while the client is hospitalized to prevent worsening of the client’s
symptoms.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Alzheimer disease, Nursing Interventions
MSC: Client Needs Category: Psychosocial Integrity
3. The nurse observes a client with late-stage Alzheimer disease eat breakfast. Afterward the
client states, “I am hungry and want breakfast.” What is the nurse’s best response?
a. “I see you are still hungry. I will get you some toast.”
b. “You ate your breakfast 30 minutes ago.”
c. “It appears you are confused this morning.”
d. “Your family will be here soon. Let’s get you dressed.”
ANS: A
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Use of validation therapy with clients who have late-stage Alzheimer disease involves
acknowledgment of the client’s feelings and concerns. This technique has proved more
effective in later stages of the disease because reality orientation only increases agitation. The
other statements do not validate the client’s concerns.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Alzheimer disease, Therapeutic communication
MSC: Client Needs Category: Psychosocial Integrity
4. The nurse cares for a client with middle-stage (moderate) Alzheimer disease. The client’s
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caregiver states, “She is always wandering off. What can I do to manage this restless
behavior?” What is the nurse’s best response?
a. “This is a sign of fatigue. The client would benefit from a daily nap.”
b. “Engage the client in scheduled activities throughout the day.”
c. “It sounds like this is difficult for you. I will consult the social worker.”
d. “The provider can prescribe a mild sedative for restlessness.”
ANS: B
co
Several strategies may be used to cope with restlessness and wandering. One strategy is to
engage the client in structured activities. Another is to take the client for frequent walks. Daily
naps and a mild sedative will not be as effective in the management of restless behavior.
Consulting the social worker does not address the caregiver’s concern.
s.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Alzheimer disease, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
nk
5. The nurse prepares to discharge a client with early to moderate Alzheimer disease. Which
st
ANS: D
ba
statement to maintain client safety would the nurse include in the discharge teaching for the
caregiver?
a. “Provide periods of exercise and rest for the client.”
b. “Place a padded throw rug at the bedside.”
c. “Provide a highly stimulating environment.”
d. “Install safety locks on all outside doors.”
Bt
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Clients with early to moderate Alzheimer disease have a tendency to wander, especially at
night. If possible, alarms would be installed on all outside doors to alert family members if the
client leaves. At a minimum, all outside doors should have safety locks installed to prevent the
client from going outdoors unsupervised. The client would be allowed to exercise within his
or her limits, but this action does not ensure his or her safety. Throw rugs are a slip and fall
hazard and would be removed. A highly stimulating environment would likely increase the
client’s confusion.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Alzheimer disease, Safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
6. The nurse is teaching a family caregiver about how best to communicate with the client who
has been diagnosed with Alzheimer disease. Which statement by the caregiver indicates a
need for further teaching?
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a.
b.
c.
d.
“I will avoid communicating with the client to prevent agitation.”
“I should use simple, short sentences and one-step instructions.”
“I can try to use gestures or pictures to communicate with the client.”
“I will limit the number of choices I provide for the client.”
ANS: A
Communication with the client is important to provide cognitive stimulation. Using short
simple sentences, using gestures and pictures, and limiting choices provided for the client will
help promote communication.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Alzheimer disease, Therapeutic communication
MSC: Client Needs Category: Psychosocial Integrity
7. The nurse teaches assistive personnel (AP) about how to care for a client with early-stage
co
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Alzheimer disease. Which statement would the nurse include?
a. “If she is confused, play along and pretend that everything is okay.”
b. “Remove the clock from her room so that she doesn’t get confused.”
c. “Reorient the client to the day, time, and environment with each contact.”
d. “Use validation therapy to recognize and acknowledge the client’s concerns.”
ANS: C
s.
Clients who have early-stage Alzheimer disease would be reoriented frequently to person,
place, and time. The AP would reorient the client and not encourage the client’s delusions.
The room would have a clock and white board with the current date written on it. Validation
therapy is used with late-stage Alzheimer disease.
nk
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Alzheimer disease, Staff teaching
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
ba
8. The primary health care provider prescribes donepezil for a client diagnosed with early-stage
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Alzheimer disease. What teaching about this drug will the nurse provide for the client’s family
caregiver?
a. “Monitor the client’s temperature because the drug can cause a low grade fever.”
b. “Observe the client for nausea and vomiting to determine drug tolerance.”
c. “Donepezil will prevent the client’s dementia from progressing as usual.”
d. “Report any client dizziness or falls because the drug can cause bradycardia.”
ANS: D
Donepezil is a cholinesterase inhibitor that may temporarily slow cognitive decline for some
clients but does not alter the course of the disease. The family caregiver would want to
monitor the client’s heart rate and report any incidence of dizziness or falls because the drug
can cause bradycardia. It does not typically cause fever or nausea/vomiting.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Alzheimer disease, Drug therapy, Caregiver health teaching
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
9. After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife’s
understanding. Which statement by the client’s wife indicates that she correctly understands
changes associated with this disease?
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a.
b.
c.
d.
“His masklike face makes it difficult to communicate, so I will use a white board.”
“He should not socialize outside of the house due to uncontrollable drooling.”
“This disease is associated with anxiety causing increased perspiration.”
“He may have trouble chewing, so I will offer bite-sized portions.”
ANS: D
Because chewing and swallowing can be problematic, small frequent meals and a supplement
are better for meeting the client’s nutritional needs. A masklike face and drooling are common
in clients with Parkinson disease. The client would be encouraged to continue to socialize and
communicate as normally as possible. The wife should understand that the client’s masklike
face can be misinterpreted and additional time may be needed for the client to communicate
with her or others. Excessive perspiration is also common in clients with Parkinson disease
and is associated with the autonomic nervous system’s response.
m
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Parkinson disease, Signs and symptoms
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. The nurse plans care for a client with Parkinson disease. Which intervention would the nurse
s.
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include in this client’s plan of care?
a. Restrain the client to prevent falling.
b. Ensure that the client uses incentive spirometry.
c. Teach the client pursed-lip breathing techniques.
d. Keep the head of the bed at 30 degrees or greater.
ANS: D
ba
nk
Elevation of the head of the bed will help prevent aspiration. The other options will not
prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do
these interventions address any of the complications of Parkinson disease. Pursed-lip
breathing increases exhalation of carbon dioxide; incentive spirometry expands the lungs. The
client should not be restrained to prevent falls. Other less restrictive interventions should be
used to maintain client safety.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Parkinson disease, Complication prevention
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
11. A nurse teaches assistive personnel (AP) about how to care for a client with Parkinson
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disease. Which statement would the nurse include as part of this teaching?
a. “Allow the client to be as independent as possible with activities.”
b. “Assist the client with frequent and meticulous oral care.”
c. “Assess the client’s ability to eat and swallow before each meal.”
d. “Schedule appointments early in the morning to ensure rest in the afternoon.”
ANS: A
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Clients with Parkinson disease do not move as quickly and can have functional problems. The
client would be encouraged to be as independent as possible and provided time to perform
activities without rushing. Although oral care is important for all clients, instructing the UAP
to provide frequent and meticulous oral is not a priority for this client. This statement would
be a priority if the client was immune-compromised or NPO. The nurse would assess the
client’s ability to eat and swallow; this would not be delegated. Appointments and activities
would not be scheduled early in the morning because this may cause the client to be rushed
and discourage the client from wanting to participate in activities of daily living.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Parkinson disease, Staff teaching
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
12. A client diagnosed with Parkinson disease will be starting ropinirole for symptom control.
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Which statement by the client indicates a need for further teaching?
a. “This drug should help decrease my tremors and help me move better.”
b. “I need to change positions slowly to prevent dizziness or falls.”
c. “I should take the drug at the same time each day for the best effect.”
d. “I know the drug will probably make help me prevent constipation.”
ANS: D
s.
Although ropinirole is a dopamine agonist and mimics dopamine to promote movement, it
does not work to prevent constipation. This class of drugs can cause orthostatic hypotension
and should be taken at the same time every day.
nk
DIF: Understanding
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Parkinson disease, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
13. A nurse is teaching a client who experiences migraine headaches and is prescribed
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propranolol. Which statement would the nurse include in this client’s teaching?
a. “Take this drug only when you have symptoms indicating the onset of a migraine
headache.”
b. “Take this drug as prescribed, even when feeling well, to prevent vascular changes
associated with migraine headaches.”
c. “This drug will relieve the pain during the aura phase soon after a headache has
started.”
d. “This drug will have no effect on your heart rate or blood pressure because you are
taking it for migraines.”
ANS: B
Propranolol is a beta-adrenergic blocker which is prescribed as prophylactic treatment to
prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure
will also be affected, and the client would monitor these side effects. The other responses do
not discuss appropriate uses of this drug.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Migraine headache, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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14. The nurse assesses a client who has a history of migraines. Which symptom would the nurse
identify as an early sign of a migraine with aura?
a. Vertigo
b. Lethargy
c. Visual disturbances
d. Numbness of the tongue
ANS: C
Early warning of impending migraine with aura usually consists of visual changes, flashing
lights, or diplopia. The other symptoms are not associated with an impending migraine with
aura.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Migraine headache, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
m
15. The nurse obtains a health history on a client prior to administering prescribed sumatriptan
co
succinate for migraine headaches. Which condition would alert the nurse to withhold the
medication and contact the primary health care provider?
a. Bronchial asthma
b. Heart disease
c. Diabetes mellitus
d. Rheumatoid arthritis
s.
ANS: B
nk
Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine
headache by binding to serotonin receptors and triggering cranial vasoconstriction.
Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in
clients with heart disease, hypertension, or Prinzmetal angina. The other conditions would not
affect the client’s treatment.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Analysis
KEY: Migraine headache, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
st
16. The nurse assesses a client with a history of epilepsy who experiences stiffening of the
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muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of
all extremities. How would the nurse document this type of seizure?
a. Atonic
b. Myoclonic
c. Absence
d. Tonic-clonic
ANS: D
Seizure activity that begins with stiffening of the arms and legs, followed by loss of
consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An
atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A
myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur
singly or in groups. Absence seizures present with automatisms, and the client is unaware of
his or her environment.
DIF: Remembering
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TOP: Integrated Process: Communication and Documentation KEY: Epilepsy, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
17. The nurse witnesses a client begin to experience a tonic-clonic seizure and loss of
consciousness. What action would the nurse take first?
a. Start fluids via a large-bore catheter.
b. Administer IV push diazepam.
c. Turn the client’s head to the side.
d. Prepare to intubate the client.
ANS: C
The nurse would turn the client’s head to the side to prevent aspiration and allow drainage of
secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the
seizure is sustained (status epilepticus), the client must be intubated and would be
administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Seizure, Aspiration precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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18. A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication
s.
would the nurse anticipate to prepare for administration?
a. Atenolol
b. Lorazepam
c. Phenytoin
d. Lisinopril
nk
ANS: B
ba
Initially, intravenous lorazepam or diazepam is administered to stop motor movements. This
is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an
angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These
drugs are typically administered for hypertension and heart failure.
st
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Epilepsy, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
19. After teaching a client who is diagnosed with new-onset epilepsy and prescribed phenytoin,
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the nurse assesses the client’s understanding. Which statement by the client indicates a
correct understanding of the teaching?
a. “To prevent complications, I will drink at least 2 L of water daily.”
b. “This medication will stop me from getting an aura before a seizure.”
c. “I will not drive a motor vehicle while taking this medication.”
d. “Even when my seizures stop, I will continue to take this drug.”
ANS: D
Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus.
The client does not need to drink more water and can drive while taking this medication. The
drug will not stop an aura before a seizure.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Epilepsy, Drug therapy
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MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
20. After teaching a client newly diagnosed with epilepsy, the nurse assesses the client’s
understanding. Which statement by the client indicates a need for additional teaching?
a. “I will wear my medical alert bracelet at all times.”
b. “While taking my medications, I will not drink any alcoholic beverages.”
c. “I will tell my doctor about my prescription and over-the-counter medications.”
d. “If I am nauseated, I will not take my epilepsy medication.”
ANS: D
The nurse must emphasize that antiepileptic drugs must be taken even if the client is
nauseated. Discontinuing the medication can predispose the client to seizure activity and
status epilepticus. The client should not drink alcohol while taking seizure medications. The
client should wear a medical alert bracelet and should make the primary health care provider
aware of all drugs he or she is taking to prevent complications of polypharmacy.
m
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Epilepsy, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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21. The nurse is teaching a group of college students about the importance of preventing
nk
s.
meningitis. Which health promotion activity is the most appropriate for preventing this
disease?
a. Eating a well-balanced diet that is high in protein
b. Having an annual physical examination
c. Obtaining the recommended meningitis vaccination and boosters
d. Identifying signs and symptoms for early treatment
ANS: C
ba
CDC-recommended vaccinations and boosters are available for prevention of a number of
diseases including meningococcal meningitis. While the other activities are appropriate for
general health promotion, they are not specific to meningitis prevention.
st
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Meningitis, Health promotion
MSC: Client Needs Category: Health Promotion and Maintenance
22. A nurse obtains a focused health history for a client who is suspected of having bacterial
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meningitis. Which question would the nurse ask?
a. “Do you live in a crowded residence?”
b. “When was your last tetanus vaccination?”
c. “Have you had any viral infections recently?”
d. “Have you traveled out of the country in the last month?”
ANS: A
Bacterial meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of
high-density population, such as college dormitories, prisons, and military barracks. A tetanus
vaccination would not place the client at increased risk for meningitis or protect the client
from meningitis. A viral infection would not lead to bacterial meningitis but could lead to
viral meningitis. Simply knowing if the client traveled out of the country does not provide
enough information.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Meningitis, Infection control
MSC: Client Needs Category: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The nurse plans care for a client with epilepsy who is admitted to the hospital. Which
interventions would the nurse include in this client’s plan of care? (Select all that apply.)
a. Have suction equipment with an airway at the bedside.
b. Place a padded tongue blade at the bedside.
c. Permit only clear oral fluids.
d. Have oxygen administration set at the bedside.
e. Maintain the client on strict bedrest.
f. Ensure that the client has IV access.
ANS: A, D, F
co
m
Oxygen and suctioning equipment with an airway must be readily available. If the client does
not have an IV access, insert a saline lock, especially for those clients who are at significant
risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug
therapy must be given to stop the seizure. Padded tongue blades may pose a danger to the
client or nurse during a seizure and would not be used. Dietary restrictions and strict bedrest
are not interventions associated with epilepsy.
nk
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Epilepsy, Seizure precautions, Client safety
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
2. The nurse assesses a client who is experiencing a common migraine without an aura. Which
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assessment finding(s) would the nurse expect? (Select all that apply.)
a. Headache lasting up to 72 hours
b. Unilateral and pulsating headache
c. Abrupt loss of consciousness
d. Acute confusion
e. Pain worsens with physical activities
f. Photophobia
ANS: A, B, E, F
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A common migraine with an aura is usually accompanied by photophobia, phonophobia,
unilateral and pulsating pain, and nausea and/or vomiting. These migraines usually last 4 to 72
hours and are aggravated by physical activity. Loss of consciousness and acute confusion are
not associated with a common migraine without an aura.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Migraine headache, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which
personal protective equipment would the nurse wear? (Select all that apply.)
a. Particulate respirator
b. Isolation gown
c. Shoe covers
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d. Surgical mask
e. Gloves
ANS: D, E
Meningococcal meningitis is spread via saliva and droplets, and Droplet Precautions are
necessary. Caregivers would wear a surgical mask when within 6 feet (1.8 m) of the client and
would continue to use Standard Precautions, including gloves. A particulate respirator, an
isolation gown, and shoe covers are not necessary for Droplet Precautions.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Meningitis, Infection control, Transmission-Based Precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
4. The nurse assesses clients on a medical-surgical unit. Which clients would the nurse identify
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as at risk for secondary seizures? (Select all that apply.)
a. A 26-year-old woman with a left temporal brain tumor
b. A 38-year-old male client in an alcohol withdrawal program
c. A 42-year-old football player with a traumatic brain injury
d. A 66-year-old female client with multiple sclerosis
e. A 72-year-old man with chronic obstructive pulmonary disease
ANS: A, B, C
nk
s.
Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma,
and those who are experiencing a metabolic disorder, acute alcohol withdrawal, electrolyte
disturbances, and high fever. Clients with a history of stroke, heart disease, and substance
abuse are also at risk. Clients with multiple sclerosis or chronic obstructive pulmonary disease
are not at risk for secondary seizures.
ba
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Seizure, Assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A nurse assesses a client who is recovering from the implantation of a vagal nerve-stimulation
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device. For which signs and symptoms would the nurse assess as common complications of
this procedure? (Select all that apply.)
a. Bleeding
b. Infection
c. Hoarseness
d. Dysphagia
e. Seizures
ANS: C, D
Complications of surgery to implant a vagal nerve-stimulation device include hoarseness
(most common), dyspnea, neck pain, and dysphagia. The device is tunneled under the skin
with an electrode connected to the vagus nerve to control simple or complex partial seizures.
Bleeding is not a common complication of this procedure, and infection would not occur
during the recovery period.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Epilepsy, Surgical Management
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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6. The nurse assesses a client who has meningitis. Which sign(s) and symptom(s) would the
nurse anticipate? (Select all that apply.)
a. Photophobia
b. Decreased level of consciousness
c. Severe headache
d. Fever and chills
e. Bradycardia
ANS: A, B, C, D
All of the choices except for bradycardia are key features of meningitis. Tachycardia is more
likely than bradycardia due to the infectious process and fever.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Meningitis, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
m
7. The nurse assesses a client who has Parkinson disease. Which signs and symptoms would the
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nurse recognize as a key feature of this disease? (Select all that apply.)
a. Flexed trunk
b. Long, extended steps
c. Slow movements
d. Uncontrolled drooling
e. Tachycardia
s.
ANS: A, C, D
nk
Key features of Parkinson disease include a flexed trunk, slow and hesitant steps,
bradykinesia, and uncontrolled drooling. Tachycardia is not a key feature of this disease.
ba
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Parkinson disease, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. A nurse teaches the spouse of a client who has Alzheimer disease. Which statements should
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the nurse include in this teaching related to caregiver stress reduction? (Select all that apply.)
a. “Establish advanced directives early.”
b. “Trust that family and friends will help.”
c. “Set aside time each day to be away from the client.”
d. “Use discipline to correct inappropriate behaviors.”
e. “Seek respite care periodically for longer periods of time.”
ANS: A, C, D
To reduce caregiver stress, the spouse should be encouraged to establish advanced directives
early, set aside time each day for rest or recreation away from the client, seek respite care
periodically for longer periods of time, use humor with the client, and explore alternative care
settings and resources. Family and friends may not be available to help. A structured
environment will assist the client with AD, but discipline will not correct inappropriate
behaviors and not reduce caregiver stress.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Alzheimer disease, Caregiver stress, Elder abuse
MSC: Client Needs Category: Psychosocial Integrity
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9. The nurse is caring for a client who has Alzheimer disease. The client’s wife states, “I am
having trouble managing his behaviors at home.” Which questions would the nurse ask to
assess potential causes of the client’s behavior problems? (Select all that apply.)
a. “Does your husband bathe and dress himself independently?”
b. “Do you weigh your husband each morning around the same time?”
c. “Does his behavior become worse around large crowds?”
d. “Does your husband eat healthy foods including fruits and vegetables?”
e. “Do you have a clock and calendar in the bedroom and kitchen?”
ANS: A, C, E
m
To minimize behavior problems, the nurse would encourage the patient to be as independent
as possible with ADLs, minimize excessive simulation, and assist the patient to remain
orientated. The nurse would assess these activities by asking if the patient is independent with
bathing and dressing, if behavior worsens around crowds, and if a clock and single-date
calendar are readily available. Diet and weight are not related to the management of behavior
problems for a patient who has Alzheimer disease.
co
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Alzheimer disease, Communication
MSC: Client Needs Category: Psychosocial Integrity
10. The nurse is caring for a client in late-stage Alzheimer disease. Which assessment finding(s)
nk
s.
will the nurse anticipate? (Select all that apply.)
a. Immobile
b. Has difficulty driving
c. Wandering
d. ADL dependent
e. Incontinent
f. Possible seizures
ANS: A, D, E, F
ba
The client in late-stage Alzheimer disease is totally bedridden and immobile, and therefore,
cannot ambulate to wander or drive. The client is incontinent and ADL dependent.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Parkinson disease, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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Chapter 40: Concepts of Care for Patients With Problems of the Central Nervous
System: The Spinal Cord
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is preparing to teach a client recently diagnosed with multiple sclerosis about taking
glatiramer acetate. Which statement by the client indicates a need for further teaching?
a. “I will rotate injection sites to prevent skin irritation.”
b. “I need to avoid large crowds and people with infection.”
c. “I should report any flulike symptoms to my primary health care provider.”
d. “I will report any signs of infection to my primary health care provider.”
ANS: C
co
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Glatiramer is given by subcutaneous injection. The first dose is administered under medical
supervision, but the nurse teaches the client how to self-administer the medication after the
initial dose, reminding the client about the need to rotate injection sites. Like other
immunomodulators, this drug can make the client susceptible to infection. However, flulike
symptoms occur more commonly with interferons rather than glatiramer.
s.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Multiple sclerosis, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
2. A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod.
ANS: B
ba
nk
For which common side effect would the nurse monitor?
a. Peripheral edema
b. Facial flushing
c. Tachycardia
d. Fever
st
Fingolimod is an oral immunomodulator that has two common side effects—facial flushing
and GI disturbance, such as diarrhea. Peripheral edema, tachycardia, and fever are not
common side effects of this drug.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Multiple sclerosis, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
3. A client who has multiple sclerosis reports increased severe muscle spasticity and tremors.
What nursing action is most appropriate to manage this client’s concern?
a. Request a prescription for an antispasmodic drug such as baclofen.
b. Prepare the client for deep brain stimulation surgery.
c. Refer the client to a massage therapist to relax the muscles.
d. Consult with the occupational therapist for self-care assistance.
ANS: A
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Clients who have multiple sclerosis often have muscle spasticity which may be reduced by
drug therapy, such as baclofen. While massage and assistance with self-care may be helpful,
these interventions are not the most effective and therefore not the most appropriate in
managing muscle spasticity. If drug therapy and other interventions do not help reduce muscle
spasms, some client are candidates for deep brain stimulation as a last resort.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Multiple sclerosis, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
4. A client with multiple sclerosis is being discharged from rehabilitation. Which statement
m
would the nurse include in the client’s discharge teaching?
a. “Be sure that you use a wheelchair when you go out in public.”
b. “Wear an undergarment brief at all times in case of incontinence.”
c. “Avoid overexertion, stress, and extreme temperature if possible.”
d. “Avoid having sexual intercourse to conserve energy.”
ANS: C
s.
co
Clients who have multiple sclerosis have chronic fatigue and are prone to disease exacerbation
(flare-up) is they overexert, are stressed, or are exposed to extreme temperature and humidity.
They should not wear briefs unless they have actual problems with continence and should not
use a wheelchair if they are able to ambulate with a cane or walker. Maintaining independence
and self-esteem is important, so participating in sexual activities is encouraged.
nk
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Multiple sclerosis, Self-management
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. A nurse assesses a client with a spinal cord injury at level T5. The client’s blood pressure is
ANS: C
st
ba
184/95 mm Hg, and the client presents with a flushed face and blurred vision. After raising
the head of the bed, what action would the nurse take next?
a. Initiate oxygen via a nasal cannula.
b. Recheck the client’s blood pressure.
c. Palpate the bladder for distention.
d. Administer a prescribed beta blocker.
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The client is manifesting symptoms of autonomic dysreflexia. Common causes include
bladder distention, tight clothing, increased room temperature, and fecal impaction. If
persistent, the client could experience neurologic injury such as s stroke. The other actions are
not appropriate for this complication.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Spinal cord injury, Complications
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
6. The nurse initiates care for a client with a cervical spinal cord injury who arrives via
emergency medical services. What action would the nurse take first?
a. Assess level of consciousness.
b. Obtain vital signs.
c. Administer oxygen therapy.
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d. Evaluate respiratory status.
ANS: D
The first priority for a client with a spinal cord injury is assessment of respiratory status and
airway patency. Clients with cervical spine injuries are particularly prone to respiratory
compromise due to interference with diaphragmatic innervation. The other actions would be
performed after airway and breathing are assessed.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Spinal cord injury, Assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A client who had a complete spinal cord injury at level L5-S1 is admitted with a sacral
m
pressure injury. What other assessment finding will the nurse anticipate for this client?
a. Quadriplegia
b. Flaccid bowel
c. Spastic bladder
d. Tetraparesis
ANS: B
s.
co
A low-level complete spinal cord injury (SCI) is a lower motor neuron injury because the
reflect arc is damaged. Therefore, the client would be expected to have paraplegia and a
flaccid bowel and bladder. Quadriplegia and tetraparesis are seen in clients with cervical or
high thoracic SCIs.
nk
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Spinal cord injury, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. The nurse is collaborating with the occupational therapist to assist a client with a complete
ANS: D
st
ba
cervical spinal cord injury to transfer from the bed to the wheelchair. What ambulatory aid
would be most appropriate for the client to meet this outcome?
a. Rolling walker
b. Quad cane
c. Adjustable crutches
d. Sliding board
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A client who has a complete cervical spinal cord injury is unable to use any extremity except
for parts of the hands and possibly the lower arms. Therefore, the client would be unable to
use any of these ambulatory aids except for a sliding board, also known as a slider, which
provides a “bridge” between the bed and a chair. The client uses his or her arms in a locked
position to support the body while moving slowly across the board.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Spinal cord injury, Rehabilitation
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. The nurse is caring for a 60-year-old female client who sustained a thoracic spinal cord injury
10 years ago. For which potential complication will the nurse assess during this client’s care?
a. Fracture
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b. Malabsorption
c. Delirium
d. Anemia
ANS: A
Older adults who have impaired mobility due to a health problem or injury are at risk for
complications of immobility, such as osteoporosis (bone loss) which leads to fracture. Being
an older woman increases that risk due to loss of estrogen to protect bone loss. The other
choices are not problems of immobility. Delirium is possible but is more common in clients
over 70 years of age.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Spinal cord injury, Older adult care
MSC: Client Needs Category: Health Promotion and Maintenance
10. A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation
s.
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program. The client states, “I don’t understand the need for rehabilitation; the paralysis will
not go away and it will not get better.” How would the nurse respond?
a. “If you don’t want to participate in the rehabilitation program, I’ll let your primary
health care provider know.”
b. “Rehabilitation programs have helped many patients with your injury. You should
give it a chance.”
c. “The rehabilitation program will teach you how to maintain the functional ability
you have and prevent further disability.”
d. “When new discoveries are made regarding paraplegia, people in rehabilitation
programs will benefit first.”
nk
ANS: C
ba
Participation in rehabilitation programs has many purposes, including prevention of disability,
maintenance of functional ability, and restoration of function. The other responses do not meet
this client’s needs.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Spinal cord injury, Rehabilitation
MSC: Client Needs Category: Psychosocial Integrity
st
11. A nurse cares for a client with a spinal cord injury. With which interprofessional health team
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member would the nurse collaborate to assist the client with activities of daily living?
a. Social worker
b. Physical therapist
c. Occupational therapist
d. Case manager
ANS: C
The occupational therapist instructs the patient in the correct use of all adaptive equipment. In
collaboration with the therapist, the nurse instructs family members or the caregiver about
transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members
are consulted to assist the client with other issues.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Spinal cord injury, Interprofessional collaboration
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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12. After teaching a client with a high thoracic spinal cord injury, the nurse assesses the client’s
understanding. Which statement by the client indicates a correct understanding of how to
prevent respiratory problems at home?
a. “I’ll use my incentive spirometer every 2 hours while I’m awake.”
b. “I’ll drink thinned fluids to prevent choking.”
c. “I’ll take cough medicine to prevent excessive coughing.”
d. “I’ll position myself on my right side so I don’t aspirate.”
ANS: A
m
The client with a cervical or high thoracic spinal cord injury typically has weak intercostal
muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an
incentive spirometer every 2 hours helps the client expand the lungs more fully and helps
prevent atelectasis and other respiratory problems. Clients should drink fluids that they can
tolerate; usually thick fluids are easier to tolerate. The client would be encouraged to cough
and clear secretions, and placed in high-Fowler position to prevent aspiration.
co
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Spinal cord injury, Prevention of Complications
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
13. A client continues to have persistent low back pain even after using a number of
nk
s.
nonpharmacologic pain management strategies. Which prescribed drug would the nurse
anticipate that the client might need to manage the pain?
a. Oxycontin
b. Gabapentin
c. Lorazepam
d. Tramadol
ANS: D
ba
When nonpharmacologic strategies, including physical therapy, are not effective in managing
pain, current standards recommend a mild opioid such as tramadol or
serotonin-norepinephrine reuptake inhibitor. Strong opioids such as oxycontin and
benzodiazepines such as lorazepam are not considered best practice.
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st
DIF: Remembering
TOP: Integrated Process: Caring
KEY: Low back pain, Pain management
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
14. A client is scheduled for a percutaneous endoscopic lumbar discectomy. Which statement by
the client indicates a need for further teaching?
a. “I should have a lot less pain after surgery.”
b. “I’ll be in the hospital for 2 to 3 days.”
c. “I should not have any major surgical complications.”
d. “I could possibly get an infection after surgery.”
ANS: B
Percutaneous endoscopic discectomy is a minimally invasive surgical procedure that requires
a shorter hospital stay (23 hours or less) when compared to open traditional surgery. The risk
for surgical complications is very low and clients experience less far pain from this procedure.
However, due to interrupting skin integrity, infection may occur at the surgical site.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Low back pain, Perioperative care
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
15. A nurse assesses clients at a community center. Which client is at greatest risk for low back
pain?
a. A 24-year-old female who is 25 weeks pregnant.
b. A 36-year-old male who uses ergonomic techniques.
c. A 53-year-old female who uses a walker.
d. A 65-year-old female with osteoarthritis.
ANS: D
Osteoarthritis causes changes to support structures, increasing the client’s risk for low back
pain. The other clients are not at high risk.
m
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Low back pain, Risk factors
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
16. A nurse teaches a client who is recovering from an open traditional cervical spinal fusion.
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Which statement would the nurse include in this client’s postoperative instructions?
a. “Only lift items that are 10 lb (4.5 kg) or less.”
b. “Wear your neck brace whenever you are out of bed.”
c. “You must remain in bed for 3 weeks after surgery.”
d. “You will be prescribed medications to prevent graft rejection.”
ANS: B
ba
nk
Clients who undergo spinal fusion are fitted with a neck brace that they must wear throughout
the healing process whenever they are out of bed. The client should not lift anything more
than 10 lb (4.5 kg). The client does not need to remain in bed. Medications for rejection
prevention are not necessary for this procedure.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Cervical neck pain, Perioperative care
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
st
17. A nurse assesses a client who is recovering from an open anterior cervical discectomy and
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fusion. Which complication would alert the nurse to urgently communicate with the primary
health care provider?
a. Auscultated stridor
b. Weak pedal pulses
c. Difficulty swallowing
d. Inability to shrug shoulders
ANS: A
Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and
manifest as stridor. The client may also have trouble swallowing, but maintaining an airway
takes priority. Weak pedal pulses and an inability to shrug the shoulders are not complications
of this surgery.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cervical neck pain, Perioperative care
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MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
18. A nurse assesses the health history of a client who is prescribed ziconotide for chronic low
back pain. Which assessment question would the nurse ask?
a. “Are you taking a nonsteroidal anti-inflammatory drug?”
b. “Have you been diagnosed with a mental health problem?”
c. “Are you able to swallow oral medications?”
d. “Do you smoke cigarettes or any illegal drugs?”
ANS: B
Clients who have a severe mental health or behavioral health problem would not take
ziconotide because the drug can cause psychotic symptoms such as hallucinations. The other
questions do not identify a contraindication for this medication.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Low back pain, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
co
MULTIPLE RESPONSE
1. A nurse promotes the prevention of lower back pain by teaching clients at a community
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s.
center. Which statement(s) would the nurse include in this education? (Select all that apply.)
a. “Participate in an exercise program to strengthen back muscles.”
b. “Purchase a mattress that allows you to adjust the firmness.”
c. “Wear flat instead of high-heeled shoes to work each day.”
d. “Keep your weight within 20% of your ideal body weight.”
e. “Avoid prolonged standing or sitting, including driving.”
ANS: A, C, E
ba
Exercise can strengthen back muscles, reducing the incidence of low back pain. Women
should avoid wearing high-heeled shoes because they cause misalignment of the back.
Prolonged standing and sitting should also be avoided. The other options will not prevent low
back pain.
st
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Low back pain, Injury prevention
MSC: Client Needs Category: Health Promotion and Maintenance
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2. A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which
assessment data would the nurse obtain to assess the client’s coping strategies? (Select all that
apply.)
a. Spiritual beliefs
b. Level of pain
c. Family support
d. Level of independence
e. Annual income
f. Previous coping strategies
ANS: A, C, D, F
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Information about the client’s preinjury psychosocial status, usual methods of coping with
illness, difficult situations, and disappointments would be obtained. Determine the client’s
level of independence or dependence and his or her comfort level in discussing feelings and
emotions with family members or close friends. Clients who are emotionally secure and have
a positive self-image, a supportive family, and financial and job security often adapt to their
injury. Information about the client’s spiritual and religious beliefs or cultural background
also assists the nurse in developing the plan of care. The other options do not supply as much
information about coping.
DIF: Applying
TOP: Integrated Process: Caring
KEY: Spinal cord injury, Psychosocial assessment, Coping
MSC: Client Needs Category: Psychosocial Integrity
3. After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the his
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understanding. Which client statements indicate a correct understanding of the teaching
related to sexual effects of his injury? (Select all that apply.)
a. “I will explore other ways besides intercourse to please my partner.”
b. “I will not be able to have an erection because of my injury.”
c. “Ejaculation may not be as predictable as before.”
d. “I may urinate with ejaculation but this will not cause infection.”
e. “I should be able to have an erection with stimulation.”
ANS: C, D, E
nk
s.
Men with injuries above T6 often are able to have erections by stimulating reflex activity. For
example, stroking the penis will cause an erection. Ejaculation is less predictable and may be
mixed with urine. However, urine is sterile, so the client’s partner will not get an infection.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Spinal cord injury, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
ba
4. A nurse assesses a client who is recovering from an open traditional lumbar laminectomy with
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fusion. Which complications would the nurse report to the primary health care provider?
(Select all that apply.)
a. Surgical discomfort
b. Redness and itching at the incision site
c. Incisional bulging
d. Clear drainage on the dressing
e. Sudden and severe headache
ANS: C, D, E
Bulging at the incision site or clear fluid on the dressing after open back surgery strongly
suggests a cerebrospinal fluid leak, which constitutes an emergency. Loss of cerebrospinal
fluid may cause a sudden and severe headache. Pain, redness, and itching at the site are
normal.
DIF: Applying
TOP: Integrated Process: Nursing Process: Analysis
KEY: Low back pain, Perioperative care
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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5. A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas
over the client’s hips and sacrum. What actions would the nurse take? (Select all that apply.)
a. Apply a barrier cream to protect the skin from excoriation.
b. Perform range-of-motion (ROM) exercises for the hip joint.
c. Reposition the client off of the reddened areas.
d. Get the client out of bed and into a chair several times a day.
e. Apply a pressure-reducing mattress.
ANS: C, E
Appropriate interventions to relieve pressure on the reddened areas include frequent
repositioning, using a pressure-reducing mattress, and having the client sit in a chair to
remove pressure from the hips and sacrum. Correct sitting position would allow the pressure
to be on both ischial tuberosities. ROM exercises are used to prevent contractures.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Spinal cord injury, Skin care
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
6. A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago.
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Which assessment findings would the nurse correlate with neurogenic shock? (Select all that
apply.)
a. Heart rate of 34 beats/min
b. Blood pressure of 185/65 mm Hg
c. Urine output less than 30 mL/hr
d. Decreased level of consciousness
e. Increased oxygen saturation
nk
ANS: A, C, D
ba
Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation,
symptomatic bradycardia, decreased level of consciousness, decreased urine output, and
hypotension.
st
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Spinal cord injury, Complications
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. A nurse plans care for a client with a halo fixator. Which interventions would the nurse
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include in this client’s plan of care? (Select all that apply.)
a. Remove the vest for client bathing.
b. Assess the pin sites for signs of infection.
c. Loosen the pins when sleeping.
d. Decrease the patient’s oral fluid intake.
e. Assess the chest and back for skin breakdown.
ANS: B, E
The nurse would assess the pin sites for signs of infection or loose pins. The nurse would also
assess the client’s chest and back for skin breakdown from the halo vest. The vest is not
removed for bathing and the pins are not intentionally loosened.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Spinal cord injury, Immobilization
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
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8. A nurse assesses a client who is recovering from an open traditional anterior cervical fusion.
Which assessment findings would alert the nursing to a complication from this procedure?
(Select all that apply.)
a. Difficulty swallowing
b. Hoarse voice
c. Constipation
d. Bradycardia
e. Hypertension
ANS: A, B
Complications of the open traditional anterior cervical discectomy and fusion include
dysphagia and hoarseness. Constipation, bradycardia, and hypertension are not complications
of this procedure.
m
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Cervical pain, Perioperative care
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
s.
would the nurse take? (Select all that apply.)
a. Place the client in a flat position.
b. Monitor vital signs for hypotension.
c. Utilize a bedside commode.
d. Assess for abdominal distension.
e. Report the leak to the surgeon.
co
9. A nurse assesses cerebrospinal fluid leaking onto a client’s surgical dressing. What actions
nk
ANS: A, E
ba
If cerebrospinal fluid (CSF) is leaking from a surgical wound, the nurse would place the client
in a flat position and contact the surgeon for repair of the leak. Hypotension and abdominal
distension are not complications of CSF leakage.
st
DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Low back pain, Surgical complications
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
10. The nurse is taking a history on an older adult. Which factors would the nurse assess as
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potential risks for low back pain? (Select all that apply.)
a. Scoliosis
b. Spinal stenosis
c. Hypocalcemia
d. Osteoporosis
e. Osteoarthritis
ANS: A, B, C, D, E
All of these factors place the client at risk for low back pain due to changes in spinal
alignment, loss of bone, or joint degeneration. Bone loss worsens if serum calcium levels are
below normal.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Low back pain, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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Chapter 41: Critical Care of Patients With Neurologic Emergencies
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A client is in the emergency department reporting a brief episode during which he was dizzy,
unable to speak, and felt numbness in his left leg. Currently the client’s neurologic
examination is normal. About what drug would the nurse plan to teach the patient?
a. Alteplase
b. Clopidogrel
c. Heparin sodium
d. Mannitol
ANS: B
m
This client’s signs and symptoms are consistent with a transient ischemic attack, and the client
would likely be prescribed aspirin or clopidogrel to prevent platelet aggregation on discharge.
Alteplase is used for ischemic stroke. Heparin and mannitol are not used for this condition.
co
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Transient ischemic attack, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
s.
2. The nurse is preparing a client for discharge from the emergency department after
ba
ANS: C
nk
experiencing a transient ischemic attack (TIA). Before discharge, which factor would the
nurse identify as placing the client at high risk for a stroke?
a. Age greater than or equal to 75
b. Blood pressure greater than or equal to 160/95
c. Unilateral weakness during a TIA
d. TIA symptoms lasting less than a minute
st
The client who has a TIA is at risk for a stroke is he or she has one-sided (unilateral)
weakness during a TIA. Risk factors also include an age greater than or equal to 60, blood
pressure greater than or equal to 140/90 (either or both systolic and diastolic), and/or a long
duration of TIA symptoms. One minute is not a very long time for symptoms to occur.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Transient ischemic attack, Risk factors
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. The nurse is taking a history from a daughter about her father’s onset of stroke signs and
symptoms. Which statement by the daughter indicates that the client likely had an embolic
stroke?
a. Client’s symptoms occurred slowly over several hours.
b. Client because increasingly lethargic and drowsy.
c. Client reported severe headache before other symptoms.
d. Client has a long history of atrial fibrillation.
ANS: D
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The major cause of embolic strokes is a history of heart disease, especially atrial fibrillation.
Most clients who have an embolic stroke have acute sudden neurologic symptoms but stay
alert rather than lethargic. Decreasing level of consciousness and severe headache are more
common in clients who have hemorrhagic strokes.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Stroke, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A client is admitted with a sudden decline in level of consciousness. What is the nursing
action at this time?
a. Assess the client for hypoglycemia and hypoxia.
b. Place the client on his or her side.
c. Prepare for administration of a fibrinolytic agent.
d. Start a continuous IV heparin sodium infusion.
m
ANS: A
s.
co
The cause of a sudden decline in level of consciousness may or may not be related to a
neurologic health problem. Therefore, the client must be evaluated for other common causes,
especially hypoglycemia and hypoxia. Placing the client on his or her side may be helpful to
prevent aspiration in case the client experiences vomiting, but the clinical situation does not
indicate that the client has nausea or vomiting. Administering either an anticoagulant like
heparin or a fibrinolytic agent assumes that the client has an acute ischemic stroke, which has
not been confirmed through imaging tests.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Neurologic assessment, Stroke
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. The nurse is teaching assistive personnel (AP) about care for a male client diagnosed with
ANS: B
st
ba
acute ischemic stroke and left-sided weakness. Which statement by the AP indicates
understanding of the nurse’s teaching?
a. “I will use “yes” and “no” questions when communicating with the client.”
b. “I will remind the client frequently to not get out of bed without help.”
c. “I will offer a urinal every hour to the client due to incontinence.”
d. “I will feed the client slowly using soft or pureed foods.”
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The client who has left-sided weakness has likely had a right-sided stroke in the brain. Clients
who have strokes on the right side of the brain tend to be very impulsive and exhibit poor
judgment. Therefore, to keep the client safe, the staff will need to remind the client to stay in
bed unless he has assistance to prevent falling. There is no evidence in the clinical situation
that the client has aphasia (which is less common in those with right-sided strokes), difficulty
swallowing, or urinary incontinence.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Stroke, Nursing interventions
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A nurse receives a hand-off report on a female client who had a left-sided stroke with
homonymous hemianopsia. What action by the nurse is most appropriate for this client?
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a.
b.
c.
d.
Assess for bladder and bowel retention and/or incontinence.
Listen to the client’s lungs after eating or drinking for diminished breath sounds.
Support the client’s left side when sitting in a chair or in bed.
Remind the client to move her head from side to side to increase her visual field.
ANS: D
Homonymous hemianopsia is blindness on the same side of both eyes. The client must turn
his or her head to see the entire visual field. This condition is not related to bladder function,
difficulty swallowing, or lack of trunk control.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Stroke, Visual disorders
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
co
client or family is most important for the nurse to obtain?
a. Loss of bladder control
b. Other medical conditions
c. Progression of symptoms
d. Time of symptom onset
m
7. A client with a stroke is being evaluated for fibrinolytic therapy. What information from the
ANS: D
s.
The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5 hours, so the exact time
of symptom onset is the most important information for this client. The other information is
not as critical.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Stroke, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
8. The nurse is preparing to administer IV alteplase for a client diagnosed with an acute ischemic
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stroke. Which statement is correct about the administration of this drug?
a. The recommended time for drug administration is within 90 minutes after
admission to the emergency department.
b. The drug is given in a bolus over the first 3 minutes followed by a continuous
infusion.
c. The maximum dosage of the drug, including the bolus, is 120 mg intravenously.
d. The drug is not given to clients who are already on anticoagulant or antiplatelet
therapy.
ANS: D
Alteplase is a thrombolytic which dissolves clots and can cause bleeding as an adverse effect.
Clients who are already taking an anticoagulant or antiplatelet agent are at risk for bleeding
and therefore they are not candidates for alteplase therapy.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Stroke, Fibrinolytic therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
9. A client is receiving IV alteplase and reports a sudden severe headache. What is the nurse’s
first action?
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a.
b.
c.
d.
Perform a comprehensive pain assessment.
Discontinue the infusion of the drug.
Conduct a neurologic assessment.
Administer an antihypertensive drug.
ANS: B
A severe headache may indicate that the client’s blood pressure has markedly increased and,
therefore, the drug should be stopped immediately as the first action. The nurse would then
perform the appropriate assessments and possibly administer an antihypertensive medication.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Stroke, Fibrinolytic therapy
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
10. A client experiences impaired swallowing after a stroke and has worked with speech–
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language pathology on eating. What nursing assessment best indicates that the
expected outcome for this problem has been met?
a. Chooses preferred items from the menu.
b. Eats 75 to 100% of all meals and snacks.
c. Has clear lung sounds on auscultation.
d. Gains 2 lb (1 kg) after 1 week.
ANS: C
nk
s.
Impaired swallowing can lead to aspiration and then aspiration pneumonia, so the expected
outcome for this problem is to experience no aspiration. Clear lung sounds is the best
indicator that aspiration has not occurred. Choosing menu items is not related to this problem.
Eating meals does not indicate that the client is not still aspirating. A weight gain indicates
improved nutrition but still does not show a lack of aspiration.
ba
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Stroke, Complications
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
11. A male client was admitted with a left-sided stroke this morning. The assistive personnel asks
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about meeting the client’s nutritional needs. Which response by the nurse is appropriate?
a. “He is NPO until the speech–language pathologist performs a swallowing
evaluation.”
b. “You may give him a full-liquid diet, but please avoid solid foods until he gets
stronger.”
c. “Just be sure to add some thickener in his liquids to prevent choking and
aspiration.”
d. “Be sure to sit him up when you are feeding him to make him feel more natural.”
ANS: A
Any client who has or is suspected of having a stroke should have nothing by mouth until he
or she is evaluated for any swallowing problem by the speech–language pathologist (SLP). If
dysphagia is present, the SLP makes specific recommendations for the client’s plan of care
which all staff members must follow to prevent choking and aspiration/aspiration pneumonia.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Stroke, Complications
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
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12. A client is admitted with a diagnosis of cerebellar stroke. What intervention is most
appropriate to include on the client’s plan of care?
a. Ambulate only with a gait belt.
b. Encourage double swallowing.
c. Monitor lung sounds after eating.
d. Perform postvoid residuals.
ANS: A
The client who has a cerebellar stroke would be expected to have ataxia, an abnormal gait. For
the client’s safety, he or she should have assistance and use a gait belt when ambulating.
Ataxia is not related to swallowing, aspiration, or voiding.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Stroke, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
m
13. A nurse is providing community screening for risk factors associated with stroke. Which
co
person would the nurse identify as being at the highest risk for a stroke?
a. A 27-year-old heavy-cocaine user.
b. A 30-year-old who drinks a beer a day.
c. A 40-year-old who uses seasonal antihistamines.
d. A 65-year-old who is active and on no medications.
s.
ANS: A
nk
Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a
risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain
phenylpropanolamine, which also increases the risk for stroke, but this person uses them
seasonally and there is no information that they are abused or used heavily. The 65 year old
has only age as a risk factor.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Stroke, Health screening
MSC: Client Needs Category: Health Promotion and Maintenance
st
14. The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is
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the earliest sign of increasing intracranial pressure (ICP) for this client?
a. Projectile vomiting
b. Dilated and nonreactive pupils
c. Severe hypertension
d. Decreased level of consciousness
ANS: D
The earliest sign of increasing ICP is decreased level of consciousness. The other signs occur
later.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Stroke, Complications
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
15. A client is admitted with a traumatic brain injury. What is the nurse’s priority assessment?
a. Complete neurologic assessment
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b. Comprehensive pain assessment
c. Airway and breathing assessment
d. Functional assessment
ANS: C
Although the client has a brain injury, the most important assessment is to assess the client’s
ABCs, which includes airway, breathing, and circulation. The other assessments are
performed later after the client is stabilized.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Stroke, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
16. A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The
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patient’s spouse is very frustrated, stating that the patient’s personality has changed and the
situation is very difficult. What response by the nurse is most appropriate?
a. Explain that personality changes are common following brain injuries.
b. Ask the client why he or she is acting out and behaving differently.
c. Refer the client and spouse to a head injury support group.
d. Tell the spouse that this is expected and he or she will have to learn to cope.
ANS: A
nk
s.
Personality and behavior often change permanently after head injury. The nurse will explain
this to the spouse. Asking the client about his or her behavior isn’t useful because the patient
probably cannot help it. A referral might be a good idea, but the nurse needs to do something
in addition to just referring the couple. Telling the spouse to learn to cope belittles his or her
concerns and feelings.
ba
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Traumatic brain injury, Therapeutic communication, Coping
MSC: Client Needs Category: Psychosocial Integrity
17. The nurse is caring for four clients with traumatic brain injuries. Which client would the nurse
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assess first?
a. Client with amnesia for the incident
b. Client who has a Glasgow Coma Scale score of 12
c. Client with a PaCO2 of 36 mm Hg and on a ventilator
d. Client who has a temperature of 102° F (38.9° C)
ANS: D
A fever is a poor prognostic indicator in patients with brain injuries. The nurse should see this
client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and amnesia for the incident
are all either expected or positive findings.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Traumatic brain injury, Assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
18. A client with a severe traumatic brain injury has an organ donor card in his wallet. Which
nursing action is appropriate?
a. Request a directive form the client’s primary health care provider.
b. Ask the family if they agree to organ donation for the client.
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c. Wait until brain death is determined before acting on organ donation.
d. Contact the local organ procurement organization as soon as possible.
ANS: D
The appropriate nursing action is to respect the client’s desire to be an organ donor and
contact the local organ procurement organization even if family members do not agree. In
most agencies, the primary health care provider does not have to write an order or directive to
approve the organ donation. Family consent is not required.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Traumatic brain injury, Brain death
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
19. After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes,
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m
acute confusion, and restlessness. The client has IV fluids running at 75 mL/hr. What action
by the nurse would the nurse take first?
a. Assess the client’s urinary output.
b. Assess the client’s serum sodium level.
c. Increase the rate of the IV infusion.
d. Provide oral care every hour.
ANS: B
nk
s.
This client has signs and symptoms of hypernatremia, which is a possible complication after
craniotomy. The nurse would assess the client’s serum sodium level first and then possibly
increase the rate of the IV infusion. Providing oral care is also a good option but does not take
priority over assessing laboratory results.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Craniotomy, Complications
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
20. A client who had therapeutic hypothermia after a traumatic brain injury is slowly rewarmed to
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a normal core temperature. For which assessment finding would the nurse monitor during the
rewarming process?
a. Cardiac dysrhythmias
b. Loss of consciousness
c. Nausea and vomiting
d. Fever
ANS: A
Due to fluid and electrolyte changes that typically occur during the rewarming process, the
nurse monitors for cardiac dysrhythmias. The other findings are not common during this
process.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Traumatic brain injury, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
21. A client who is experiencing a traumatic brain injury has increasing intracranial pressure
(ICP). What drug will the nurse anticipate to be prescribed for this client?
a. Phenytoin
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b. Lorazepam
c. Mannitol
d. Morphine
ANS: C
Increased intracranial pressure is often the result of cerebral edema as a result of traumatic
brain injury. Therefore, as osmotic diuretic such as mannitol or a loop diuretic like furosemide
is administered. The other drugs are not appropriate to manage increasing ICP.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Traumatic brain injury, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
22. A client has a brain tumor and is receiving phenytoin (Dilantin). The spouse questions the use
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of the drug, saying that the client does not have a seizure disorder. What response by the nurse
is correct?
a. “Increased pressure from the tumor can cause seizures.”
b. “Preventing febrile seizures with a tumor is important.”
c. “Seizures always occur in clients with brain tumors.”
d. “This drug is used to sedate with a brain tumor.”
ANS: A
s.
Brain tumors can lead to seizures as a complication. The nurse would explain this to the
spouse. Preventing febrile seizures is not related to a tumor. Seizures are possible but do not
always occur in clients with brain tumors. This drug is not used for sedation.
nk
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Brain tumor, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
ba
MULTIPLE RESPONSE
1. The nurse is assessing a client who has symptoms of stroke. What are the leading causes of a
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stroke for which the nurse would assess for this client? (Select all that apply.)
a. Heavy alcohol intake
b. Diabetes mellitus
c. Elevated cholesterol
d. Obesity
e. Smoking
f. Hypertension
ANS: A, B, C, D, E, F
The leading causes of stroke include all of these factors.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Stroke, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. Based on the known risk factors for stroke, which health promotion practices would the nurse
teach a client to promote heart health and prevent strokes? (Select all that apply.)
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a.
b.
c.
d.
e.
f.
Blood pressure control
Aspirin use
Smoking cessation
Low carbohydrate diet
Cholesterol management
Increased red wine consumption
ANS: A, B, C, E
The evidence-based health promotion practices include blood pressure control, aspirin use,
smoking cessation, and cholesterol management. There is no consensus on which diet is best
to promote heart health and red wine does not protect the heart or prevent strokes.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Stroke, Health promotion
MSC: Client Needs Category: Health Promotion and Maintenance
s.
co
findings will the nurse expect? (Select all that apply.)
a. Ataxia
b. Dysphagia
c. Aphasia
d. Apraxia
e. Hemiparesis/hemiplegia
f. Ptosis
m
3. A client is admitted with a confirmed left middle cerebral artery occlusion. Which assessment
ANS: B, C, D, E, F
nk
All of these assessment findings are common in clients who have a stroke caused by an
occlusion of the left middle cerebral artery with the exception of ataxia (most often present in
clients who have cerebellar strokes). This artery supplies the majority of the left side of the
brain where motor, sensory, speech, and language centers are located.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Stroke, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
st
4. The nurse is preparing for discharge of a client who had a carotid artery angioplasty with
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stenting to prevent a stroke. For which signs and symptoms with the nurse teach the family to
report to the primary health care provider immediately? (Select all that apply.)
a. Muscle weakness
b. Hoarseness
c. Acute confusion
d. Mild neck discomfort
e. Severe headache
f. Dysphagia
ANS: A, B, C, E, F
Muscle weakness, acute confusion, severe headache, and dysphagia are all signs and
symptoms that could indicate that a stroke occurred. Hoarseness and severe neck pain and
swelling may occur as a result of the interventional radiologic procedure.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Stroke, Interventional radiological procedures
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MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. The nurse is caring for a client with increasing intracranial pressure (ICP) following a stroke.
Which evidence-based nursing actions are indicated for this client? (Select all that apply.)
a. Hyperoxygenate the client before and after suctioning.
b. Avoid sudden or extreme hip or neck flexion.
c. Provide oxygen to maintain an SaO2 of 95% or greater.
d. Maintain the client in a supine position at all times.
e. Avoid clustering care nursing activities and procedures.
f. Provide environmental stimulation to improve cognition.
ANS: A, B, C, E
These precautions help prevent further increases in ICP. Clustering nursing activities and
procedures and providing stimulation can increase ICP and should be avoided.
m
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Stroke, Complications
MSC: Client Needs Category: Physiological Adaptation: Reduction of Risk Potential
6. A nurse cares for older clients who have traumatic brain injury. What does the nurse
s.
co
understand about this population? (Select all that apply.)
a. Admission can overwhelm the coping mechanisms for older clients.
b. Alcohol is typically involved in most traumatic brain injuries for this age-group.
c. These clients are more susceptible to systemic and wound infections.
d. Other medical conditions can complicate treatment for these clients.
e. Very few traumatic brain injuries occur in this age-group.
nk
ANS: A, C, D
ba
Older adults often tolerate stress poorly, which includes being admitted to a hospital that is
unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible
to both local and systemic infections. Other medical conditions can complicate their treatment
and recovery. Alcohol is typically not related to traumatic brain injury in this population; such
injury is most often from falls and motor vehicle crashes.
st
DIF: Understanding
TOP: Integrated Process: Culture and Spirituality
KEY: Traumatic brain injury, Developmental stages
MSC: Client Needs Category: Health Promotion and Maintenance
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7. A nurse is caring for a group of stroke patients. Which clients would the nurse consider
referring to a mental health provider? (Select all that apply.)
a. Female client who exhibits extreme emotional lability
b. Male client with an initial National Institutes of Health (NIH) Stroke Scale score of
38
c. Female client with mild forgetfulness and a history of depression
d. Male client who has a past hospitalization for a suicide attempt
e. Male client who is unable to walk or eat 3 weeks poststroke
ANS: A, B, C, D, E
Patients most at risk for poststroke depression are those with a previous history of depression,
severe stroke (NIH Stroke Scale score of 38 is severe), and poststroke physical or cognitive
impairment.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Stroke, Psychosocial assessment
MSC: Client Needs Category: Psychosocial Integrity
8. A nurse is discharging a client from the emergency department who has a mild traumatic brain
injury. What information obtained from the client represents a possible barrier to
self-management? (Select all that apply.)
a. Does not want to purchase a thermometer.
b. Is allergic to acetaminophen.
c. Laughing, says “Strenuous? What’s that?”
d. Lives alone and is new in town with no friends.
e. Plans to have a beer and go to bed once home.
ANS: B, D, E
co
m
Clients who have mild traumatic brain injuries should take acetaminophen for headache. An
allergy to this drug may mean that the patient takes aspirin or ibuprofen, which should be
avoided. The patient needs neurologic checks every 1 to 2 hours, and this client does not seem
to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A
thermometer is not needed. The patient laughing at strenuous activity probably does not
engage in any kind of strenuous activity, but the nurse should confirm this.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Traumatic brain injury, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
s.
9. The nurse assesses a client who has a mild traumatic brain injury (TBI) for signs and
ANS: A, B
ba
nk
symptoms consistent with this injury. What signs and symptoms does the nurse expect?
(Select all that apply.)
a. Sensitivity to light and sound
b. Reports “feeling foggy”
c. Unconscious for an hour after injury
d. Elevated temperature
e. Widened pulse pressure
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e
st
A mild TBI would possibly lead to sensitivity to light and sound and a feeling of mental
fogginess. The patient would have been unconscious for less than 30 minutes. An elevated
temperature is not related. A widened pulse pressure is indicative of increased intracranial
pressure, not a mild TBI.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Traumatic brain injury, Assessment, Brain injury
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. The nurse would recognize which signs and symptoms as consistent with brainstem tumors?
(Select all that apply.)
a. Hearing loss
b. Facial pain
c. Nystagmus
d. Vomiting
e. Hemiparesis
ANS: A, B, C
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Hearing loss (CN VIII), facial pain (CN V), and nystagmus (CN III, IV, and VI) all are
indicative of a brainstem tumor because these cranial nerves originate in the brainstem.
Vomiting and hemiparesis are more indicative of cerebral tumors.
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ba
nk
s.
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m
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Brain tumor, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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Chapter 42: Assessment and Care of Patients With Eye and Vision Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is teaching a group of older adults about basic eye examinations. What would the
nurse recommend about the frequency for eye examinations for most people over 65 years of
age?
a. Every 1 to 2 years
b. Every 2 to 4 years
c. Every 3 to 5 years
d. When the primary health care provider recommends
ANS: A
m
Older adults need more frequent basic eye examinations due to the increased risk of glaucoma
and cataracts associated with aging. Therefore, every 1 to 2 years for eye examination in the
current best practice recommendation.
co
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Eye and vision health, Eye examinations
MSC: Client Needs Category: Health Promotion and Maintenance
s.
2. A client with a family history of glaucoma asks the nurse how to prevent glaucoma? What
ANS: C
ba
nk
statement by the nurse is appropriate?
a. “You should check with your primary health care provider about eye
examination.”
b. “You should have genetic testing to determine your risk for glaucoma.”
c. “You should have your intraocular pressure measured once or twice a year.”
d. “You should check with your primary health care provider about preventive drug
therapy.”
st
Glaucoma tends to occur more often in clients who have a family history but cannot be
prevented. Genetic testing is not the best response because the client’s family history is
already known. Therefore, early detection by having intraocular pressure measured frequently.
Bt
e
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Glaucoma, Health promotion
MSC: Client Needs Category: Health Promotion and Maintenance
3. A client presents to the emergency department reporting a foreign body in the eye. For what
diagnostic testing would the nurse prepare the client?
a. Corneal staining
b. Fluorescein angiography
c. Ophthalmoscopy
d. Tonometry
ANS: A
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Corneal staining is used when the possibility of eye trauma exists, including a foreign body.
Fluorescein angiography is used to assess problems of retinal circulation. Ophthalmoscopy
looks at both internal and external eye structures. Tonometry tests the intraocular pressure.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Eye trauma, Diagnostic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. The nurse enters an examination room to help with an eye assessment. The client is directed
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toward the chart shown below:
nk
s.
What is the primary health care provider assessing?
a. Color vision
b. Depth perception
c. Spatial perception
d. Visual acuity
ANS: A
ba
This is an Ishihara chart, which is used for assessing color vision. Depth and spatial
perception are not typically assessed in a routine vision assessment. Visual acuity is usually
tested with a Snellen chart.
st
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Eye and vision examination, Assessment
MSC: Client Needs Category: Health Promotion and Maintenance
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5. The nurse assesses a client for factors that place the client at risk for cataracts. Which factor
places the client at the highest risk for cataract development?
a. Heart disease
b. Glaucoma
c. Diabetes mellitus
d. Advanced age
ANS: D
Advanced age is the major risk factor for developing cataracts because the lens loses water
and lens fibers become more compact.
DIF: Remembering
KEY: Cataracts, Assessment
TOP: Integrated Process: Nursing Process: Assessment
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MSC: Client Needs Category: Health Promotion and Maintenance
6. The nurse is teaching about signs and symptoms of cataracts. Which change would the nurse
emphasize as possibly indicating beginning cataract formation?
a. Diplopia
b. Cloudy pupil
c. Loss of peripheral vision
d. Blurred vision
ANS: D
A cloudy pupil is a sign of late cataracts and loss of peripheral vision is more common in
clients who have glaucoma. Diplopia occurs with a number of neurologic diseases. Blurred
vision is the earliest sign that the lens of the eye is undergoing changes.
m
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Cataracts, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. The nurse is teaching a client about cataract surgery. Which statement would the nurse include
s.
co
as part of preoperative preparation?
a. “You will receive general anesthesia for the surgical procedure.”
b. “You will be in the hospital for only 1 to 2 days if everything goes as expected.”
c. “You will need to put several types of eyedrops in your eyes before and after
surgery.”
d. “You will be on bedrest for about a week after the surgical procedure.”
ANS: C
nk
Cataract surgery is done as an ambulatory care procedure and the client is not hospitalized,
does not receive general anesthesia, and does not need to be on bedrest postoperatively.
ba
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Cataract, Perioperative care
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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st
8. A client’s intraocular pressure (IOP) is 28 mm Hg. What action would the nurse anticipate?
a. Educate the client on corneal transplantation.
b. Facilitate scheduling the eye surgery.
c. Teach about drugs for glaucoma.
d. Refer the patient to local Braille classes.
ANS: C
This increased IOP indicates glaucoma. The nurse’s main responsibility is teaching the client
about drug therapy. Corneal transplantation is not used in glaucoma. Eye surgery is not
indicated at this time. Braille classes are also not indicated at this time.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Glaucoma, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
9. A client had a retinal detachment and has undergone surgical correction. What discharge
health teaching is most important for the nurse to include?
a. “Avoid reading, writing, or close work such as sewing.”
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b. “Report immediate loss of vision of pain in the affected eye.”
c. “Keep the follow-up appointment with the ophthalmologist.”
d. “Remove your eye patch every hour for eyedrops.”
ANS: B
After surgery for retinal detachment, the client is advised to avoid reading, writing, and close
work because these activities cause rapid eye movements. However, more importantly is the
need for the client or family to report loss of vision or pain in the surgical eye. Keeping a
postoperative appointment is important for any surgical patient. The eye patch is not removed
for eyedrops after retinal detachment repair.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Retinal detachment, Perioperative care
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
10. A client has a foreign body in one eye. What action by the nurse is appropriate for the
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client’s care?
a. Administering ordered antibiotics
b. Assessing the patient’s visual acuity
c. Obtaining consent for enucleation
d. Removing the object immediately
ANS: A
s.
To prevent infection, antibiotics are provided. Visual acuity in the affected eye cannot be
assessed. The client may or may not need enucleation. The object is only removed by the
ophthalmologist.
nk
DIF: Applying TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Eye trauma, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
ba
11. A client who is nearly blind is admitted to the hospital. What action by the nurse is most
ANS: C
st
important?
a. Allow the client to feel his or her way around.
b. Let the client arrange objects on the bedside table.
c. Orient the client to the room using a focal point.
d. Speak loudly and slowing when talking to the client.
Bt
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Using a focal point, orient the client to the room by giving descriptions of items as they relate
to the focal point. Letting the client arrange the bedside table is appropriate, but not as
important as orienting the client to the room for safety. Allowing the client to just feel around
may cause injury. Unless the client is also hearing impaired, use a normal tone of voice.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Decreased visual acuity, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
12. A client is taking timolol eyedrops. The nurse assesses the client’s pulse at 48 beats/min.
What action by the nurse is the priority?
a. Ask the client about excessive salivation.
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b. Take the client’s blood pressure and temperature.
c. Give the drops using punctal occlusion.
d. Hold the eyedrops and notify the primary health care provider.
ANS: D
The nurse would hold the eyedrops and notify the primary health care provider because beta
blockers can slow the heart rate. Excessive salivation can occur with cholinergic agonists.
Taking the blood pressure and temperature are not necessary. If the drops are given, the nurse
uses punctal occlusion to avoid systemic absorption.
DIF: Applying
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Glaucoma, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
13. A client has been prescribed brinzolamide for glaucoma. What assessment by the nurse
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requires communication with the primary health care provider?
a. Allergy to eggs
b. Allergy to sulfonamides
c. Use of contact lenses
d. Use of beta blockers
ANS: B
s.
Brinzolamide is similar to sulfonamides, so an allergic reaction could occur. The other
assessment findings are not related to brinzolamide.
nk
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Glaucoma, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
14. A client is brought to the emergency department after a car crash. The client has a large piece
st
ANS: B
ba
of glass in the left eye. What action by the nurse takes priority?
a. Administer a tetanus booster shot.
b. Ensure that the client has a patent airway.
c. Prepare to irrigate the client’s eye.
d. Turn the client on the unaffected side.
Bt
e
Airway always comes first. After ensuring a patent airway and providing cervical spine
precautions (do not turn the client to the side), the nurse provides other care that may include
administering a tetanus shot. The client’s eye may or may not be irrigated.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Eye trauma, Primary survey
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
15. A nurse is seeing clients in the ophthalmology clinic. Which client would the nurse see first?
a. Client with intraocular pressure reading of 24 mm Hg
b. Client with a tearing, reddened eye with exudate
c. Client whose red reflex is absent on ophthalmologic examination
d. Client who has had cataract surgery and has worsening vision
ANS: D
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After cataract surgery, worsening vision indicates a postoperative infection or other
complication. The nurse would see this client first. The intraocular pressure is slightly
elevated. An absent red reflex may indicate cataracts. The client who has the tearing eye may
have an infection.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Eye and visual disorders, Prioritization
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. The nurse teaches assistive personnel about age-related changes that affect the eyes and
m
vision. Which changes would the nurse include? (Select all that apply.)
a. Decreased eye muscle tone
b. Development of arcus senilis
c. Increase in far point of near vision
d. Decrease in general color perception
e. Increase in point of near vision
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ANS: A, B, D, E
s.
Normal age-related changes include decreased eye muscle tone, development of arcus senilis,
decreased color perception, and increased point of near vision. The far point of near vision
typically decreases.
nk
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Eye and vision health, Developmental stage
MSC: Client Needs Category: Health Promotion and Maintenance
2. The nurse is teaching a group of adults about ways to prevent early cataract formation. What
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health teaching would the nurse include? (Select all that apply.)
a. “Wear eye and head protection when playing sports.”
b. “Be sure to get 7 to 8 hours of sleep each night.”
c. “Drink less carbonated beverages, especially those with caffeine.”
d. “Wear sunglasses when going outdoors or in ultraviolet light.”
e. “Increase consumption of high-protein, low-carbohydrate foods.”
f. “Avoid smoking or participate in a smoking cessation program.”
ANS: A, D, F
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Although all of these choices are strategies for overall health promotion. Wearing eye and
head protection and sunglasses, and avoiding or quitting smoking are specific strategies to
promote eye health. Cataracts may occur earlier in a client’s life if these recommendations are
not followed.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Eye and vision health, Health promotion
MSC: Client Needs Category: Health Promotion and Maintenance
3. The nurse is teaching a client about preventing intraocular pressure increase after cataract
surgery. Which health teaching would the nurse include? (Select all that apply.)
a. “Don’t lift objects weighing more than 20 lb (9.1 kg).”
b. “Avoid blowing your nose or sneezing.”
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c.
d.
e.
f.
“Don’t bend down from the waist.”
“Don’t strain to have a bowel movement.”
“Avoid having sexual intercourse.”
“Don’t wear tight shirt or blouse collars.”
ANS: B, C, D, E, F
All of these precautions can help prevent an increase in intraocular pressure except that the
client should not lift anything weighing more than 10 lb (4.5 kg).
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Cataract, Perioperative care
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. The nurse is teaching a client and family regarding symptoms to report to the primary health
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care provider after cataract surgery. Which symptoms would the nurse include in the
teaching? (Select all that apply.)
a. Sharp sudden pain in the surgical eye
b. Green or yellow discharge from the surgical eye
c. Eyelid swelling of the surgical eye
d. Decreased vision in the surgical eye
e. Blindness in the surgical eye
f. Flashes or floaters seen in the surgical eye
ANS: A, B, C, D, E, F
s.
All of these symptoms are not normal and should be reported immediately to the surgeon or
other appropriate primary health care provider.
nk
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Cataract, Perioperative care
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
ba
5. The nurse is assessing a client admitted to the emergency department with possible retinal
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detachment. What assessment findings would the nurse expect? (Select all that apply.)
a. Presence of bright light flashes
b. Decreased visual field in affected eye
c. Feeling like a curtain is over one eye
d. Gradual changes in visual acuity
e. Painful throbbing in the affected eye
ANS: A, B, C
Changes that occur in clients experiencing retinal detachment are usually sudden and painless.
Typical changes that occur include bright light flashes, sudden decrease in visual filed, and a
feeling like a curtain is over all or part of the affected eye.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Retinal detachment, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. The nurse is teaching a client about care after surgery to repair a retinal detachment. What
health teaching would the nurse include? (Select all that apply.)
a. “Report sudden pain in the surgical eye.”
b. “Report if the surgical eye remains dilated.”
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c. “Avoid close vision activities in the first week.”
d. “Avoid activities that increase intraocular pressure.”
e. “Report sudden reduced visual acuity.”
ANS: A, B, C, D, E
All of these instructions are important for the client who has a retinal detachment repair.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Retinal detachment, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. The nurse is teaching a client about postoperative care after a LASIK procedure. Which
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common complications/adverse effects could occur either immediately or later after this type
of surgery? (Select all that apply.)
a. Halos around lights
b. Blurred vision
c. Blindness
d. Infection
e. Dry eyes
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ANS: A, B, D, E
All of these common problems can occur after LASIK surgery except for blindness. Some
decrease in visual acuity can occur, however.
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ba
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s.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Refraction errors, Perioperative care
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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Chapter 43: Assessment and Care of Patients With Ear and Hearing Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is teaching a client about ear hygiene and health. Which statement by the client
indicates a need for further teaching?
a. “A soft cotton swab is alright to clean my ears with.”
b. “I make sure my ears are dry after I go swimming.”
c. “I use good earplugs when I practice with the band.”
d. “Keeping my diabetes under control helps my hearing.”
ANS: A
m
Clients should be taught not to put anything larger than their fingertip into their ears. Using a
cotton swab, although soft, can cause damage to the ears and cerumen buildup. The other
statements are accurate.
co
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Ear and hearing health, Assessment
MSC: Client Needs Category: Health Promotion and Maintenance
2. The nurse is teaching new assistive personnel (AP) about caring for older adults. Which
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statement would the nurse include about hearing ability of this client group?
a. “You need to talk very loudly when communicating with these clients.”
b. “You always need to check each client’s ears for excess ear wax.”
c. “Remember to face the client when talking with him or her.”
d. “Assess each client’s hearing ability using the voice or whisper test.”
ANS: C
ba
Losing one’s hearing is not a normal change of aging although high frequency sounds may be
more difficult to hear. AP does not perform assessments and it is not necessary to talk loudly
or shout unless a hearing impairment exists. Therefore, facing the client is the best strategy
when communicating with most older adults.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Hearing assessment, Developmental stage
MSC: Client Needs Category: Health Promotion and Maintenance
3. The client’s electronic health record indicates a sensorineural hearing loss. What assessment
question does the nurse ask to determine the possible cause?
a. “Do you feel like something is in your ear?”
b. “Do you have frequent ear infections?”
c. “Have you been exposed to loud noises?”
d. “Have you been told your ear bones don’t move?”
ANS: C
Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or
the brain. Exposure to loud music is one etiology. The other questions are related to
conductive hearing loss.
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
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KEY: Ear and hearing problems, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A client has external otitis. About what comfort measure would the nurse instruct the client?
a. Applying ice four times a day
b. Instilling vinegar-and-water drops
c. Use of a heating pad to the ear
d. Using a home humidifier
ANS: C
A heating pad on low or a warm moist pack can provide comfort to the client with otitis
externa. The other options are not appropriate.
DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Otitis media, Comfort measures
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
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week. What action by the nurse is most appropriate?
a. Assess for cerumen buildup.
b. Facilitate audiological testing.
c. Perform tuning fork tests.
d. Review the medication list.
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5. An older adult in the family practice clinic reports a decrease in hearing in one ear for over a
s.
ANS: A
nk
All options are possible actions for the client with hearing loss. The first action the nurse
would take is to look for cerumen buildup, which can decrease hearing in the older adult. If
this is normal, medications would be assessed for ototoxicity. Further auditory testing may be
needed for this patient.
ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Ear and hearing problems, Assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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6. A client had a myringotomy. What would the nurse include as part of discharge teaching?
a. Buy dry shampoo to use for a week.
b. Drink liquids through a straw.
c. Flying is not allowed for 1 month.
d. Hot water showers will help the pain.
ANS: A
The client cannot shower or get the head wet for 1 week after surgery, so using dry shampoo
is a good suggestion. The other instructions are incorrect: straws are not allowed for 2 to 3
weeks, flying is not allowed for 2 to 3 weeks, and the client should not shower.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Ear and hearing problems, Perioperative care
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. A nurse is teaching a community group about noise-induced hearing loss. Which client who
does not use ear protection would the nurse refer to an audiologist as the priority?
a. Client with an hour car commutes on the freeway each day.
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b. Client who rides a motorcycle to work 20 minutes each way.
c. Client who sat in the back row at a rock concert recently.
d. Client who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day.
ANS: D
A chainsaw becomes dangerous to hearing after several hours of exposure without hearing
protection. This client needs to be referred as the priority. Normal car traffic and motorcycle
noise is safe unless for a very long time. Although a client was at a rock concert, he or she
was in the back row and had less exposure. In addition, a one-time exposure is less damaging
than chronic exposure.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Ear and hearing problems, Referral
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
8. A client who has had cold symptoms for a week visits the local urgent care center with report
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of left ear discomfort, dizziness, and decreased hearing. What additional assessment findings
would the nurse expect?
a. High fever
b. Nausea and vomiting
c. Elevated blood pressure
d. Purulent ear drainage
ANS: D
nk
s.
The client presents with symptoms that indicate possible serous otitis or otitis media. In either
case, the client would not have a high fever or blood pressure. Nausea and vomiting are not
common with either diagnosis, but purulent ear drainage is likely to occur if the tympanic
eardrum perforates. The client’s decreased hearing could indicate that perforation already
occurred.
ba
DIF: Analyzing
TOP: Integrated Process: Assessment
KEY: Otitis media, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. The nurse is teaching a client about factors that can cause external otitis. Which of these
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factors would the nurse emphasize as the highest risk?
a. Excess cerumen
b. Swimming
c. Sinus congestion
d. Meniere disease
ANS: B
External otitis is often called “swimmer’s ear” because it is most often caused by swimming
in lakes, ponds, and untreated pools.
DIF: Remembering
TOP: Integrated Process: Assessment
KEY: Ear and hearing problems, Assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
10. A nurse is teaching a community group about preventing hearing loss. What instruction is
appropriate?
a. “Always wear a bicycle helmet.”
b. “Avoid swimming in ponds or lakes.”
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c. “Don’t attend fireworks shows.”
d. “Use a cerumen spoon to clean ears.”
ANS: A
Avoiding head trauma is a practical way to help prevent hearing loss. Swimming can lead to
hearing loss only if the client has repeated infections. Fireworks displays/shows are loud, but
usually brief and only occasional. A cerumen spoon is only used by primary health care
providers to remove ear wax from in the ear canal.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Ear and hearing problems, Health promotion
MSC: Client Needs Category: Health Promotion and Maintenance
appropriate?
a. Advise the client to take antianxiety medication.
b. Educate the client on nerve-cutting procedures.
c. Refer the client to online or local support groups.
d. Refer the client to a mental health professional.
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ANS: C
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11. A client has severe tinnitus that has not responded to treatment. What action by the nurse is
s.
If the client’s tinnitus cannot be treated, he or she will need to learn how to cope with it.
Referring the client to tinnitus support groups can be helpful. The other options are not
warranted.
nk
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Tinnitus, Referral
MSC: Client Needs Category: Psychosocial Integrity
12. A client has mastoiditis and is prescribed antibiotics. What health teaching by the nurse is
ANS: A
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most important for this client?
a. “Immediately report headache or stiff neck.”
b. “Keep all follow-up appointments.”
c. “Take the antibiotics with a full glass of water.”
d. “Take the antibiotic on an empty stomach.”
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Meningitis is a complication of mastoiditis. The client should be taught to take all antibiotics
as prescribed and to report manifestations of meningitis such as fever, headache, or stiff neck.
Keeping follow-up appointments is important for all clients. Without knowing what antibiotic
was prescribed, the nurse cannot instruct the client on how to take it.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Mastoiditis, Infection control
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
13. A client with Ménière disease is in the hospital when the client has an episode of this disorder.
What action by the nurse is appropriate?
a. Assess vital signs every 15 minutes.
b. Dim or turn off lights in the client’s room.
c. Place the client in bed with the upper side rails up.
d. Provide a cool, wet cloth for the client’s face.
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ANS: C
Clients with Ménière disease can have vertigo so severe that they can fall. The nurse would
assist the client into bed and put the side rails up to keep the client from falling out of bed due
to the intense whirling feeling. The other actions are not warranted for clients with Ménière
disease.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Meniere disease, Client safety
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
14. A client is scheduled to have a tumor of the middle ear removed. Which perioperative health
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teaching is most important for the nurse to include?
a. Expecting hearing loss in the affected ear
b. Managing postoperative pain
c. Maintaining NPO status prior to surgery
d. Understanding which medications are allowed the day of surgery
ANS: A
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Removal of an inner ear tumor will likely destroy hearing in the affected ear. The other
teaching topics are appropriate for any surgical client.
s.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Ear and hearing problems, Perioperative care
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
15. The nurse is teaching an older adult how to prevent buildup of ear wax. Which statement by
ANS: D
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the nurse is most appropriate?
a. “Visit your primary health care provider each month for wax removal.”
b. “Drink plenty of water and other liquids to prevent hardening of the ear wax.”
c. “Irrigate each ear once a month to remove wax and prevent was buildup.”
d. “Put one drop of mineral oil in each ear once a week at bedtime.”
st
Mineral oil provides lubrication to soften cerumen so that it flows out of the ears to prevent
buildup. It is a safer method than irrigating the ears. If needed, the client would need to go to a
primary health care provider for removal of impaction. Drinking water helps prevent
hardening of wax but does not necessarily prevent wax buildup.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Ear and hearing problems, Developmental stage
MSC: Client Needs Category: Health Promotion and Maintenance
16. The nurse is assessing a client’s medication profile to determine risk for tinnitus. Which drug
classification is most likely to cause this health problem?
a. Cephalosporins
b. NSAIDs
c. Beta-adrenergic blockers
d. Osmotic diuretics
ANS: B
None of these drug classifications except for NSAIDs pose a risk to clients for tinnitus as a
side effect.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Tinnitus, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
MULTIPLE RESPONSE
1. A client is scheduled for a tympanoplasty. What action(s) by the nurse are (is) most
appropriate? (Select all that apply.)
a. Administer preoperative opioids.
b. Assess for allergies to local anesthetics.
c. Ensure that informed consent is on the health record.
d. Give prescribed antivertigo medications.
e. Teach that hearing improves immediately.
ANS: C
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Preoperatively, the nurse ensures that informed consent is in the health record. Local
anesthetics can be used, but general anesthesia is used more often. Antivertigo medications
are not used. Hearing will be decreased immediately after the operation until the ear packing
is removed.
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Ear and hearing problems, Perioperative care
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
2. A client has a hearing aid. What care instructions does the nurse provide the assistive
ANS: A, C, D, F
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personnel (AP) in the care of this client? (Select all that apply.)
a. “Be careful not to drop the hearing aid when handling.”
b. “Soak the hearing aid in hot water for 20 minutes.”
c. “Turn the hearing aid off when the client goes to bed.”
d. “Use a toothpick to clean debris from the device.”
e. “Wash the device with soap and a small amount of warm water.”
f. “Avoid using hair or cosmetic products near the hearing aid.”
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All these actions except using water are proper instructions for the nurse to give to the AP.
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DIF: Understanding
TOP: Integrated Process: Communication and Documentation
KEY: Ear and hearing problems, Assistive devices
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
3. A hospitalized client has a new diagnosis of Ménière disease. What would the nurse include in
health teaching to reduce symptoms for this disorder? (Select all that apply.)
a. “Apply heat to the ear for 20 minutes three times a day.”
b. “Move the head slowly to prevent worsening of the vertigo.”
c. “Avoid food additives such as monosodium glutamate (MSG).”
d. “Quit smoking to increase blood flow to the inner ear.”
e. “Avoid caffeinated beverages.”
f. “Avoid standing on chairs, step stools, or ladders.”
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ANS: B, C, D, E, F
Ménière disease is an excess of endolymphatic fluid that distorts the entire inner-canal system
causing vertigo, tinnitus, and unilateral hearing loss. Applying heat or irrigating the ear canal
will not alleviate symptoms. Moving the head slowly will prevent worsening of the vertigo.
The diet recommendations for Ménière disease include avoiding caffeine and certain food
additives. Smoking causes constriction of blood vessels and decreased blood flow to the inner
ear. Clients should also avoid standing on high surfaces to prevent vertigo and falls.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Meniere disease, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. The nurse is caring for a client after ear surgery. What health teaching instruction(s) would the
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nurse provide for this client to promote healing? (Select all that apply.)
a. “Avoid straining when having a bowel movement.”
b. “Avoid drinking through a straw for 2 to 3 weeks.”
c. “Avoid air travel for 2 to 3 weeks after surgery.”
d. “Avoid crowds and people with infection, especially respiratory infection.”
e. “Avoid moving your head quickly, jumping, or bending over for 2 to 3 weeks.”
f. “Blow your nose very gently without blocking either nostril and keep your mouth
open.”
ANS: A, B, C, D, E, F
nk
s.
It is imperative that the patient having ear surgery is free from ear infection. The other
precautions help to prevent increased intra-ear pressure which can affect the surgical
procedure.
DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Ear and hearing problems, Perioperative care
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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5. The nurse is teaching a family member who is caring for a client who is hearing impaired.
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What health teaching would the nurse include about communicating with the client? (Select
all that apply.)
a. “Make sure that the room is well lighted.”
b. “Speak slowly and clearly.”
c. “Do not shout but you may need to speak loudly.”
d. “Have conversations in a quiet room with minimal noise.”
e. “Get the client’s attention before you begin to speak.”
f. “Move closer to the better hearing ear if possible.”
ANS: A, B, C, D, E, F
All of these recommendations are useful when communicating with clients who are hearing
impaired.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Hearing Loss, Impairment, Communication Physiological Integrity: Physiological Adaptation
MSC: Client Needs Category: Health Promotion and Maintenance
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Chapter 44: Assessment of the Musculoskeletal System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. The nurse is caring for an older client who has kyphosis and a widened gait. For which health
problems is the client at risk?
a. Osteoporosis
b. Contracture
c. Osteopenia
d. Falls
ANS: D
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Kyphosis is caused by bone loss and causes the client to bend forward which changes the
center of gravity leading to problems with balance. Older adults who have balance issues are
at risk for falls.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Spinal deformities
MSC: Client Needs Category: Health Promotion and Maintenance
2. The nurse is teaching assistant personnel (AP) about care of an older ambulatory adult who
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has osteopenia. Which statement by the AP indicates understanding of the teaching?
a. “I will tell the client to change positions frequently to prevent pressure injury.”
b. “I will remind the client to take frequent walks to strengthen bones.”
c. “I will assist the client with activities of daily living as needed.”
d. “I will apply warm compresses to the joints to relieve pain.”
ANS: B
ba
The ambulatory client who has osteopenia has experienced bone loss. Therefore, taking walks
as a weight-bearing exercise helps to prevent further bone loss. The client does not have joint
pain and does not need assistance or position changes because the client is ambulatory and
probably independent.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Health promotion
MSC: Client Needs Category: Health Promotion and Maintenance
3. A client had an arthroscopy 1 hour ago on the left knee. The nurse finds the left lower leg to
be pale and cool, with a 1+ pedal pulse. What action would the nurse perform first?
a. Assess the neurovascular status of the right leg.
b. Document the findings in the patient’s chart.
c. Elevate the left leg on at least two pillows.
d. Notify the primary health care provider immediately.
ANS: A
The nurse would compare findings of the two legs as these findings may be normal for the
client. If a difference is observed, the nurse would then notify the primary health care
provider. Documentation would occur after the nurse has all the data. Elevating the left leg
will not improve perfusion if there is a problem.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Diagnostic tests
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. A hospitalized client’s strength of the upper extremities is rated at a 4. What does the nurse
understand about this client’s ability to perform activities of daily living (ADLs)?
a. The client is able to perform ADLs but not lift some items.
b. The client is unable to perform ADLs alone.
c. No difficulties are expected with ADLs.
d. The client would need almost total assistance with ADLs.
ANS: C
This rating indicates good muscle strength with full range of motion.
m
DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Muscle strength
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. An older client is distressed at body changes related to kyphosis. What response by the nurse
s.
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is appropriate?
a. Ask the client to explain more about these feelings.
b. Explain that these changes are irreversible.
c. Offer to help select clothes to hide the deformity.
d. Tell the client that safety is more important than looks.
ANS: A
ba
nk
Assessment is the first step of the nursing process, and the nurse would begin by getting as
much information about the client’s feelings as possible. Explaining that the changes are
irreversible discounts the client’s feelings. Depending on the extent of the deformity, clothing
will not hide it. While safety is more objectively important than looks, the client is worried
about looks and the nurse needs to address this issue.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Psychosocial assessment
MSC: Client Needs Category: Psychosocial Integrity
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6. The nurse is taking a history from an older client who reports having frequent falls. Which
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dietary habit could be contributing to the client’s problem?
a. Consumes high-protein foods.
b. Eats few concentrated sweets.
c. Limits fatty or greasy foods.
d. Avoids dairy products.
ANS: D
Falls can occur when older adults have inadequate calcium and Vitamin D because they are at
risk for osteopenia and osteoporosis. Dairy products have a high concentration of both
calcium and Vitamin D and this client avoids those foods. High-protein foods are
recommended to help prevent osteopenia and sweets and fatty/greasy foods have no impact on
bone health.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Changes associated with aging
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MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
7. The client’s electronic health record indicates genu varum. What does the nurse understand
this term to mean?
a. Bow-legged
b. Fluid accumulation
c. Knock-kneed
d. Spinal curvature
ANS: A
Genu varum is a bow-legged deformity. A fluid accumulation is an effusion. Genu valgum is
knock-kneed. A spinal curvature could be kyphosis or lordosis.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Musculoskeletal deformities
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
m
8. The nurse is teaching a client who had a left humeral biopsy about home care. Which
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statement by the client indicates understanding of the nurse’s teaching?
a. “I will take my opioids only when I have severe pain.”
b. “I will keep my left arm elevated for 24 hours.”
c. “I will watch for tenderness and warmth around the biopsy site.”
d. “I will report any discomfort to my primary health care provider immediately.”
s.
ANS: C
nk
Bone biopsy is an ambulatory procedure which can cause some discomfort but not severe
pain. The client can use the affected arm soon after the procedure but should watch for
tenderness and warmth which could indicate infection.
ba
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Musculoskeletal assessment, Diagnostic tests
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
9. The nurse is teaching assistive personnel (AP) about the risk for osteoporosis associated with
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race or ethnicity. Which population typically has a decreased incidence of osteoporosis when
compared to Euro-Americans?
a. Irish Americans
b. African Americans
c. American Indians
d. Asian Americans
ANS: B
African Americans usually have more bone mass when compared to Euro-Americans which
makes them at a decreased risk for osteoporosis.
DIF: Remembering
TOP: Integrated Process: Culture and Spirituality
KEY: Musculoskeletal assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
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1. A female client is preparing to have open magnetic resonance imaging (MRI) of the spine.
What action(s) by the nurse is (are) most important to assess before the test? (Select all that
apply.)
a. Ask if the client has a history of kidney disease.
b. Ask the client if she could possibly be pregnant.
c. Ensure that the patient has no metal or electronic implants.
d. Assess the client for the ability to communicate.
e. Assess the client for a history of claustrophobia.
ANS: A, B, C, D
The contrast agent that is used for an MRI is gadolinium which can cause complications if the
client is pregnant or has kidney disease. The client needs to be able to communicate and
should not have any metal or electronic implants due to the magnetic nature of the machine.
For an open MRI, claustrophobia is not an issue because the client is not encased in the
device.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Diagnostic tests
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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2. The nurse is reviewing the laboratory profile for a client who has muscular dystrophy. Which
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laboratory value(s) would the nurse expect to be elevated? (Select all that apply.)
a. Calcium (Ca)
b. Phosphate (PO4)
c. Creatine kinase (CK)
d. Lactic dehydrogenase (LDH)
e. Aspartate aminotransferase (AST)
f. Aldolase (ALD)
ANS: C, D, E, F
ba
Muscular dystrophy causes elevations in muscle enzymes and does not affect minerals like
calcium and phosphorus.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Diagnostic tests
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. An older client’s serum calcium level is 8.7 mg/dL (2.18 mmol/L). What possible
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etiology(ies) does the nurse consider for this result? (Select all that apply.)
a. Good dietary intake of calcium and vitamin D
b. Normal age-related decrease in serum calcium
c. Possible occurrence of osteoporosis or osteopenia
d. Potential for metastatic cancer or Paget disease
e. Recent bone fracture in a healing stage
ANS: B, C
This slightly low calcium level could be an age-related decrease in serum calcium or could
indicate a metabolic bone disease, such as osteoporosis or osteopenia. A good dietary intake
would be expected to produce normal values. Metastatic cancer, Paget disease, or healing
bone fractures will elevate calcium.
DIF: Applying
TOP: Integrated Process: Nursing Process: Analysis
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KEY: Musculoskeletal assessment, Diagnostic tests
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. When assessing gait, what feature(s) would the nurse inspect? (Select all that apply.)
a. Balance
b. Ease of stride
c. Goniometer readings
d. Length of stride
e. Steadiness
ANS: A, B, D, E
To assess gait, look at balance, ease and length of stride, and steadiness. Goniometer readings
assess flexion and extension or joint range of motion.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, Gait
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. The nurse takes a history on a male client reporting chronic back pain. Which factor(s) in the
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client’s history may have contributed to his pain? (Select all that apply.)
a. Had a motor vehicle crash 10 years ago.
b. Played football in college and high school.
c. Has installed carpet and other flooring for 30 years.
d. Typically takes walks 3 to 4 days each week.
e. Eats two servings of dark, green leafy vegetables daily.
ANS: A, B, C
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A history of trauma caused by an accident, occupation, or contact sports can result in chronic
back pain. Regular exercise and diet helps to promote bone health.
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ba
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal assessment, History
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
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Chapter 45: Concepts of Care for Patients With Musculoskeletal Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A client has a bone density score of –2.8. What intervention would the nurse anticipate based
on this assessment?
a. Asking the client to complete a food diary
b. Planning to teach about bisphosphonates
c. Scheduling another scan in 2 years
d. Scheduling another scan in 6 months
ANS: B
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A T-score from a bone density scan at or lower than –2.5 indicates osteoporosis. The nurse
would plan to teach about medications used to treat this disease, such as the bisphosphonates.
A food diary is helpful to determine if the client gets adequate calcium and vitamin D, but at
this point, dietary changes will not prevent the disease. Simply scheduling another scan will
not help treat the disease either.
s.
DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Musculoskeletal disorders, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. The nurse teaches assistive personnel (AP) about care of an older adult diagnosed with
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ANS: C
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osteoporosis. What teaching would the nurse include?
a. “Teach the client to eat high-calcium foods in the diet.”
b. “Assist the client with activities of daily living.”
c. “Osteoporosis places the client is at risk for fractures.”
d. “The client should stay in bed to prevent falling.”
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Anyone who has osteoporosis is at risk for fragility fractures even if he or she does not
experience trauma like a fall. The client needs to keep active rather than stay in bed where
more bone could be lost. High-calcium foods may not be helpful because bone loss is already
severe. There is no indication that the client needs assistance with ADLs.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Musculoskeletal disorders, Osteoporosis
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A client has been advised to perform weight-bearing exercises to help slow bone loss, but has
not followed this advice. What response by the nurse is appropriate at this time?
a. Ask the client about fear of falling.
b. Instruct the client to increase calcium.
c. Suggest other exercises the client can do.
d. Tell the client to try weight lifting.
ANS: A
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Fear of falling can limit participation in activity. The nurse would first assess if the client has
this fear and then offer suggestions for dealing with it. The client may or may not need extra
calcium, other exercises, or weight lifting.
DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal disorders, Osteoporosis
MSC: Client Needs Category: Psychosocial Integrity
4. The nurse is caring for several clients with osteoporosis. For which client would
bisphosphonates not be a good option?
a. Client with diabetes who has a serum creatinine of 0.8 mg/dL (61 mcmol/L).
b. Client who recently fell and has vertebral compression fractures.
c. Hypertensive client who takes calcium channel blockers.
d. Client with a spinal cord injury who cannot tolerate sitting up.
ANS: D
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Clients on bisphosphonates must be able to sit upright for 30 to 60 minutes after taking them.
The client who cannot tolerate sitting up is not a good candidate for this class of drug. Poor
renal function also makes clients poor candidates for this drug, but the client with a creatinine
of 0.8 mg/dL (61 mcmol/L) is within normal range. Diabetes and hypertension are not related
unless the client also has renal disease. The client who recently fell and sustained fractures is a
good candidate for this drug if the fractures are related to osteoporosis.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Musculoskeletal disorders, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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5. A client has been prescribed denosumab. What health teaching about this drug is most
ANS: B
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appropriate for the nurse to include?
a. “Drink at least 8 ounces (240 mL) of water with it.”
b. “Make appointments to come get your injection.”
c. “Sit upright for 30 to 60 minutes after taking it.”
d. “Take the drug on an empty stomach.”
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Denosumab is given by subcutaneous injection twice a year. The client does not need to drink
8 ounces (240 mL) of water with this medication as it is not taken orally. The client does not
need to remain upright for 30 to 60 minutes after taking this medication, nor does the client
need to take the drug on an empty stomach.
DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Musculoskeletal disorders, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
6. The nurse is performing an assessment of a client with possible plantar fasciitis in the right
foot. What assessment finding would the nurse expect in the right foot?
a. Multiple toe deformities
b. Numbness and paresthesias
c. Severe pain in the arch of the foot
d. Redness and severe swelling
ANS: C
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The most common assessment finding is the client’s report of severe pain in the arch of the
foot, especially when walking. The other findings are not typical in clients with this health
problem.
DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal disorders, Plantar fasciitis
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. The nurse is caring for a young client who has been diagnosed with osteopenia. Which risk
factor in the client’s history most likely contributed to the bone loss?
a. Osteoarthritis
b. Hypothyroidism
c. Addison disease
d. Rheumatoid arthritis
ANS: D
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Rheumatoid arthritis often occurs in young female adults and can lead to osteoporosis as a
common complication. Cushing disease (rather than Addison disease) and hyperthyroidism
(rather than hypothyroidism) are also risk factors. Osteoarthritis is a joint disease.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal disorders, Osteopenia
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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8. An older client with diabetes is admitted with a heavily draining leg wound. The client’s
ANS: C
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white blood cell count is 38,000/mm3 (38  109/L) but the client is afebrile. Which nursing
action is most appropriate at this time?
a. Administer acetaminophen as needed.
b. Educate the client on amputation.
c. Place the client on Contact Precautions.
d. Refer the client to the wound care nurse.
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In the presence of a heavily draining wound, the nurse would place the client on Contact
Precautions. If the client has discomfort, acetaminophen can be used, but this client has not
reported pain and is afebrile. The client may or may not need an amputation in the future. The
wound care nurse may be consulted but not as the most appropriate action.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Musculoskeletal disorders, Transmission-Based Precautions
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
9. A nurse is caring for four clients. After the hand-off report, which client would the nurse see
first?
a. Client with osteoporosis and a white blood cell count of 27,000/mm3 (27  109/L)
b. Client with osteoporosis and a bone fracture who requests pain medication
c. Post-microvascular bone transfer client whose distal leg is cool and pale
d. Client with suspected bone tumor who just returned from having a spinal CT
ANS: C
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This client is the priority because the assessment findings indicate a critical lack of perfusion.
A high white blood cell count is an expected finding for the client with osteoporosis. The
client requesting pain medication should be seen second. The client who just returned from a
CT scan is stable and needs no specific postprocedure care.
DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Musculoskeletal disorders, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
10. A client has a metastatic bone tumor in the left leg. What action by the nurse is appropriate?
a. Administer pain medication as prescribed.
b. Elevate the extremity and apply moist heat.
c. Teach the client about amputation care.
d. Place the client on protective precautions.
ANS: A
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Pain medication should be given to control metastatic bone pain. Elevation and heat may or
may not be helpful. Protective precautions are not needed for this client.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Planning and Implementation
KEY: Musculoskeletal disorders, Cancer
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
11. A client with bone cancer is hospitalized for a limb salvage procedure. How can the nurse best
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address the client’s psychosocial needs?
a. Assess the client’s coping skills and support systems.
b. Explain that the surgery leads to a longer life expectancy.
c. Refer the client to the social worker or hospital chaplain.
d. Reinforce physical therapy to aid with ambulating normally.
ANS: A
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The first step in the nursing process is assessment. The nurse would assess coping skills and
possible support systems that will be helpful in this client’s treatment. Explaining that a limb
salvage procedure will extend life does not address the client’s psychosocial needs. Referrals
may be necessary, but the nurse should assess first. Reinforcing physical therapy is also
helpful but again does not address the psychosocial needs of the client.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal disorders, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
12. A client had a bunionectomy with osteotomy. The client asks why healing may take up to 3
months. What explanation by the nurse is best?
a. “The bones in your feet are hard to operate on.”
b. “The surrounding bones and tissue are damaged.”
c. “Your feet have less blood flow, so healing is slower.”
d. “Your feet bear weight so they never really heal.”
ANS: C
The feet are the most distal to the heart and receive less blood flow than other organs and
tissues, prolonging the healing time after surgery. The other explanations are not correct.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Musculoskeletal disorders, Health teaching
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
13. A nurse assesses clients in an osteoporosis clinic. Which client would the nurse assess first?
a. Client taking calcium with vitamin D who reports flank pain 2 weeks ago.
b. Client taking ibandronate who cannot remember when the last dose was.
c. Client taking raloxifene who reports unilateral calf swelling.
d. Client taking risedronate who reports occasional dyspepsia.
ANS: C
The client on raloxifene needs to be assessed first because of the potential for deep vein
thrombosis, which is an adverse effect of raloxifene. The client with flank pain may have had
a kidney stone but is not acutely ill now. The client who cannot remember taking the last dose
of ibandronate can be seen last. The client on risedronate may need to change medications.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal disorders, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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14. What information does the nurse teach a women’s group about osteoporosis?
a. “Primary osteoporosis occurs in postmenopausal women due to lack of estrogen.”
b. “Men actually have higher rates of the disease but are underdiagnosed.”
c. “There is no way to prevent or slow osteoporosis after menopause.”
d. “Women and men have an equal chance of getting osteoporosis.”
ANS: A
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Women are more at risk of developing primary osteoporosis after menopause due to the lack
of estrogen. Men have a slower loss of bone after the age of 75. Many treatments are now
available for women to slow osteoporosis after menopause.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Musculoskeletal disorders, Osteoporosis
MSC: Client Needs Category: Health Promotion and Maintenance
15. A client with osteoporosis is going home where the client lives alone. What action by the
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nurse is best?
a. Refer the client to Meals on Wheels.
b. Arrange a home safety evaluation.
c. Ensure that the client has a walker at home.
d. Help the client look into assisted living.
ANS: B
This client has several risk factors that place him or her at a high risk for falling. The nurse
should consult social work or home health care to conduct a home safety evaluation. The
other options may or may not be needed based upon the client’s condition at discharge.
DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Musculoskeletal disorders, Osteoporosis
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
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1. A nurse is assessing a community group for dietary factors that contribute to osteoporosis. In
addition to inquiring about calcium, the nurse also assesses for which other dietary
components? (Select all that apply.)
a. Alcohol
b. Caffeine
c. Fat
d. Carbonated beverages
e. Vitamin D
ANS: A, B, D, E
Dietary components that affect the development of osteoporosis include alcohol, caffeine,
high phosphorus intake, carbonated beverages, and vitamin D. Tobacco is also a contributing
lifestyle factor. Fat intake does not contribute to osteoporosis.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal disorders, Osteoporosis
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse is providing education to a community women’s group about lifestyle changes helpful
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in preventing osteoporosis. What topics does the nurse cover? (Select all that apply.)
a. Cut down on tobacco product use.
b. Limit alcohol to two drinks a day.
c. Strengthening exercises are important.
d. Take recommended calcium and vitamin D.
e. Walk for 30 minutes at least three times a week.
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ANS: C, D, E
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Lifestyle changes can be made to decrease the occurrence of osteoporosis and include
strengthening and weight-bearing exercises and getting the recommended amounts of both
calcium and vitamin D. Tobacco should be totally avoided. Women should not have more
than one drink per day.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Musculoskeletal disorders, Osteoporosis
MSC: Client Needs Category: Health Promotion and Maintenance
3. A client with chronic osteomyelitis is being discharged from the hospital. What information is
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important for the nurse to teach this client and family? (Select all that apply.)
a. Adherence to the antibiotic regimen
b. Correct intramuscular injection technique
c. Eating high-protein and high-carbohydrate foods
d. Keeping daily follow-up appointments
e. Proper use of the intravenous equipment
ANS: A, C, E
The client going home with chronic osteomyelitis will need long-term antibiotic therapy—
first intravenous, and then oral. The client needs education on how to properly administer IV
antibiotics, care for the IV line, adhere to the regimen, and eat a healthy diet to encourage
wound healing. The antibiotics are not given by IM injection. The client does not need daily
follow-up.
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DIF: Applying
TOP: Integrated Process: Teaching/Learning
KEY: Musculoskeletal disorders, Osteomyelitis
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. The nurse is assessing a client for chronic osteomyelitis. Which features distinguish this from
the acute form of the disease? (Select all that apply.)
a. Draining sinus tracts
b. High fevers
c. Presence of foot ulcers
d. Swelling and redness
e. Tenderness or pain
ANS: A, C
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Draining sinus tracts and foot ulcers are seen in chronic osteomyelitis. High fever, swelling,
and redness are more often seen in acute osteomyelitis. Pain or tenderness can be in either
case.
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DIF: Understanding
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal disorders, Osteomyelitis
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
5. The nurse reviews a list of drugs that can cause secondary osteoporosis.Which drugs are most
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commonly associated with this health problem? (Select all that apply.)
a. Antianxiety agents
b. Antibiotics
c. Barbiturates
d. Corticosteroids
e. Loop diuretics
ANS: C, D, E
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Several classes of drugs can cause secondary osteoporosis, including barbiturates,
corticosteroids, and loop diuretics. Antianxiety agents and antibiotics are not associated with
the formation of osteoporosis.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Musculoskeletal disorders, Drug therapy
MSC: Client Needs Category: Physiological Integrity: Ph