Medical-Surgical Nursing in Canada
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Medical-Surgical Nursing in Canada 4th
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Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is caring for a client with a new diagnosis of pneumonia and explains to the
client that together they will plan the client’s care and set goals for discharge. The client
asks, “How is that different from what the doctor does?” Which response by the nurse is
most appropriate?
a. “The role of the nurse is to administer medications and other treatments prescribed
by your doctor.”
b. “The nurse’s job is to help the doctor by collecting data and communicating when
there are problems.”
c. “Nurses perform many of the procedures done by physicians, but nurses are here in
the hospital for a longer time than doctors.”
d. “In addition to caring for you while you are sick, the nurses will assist you to
develop an individualized plan to maintain your health.”
ANS: D
This response is consistent with the Canadian Nurses Association (CNA) definition of
nursing. Registered nurses are self-regulated health care professionals who work
autonomously and in collaboration with others. RNs enable individuals, families, groups,
communities and populations to achieve their optimal level of health. RNs coordinate
health care, deliver direct services, and support clients in their self-care decisions and
actions in situations of health, illness, injury, and disability in all stages of life. The other
responses describe some of the dependent and collaborative functions of the nursing role
but do not accurately describe the nurse’s role in the health care system.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
2. When caring for clients using evidence-informed practice, which of the following does the
nurse use?
a. Clinical judgement based on experience
b. Evidence from a clinical research study
c. The best available evidence to guide clinical expertise
d. Evaluation of data showing that the client outcomes are met
ANS: C
Evidence-informed nursing practice is a continuous interactive process involving the
explicit, conscientious, and judicious consideration of the best available evidence to
provide care. Four primary elements are: (a) clinical state, setting, and circumstances; (b)
client preferences and actions; (c) best research evidence, and (d) health care resources.
Clinical judgement based on the nurse’s clinical experience is part of EIP, but clinical
decision making also should incorporate current research and research-based guidelines.
Evidence from one clinical research study does not provide an adequate substantiation for
interventions. Evaluation of client outcomes is important, but interventions should be
based on research from randomized control studies with a large number of subjects.
DIF:
Cognitive Level: Comprehension
TOP: Nursing Process: Planning
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MSC: NCLEX: Safe and Effective Care Environment
3. Which of the following best explains the nurses’ primary use of the nursing process when
providing care to clients?
a. To explain nursing interventions to other health care professionals
b. As a problem-solving tool to identify and treat clients’ health care needs
c. As a scientific-based process of diagnosing the client’s health care problems
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
ANS: B
The nursing process is an assertive problem-solving approach to the identification and
treatment of clients’ problems. Diagnosis is only one phase of the nursing process. The
primary use of the nursing process is in client care, not to establish nursing theory or
explain nursing interventions to other health care professionals.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
4. The nurse is caring for a critically ill client in the intensive care unit and plans an
every-2-hour turning schedule to prevent skin breakdown. Which type of nursing function
is demonstrated with this turning schedule?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D
When implementing collaborative nursing actions, the nurse is responsible primarily for
monitoring for complications of acute illness or providing care to prevent or treat
complications. Independent nursing actions are focused on health promotion, illness
prevention, and client advocacy. A dependent action would require a physician order to
implement. Cooperative nursing functions are not described as one of the formal nursing
functions.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
5. The nurse is caring for a client who has been admitted to the hospital for surgery and tells
the nurse, “I do not feel right about leaving my children with my neighbour.” Which
action should the nurse take next?
a. Reassure the client that these feelings are common for parents.
b. Have the client call the children to ensure that they are doing well.
c. Call the neighbour to determine whether adequate childcare is being provided.
d. Gather more data about the client’s feelings about the childcare arrangements.
ANS: D
Since a complete assessment is necessary in order to identify a problem and choose an
appropriate intervention, the nurse’s first action should be to obtain more information. The
other actions may be appropriate, but more assessment is needed before the best
intervention can be chosen.
DIF:
Cognitive Level: Application
TOP: Nursing Process: Assessment
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MSC: NCLEX: Psychosocial Integrity
6. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
assesses a pressure injury on the client’s left hip. Which of the following is the most
appropriate nursing diagnosis for this client?
a. Impaired physical mobility related to decrease in muscle control (left-sided
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
protecting tissue integrity
c. Impaired skin integrity related to pressure over bony prominence (impaired
circulation)
d. Ineffective peripheral tissue perfusion related to sedentary lifestyle
ANS: C
The client’s major problem is the impaired skin integrity as demonstrated by the presence
of a pressure injury. The nurse is able to treat the cause of impaired circulation and
pressure over bony prominence by frequently repositioning the client. Although left-sided
weakness is a problem for the client, the nurse cannot treat the weakness. The “risk for”
diagnosis is not appropriate for this client, who already has impaired tissue integrity. The
client does have ineffective peripheral tissue perfusion, but the impaired skin integrity
diagnosis indicates more clearly what the health problem is.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Diagnosis
7. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
volume related to excessive fluid loss through normal route (diaphoresis). Which of the
following is an appropriate client outcome?
a. Client has a balanced intake and output.
b. Client’s bedding is changed when it becomes damp.
c. Client understands the need for increased fluid intake.
d. Client’s skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid
volume that was identified in the nursing diagnosis statement. The other statements would
not indicate that the problem of deficient fluid volume was resolved.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
8. Which of the following represents a nursing activity that is carried out during the
evaluation phase of the nursing process?
Determining if interventions have been effective in meeting client outcomes.
Documenting the nursing care plan in the progress notes in the medical record.
Deciding whether the client’s health problems have been completely resolved.
Asking the client to evaluate whether the nursing care provided was satisfactory.
a.
b.
c.
d.
ANS: A
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Evaluation consists of determining whether the desired client outcomes have been met and
whether the nursing interventions were appropriate. The other responses do not describe
the evaluation phase.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
9. Which of the following would the nurse perform during the assessment phase of the
nursing process?
a. Obtains data with which to diagnose client problems.
b. Uses client data to develop priority nursing diagnoses.
c. Teaches interventions to relieve client health problems.
d. Assists the client to identify realistic outcomes to health problems.
ANS: A
During the assessment phase, the nurse gathers information about the client. The other
responses are examples of the intervention, diagnosis, and planning phases of the nursing
process.
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
10. Which of the following is an example of a correctly written nursing diagnosis statement?
a. Altered tissue perfusion related to heart failure.
b. Risk for impaired tissue integrity related to sacral redness.
c. Ineffective coping related to insufficient sense of control.
d. Altered urinary elimination related to urinary tract infection.
ANS: C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that
describes a client’s response to a health problem that can be treated by nursing. The use of
a medical diagnosis (as in the responses beginning “Altered tissue perfusion” and “Altered
urinary elimination”) is not appropriate. The response beginning “Risk for impaired tissue
integrity” uses the defining characteristics as the etiology.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
11. Which of the following includes the components required for a complete nursing diagnosis
statement?
a. A problem and the suggested client goals or outcomes.
b. A problem, its cause, and objective data that support the problem.
c. A problem with all its possible causes and the planned interventions.
d. A problem with its etiology and the signs and symptoms of the problem.
ANS: D
The PES format is used when writing nursing diagnoses. The subjective, as well as
objective, data should be included in the defining characteristics. Interventions and
outcomes are not included in the nursing diagnosis statement.
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
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12. Which of the following refers to a situation that results in unintended harm to the client
and is related to the care or services provided rather than the client’s medical condition?
a. Negligence
b. Adverse event
c. Incident report
d. Nonmaleficence
ANS: B
An adverse event is an event that results in unintended harm to the client and is related to
the care or services provided to the client rather than to the client’s underlying medical
condition.
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
13. Which of these nursing actions for the client with heart failure is appropriate for the nurse
to delegate to experienced unregulated care providers?
a. Assess for shortness of breath or fatigue after ambulation.
b. Instruct the client about the need to alternate activity and rest.
c. Obtain the client’s blood pressure and pulse rate after ambulation.
d. Determine whether the client is ready to increase the activity level.
ANS: C
Unregulated care provider education varies according to the type of worker; however,
unregulated care providers are able to measure vital signs. Assessment and client teaching
require RN education and scope of practice and cannot be delegated.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
14. Which action by a newly graduated RN working on the postsurgical unit indicates that
more education about delegation and assignment is needed?
a. The nurse delegates measurement of client oral intake and urine output to an
unregulated care provider.
b. The nurse delegates assessment of a client’s bowel sounds to an experienced
unregulated care provider.
c. The nurse assigns an LPN/LVN to administer oral medications to several clients.
d. The nurse assigns a “float” RN from pediatrics to care for a client with diabetes.
ANS: B
Assessment requires RN education and scope of practice and cannot be delegated to an
unregulated care provider. The other actions by the new RN are appropriate.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
15. Which of these tasks is appropriate for the registered nurse to delegate to an unregulated
care provider?
a. Perform a sterile dressing change for an infected wound.
b. Complete the clients’ initial bath.
c. Teach a client about the effects of prescribed medications.
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d. Document client teaching about a routine surgical procedure.
ANS: B
Unregulated care providers are able to provide personal care to clients. Client teaching and
the initial assessment and development of the plan of care are nursing actions that require
RN-level education and scope of practice when working with clients that are not stable.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. When using the Five Steps of the Evidence-Informed Practice (EIP) Process, in which
order should the nurse construct a clinical question? (Select all that apply.)
a. Comparison of interest
b. Population of interest
c. Outcome of interest
d. Intervention of interest
e. Timeframe
ANS: A, B, C, D, E
The order of the nurse’s statements follows the PICOT format.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
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Chapter 02: Cultural Competence and Health Equity in Nursing Care
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. Which of the following terms refer to characteristics of a group whose members share a
common social, cultural, linguistic, or religious heritage?
a. Diversity
b. Ethnicity
c. Ethnocentrism
d. Cultural imposition
ANS: B
Ethnicity is the common social, cultural, linguistic, or religious heritage of a group of
people. Diversity is a presence of persons with differences from the majority or dominant
group that is assumed to be the norm. Ethnocentrism is a tendency of individuals to
believe that their way of viewing and responding to the world is the most correct, natural,
and superior one. Cultural imposition is imposition of one person’s own cultural beliefs
and practices, intentionally or unintentionally, on another person or group of people.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Planning
2. The nurse is caring for Indigenous clients in a community clinic setting. Which of the
following would the nurse include when developing strategies to decrease health care
disparities?
a. Improve public transportation.
b. Obtain low-cost medications.
c. Update equipment and supplies for the clinic.
d. Educate staff about Indigenous health beliefs.
ANS: D
Health care disparities are due to stereotyping, biases, and prejudice of health care
providers; the nurse can decrease these through staff education. The other strategies also
may be addressed by the nurse but will not impact health disparities.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
3. A family member of an elderly Hispanic client admitted to the hospital tells the nurse that
the client has traditional beliefs about health and illness. Which of the following actions is
most appropriate for the nurse in this situation?
a. Avoid asking any questions unless the client initiates conversation.
b. Ask the client whether it is important that cultural healers are contacted.
c. Explain the usual hospital routines for meal times, care, and family visits.
d. Obtain further information about the client’s cultural beliefs from the daughter.
ANS: B
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Because the client has traditional health care beliefs, it is appropriate for the nurse to ask
whether the client would like a visit from a cultural healer. Nurses ask key questions with
regard to language, diet, religion, and acculturation and eliciting the client’s explanatory
model of health and illness. There is no cultural reason for the nurse to avoid asking the
client questions, and questions may be necessary to obtain necessary health information.
The client (rather than the daughter) should be consulted about personal cultural beliefs.
The hospital routines for meals, care, and visits should be adapted to the client’s
preferences rather than expecting the client to adapt to the hospital schedule.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
4. When caring for an Indigenous client, which of the following actions is the best initial
approach in relation to eye contact for the nurse to take?
Avoid all eye contact with the client.
Observe the client’s use of eye contact.
Look directly at the client when interacting.
Ask the family about the client’s cultural beliefs.
a.
b.
c.
d.
ANS: B
Eye contact varies greatly among and within cultures so the nurse’s initial action is to
assess the client’s use of eye contact. Although nurses are often taught to maintain direct
eye contact, clients who are Asian, Arab, or Indigenous may avoid direct eye contact and
consider direct eye contact disrespectful or aggressive. Looking directly at the client or
avoiding eye contact may be appropriate, depending on the client’s individual cultural
beliefs. The nurse should assess the client, rather than asking family members about the
client’s beliefs.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
5. A graduate nurse is assessing a newly admitted non–English-speaking Chinese client who
complains of severe headaches. Which of the following actions by the graduate nurse
would cause the charge nurse to intervene during this assessment interview?
a. Sit down at the bedside.
b. Palpate the client’s scalp.
c. Call for a medical interpreter.
d. Avoid eye contact with the client.
ANS: B
Many people of Asian ethnicity believe that touching a person’s head is disrespectful; the
nurse should always ask permission before touching any client’s head. The other actions
are appropriate.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
6. The nurse is caring for a client who speaks a language different from the nurse’s language
and there is no interpreter available. Which of the following actions is the most
appropriate for the nurse to implement?
a. Use specific medical terms in the Latin form.
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b. Talk loudly and slowly so that each word is clearly heard.
c. Repeat important words so that the client recognizes their importance.
d. Use simple gestures to demonstrate meaning while talking to the client.
ANS: D
The use of gestures will enable some information to be communicated to the client. The
other actions will not improve communication with the client.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
7. According to the ABC(DE)s of cultural competence, awareness of and sensitivity to
cultural values is in which of the following domains?
a. Skills domain
b. Affective domain
c. Knowledge domain
d. Behavioural domain
ANS: B
The affective domain reflects an awareness of and sensitivity to cultural values, needs, and
biases. The skills domain does not reflect an awareness of and sensitivity to cultural values,
needs, and biases. There is no skills or knowledge domain; with ABC(DE) it is affective,
behavioural, and cognitive domains as well as dynamics of difference and environment.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Planning
8. Which of the following actions represent the best example of culturally appropriate
nursing care when caring for a newly admitted client?
a. Have family members provide most of the client’s personal care.
b. Maintain a personal space of at least 0.5 m when assessing the client.
c. Ask permission before touching a client during the physical assessment.
d. Consider the client’s ethnicity as the most important factor in planning care.
ANS: C
Many cultures consider it disrespectful to touch a client without asking permission, so
asking a client for permission is always culturally appropriate. The other actions may be
appropriate for some clients but are not appropriate across all cultural groups or for all
individual clients.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
9. While talking with the nursing supervisor, a staff nurse expresses frustration that an
Indigenous client always has several family members at the bedside. Which of the
following actions is the most appropriate action for the nursing supervisor in this
situation?
a. Remind the nurse that family support is important to this family and client.
b. Have the nurse explain to the family that too many visitors will tire the client.
c. Suggest that the nurse ask family members to leave the room during client care.
d. Ask about the nurse’s personal beliefs about family support during hospitalization.
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ANS: D
The first step in providing culturally competent care is to understand one’s own beliefs and
values related to health and health care. Asking the nurse about personal beliefs will help
to achieve this step. Reminding the nurse that this cultural practice is important to the
family and client will not decrease the nurse’s frustration. The remaining responses
(suggest that the nurse ask family members to leave the room, and have the nurse explain
to family that too many visitors will tire the client) are not culturally appropriate for this
client.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
10. An elderly Asian Canadian client tells the nurse that she has lived in Canada for 50 years.
The client speaks English but lives in a predominantly Asian neighbourhood. Which of the
following actions is most appropriate for the nurse?
a. Arrange to have a folk healer available when planning the client’s care.
b. Ask the client about any special cultural beliefs or practices.
c. Avoid making direct eye contact with the client during care.
d. Involve the client’s oldest son in making health care decisions.
ANS: B
Further assessment of the client’s health care preferences is needed before making further
plans for culturally appropriate care. The other responses indicate stereotyping of the
client, based on ethnicity, and would not be appropriate initial actions.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Planning
11. Which of the following statements is true related to immigrants to Canada?
a. Decreased risk of social exclusion related to Canada’s multicultural population.
b. New immigrants tend to be in overall better health than the resident population.
c. Health status of immigrants is not related to length of time in Canada.
d. Unemployment is not associated with poorer health outcomes for immigrants.
ANS: B
The healthy immigrant effect indicates that new immigrants tend to be in better overall
health than the general resident population. This finding is not surprising inasmuch as
immigrants are screened before being granted admittance to Canada. Health status is
related to length of time in Canada, the health of immigrants, 20 years after immigration,
as determined by age-standardized mortality rates, is generally poorer than those of the
Canadian-born population. Underemployment, unemployment, and workplace stress place
immigrants at increased health risks as well as the risk for social exclusion.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
12. Which of the following question formats is the most appropriate for the nurse to ask when
communicating with a client that has limited English proficiency?
a. Are you tired and in discomfort?
b. You have taken your pills right?
c. Are you alright?
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d. Are you in pain?
ANS: D
When communicating with a client that has limited English proficiency the best questions
to ask are ones that are in simple language a couple of words, plain simple terms, such as
“Are you in pain?” Asking about tiredness and discomfort in the same sentence should be
avoided—ask one item at a time and use the term “pain,” not discomfort. Asking the client
“are you alright” is vague and will elicit a yes or no answer. “You have taken your pills,
right?” is accusatory and should be avoided.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
13. An Indigenous client tells the nurse that he thinks his abdominal pain is caused by eating
too much seal fat and that strong massage over the stomach will help it. Which of the
following statements depicts what the client is describing to the nurse?
a. Evidence-informed national guidelines
b. Awareness and knowledge of his own culture
c. The explanatory model of health and health practices
d. Knowledge about the difference in modern and folk health practices
ANS: C
The explanatory model is a set of beliefs regarding what causes the disease or illness and
the methods that would potentially treat the condition best. Different cultural groups have
different beliefs about the causes of illness and the appropriateness of various treatments.
The situation is not reflective of national guidelines. There is no comparison between
modern and folk health practices. The client is explaining experiences and beliefs rather
than awareness and knowledge.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Assessment
14. Which of the following statements represents a health inequity currently experienced in
Canada?
a. Indigenous adults are less likely to smoke tobacco than other adults in Canada.
b. Overall suicide rate among First Nation communities is about twice the rate of the
general population.
c. Individuals from lower income neighbourhoods undergo preventive health
screening more that their higher income counterparts.
d. Recent immigrants are more likely to have a primary care physician than
Canadian-born individuals.
ANS: B
Suicide rates are five to seven times higher among Indigenous youth than among
non-Indigenous youth. Suicide rates among Indigenous youth are among the highest in the
world, at 11 times the national average. Smoking rates are more than two times higher
among the three Indigenous groups than among the non-Indigenous population.
Individuals from higher income neighbourhoods undergo preventive health screening
more than those from lower income neighbourhoods. Recent immigrants are less likely to
have a primary care physician than Canadian-born individuals.
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DIF: Cognitive Level: Comprehension
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Assessment
15. When performing a cultural assessment with a client of a different culture, which of the
following actions is the initial action to be taken by the nurse?
a. Wait until a cultural healer is available to help with the assessment.
b. Obtain a list of any cultural remedies that the client currently uses.
c. Ask the client about any affiliation with a particular cultural group.
d. Tell the client what the nurse already knows about the client’s culture.
ANS: C
An early step in performing a cultural assessment is to determine the cultural group with
which the client identifies. The other actions may be appropriate if the client does identify
with a particular culture.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Assessment
MULTIPLE RESPONSE
1. Equity in health care is concerned with creating equal opportunities for good health for
everyone in which of the following ways? (Select all that apply.)
a. Decrease negative effect of social determinants of health.
b. Increase awareness of acute care programs.
c. Enhance access to services.
d. Reduce exclusion.
e. Decrease nonmodifiable risk factors.
ANS: A, C, D
Health equity is concerned with creating equal opportunities for good health for everyone
in two ways: (a) decreasing the negative effect of the social determinants of health and (b)
by improving services to enhance access and reduce exclusion.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
2. Which of the following characteristics represent the affective domain of the ABCs of
cultural competence? (Select all that apply.)
a. Openness
b. Desire to learn
c. Respect for others
d. Promote health literacy
e. Support informed client choice
ANS: A, B, C
This domain is often seen as the first step toward achieving cultural competence. Openness,
a desire to learn, valuing differences, respect for others, and developing humility are
characteristics of this domain. Promoting health literacy and supporting informed client
choice are part of the behavioural domain of the ABCs of cultural competence.
DIF:
Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
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Chapter 03: Health History and Physical Examination
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. An older-adult client who is having difficulty breathing is admitted to the hospital. Which
of the following approaches is the best for the nurse to use to obtain a complete health
history?
a. Obtain subjective data about the client from family members.
b. Omit subjective data collection and obtain the physical examination.
c. Use the health care provider’s medical history to obtain subjective data.
d. Schedule several short sessions with the client to gather subjective data.
ANS: D
In the case of an older-adult client with a low energy level, several short sessions may
have to be scheduled. Allowing time for the client to volunteer information about
particular areas of concern enables the nurse to work with the client to identify existing
and potential health problems. In an emergency situation, the nurse may need to ask only
the most pertinent questions for a specific problem and obtain more information later. A
complete health history will include subjective information that is not available in the
health care provider’s medical history. Family members may be able to provide some
subjective data, but only the client will be able to give subjective information about the
shortness of breath. Since the subjective data about the client’s respiratory status will be
essential, obtaining the physical examination alone will not provide sufficient information.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
2. Immediate surgery is planned for a client with acute abdominal pain. Which of the
following questions will elicit the most complete information about the client’s
coping-stress tolerance pattern?
a. “Can you tell me how intense your pain is now?”
b. “What do you think caused this abdominal pain?”
c. “How do you feel about yourself and your hospitalization?”
d. “Are there other major problems that are a concern right now?”
ANS: D
The coping-stress tolerance pattern includes information about other major stressors
confronting the client. The health perception–health management pattern includes
information about the client’s ideas about risk factors. Feelings about self and the
hospitalization are assessed in the self-perception–self-concept pattern. Intensity of pain is
part of the cognitive–perceptual pattern.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Assessment
3. During the health history interview, a client tells the nurse about periodic fainting spells.
Which question by the nurse will be most helpful in determining the setting in which the
fainting spells occur?
a. “How frequently do you have the fainting spells?”
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b. “Where are you when you have the fainting spells?”
c. “Do the spells tend to occur at any special time of day?”
d. “Do you have any other symptoms along with the spells?”
ANS: B
Information about the setting is obtained by asking where the client was and what the
client was doing when the symptom occurred. The other questions from the nurse are
appropriate for obtaining information about chronology, frequency, and associated clinical
manifestations.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
4. The nurse records the following general survey of a client: “The client is a 68-year-old
male Asian accompanied by his wife and two daughters. Alert and oriented. Does not
make eye contact with the nurse and responds slowly, but appropriately, to questions. No
apparent disabilities or distinguishing features.” Which of the following information
should be added to this general survey documentation?
a. Nutritional status
b. Intake and output
c. Reasons for contact with the health care system
d. Comments of family members about his condition
ANS: A
The general survey also describes the client’s general nutritional status. The other
information will be obtained when doing the complete nursing history and examination but
is not obtained through the initial scanning of a client.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
5. A nurse is performing a health history and physical examination for a client with
right-sided rib fractures. Which of the following data is a pertinent negative finding?
a. Client states that there have been no other health problems recently.
b. Client denies having pain when the area over the fractures is palpated.
c. Client has several bruised and swollen areas on the right anterior chest.
d. Client refuses to take a deep breath because of the associated chest pain.
ANS: B
The nurse expects that a client with rib fractures will have pain over the fractured area.
The first statement is neither a positive nor a negative finding with regard to the rib
fractures. The bruising and swelling and pain with breathing are positive findings.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
6. As the nurse assesses the client’s neck, the client says, “My neck is so stiff I can hardly
move it.” This client statement indicates the nurse should perform which of the following
assessments?
a. Focused
b. Screening
c. Emergency
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d. Comprehensive
ANS: A
The focused assessment is needed when a client has clinical manifestations that indicate a
problem. An emergency assessment is done when the nurse needs to obtain information
about life-threatening problems quickly while simultaneously taking action to maintain
vital function. The screening assessment is not recognized as one of the three main types
of assessment. A comprehensive assessment is a detailed health history and physical
examination.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
7. The nurse is preparing to perform a focused abdominal assessment for a client who has
high-pitched bowel sounds. Which equipment will be needed?
a. Flashlight
b. Stethoscope
c. Tongue blades
d. Percussion hammer
ANS: B
A stethoscope is used to auscultate bowel sounds. The other equipment may be used for a
comprehensive assessment, but will not be needed for a focused abdominal assessment.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
8. When the nurse is planning for the physical examination of an alert older-adult client,
which of the following adaptations to the examination technique should be considered?
a. Speaking slowly when directing the client.
b. Avoiding the use of touch as much as possible.
c. Using slightly more pressure for palpation of the liver.
d. Organizing the sequence to minimize position changes.
ANS: D
Older clients may have age-related changes in mobility that make it more difficult to
change position. There is no need to avoid the use of touch when examining older clients.
Less pressure should be used over the liver. Since the client is alert, there is no indication
that there is any age-related difficulty in understanding directions from the nurse.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
9. While the nurse is taking the health history, a client states, “My father and grandfather
both had heart attacks and were unable to be very active afterwards.” This statement
reflects which of the following functional health patterns?
a. Activity-exercise
b. Cognitive-perceptual
c. Coping-stress tolerance
d. Health perception–health management
ANS: D
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The information in the client statement relates to risk factors that may cause
cardiovascular problems in the future. Identification of risk factors falls into the health
perception–health maintenance pattern.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
10. A client is seen in the emergency department with chest pain and hypotension. Which type
of assessment should the nurse do at this time?
a. Focused
b. Subjective
c. Emergency
d. Comprehensive
ANS: C
Since the client is hemodynamically unstable, an emergency assessment is needed.
Comprehensive and focused assessments may be needed after the client is stabilized.
Subjective information is needed, but objective data such as vital signs also are essential
for the unstable client.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
11. The nurse records the following general survey of a client: “The client is a 68-year-old
Indigenous male accompanied by his wife and two daughters. Alert and oriented. Does not
make eye contact with the nurse and responds slowly, but appropriately, to questions. No
apparent disabilities or distinguishing features.” Which of the following areas does the
nurse need to assess to complete the general survey?
a. Body movements
b. Intake and output
c. Reasons for contact with the health care system
d. Comments of family members about his condition
ANS: A
To complete a general survey, the nurse needs to assess the client’s body movements.
Intake and output, reasons for contact with the health care system, and comments of family
members about the client’s condition are not part of the general survey.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
12. When assessing the circulation to the lower leg of a client who has had knee surgery,
which action should the nurse take first?
Feel for the temperature of the foot.
Visually inspect the colour of the foot.
Check the client’s pedal pulses using the fingertips.
Compress the nail beds to determine capillary refill time.
a.
b.
c.
d.
ANS: B
Inspection is the first of the major techniques used in the physical examination. Palpation
and auscultation are used later in the examination.
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DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
13. When assessing a client’s abdomen during the admission assessment, which of these
actions should the nurse take first?
a. Feel for any masses.
b. Palpate the abdomen.
c. Percuss the liver borders.
d. Listen to the bowel sounds.
ANS: D
When assessing the abdomen, auscultation is done before palpation or percussion because
palpation and percussion can cause changes in bowel sounds and alter the findings. All of
the techniques are appropriate, but auscultation should be done first.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
14. When admitting a client who has just arrived on the medical unit with severe abdominal
pain, what should the nurse do first?
a. Complete only basic demographic data before addressing the client’s abdominal
pain.
b. Medicate the client for the abdominal pain before attending to the health history
and examination.
c. Inform the client that the abdominal pain will be treated as soon as the health
history is completed.
d. Take the initial vital signs and then deal with the abdominal pain before
completing the health history.
ANS: D
The client priority in this situation will be to decrease the pain level because the client will
be unlikely to cooperate in providing demographic data or the health history until the nurse
addresses the pain. However, obtaining information about vital signs is essential before
using either pharmacological or nonpharmacological therapies for pain control. The vital
signs may indicate hemodynamic instability that would need to be addressed immediately.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
MULTIPLE RESPONSE
1. The nurse is completing a neurological assessment on an adult client. Which of the
following assessments should the nurse include when assessing the client’s coordination?
(Select all that apply.)
a. Toe walk
b. Finger to nose
c. Drift
d. Romberg
e. Heel to opposite shin
ANS: B, D, E
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A neurological assessment is completed to observe motor status by assessing gait, toe and
heel walk, and drift whereas when assessing coordination, the nurse observes finger to
nose, Romberg sign, and heel to opposite shin.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
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Chapter 04: Patient and Caregiver Teaching
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. A client with newly diagnosed breast cancer has a nursing diagnosis of deficient
knowledge related to insufficient information (about breast cancer). When the nurse is
planning teaching for the client, which is the most important initial learning goal?
a. The client will select the most appropriate breast cancer therapy.
b. The client will state ways of preventing the recurrence of the tumour.
c. The client will demonstrate coping skills needed to manage the disease.
d. The client will choose methods to minimize adverse effects of treatment.
ANS: A
Adults learn best when given information that can be used immediately. The first action
the client will need to take after a cancer diagnosis is to choose a treatment option. The
other goals may be appropriate as treatment progresses.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
2. After the nurse implements diet instruction for a client with heart disease, the client can
explain the information but fails to make the recommended dietary changes. Which of the
following statements reflects the correct evaluation of the intervention?
a. Learning did not occur because the client’s behaviour did not change.
b. Choosing not to follow the diet is the behaviour that resulted from learning.
c. The nursing responsibility for helping the client make dietary changes has been
fulfilled.
d. The teaching methods were ineffective in helping the client learn the dietary
information.
ANS: B
Although the client’s behaviour has not changed, the client’s ability to explain the
information indicates that learning has occurred and the client is choosing at this time to
continue with the previous diet. The client may be in the contemplation or preparation
state in the Transtheoretical Model. The nurse should reinforce the need for change and
continue to provide information and assistance with planning for change.
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX: Health Promotion and Maintenance
3. The nurse is caring for an adult client who has been diagnosed with type 2 diabetes
mellitus after being admitted to the hospital with an infected foot wound. When applying
principles of adult learning, which teaching strategy by the nurse is most likely to be
effective?
a. Discuss the importance of blood glucose control in maintenance of long-term
health.
b. Demonstrate the correct method for cleaning and redressing the wound to the
client.
c. Assure the client that the nurse is an expert on management of diabetes
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complications.
d. Wait until after discharge and have a home health nurse teach about foot care and
diabetes management.
ANS: B
Principles of adult education indicate that readiness and motivation to learn are high when
facing new tasks (such as wound care) and when demonstration and practice of skills are
available. Although a home health referral may be needed for this client, teaching should
not be postponed until discharge. Adult learners are independent; the nurse should act as a
facilitator for learning, rather than as the expert. Adults learn best when the topic is of
immediate usefulness; long-term goals may not be very motivating.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
4. A client admitted to the hospital with hyperglycemia and newly diagnosed diabetes
mellitus is scheduled for discharge the second day after admission. When implementing
client teaching, which is the best action for the nurse to take?
a. Instruct about the increased risk for cardiovascular disease.
b. Provide detailed information about dietary control of glucose.
c. Teach glucose self-monitoring and medication administration.
d. Give information about the effects of exercise on glucose control.
ANS: C
When time is limited, the nurse should focus on the priorities of teaching. In this situation,
the client should know how to test blood glucose and administer medications to control
glucose levels. The client will need further teaching about the role of diet, exercise,
various medications, and the many potential complications of diabetes, but these topics
can be addressed through planning for appropriate referrals.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
5. When using the Transtheoretical Model of Health Behaviour Change during client
teaching, the nurse identifies that the client who states, “I told my wife that I was going to
start exercising, and I think I will join a fitness club,” is in which of the following stages?
a. Preparation
b. Termination
c. Maintenance
d. Contemplation
ANS: A
The client’s statement indicating that the plan for change is being shared with someone
else indicates that the preparation stage has been achieved. Contemplation of a change
would be indicated by a statement like “I know I should exercise.” Maintenance of a
change occurs when the client practises the behaviour regularly. Termination would be
indicated when the change is a permanent part of the lifestyle.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
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6. While admitting a client to the medical unit, the nurse learns that the client has difficulty
reading. This information will guide the nurse in determining which of the following
strategies would be the most appropriate when planning for client teaching?
a. Assessing the degree of client motivation and readiness to learn.
b. Deciding what information the client will be able to understand.
c. Ensuring that the family be included in the teaching process.
d. Choosing which instructional strategies should be used in teaching.
ANS: D
The information that the client has poor health literacy skills indicates that the nurse
should avoid the use of written materials in teaching and choose other strategies. The
client does not indicate a lack of motivation or an inability to understand new information.
The client’s lack of reading ability does not necessarily imply that the family must be
included in the teaching process.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
7. When assessing the learning needs for a client who has coronary heart disease, the nurse
finds that the client has recently made dietary changes to decrease fat intake and has
stopped smoking. Which of the following is the most appropriate initial statement by the
nurse at this time?
a. “Although those are important, it is essential that you make other changes, too.”
b. “Are you having any difficulty in maintaining the changes you have already
made?”
c. “You have already accomplished some changes that are important in heart health.”
d. “Which additional changes in your lifestyle would you like to implement at this
time?”
ANS: C
Positive reinforcement of the learner’s achievements is critical in making lifestyle changes.
This client is in the action stage of the Transtheoretical Model, when reinforcement of the
changes being made is an important nursing intervention. The other responses are also
appropriate, but are not the best initial response.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
8. When assessing a client’s readiness to learn before planning teaching activities, which
question should the nurse ask?
a. “What kind of work and leisure activities do you do?”
b. “What information do you think you need right now?”
c. “Do you have any religious beliefs that are inconsistent with the treatment?”
d. “Can you describe the types of activities that help you learn new information?”
ANS: B
Motivation and readiness to learn depend on what the client values and perceives as
important. The other questions are also important in developing the teaching plan, but do
not address what information most interests the client at present.
DIF:
Cognitive Level: Application
TOP: Nursing Process: Assessment
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MSC: NCLEX: Health Promotion and Maintenance
9. The nurse is caring for a client with diabetes and develops a nursing diagnosis of
ineffective health management related to insufficient knowledge of therapeutic regimen
(resulting in low motivation). Which of the following client actions is the basis for this
nursing diagnosis?
a. Does not perform capillary blood glucose tests as directed.
b. Occasionally forgets to take the daily prescribed medication.
c. Says that dietary intake does not seem to impact fatigue level.
d. Cannot identify signs or symptoms of high and low blood glucose.
ANS: C
The client’s motivation to follow a diabetic diet will be decreased if the client feels that
dietary changes do not impact symptoms. The other responses do not indicate that the
ineffective health maintenance is caused by lack of motivation.
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
MSC: NCLEX: Health Promotion and Maintenance
10. A client with poor circulation to the feet requires teaching about foot care. Which learning
goal should the nurse include in the teaching plan?
a. The nurse will demonstrate the proper technique for trimming toenails.
b. The client will list three ways to protect the feet from injury by discharge.
c. The nurse will instruct the client on appropriate foot care before discharge.
d. The client will understand the rationale for proper foot care after instruction.
ANS: B
Learning goals should state clear, measurable outcomes of what is to be accomplished
from the learning process. Demonstrating a proper technique or providing instruction are
actions that the nurse will take, rather than behaviours that would indicate if client learning
has occurred. Having the client understand the rational for proper foot care after
instruction is an example of a learning outcome.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
11. The nurse is planning a teaching session for a client who needs to improve skills in being
more assertive. Which of the following is the most effective teaching strategy for this
client?
a. Role playing
b. Peer teaching
c. Printed materials
d. Lecture-discussion
ANS: A
Role playing allows the client to practise assertive behaviour and receive feedback about
how the behaviour is perceived. This strategy is most often used when clients need to
examine their attitudes and behaviours; understand the viewpoints and attitudes of others;
or practise carrying out thoughts, ideas, or decisions. Lecture-discussion, peer teaching,
and printed materials are more useful for other learning needs.
DIF:
Cognitive Level: Comprehension
TOP: Nursing Process: Planning
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MSC: NCLEX: Health Promotion and Maintenance
12. The client’s teaching plan includes this goal: “The client will select a 2-g sodium diet from
the hospital menu for the next 3 days.” Which evaluation method will be best for the nurse
to use when determining whether teaching was effective?
a. Check the sodium content of the client’s menu choices over the next 3 days.
b. Ask the client to identify which foods on the hospital menus are high in sodium.
c. Have the client list favourite foods that are high in sodium and foods that could be
substituted for these favourites.
d. Compare the client’s sodium intake over the next 3 days with the sodium intake
before the teaching was implemented.
ANS: A
All of the answers address the client’s sodium intake, but the desired client behaviours in
the learning objective are most clearly addressed by evaluation of the client’s menu
choices.
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX: Health Promotion and Maintenance
13. The nurse is preparing written handouts to be used as part of the standardized teaching
plan for clients who have been recently diagnosed with diabetes and requires an awareness
of literacy levels. Which of the following literacy levels is generally reflective of students
who graduate from high school?
a. 1
b. 2
c. 3
d. 4
ANS: C
People with Level 3 literacy have the minimum skills necessary for everyday life in a
complex society, such as graduation from high school. People with Level 1 literacy have
very poor skills; for example, they were unable to determine the correct dose of
medication from information on the package. People with Level 2 literacy require material
to be simple and clearly laid out, and only tasks that are not too complex are to be included
in learning material. People at this level could read but had poor test results. People with
Levels 4 and 5 literacy had higher order skills in information processing.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
14. The nurse in the hospital has implemented a teaching plan to assist a client with
rheumatoid arthritis in accomplishing daily activities independently. Which of the
following actions is the best approach for the nurse to take in order to evaluate the client’s
long-term response to the teaching?
a. Make a referral to the home health nursing department for home visits.
b. Assess the client’s ability to bathe without any assistance the next day.
c. Have the client demonstrate the learned skills at the end of the teaching session.
d. Arrange a physical therapy visit before the client is discharged from the hospital.
ANS: A
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The client’s long-term response may need to be assessed after discharge; long-term
evaluation necessitates follow-up by the nurse, outpatient clinic, or outside agency. In this
case, a home health referral would allow this to occur. The other actions allow evaluation
of the client’s short-term response to teaching.
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX: Health Promotion and Maintenance
15. A young adult client tells the nurse, “I enjoy smoking and have no plans to quit.” Which
stage of the Transtheoretical Model of Health Behaviour Change does this example
portray?
a. Contemplation
b. Precontemplation
c. Preparation
d. Maintenance
ANS: B
The precontemplation phase indicates that the client is not considering a change and is not
ready to learn. In the contemplation phase, a change is being considered. The client starts
gathering information for the change in the preparation stage. In the maintenance stage,
the change has already occurred.
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
MSC: NCLEX: Health Promotion and Maintenance
16. An older-adult client is seen at the health clinic and diagnosed with protein malnutrition.
Which of the following actions is priority to be included in the teaching plan?
a. Suggest the use of liquid supplements as a way to increase protein intake.
b. Encourage the client to increase the dietary intake of meat, cheese, and milk.
c. Ask the client to record the intake of all foods and beverages for a 3-day period.
d. Focus on the use of combinations of beans and rice to improve daily protein intake.
ANS: C
Assessment is the first step in assisting a client with health changes. The other answers
may be appropriate for the client, but the nurse will not be able to determine this until the
assessment of the client is complete.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
17. The nurse is caring for a client who has been newly diagnosed with diabetes. The client
tells the nurse, “I want to know how to give my own insulin.” Which initial action will the
nurse take when implementing the standardized diabetic teaching plan?
a. Demonstrate how to draw up and administer insulin.
b. Discuss the use of exercise to decrease insulin needs.
c. Teach about differences between the various types of insulin.
d. Provide handouts about therapeutic and adverse effects of insulin.
ANS: A
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Adult education is most effective when focused on information that the client thinks is
needed right now. All of the indicated information will need to be included when planning
teaching for this client, but the teaching will be most effective if the nurse starts with the
client’s stated priority topic.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
18. Which action should the nurse take first when teaching a client’s spouse how to manage
the blood pressure (BP) for a client with newly diagnosed hypertension?
a. Teach the caregiver how to take the client’s BP using a manual blood pressure
cuff.
b. Have the dietitian meet with the client and caregiver to discuss low sodium dietary
choices.
c. Ask the client and caregiver to select important information from a list of
hypertension teaching topics.
d. Provide written information about treatment and complications of hypertension for
the client and caregiver.
ANS: C
Since adults learn best when given information that they view as being needed
immediately, asking the caregiver and client to prioritize learning needs is likely to be the
most successful approach to home management of health problems. The other actions also
may be appropriate, depending on what learning needs the caregiver and client have, but
the initial action should be to assess what the learners feel is important.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Which of the following are determinants of learning that require learning assessments?
(Select all that apply.)
a. Learner needs
b. Demonstrated learner behaviour
c. Learner self-concept
d. State of learner readiness
e. Preferred learning style
ANS: A, D, E
The three determinants of learning that require learning assessments are learner needs,
state of learner readiness, and the client’s preferred learning style. Demonstrated learner
behaviour is an evaluation of learning. Self-concept is not a determinant of learning.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
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Chapter 05: Chronic Illness
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is caring for a client with type 2 diabetes who has been hospitalized with severe
hyperglycemia. Which of the following topics will be most important to include in
discharge teaching?
a. Effect of endogenous insulin on transportation of glucose into cells
b. Function of the liver in formation of glycogen and gluconeogenesis
c. Impact of the client’s family history on likelihood of developing diabetes
d. Symptoms indicating that the client should contact the health care provider
ANS: D
One of the tasks for clients with chronic illnesses is to prevent and manage a crisis. The
client needs instruction on recognition of symptoms of hyperglycemia and appropriate
actions to take if these symptoms occur. The other information also may be included in
client teaching, but is not as essential in the client’s self-management of the illness.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
2. Which of the following diseases has the highest proportion of chronic illness deaths in
Canada?
a. Cancer
b. Diabetes
c. Cardiovascular disease
d. Chronic respiratory disease
ANS: C
Cardiovascular diseases (37%) were responsible for the highest proportion of global
deaths in 2012, followed by cancers (27%), chronic respiratory diseases (8%), and
diabetes (4%).
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
3. Which of the following is an example of multimorbidity?
a. Chronic obstructive pulmonary disease and a urinary tract infection
b. Lung cancer and pneumonia
c. Chronic kidney disease and appendicitis
d. Diabetes and exacerbation of rheumatoid arthritis
ANS: D
Multimorbidity is the simultaneous occurrence of several chronic medical conditions,
which may or may not be related to each other, in the same person. Pneumonia, urinary
tract infection, and appendicitis are all acute conditions.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
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4. Which of the following factors has a major impact on the development of chronic illness?
a. Poverty
b. Social stability
c. Urban dwelling
d. High school diploma
ANS: A
Poverty and socioeconomic disadvantage are recognized to have a major impact on the
development of chronic illness. Social stability, urban living, and having a high school
education are not factors contributing to the development of chronic illness.
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
5. Which of the following statements is true related to nonmodifiable risk factors for chronic
illness?
a. Cannot be changed
b. Requires intervention in order to change
c. Can be altered to benefit health outcomes
d. Can be changed with client perseverance
ANS: A
Nonmodifiable risk factors cannot be changed. Requiring intervention in order to change,
altering, and changed with perseverance all indicate that change is possible.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
6. What is the average life expectancy in Canada?
a. 60 years
b. 70 years
c. 80 years
d. 90 years
ANS: C
The life expectancy in Canada is estimated to be 80 years, specifically in 2010, it was 78.5
years for males and 82.7 years for females.
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
7. Which of the following types of cancers has a genetic predisposition to its occurrence?
a. Lung
b. Breast
c. Cervix
d. Testicles
ANS: B
Genetic testing can also show an inherited predisposition to several different types of
cancer, including breast and ovarian cancer, melanoma, and colon cancer.
DIF:
Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
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MSC: NCLEX: Physiological Integrity
8. Which of the following models view disability as directly caused by disease or trauma?
a. Social
b. Nursing
c. Medical
d. Collaborative
ANS: C
The medical model views disability as directly caused by disease, trauma, or another
health condition. Disability, from the medical model perspective, necessitates medical care
provided in the form of individual treatment by providers to “correct” the problem with the
individual. The social model of disability, conversely, sees disability as a socially created
problem and not an inherent attribute of an individual.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
9. Which of the following client statements reflect an outcome expectancy statement?
a. “I am not able to exercise.”
b. “Exercise helps people lose weight.”
c. “Exercise is too hard on my arthritis.”
d. “Dietary restrictions work better than exercise to lose weight.”
ANS: B
An outcome expectancy is the individual’s belief that a specific behaviour will lead to
certain outcomes. For example, the client who tells the nurse that exercising helps people
to lose weight is voicing an outcome expectancy.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
10. What is the most influential source of self-efficacy?
a. Mastery
b. Affective states
c. Verbal persuasion
d. Vicarious experience
ANS: A
Four primary influences shape an individual’s self-efficacy beliefs: mastery; vicarious
experience; verbal persuasion and other social influences; and physiological and affective
states that help us judge our capability and our vulnerability to dysfunction. Mastery
reflects a belief about whether or not “we have what it takes to succeed” and is considered
the most influential source of self-efficacy.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
11. Which of the following is a characteristic of health-related hardiness known as
“challenge”?
a. Confidence to appraise a health stressor
b. Ability to modify responses to health stressors
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c. Viewing a health stressor as an opportunity for growth
d. Optimal psychosocial adaptation to a health stressor
ANS: C
Challenge is the anticipation of change. The person with health-related hardiness, when
confronted with a health stressor, possesses sufficient self-mastery and confidence to
appraise and modify responses appropriately (control) and cognitively reappraises the
health stressor so it is viewed as stimulating and beneficial or an opportunity for growth
(challenge).
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
12. Which of the following characteristics is true related to chronic illness?
a. Abrupt onset
b. Usually single cause
c. Short latency period
d. Noninfectious origin
ANS: D
Chronic (or noncommunicable) illnesses are typically characterized as having an uncertain
etiology, multiple risk factors, long latency, prolonged duration, and a noninfectious origin
and can be associated with impairments or functional disability. Abrupt onset, usually a
single cause and cure most likely are characteristic of acute illness.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
13. Clients with chronic illness want the health care system to provide them with which of the
following?
a. Less information
b. Less travel time
c. Ways to adjust to disease consequences
d. Limited information on ways to cope with their symptoms
ANS: C
Clients with chronic illness want the health care system to provide them with ways to
adjust to disease consequences such as uncertainty, fear and depression, anger, loneliness,
sleep disorders, memory loss, exercise needs, nocturia, sexual dysfunction, and stress.
They did not identify wanting less information, less travel time, or limited information on
coping strategies but they do also want shorter wait times.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
14. Which of the following models calls for a political response to disability?
a. Social
b. Medical
c. Activist
d. Collaborative
ANS: A
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The social model of disability, conversely, sees disability as a socially created problem
and not an inherent attribute of an individual (Barnes, 2012). The social model perspective
calls for a political response, because the problem is created by an unaccommodating
physical environment brought about by attitudes and other features of the social
environment.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Assessment
15. According to the World Health Organization’s ICF Bio-Psycho-Social Model, which of
the following factors is an environmental contextual factor?
a. Social background
b. Behaviour pattern
c. Social attitudes
d. Coping style
ANS: C
Contextual factors are composed of external environmental factors (e.g., social attitudes,
architectural characteristics, and legal and social structures, as well as climate, terrain, and
so forth). The other choices represent internal personal factors (e.g., gender, age, coping
styles, social background, education, profession, past and current experience, overall
behaviour pattern, character, and other factors that influence how disability is experienced
by the individual).
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
16. Which of these clients assigned to the nurse is most likely to need planning for long-term
nursing management?
a. 22-year-old with appendicitis who has had an emergency appendectomy
b. 56-year-old with bilateral knee osteoarthritis who weighs 159 kg
c. 34-year-old with cholecystitis who has had a laparoscopic cholecystectomy
d. 62-year-old with acute sinusitis who will require antibiotic therapy for 5 days
ANS: B
The client’s osteoarthritis is a chronic problem that will require planning for long-term
interventions such as physical therapy and nutrition counselling. The other clients have
acute problems that are not likely to require long-term management.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
17. “Set in motion and continue the trajectory projection and scheme” is a goal of
management in which of the following trajectory phases?
Pretrajectory
Onset
Comeback
Downward
a.
b.
c.
d.
ANS: C
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“Set in motion and continue the trajectory projection and scheme” is a goal of
management in the trajectory phase of comeback. Pretrajectory goal is to prevent the onset
of chronic illness. The onset goal of management is to form an appropriate trajectory
projection and scheme. The goal of the downward phase is to adapt to increasing
disability.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. Which of the following levels are part of the client response to health care
recommendations based on a continuum of self-care? (Select all that apply.)
a. Compliance
b. Adherence
c. Self-care
d. Denial
e. Acceptance
ANS: A, B, C
Compliance, adherence, and self-care makeup the three levels of client response to health
care recommendations on a continuum of self-care. Compliance reflects coercion of the
client to engage in particular recommendations, whereas adherence implies conformity of
the client with the recommendations. Self-care connotes a therapeutic alliance between the
client and the provider. Adherence is now the term most widely accepted because it
incorporates the notion of the client agreeing with the treatment plan presented by the
health care provider.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
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Chapter 06: Community-Based Nursing and Home Care
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. A family caregiver tells the home health nurse, “I feel like I can never get away to do
anything for myself.” Which action is the most appropriate for the nurse to take?
a. Assist the caregiver in finding respite services.
b. Assure the caregiver that the work is appreciated.
c. Teach the caregiver that family members provide excellent client care.
d. Encourage the caregiver to discuss feelings openly with the nurse as needed.
ANS: A
Respite services allow family caregivers to have free time. The other actions also may be
helpful, but the caregiver’s statement clearly indicates the need for some free time.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
2. A client who was in an automobile accident is assigned a nurse as a case manager. Which
of the following responsibilities is required of the nurse in this role?
a. Care for the client during hospitalization for the injuries.
b. Assist the client with home care activities during recovery.
c. Coordinate the services that the client receives in the hospital and at home.
d. Determine the types of medical care the client needs for optimal rehabilitation.
ANS: C
The role of the case manager is to coordinate the client’s care through multiple settings
and levels of care to allow the maximal client benefit at the least cost. The case manager
does not provide direct care in either the acute or home setting. The case manager
coordinates and advocates for care but does not determine what types of medical care are
needed, that is done by the health care provider or other provider.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
3. The nurse is conducting a home visit and notes that the caregiver may be experiencing
caregiver burnout. Which of the following assessments would support this finding?
a. Anxiety
b. Sleeplessness
c. Weight gain
d. Increased use of respite care
ANS: B
Assessment of the signs of caregiver burnout (e.g., sleeplessness, difficulty concentrating)
is a critical role of the home care nurse. Weight gain is an indication that the caregivers’
nutritional intake exceeds requirements. An increased use of respite care could indicate an
increased involvement of the caregiver in outside support and activity groups. This
assessment finding would require further assessment before linking it to caregiver burnout.
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DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Assessment
4. An older-adult client who lives alone was hospitalized for a fractured hip and has
recovered from the surgery but needs to continue to work to improve mobility. Which of
the following settings would the nurse anticipate that the client be transferred to?
a. Another acute care setting
b. A transitional care setting
c. A residential care facility
d. Their own home with home health nursing
ANS: D
Home health nursing is appropriate for clients who need continued rehabilitation and can
implement this in their own home. The client is no longer in need of the more continuous
assessment and care given in acute care settings. There is no indication that the client will
need the permanent and ongoing medical and nursing services available in intermediate
care. The client is not yet independent enough to transfer to a residential care facility.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
5. The nurse is describing home care services to a client that requires extended care. Which
of the following statements is true related to home care services?
a. Technologically complex therapies must be managed in the hospital.
b. The client’s family will be included in planning and the client’s care.
c. Home care services are limited to visits by registered nurses or home health aides.
d. In order for insurance to cover the home care, the client must be confined to bed.
ANS: B
Family members who are providing care are included in planning the client’s care and
treatments. Other disciplines, such as physical and occupational therapy, also provide
appropriate home health services. The client must be homebound, but not bed bound, to
receive reimbursement for home care services. High-tech services are increasingly
accomplished in the home setting where the client is more comfortable and the risks for
complications such as infection are less.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
6. Which of the following statements represent a current trend in home health nursing?
a. Increased numbers of registered nurses are being employed as home health nurses.
b. Decreased numbers of licensed practical nurses are being employed as home health
nurses.
c. There are more employment opportunities for newly graduated nurses.
d. That a minimum of two years of acute care experience is required before
employment as a home health nurse.
ANS: C
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There are many opportunities for newly graduated nurses to begin practice as a home
health nurse. It was widely believed for many years that nurses required a minimum of 2
years of acute care hospital experience before being hired as a home health nurse but is no
longer true. Registered nurses generally received hiring preference over licensed practical
nurses because it was believed that registered nurse preparation provided the best
foundation for home care nursing. However, partly because the growing nursing shortage,
enhancements to the scope of practice and educational programs for licensed practical
nurses, and the need to provide long-term interventions to a growing population with
complex and unpredictable care needs, many home health employers now hire both
registered nurses and licensed practical nurses right after graduation.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
7. When the home health nurse is caring for a client who needs to relearn self-care skills such
as dressing and self-feeding, which referral will be best?
a. Dietitian
b. Speech therapist
c. Physical therapist
d. Occupational therapist
ANS: D
Occupational therapists assist clients with self-care skills. Physical therapists assist clients
with strengthening, transferring, and ambulation. Dietitians assist with nutritional choices.
Speech therapists assist with speech and swallowing needs.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
8. Which of the following statements is true in relation to nursing-sensitive outcomes?
a. Only used to evaluate client care.
b. Are outside of the nurses’ scope of practice.
c. Have no influence on health care budgets.
d. Require empirical evidence.
ANS: D
Nursing-sensitive outcomes are “those that are relevant, based on nurses’ scope and
domain of practice, and for which there is empirical evidence linking nursing inputs and
interventions to the outcomes.” Outcomes data may also be used to evaluate the nurses
own practice or that of their team or program, as well as client care. Decision makers and
funders require outcomes data to support budget needs, program design and delivery, and
the development of accountability mechanisms such as balanced scorecards.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
9. Which of these clients should the nurse refer for home health care services?
a. A 71-year-old with dementia who needs 24-hour care to prevent injury
b. An 82-year-old whose family has asked for help to organize pills into a pill box
c. A 67-year-old who requires assistance with shopping, housework, and cooking
d. A 79-year-old with terminal cancer who needs hospice palliative
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ANS: D
Hospice palliative care is one aspect of home health care services. Services such as
shopping, housework, and cooking are not skilled nursing services and do not require
home health care. Institutional care is required for clients who need 24-hour care.
Medication assistance can be achieved through the client’s pharmacy when filling
medications, request bubble packs.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
10. Which of the following concepts is foundational to home health nursing?
a. Acute care management
b. Health promotion
c. Chronic disease management
d. Health restoration
ANS: B
A foundational concept of home health nursing is health promotion. Acute care and
chronic disease management are roles; they are not the foundation upon which home
health nursing is based. Health restoration is a core expectation but is not the foundation
for home health nursing.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
11. Which of the following nursing activities is appropriate for the home care nurse who is
caring for a client newly diagnosed with diabetes to delegate to a home support worker?
a. Assist the client to choose an appropriate diet.
b. Check the client’s feet for signs of breakdown.
c. Help the client with a daily bath and oral care.
d. Teach the client how to monitor blood glucose.
ANS: C
Assisting with client hygiene is included in the home support workers’ education and
scope of practice. Assessment of the client and instructing the client in new skills, such as
diet and blood glucose monitoring, are complex skills that are included in RN education
and scope of practice.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
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Chapter 07: Older Adults
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. Findings from a health history indicate that the client takes daily supplements of the
antioxidants beta carotene, vitamin C, and vitamin E. This health practice reflects which of
the following theories of biological aging?
a. Free radicals
b. Crosslinking
c. Somatic mutation
d. Telomere-telomerase depletion
ANS: A
Free radicals are natural by-products of many normal cellular processes and are also
created under the influence of environmental factors such as smog, tobacco smoke, and
radiation. Numerous natural protective mechanisms are in place to prevent oxidative
damage. Recent research has focused on the roles of various antioxidants, including
vitamins C and E, in slowing down the oxidative process and, ultimately, the aging
process. The somatic mutation theory focuses on spontaneous mutations. The crosslinking
theory is based upon lipids, proteins, CHO, and nucleic acid reactions. The
telomere-telomerase depletion theory focuses on the loss of telomeres, repeated sequences
at the ends of DNA.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
2. The nurse is assessing the nutritional status of an older-adult client using the SCALES
acronym. Which of the following should the nurse assess when completing the “S”?
a. Serum potassium level
b. Sadness or mood change
c. Social support
d. Sexual intimacy
ANS: B
The acronym SCALES can be used to remind the nurses to assess important nutritional
indicators. In the case of the “S,” the nurse is to assess sadness or mood changes.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
3. The nurse is planning care for an alert and active older-adult client who takes multiple
medications for chronic cardiac and respiratory disease and lives with a daughter who
works during the day. Which nursing diagnosis is most appropriate?
a. Risk for injury as evidenced by exposure to toxic chemical (drug-drug interactions)
b. Social isolation related to social behavior incongruent with norms (weakness and
fatigue)
c. Disabled family coping related to differing coping styles between support person
and client
d. Caregiver role strain related to increase in care needs
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ANS: A
The client’s age and multiple medications indicate a risk for injury caused by interactions
between the multiple drugs being taken and a decreased drug metabolism rate. The client
data do not indicate problems with social isolation, caregiver role strain, or compromised
family coping.
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
MSC: NCLEX: Health Promotion and Maintenance
4. Which of the following actions would enable the nurse to obtain the most complete
information when doing an assessment with an older-adult client?
a. Interview both the client and the primary client caregiver.
b. Use a geriatric assessment instrument to evaluate the client.
c. Review the client’s chart for the history of medical problems.
d. Ask the client to write down medical problems and medications.
ANS: B
The most complete information about the client will be obtained through the use of an
assessment instrument specific to the geriatric population, which includes information
about both medical diagnoses and treatments and about functional health patterns and
abilities. A review of the chart, interviews of the client and caregiver, and written
information by the client will all be included in a comprehensive geriatric assessment.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
5. Which of the following actions should the nurse consider when developing the plan of care
for an older adult who is hospitalized for an acute illness?
a. Use a standardized geriatric nursing care plan.
b. Minimize activity level during hospitalization.
c. Plan for transfer to a long-term care facility after the hospitalization.
d. Consider preadmission functional abilities when setting client goals.
ANS: D
The plan of care for older adults should be individualized and based on the client’s current
functional abilities. A standardized geriatric nursing care plan will not address individual
client needs and strengths. A client’s need for discharge to a long-term care facility is
variable. Activity level should be designed to allow the client to retain functional abilities
while hospitalized and also to allow any additional rest needed for recovery from the acute
process.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
6. The nurse is caring for clients in a geriatric family practice clinic with a primary health
care provider. Which of the following actions should the nurse do when caring for older
adults who live in rural areas?
a. Assess the client for chronic diseases that are unique to rural areas.
b. Ensure transportation to appointments with the health care provider.
c. Schedule appointments for the client in an urban area for better health care.
d. Obtain adequate medications for the client to last for 4–6 months.
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ANS: B
Transportation can be a barrier to accessing health services in rural areas. There are no
chronic diseases unique to rural areas. Because medications may change, the nurse should
help the client plan for obtaining medications through alternate means such as the mail or
delivery services, not by purchasing large quantities of the medications. The client living
in a rural area may lose the benefits of a familiar situation and social support by moving to
an urban area.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
7. The nurse is providing care to older adults in a Northern outreach clinic. Which nursing
action will be most helpful in decreasing the risk for drug-drug interactions?
a. Teach the client to have all prescriptions filled at the same pharmacy.
b. Instruct the client to avoid taking over-the-counter (OTC) medications.
c. Make a medication schedule for the client as a reminder about when to take each
medication.
d. Have the client bring all the medications, supplements, and herbs to every health
care appointment.
ANS: D
The most information about drug use and possible interactions is obtained when the client
brings all prescribed medications, OTC medications, and supplements to every health care
appointment. The client should discuss the use of any OTC medications with the health
care provider and obtain all prescribed medications from the same pharmacy, but use of
supplements and herbal medications also need to be considered in order to prevent
drug-drug interactions. Use of a medication schedule will help the client take medications
as scheduled but will not prevent drug-drug interactions.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
8. Which action will the nurse take when planning for discharge of an older-adult client who
will need daily assistance with activities such as shopping and transportation?
a. Complete a referral to Medicare.
b. Apply for transfer to an assisted-living facility.
c. Arrange for home health care visits.
d. Apply for attendance at an adult day care program.
ANS: C
Home health care visits, from an unregulated health care worker, can enable the client to
remain at home but obtain assistance with shopping and transportation. Medicare,
assisted-living facilities, and adult day care programs provide funding for specific medical
services, but not for needs such as shopping or transportation.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
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9. The nurse is caring for an older-adult client with multiple health problems who states that
who reports having “no energy” and feeling increasingly weak. The client has had a 5 kg
weight loss over the last year. Which of the following interventions should the nurse
implement initially?
a. Ask the client about daily dietary intake.
b. Schedule regular range-of-motion exercise.
c. Discuss long-term care placement with the client.
d. Describe normal changes with aging to the client.
ANS: A
In the frail elderly client, nutrition is frequently compromised, and the nurse’s initial
action should be to assess the client’s nutritional status. Active range of motion may be
helpful in improving the client’s strength and endurance, but nutritional assessment is the
priority because the client has had a significant weight loss. The client may be a candidate
for long-term care placement, but more assessment is needed before this can be
determined. The client’s assessment data are not consistent with normal changes
associated with aging.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
10. The nurse is admitting an acutely ill older-adult client to the hospital. Which of the
following interventions should the nurse implement during the admission process?
a. Speak slowly and loudly while facing the client.
b. Obtain a detailed medical history from the client.
c. Interview the client before the physical assessment.
d. Determine whether the client uses glasses or hearing aids.
ANS: D
Assistive devices should be in place before assessing the client to minimize anxiety and
confusion. When a client is acutely ill, the physical assessment should be accomplished
first to detect any physiological changes that require immediate action. Not all older
clients have hearing deficits, and it is insensitive of the nurse to speak loudly and slowly to
all older clients. To avoid tiring the client, much of the medical history can be obtained
from medical records.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
11. The home health nurse is caring for an older-adult client who lives alone and is taking
seven different prescribed medications for chronic health problems. Which of the
following nursing interventions would be most appropriate to ensure medication regimen
adherence?
a. Use a marked pillbox to set up the client’s medications.
b. Discuss the option of moving to an assisted-living facility.
c. Remind the client about the importance of taking medications.
d. Visit the client daily to administer the prescribed medications.
ANS: A
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Since forgetting to take medications is a common cause of medication errors in older
adults, the use of medication reminder devices is helpful when older adults have multiple
medications to take. There is no indication that the client needs to move to assisted living
or that the client does not understand the importance of medication regimen adherence.
Home health care is not designed for the client who needs ongoing assistance with
activities of daily living (ADLs) or instrumental ADLs (IADLs).
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
12. Which information obtained by the home health nurse when making a visit to a frail
older-adult client with mild forgetfulness is of concern?
a. The client tells the nurse that a close friend recently died.
b. The client has lost 4.5 kg during the last month.
c. The client is cared for by a daughter during the day and stays with a son at night.
d. The client’s son uses a marked pillbox to set up the client’s medications weekly.
ANS: B
A 4.5 kg weight loss may be an indication of elder neglect or depression and requires
further assessment by the nurse. The use of a marked pillbox and planning by the family
for 24-hour care are appropriate for this client. It is not unusual that an elderly adult would
have friends who have died.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
13. Which information about an older-adult client who is being assessed by the home health
nurse is of most concern?
a. The client organizes medications in a marked pillbox “so I don’t forget them.”
b. The client uses three different medications for chronic heart and joint problems.
c. The client says, “I don’t go on my daily walks since I had pneumonia 3 months
ago.”
d. The client tells the nurse, “I prefer to manage my life without much help from
others.”
ANS: C
Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should
develop a plan to prevent further deconditioning and restore function for the client.
Self-management is appropriate for independently living older adults. The use of three
medications is not unusual for an older adult. The use of memory devices to assist with
safe medication administration is recommended for older adults.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
14. The nurse is admitting an older-adult client who has urinary urgency and a possible
urinary tract infection (UTI). Which of the following actions should the nurse implement
first?
a. Assess the client’s orientation.
b. Inspect for abdominal distension.
c. Question the client about hematuria.
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d. Invite the client to use the bathroom.
ANS: D
Before beginning the assessment of an older client with a UTI and urgency, the nurse
should have the client empty the bladder because bladder fullness or discomfort will
distract from the client’s ability to provide accurate information. The client may seem
disoriented if distracted by pain or urgency. The physical assessment data are obtained
after the client is as comfortable as possible.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
15. The nurse is teaching an older-adult female client about her new medications and the client
replies that she “just can’t remember all that information anymore.” Which of the
following changes may interfere with the clients’ ability to learn about the new
medications?
a. Intellectual ability declines with age.
b. All mental abilities slow as individuals age.
c. Declining physical health can impair cognitive function.
d. Impaired vocabulary and verbal function decrease reasoning with age.
ANS: C
Declining physical health is an important factor in cognitive impairment. Intellectual
ability does not decline with age. All mental abilities do not slow as an individual ages.
Vocabulary and verbal function do not decrease with age.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
16. The nurse is admitting an older-adult client who is hospitalized with an acute illness.
Which of the following interventions should the nurse do first?
a. Orientate the client to their room.
b. Administer the prescribed PRN sedative medication.
c. Ask the health care provider to order a vest restraint.
d. Place the client in a “geri chair” near the nurse’s station for observation.
ANS: A
The older adult who moves to a different location needs a thorough orientation to the
environment. The nurse should repeatedly reassure the client that he or she is safe and
attempt to answer all questions. The unit should foster client orientation by displaying
large-print clocks, avoiding complex or visually confusing wall designs, clearly
designating doors, and using simple bed and nurse-call systems. Physical or chemical
restraints may be necessary, but the nurse’s first action should be to provide an ongoing
and clear physical orientation. There is no indication that the client needs observation at
this time.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
17. The nurse suspects that elder abuse may be occurring when a frail older-adult client with a
broken arm is brought to the emergency department by a family member. Which of these
actions should the nurse take first?
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a.
b.
c.
d.
Notify an elder protective services agency about the possible abuse.
Make a referral for a home assessment visit by the home health nurse.
Have the family member stay in the waiting area while the client is assessed.
Ask the client how the injury occurred and observe the family member’s reaction.
ANS: C
The initial action should be assessment and interviewing of the client. The client should be
interviewed alone because the client will be unlikely to give accurate information if the
abuser is present. If abuse is occurring, the client should not be discharged home for a later
assessment by a home health nurse. The nurse needs to collect and document physiological
data before notifying the elder protective services agency.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
MULTIPLE RESPONSE
1. Which nursing actions will the nurse take to assess for possible malnutrition in an
older-adult client? (Select all that apply.)
a. Observe for depression.
b. Review laboratory results.
c. Assess teeth and oral mucosa.
d. Ask about transportation needs.
e. Determine food likes and dislikes.
ANS: A, B, C, D
The laboratory results, especially albumin levels, may indicate chronic poor protein intake.
Transportation impacts clients’ ability to shop for groceries. Depression may lead to
decreased appetite. Oral sores or teeth in poor condition may decrease the ability to chew
and swallow. Food likes and dislikes are not necessarily associated with malnutrition.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
2. The nurse is visiting a homeless shelter for older adults to provide a health-promotion
activity. Which of the following factors are associated with adult homelessness? (Select all
that apply.)
a. Low income
b. Reduced cognitive capacity
c. Decreased health problems
d. Abundance of affordable housing
e. Living alone
ANS: A, B, E
Key factors associated with homelessness are low income, reduced cognitive capacity, and
living alone. There is a shortage of affordable housing and homeless adults generally have
an increase in health problems.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
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Chapter 08: Stress and Stress Management
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. A young adult arrives in the emergency department (ED) with multiple abrasions after a
motor vehicle accident and has an initial blood pressure (BP) of 180/98. Which of the
following interventions should the nurse implement?
a. Discuss the need for hospital admission to control blood pressure.
b. Change the dressing on the abrasions and discuss the risks associated with
hypertension.
c. Recheck the blood pressure before the client’s discharge from the ED.
d. Start an intravenous (IV) line to administer antihypertensive medications.
ANS: C
Because hypertension is expected when a client has experienced an acute stressor, the
nurse should plan to check the BP before discharge, which will provide a more accurate
idea of the client’s usual blood pressure. Hypertension that occurs in response to acute
stress does not increase risk for health problems such as stroke, indicate a need for
hospitalization, or indicate a need for IV antihypertensive medications.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
2. A hospitalized client who is usually well organized and calm is receiving diabetic teaching
after being newly diagnosed with diabetes. The client is forgetful, irritable, and has poor
concentration. Which action should the nurse take?
a. Ask the health care provider for a psychiatric referral.
b. Administer the PRN sedative medication every 4 hours.
c. Suggest the use of a home caregiver to the client’s family.
d. Plan to reinforce and repeat teaching about diabetes management.
ANS: D
Since behavioural responses to stress include temporary changes such as irritability,
changes in memory, and poor concentration, client teaching will need to be repeated.
Psychiatric referral or home caregiver referral will not be needed for these expected
short-term cognitive changes. Sedation will decrease the client’s ability to learn the
necessary information for self-management.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
3. The nurse is caring for a client who has been hospitalized following a heart attack and tells
the nurse, “I didn’t sleep last night because I worried about missing work and losing my
insurance coverage.” Which nursing diagnosis is appropriate to include in the plan of care?
a. Anxiety
b. Defensive coping
c. Ineffective denial
d. Risk prone-health behaviour
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ANS: A
The information about the client indicates that anxiety is an appropriate nursing diagnosis.
The client data do not support defensive coping, ineffective denial, or risk-prone health
behaviour as problems for this client.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Diagnosis
4. The nurse is assisting with a breast biopsy for an alert client who has a lump in the right
breast. Which relaxation technique will be best to use at this time?
a. Massage
b. Meditation
c. Guided imagery
d. Relaxation breathing
ANS: D
Relaxation breathing is the easiest of the relaxation techniques to use. It will be difficult
for the nurse to provide massage while assisting with the biopsy. Meditation and guided
imagery require more time to practise and learn.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
5. The nurse is preparing a health-promotion session on meditation for older adults at a
community centre. Which of the following points should the nurse include in the session?
a. Have clients bring earphones to the session.
b. Breathing pattern to slowly increase speed.
c. Allow a 10–20 minute time frame for meditation.
d. Practise two to three times per week.
ANS: C
Guidelines for basic mediation include continuing it for 10–20 minutes, although even 5
minutes can be helpful. Clients won’t bring earphones as the guideline is to find a quiet
place with no distractions. The breathing pattern is to breathe slowly and consistently,
relaxation breathing, not to speed up the rate. Meditation guidelines suggest that this be
done once or twice a day.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
6. When choosing music to help relax a client who is having a painful dressing change,
which action is best for the nurse to take?
a. Use music composed by Mozart.
b. Ask the client about music preferences.
c. Select music that has 60–80 beats/minute.
d. Encourage the client to use music without words.
ANS: B
Although music with 60–80 beats/minute, music without words, and music composed by
Mozart are frequently recommended to reduce stress, each client responds individually to
music and personal preferences are important.
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DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
7. The nurse is teaching a hospitalized client to use imagery as a relaxation technique. Which
statement by the nurse is appropriate?
a. “Place your stress in the image of a form you can destroy.”
b. “Think of a place where you feel peaceful and comfortable.”
c. “Bring what you hear and sense in your present environment into your image of
the scene.”
d. “If your scene is stressful to you, continue visualizing until you can overcome the
distress.”
ANS: B
When using imagery for relaxation, the client should visualize a comfortable and peaceful
place. The goal is to offer a relaxing retreat from the actual client environment. Imagery
may be used to target a disease or pathology, but this type of imagery will not lead to
relaxation.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
8. An overweight client who enjoys active outdoor activities develops arthritis in the knees.
Which action by the nurse is most appropriate to assist the client in coping with the
diagnosis?
a. Ask the client to discuss feelings about the diagnosis.
b. Have the client practise frequent relaxation breathing.
c. Educate the client on the use of imagery to decrease pain and decrease stress.
d. Encourage the client to think about how weight loss might improve symptoms.
ANS: D
For problems that can be changed or controlled, problem-focused coping strategies, such
as encouraging the client to lose weight, are most helpful. The other strategies also may
assist the client in coping with the diagnosis, but they will not be as helpful as a
problem-oriented strategy.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
9. The nurse is caring for a hospitalized client with diabetes who states to the nurse, “I don’t
understand why I can keep my blood sugar under control at home with diet alone, but
when I get sick, my blood sugar goes up.” Which response by the nurse is appropriate?
a. “It is probably just coincidental that your blood sugars are high when you are ill.”
b. “Stressors such as illness cause the release of hormones that increase blood sugar.”
c. “Increased blood sugar occurs because the kidneys are not able to metabolize
glucose as well during stressful times.”
d. “Your diet is different here in the hospital than at home and that is the most likely
cause of the increased glucose level.”
ANS: B
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The release of cortisol, epinephrine, and norepinephrine increases blood glucose levels.
The increase in blood sugar is not coincidental. The kidneys do not control blood glucose.
A diabetic client who is hospitalized will be on an appropriate diet to help control blood
glucose.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
MULTIPLE RESPONSE
1. Which action should the nurse take to monitor the effects of an acute stressor on a
hospitalized client? (Select all that apply.)
a. Assess for bradycardia.
b. Ask about gastrointestinal pain.
c. Observe for decreased appetite.
d. Check for elevated blood glucose levels.
e. Monitor for a decrease in respiratory rate.
ANS: B, C, D
The physiological changes associated with the acute stress response can cause changes in
appetite, increased gastrointestinal upset, and elevation of blood glucose. Stress causes an
increase in respiratory and heart rates.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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Chapter 09: Sleep and Sleep Disorders
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is caring for a client in the ambulatory care setting who has chronic insomnia.
Which of the following interventions should the nurse do initially?
a. Schedule a polysomnography (PSG) study.
b. Arrange for the client to have a sleep study.
c. Ask the client to keep a 2-week sleep diary.
d. Teach the client about the use of an actigraph.
ANS: C
The diagnosis of insomnia is made on the basis of subjective complaints and an evaluation
of a 1- to 2-week sleep diary completed by the client. Actigraphy and PSG studies/sleep
studies may be used for determining specific sleep disorders, but are not necessary to
make an initial insomnia diagnosis.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
2. Which instruction will the nurse include when teaching a client with chronic insomnia
about ways to improve sleep quality?
a. Avoid aerobic exercise during the day.
b. Read in bed for a few minutes each night.
c. Keep the bedroom temperature slightly warm.
d. Try to go to bed at the same time every evening.
ANS: D
A regular evening schedule is recommended to improve sleep time and quality. Aerobic
exercise may improve sleep quality, but should occur several hours before bedtime.
Reading in bed is discouraged for clients with insomnia. The bedroom temperature should
be slightly cool.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
3. After the nurse has taught a client about the use of extended-release zopiclone for
insomnia, which client statement indicates a need for further teaching?
“I will take the medication an hour before bedtime.”
“I should take the medication on an empty stomach.”
“I should not take this medication unless I can sleep for at least 6 hours.”
“I will schedule activities that require mental alertness for later in the day.”
a.
b.
c.
d.
ANS: A
Benzodiazepine receptor agonists such as zopiclone work quickly and should be taken
immediately before bedtime, not one hour before. The other client statements are correct.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
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4. Which action is best for the nurse to include in the plan of care in order to improve sleep
quality for a critically ill client in the intensive care unit (ICU)?
a. Ask all visitors to leave the ICU for the night.
b. Lower the level of light from 8:00 P.M. until 7:00 A.M.
c. Avoid the use of opioids for pain relief during the evening hours.
d. Schedule assessments to allow at least 4 hours of uninterrupted sleep.
ANS: B
Lowering the level of light will help mimic normal day/night patterns and maximize the
opportunity for sleep. Although frequent assessments and opioid use can disturb sleep
patterns, these actions are necessary for the care of critically ill clients. For some clients,
having a family member or friend at the bedside may decrease anxiety and improve sleep.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
5. Which information will the nurse plan to include when teaching a client with narcolepsy
about management of the disorder?
a. Stimulant drugs should be used for only a short time because of the risk for abuse.
b. Driving an automobile may be possible with appropriate treatment of narcolepsy.
c. Changes in sleep hygiene are ineffective in improving sleep quality in narcolepsy.
d. Antidepressant drugs are prescribed to treat the depression caused by the disorder.
ANS: B
The accident rate for clients with narcolepsy who are receiving appropriate treatment is
similar to the general population. Stimulant medications are used on an ongoing basis for
clients with narcolepsy. The purpose of antidepressant drugs in the treatment of narcolepsy
is the management of cataplexy, not to treat depression. Changes in sleep hygiene are
recommended for clients with narcolepsy to improve sleep quality.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
6. Which action by the nurse manager of an acute care unit will improve the alertness of
nurses who work the night shift?
a. Arrange for older staff members to work most night shifts.
b. Provide a sleeping area for staff to use for napping at night.
c. Post reminders about the relationship of sleep and alertness.
d. Schedule nursing staff to rotate day and night shifts monthly.
ANS: B
Short on-site naps will improve alertness. Rotating shifts causes the most disruption in
sleep habits. Reminding staff members about the impact of lack of sleep on alertness will
not improve sleep or alertness.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
7. The nurse takes the health history for four clients in the clinic. Which information
regarding the clients’ sleep is most important to communicate to the health care provider?
a. A 21-year-old student takes melatonin to assist in sleeping when travelling from
Canada to Europe.
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b. A 32-year-old who is experiencing a stressful week uses diphenhydramine for
several nights.
c. A 41-year-old with a body mass index (BMI) of 42 kg/m2 says that the spouse
complains about the client’s snoring.
d. A 64-year-old nurse who works the night shift reports drinking hot chocolate
before going to bed in the morning.
ANS: C
The client’s BMI and snoring suggest possible sleep apnea, which can cause complications
such as cardiac dysrhythmias, hypertension, and right-sided heart failure. Melatonin is safe
to use as a therapy for jet lag. Short-term use of diphenhydramine in young adults is not a
concern. Hot chocolate contains only 5 mg of caffeine and is unlikely to be affecting this
client’s sleep quality.
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
8. Which of these actions should the nurse take first for a client in the clinic who is
complaining of insomnia and daytime fatigue?
a. Question the client about the use of over-the-counter (OTC) sleep aids.
b. Suggest that the client decrease intake of caffeine-containing beverages.
c. Advise the client to get out of bed if unable to fall asleep in 10–20 minutes.
d. Recommend that the client use any prescribed sleep aids for only 2–3 weeks.
ANS: A
The nurse’s first action should be assessment of the client for factors that may contribute
to poor sleep quality or daytime fatigue such as the use of OTC medications. The other
actions may be appropriate, but assessment is needed first to choose appropriate
interventions to improve the client’s sleep.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
9. A client with sleep apnea who received a new prescription for a continuous positive
airway pressure (CPAP) device a week ago returns to the clinic and says that severe
daytime fatigue is still a problem. Which action should the nurse take first?
a. Teach about radiofrequency ablation.
b. Plan to schedule a nighttime PSG study.
c. Ask the client whether the CPAP is being used every night.
d. Discuss the possible surgical approaches used for sleep apnea.
ANS: C
CPAP is very effective in reducing sleep apnea, but patient adherence is frequently a
problem. Surgery, radiofrequency ablation, or a follow-up PSG study may be indicated,
but the nurse’s first action should be to assess whether the CPAP is being used as
prescribed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
MULTIPLE RESPONSE
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1. The nurse is providing a health-promotion session to young adults who have difficulty
sleeping at night and has instructed them to limit their caffeine intake. Which of the
following beverages have 50 mg or more of caffeine? (Select all that apply.)
a. Green tea (237 mL)
b. Dr. Pepper soda (237 mL)
c. Chocolate cake (5 cm square)
d. Brewed coffee (237 mL)
e. Black tea (237 mL)
ANS: D, E
Brewed coffee has 135 mg caffeine and black tea, either leaf or bag, has 50 mg of caffeine.
Green tea has 30 mg, chocolate cake has 36 mg, and Dr. Pepper soda has 41 mg.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
2. The nurse is caring for a client who has sleep deprivation and teaching about the effects
that lack of sleep can have on the body. Which of the following information would be
included in the teaching plan for this client? (Select all that apply.)
a. Decreased insulin resistance
b. Increased growth hormone
c. Increased risk of type 2 diabetes
d. Irritability, moodiness
e. Increased risk of gastro-esophageal reflux disease (GERD)
ANS: C, D, E
Clients with sleep deprivation are at an increased risk of GERD, type 2 diabetes, heart
disease, hypertension, and impaired immune function and can also experience cognitive
impairment, and behavioural changes such as irritability and moodiness. Sleep deprivation
causes an increase in insulin resistance and a decrease in growth hormone.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 10: Pain
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. When doing a pain assessment for a client who has been admitted with metastatic breast
cancer, which question asked by the nurse will give the most information about the client’s
pain?
a. “How long have you had this pain?”
b. “How would you describe your pain?”
c. “How much medication do you take for the pain?”
d. “How many times a day do you medicate for pain?”
ANS: B
Because pain is a multidimensional experience, asking a question that addresses the
client’s experience with the pain is likely to elicit more information than the more specific
information asked in the other three responses. All of these questions are appropriate, but
the response beginning “How would you describe your pain?” is the best initial question.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. A client who uses a fentanyl patch for chronic cancer pain complains to the nurse of the
rapid onset of pain at a level 9 (0–10 scale) and requests “something for pain that will
work quickly.” Which of the following types of pain is the most appropriate for the nurse
to document for this client?
a. Somatic pain
b. Referred pain
c. Neuropathic pain
d. Breakthrough pain
ANS: D
Pain that occurs beyond the chronic pain already being treated by appropriate analgesics is
termed breakthrough pain. Neuropathic pain is caused by damage to peripheral nerves or
the central nervous system (CNS). Somatic pain is localized and arises from bone, joint,
muscle, skin, or connective tissue. Referred pain is pain that is localized in uninjured
tissue.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
3. A postoperative client asks the nurse how the prescribed ibuprofen will control the
incisional pain. The nurse will teach the client that ibuprofen interferes with the pain
process by decreasing which of the following physiological responses?
a. Modulating effect of descending nerves
b. Sensitivity of the brain to painful stimuli
c. Production of pain-sensitizing chemicals
d. Spinal cord transmission of pain impulses
ANS: C
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Nonsteroidal anti-inflammatory drugs (NSAIDs) provide analgesic effects by decreasing
the production of pain-sensitizing chemicals such as prostaglandins at the site of injury.
Transmission of impulses through the spinal cord, brain sensitivity to pain, and the
descending nerve pathways are not affected by the NSAIDs.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
4. The nurse is caring for a client who is taking an opioid for postoperative pain. Which of
the following interventions should the nurse include in the clients plan of care to manage
possible adverse effects of opioids?
a. Ensure the medication is given PRN only.
b. Administer the prescribed stool softener OD.
c. Ensure the administration route maximizes drug concentration at the site of the
adverse effect.
d. Request a prescription for a different classification of medication.
ANS: B
Examples of ways to manage anticipated adverse effects of opioids are to administer stool
softeners to prevent constipation and an antiemetic to prevent nausea. The medication
should have a scheduling dosage regimen to maintain blood levels rather than only PRN.
Changing to a different medication in the same classification may be appropriate rather
than changing the drug classification. Another way to manage an adverse effect is to use
an administration route that minimizes rather than maximizes drug concentrations at the
site of the adverse effect.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
5. A client with chronic abdominal pain has learned to control the pain with the use of
imagery and hypnosis. A family member asks the nurse how these techniques work.
Which of the following reasons provide the basis for the nurse’s response in relation to the
effectiveness of these strategies?
a. Impact the cognitive and affective components of pain.
b. Increase the modulating effect of the efferent pathways.
c. Prevent transmission of nociceptive stimuli to the cortex.
d. Slow the release of transmitter chemicals in the dorsal horn.
ANS: A
Cognitive therapies impact on the perception of pain by the brain rather than affecting
efferent or afferent pathways or influencing the release of chemical transmitters in the
dorsal horn.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
6. A client who is receiving sustained-release morphine sulphate every 12 hours for chronic
pain experiences level 9 (0–10 scale) breakthrough pain and anxiety. Which of these
prescribed medications should the nurse anticipate administering?
a. Lorazepam 1 mg orally
b. Amitriptyline 10 mg orally
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c. Ibuprofen 400–800 mg orally
d. Immediate-release morphine 30 mg orally
ANS: D
The severe breakthrough pain indicates that the initial therapy should be a rapidly acting
opioid such as the immediate-release morphine. The ibuprofen and amitriptyline may be
appropriate to use as adjuvant therapy, but they are not likely to block severe breakthrough
pain. Use of antianxiety agents for pain control is inappropriate because this client’s
anxiety is caused by the pain.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
7. The nurse is caring for a client with chronic back pain who has arrived at the pain clinic
for a follow-up appointment. In order to evaluate whether the pain management is
effective, which of the following questions is most appropriate for the nurse to ask?
a. “Can you describe the quality of your pain?”
b. “Has there been a change in the pain location?”
c. “How would you rate your pain on a 0–10 scale?”
d. “Does the pain keep you from doing things you enjoy?”
ANS: D
The goal for the treatment of chronic pain usually is to enhance function and quality of life.
The other questions also are appropriate to ask, but information about client function is
more useful in evaluating effectiveness.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
8. A client with second-degree burns has been receiving morphine through patient-controlled
analgesia (PCA) for a week. The client wakes up frequently during the night complaining
of pain. Which of the following actions should the nurse implement?
a. Administer a dose of morphine every 1–2 hours from the PCA machine while the
client is sleeping.
b. Consult with the health care provider about using a different treatment protocol to
control the client’s pain.
c. Request that the health care provider order a bolus dose of morphine to be given
when the client awakens with pain.
d. Teach the client to push the button every 10 minutes for an hour before going to
sleep, even if the pain is minimal.
ANS: B
PCAs are best for controlling acute pain; this client’s history indicates chronic pain and a
need for a pain management plan that will provide adequate analgesia while the client is
sleeping. Administering a dose of morphine when the client already has severe pain will
not address the problem. Teaching the client to administer unneeded medication before
going to sleep can result in oversedation and respiratory depression. It is illegal for the
nurse to administer the morphine for a client through PCA.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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9. The nurse is caring for a client who is receiving epidural morphine. Which of the
following information obtained by the nurse indicates that the client may be experiencing
an adverse effect of the medication?
a. The client has cramping abdominal pain.
b. The client becomes restless and agitated.
c. The client has not voided for over 10 hours.
d. The client complains of a “pounding” headache.
ANS: C
Urinary retention is a common adverse effect of epidural opioids. Headache is not an
anticipated adverse effect of morphine, although if there is a cerebro-spinal fluid leak, the
client may develop a “spinal” headache. Sedation (rather than restlessness or agitation)
would be a possible adverse effect. Hypotonic bowel sounds and constipation (rather than
abdominal cramping) are concerns.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
10. The nurse visits a hospice client and assesses a respiratory rate of 8 breaths/minute and the
client states “I am having severe pain.” Which of the following interventions should the
nurse implement at this time?
a. Inform the client that increasing the morphine will cause the respiratory drive to
fail.
b. Administer a nonopioid analgesic, such as a nonsteroidal anti-inflammatory drug
(NSAID), to improve client pain control.
c. Tell the client that additional morphine can be administered when the respirations
are 12.
d. Titrate the prescribed morphine dose upward until the client indicates adequate
pain relief.
ANS: D
The goal of opioid use in terminally ill clients is effective pain relief regardless of adverse
effects such as respiratory depression. The rule of double effect provides ethical
justification for administering an increased morphine dose to provide effective pain
control even though the morphine may further decrease the client’s respiratory rate. A
nonopioid analgesic like ibuprofen would not provide adequate analgesia or be absorbed
quickly.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
11. The nurse is admitting a client to hospital with a history of chronic cancer pain. When
reviewing the client’s home medications, which of the following medications should be of
most concern?
a. Amitriptyline 50 mg at bedtime
b. Oxycodone 80 mg twice daily
c. Ibuprofen 800 mg three times daily
d. Meperidine 25 mg every 4 hours
ANS: D
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Meperidine is contraindicated for chronic pain because it forms a metabolite that is
neurotoxic and can cause seizures when used for prolonged periods. The ibuprofen,
amitriptyline, and oxycodone are all appropriate medications for long-term pain
management.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
12. The nurse is caring when caring for a client with cancer pain that the client describes as at
“level 8 (0–10 scale), deep, and aching.” Which of the following prescribed medications
should the nurse administer first?
a. Fentanyl patch
b. Ketorolac tablets PO
c. Hydromorphone IV
d. Acetaminophen suppository
ANS: C
The client’s pain level indicates that a rapidly acting medication such as an IV opioid is
needed. The other medications also may be appropriate to use, but will not work as rapidly
or as effectively as hydromorphone IV.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
13. The nurse is caring for a client with diabetes who has chronic burning leg pain even when
taking oxycodone twice daily. Which of the following prescribed medications is the most
appropriate choice for the nurse to administer as an adjuvant to decrease the client’s pain?
a. Acetylsalicylic acid
b. Dextroamphetamine
c. Amitriptyline
d. Acetaminophen
ANS: C
The client’s pain symptoms are consistent with neuropathic pain and the tricyclic
antidepressants are effective for treating this type of pain. Acetylsalicylic acid and
acetaminophen are more effective for nociceptive pain and dextroamphetamine is used in
managing opioid-induced sedation.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
14. The nurse is preparing a client for discharge who has been receiving morphine 10 mg IV
for pain and will continue to take morphine PO at home. Which of the following dosages
is an equianalgesic oral dose for this client?
a. 10 mg
b. 20 mg
c. 30 mg
d. 40 mg
ANS: C
The approximate equianalgesic oral dose for morphine 10 mg parentally is 30 mg PO.
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DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
15. These medications are prescribed by the health care provider for a client who uses
long-acting morphine for chronic back pain, but still has ongoing pain. Which of the
following medications should the nurse question?
a. Morphine
b. Pentazocine
c. Celecoxib
d. Dexamethasone
ANS: B
Opioid agonist–antagonists can precipitate withdrawal if used in a client who is physically
dependent on agonist drugs such as morphine. The other medications are appropriate for
the client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
16. The nurse assesses a postoperative client who is receiving morphine through
patient-controlled analgesia (PCA). Which information is most important to report to the
health care provider?
a. The client complains of nausea after eating.
b. The client’s respiratory rate is 10 breaths/minute.
c. The client has not had a bowel movement for 3 days.
d. The client has a distended bladder and has not voided.
ANS: B
The client’s respiratory rate indicates a need to decrease the PCA dose or change the
medication in order to avoid further respiratory depression. The other information also
may require intervention, but is not as urgent to report as the respiratory rate.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
17. The nurse is caring for a client who has chronic musculo-skeletal pain and states “I feel
depressed because I ache too much to play golf.” The client says the pain is usually at a
level 7 (0–10 scale). Which of the following client goals has the highest priority when the
nurse is developing the treatment plan?
a. The client will exhibit fewer signs of depression.
b. The client will say that the aching has decreased.
c. The client will state that pain is at a level 2 of 10.
d. The client will be able to play 1–2 rounds of golf.
ANS: D
For chronic pain, clients are encouraged to set functional goals such as being able to
perform daily activities and hobbies. The client has identified playing golf as the desired
activity, so a pain level of 2 of 10 or a decrease in aching would be less useful in
evaluating successful treatment. The nurse also should assess for depression, but the client
has identified the depression as being due to the inability to play golf, so the goal of being
able to play 1 or 2 rounds of golf is the most appropriate.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
18. The nurse is caring for a client who has just started taking sustained-release morphine
sulphate for chronic pain and is nausea with abdominal fullness. Which of the following
interventions is the most appropriate for the nurse to implement?
a. Administer the ordered antiemetic medication.
b. Tell the client that the nausea will subside in about a week.
c. Order the client a clear liquid diet until the nausea decreases.
d. Consult with the health care provider about using a different opioid.
ANS: A
Nausea is frequently experienced with the initiation of opioid therapy, and antiemetics
usually are prescribed to treat this expected adverse effect. There is no indication that a
different opioid is needed, although if the nausea persists, the health care provider may
order a change of opioid. Although tolerance develops and the nausea will subside in
about a week, it is not appropriate to allow the client to continue to be nauseated. A clear
liquid diet may decrease the nausea, but the best choice would be to administer the
antiemetic medication and allow the client to eat.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
19. A client with cancer-related pain and a history of opioid abuse complains of breakthrough
pain 2 hours before the next dose of morphine sulphate extended-release is due. Which of
the following actions is priority for the nurse to implement?
a. Administer the prescribed PRN immediate-release morphine.
b. Suggest the use of alternative therapies such as heat or cold.
c. Utilize distraction by talking about things the client enjoys.
d. Consult with the doctor about increasing the morphine sulphate extended-release
dose.
ANS: A
The client’s pain requires rapid treatment and the nurse should administer the
immediate-release morphine. Increasing the morphine sulphate extended-release dose and
use of alternative therapies also may be needed, but the initial action should be to use the
prescribed analgesic medications.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
20. The nurse is caring for a client diagnosed with tendinitis in the outpatient clinic and
advises that the client use a topical ointment to assist with pain relief. The client informs
the nurse that they have never used a topical ointment for pain relief before so the nurse
provides education related to the correct use of the ointment. Which of the following
information should the nurse include in the teaching plan?
a. Apply the ointment after a 20-minute massage of the area.
b. Use moist heat for 10 minutes to the area prior to applying the ointment.
c. Test the ointment on a small area of the skin for adverse effects.
d. Use EMLA to the area prior to applying the ointment.
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ANS: C
Skin testing is advisable when the client has not used the particular medication before
because the strengths of the medications vary and different intensities of sensation are
produced. On application, these medications usually produce a strong hot or cold sensation
and should not be used after massage or a heat treatment when blood vessels are already
dilated. An eutectic mixture of local anaesthetics (EMLA) is not appropriate for tendonitis
and should not be applied prior to another pain-relieving ointment.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
21. The nurse is caring for a client who is using fentanyl patch and immediate-release
morphine for chronic cancer pain who develops new-onset confusion, dizziness, and a
decrease in respiratory rate. Which of the following actions is the priority for the nurse to
implement?
a. Remove the fentanyl patch.
b. Notify the health care provider.
c. Continue to monitor the client’s status.
d. Give the prescribed PRN naloxone.
ANS: A
The assessment data indicate possible overdose of opioid. The first action should be to
remove the patch. Naloxone administration in a client who has been chronically using
opioids can precipitate withdrawal and would not be the first action. Notification of the
health care provider and continued monitoring also are needed, but the client’s data
indicate that more rapid action is needed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
22. These medications are ordered for an older-adult client with arthritis in both hips who is
complaining of level 3 (0–10 scale) hip pain while ambulating. Which medication should
the nurse use as initial therapy?
a. Acetylsalicylic acid 650 mg orally
b. Naproxen 200 mg orally
c. Oxycodone 5 mg orally
d. Acetaminophen 650 mg orally
ANS: D
Acetaminophen is the best first-choice medication. The principle of “start low, go slow” is
used to guide therapy when treating elderly adults because the ability to metabolize
medications is decreased and the likelihood of medication interactions is increased.
Nonopioid analgesics are used first for mild to moderate pain, although opioids may be
used later. Acetylsalicylic acid and the NSAIDs are associated with a high incidence of
gastrointestinal bleeding in elderly clients.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
MULTIPLE RESPONSE
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1. The health care provider plans to titrate a patient-controlled analgesia (PCA) machine to
provide pain relief for a client with acute surgical pain who has never received opioids in
the past. Which of the following nursing actions regarding opioid administration are
appropriate at this time? (Select all that apply.)
a. Assessing for signs that the client is becoming addicted to the opioid
b. Monitoring for therapeutic and adverse effects of opioid administration
c. Emphasizing that the risk of some opioid adverse effects increases over time
d. Educating the client about how analgesics improve postoperative activity level
e. Teaching about the need to decrease opioid doses by the second postoperative day
ANS: B, D
Monitoring for pain relief and teaching the client about how opioid use will improve
postoperative outcomes are appropriate actions when administering opioids for acute pain.
Although postoperative clients usually need decreasing amount of opioids by the second
postoperative day, each client’s response is individual. Tolerance may occur, but addiction
to opioids will not develop in the acute postoperative period. The client should use the
opioids to achieve adequate pain control, and so the nurse should not emphasize the
adverse effects.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 11: Substance Use
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is assessing a client who has a history of alcohol use. Which of the following
assessment data should the nurse expect?
a. Low blood pressure
b. Decreased heart rate
c. Elevated temperature
d. Abdominal tenderness
ANS: D
Abdominal pain associated with gastrointestinal tract and liver dysfunction is common in
clients with chronic alcohol use. The other problems are not associated with alcohol use.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. The nurse is caring for a client who smokes a pack of cigarettes daily and has been
admitted to the hospital for surgery. In anticipation of nicotine withdrawal, which of the
following goals should the nurse include when planning postoperative care?
a. Improve sleep.
b. Enhance appetite.
c. Decrease diarrhea.
d. Prevent sore throat.
ANS: A
Insomnia is a characteristic of nicotine withdrawal. Diarrhea, sore throat, and anorexia are
not symptoms associated with nicotine withdrawal.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
3. The nurse is preparing to conduct an annual physical examination with a young adult
client who arrives in the clinic smelling of cigarette smoke and carrying a pack of
cigarettes. Which action will the nurse plan to take?
a. Urge the client to quit smoking as soon as possible.
b. Avoid confronting the client about smoking at this time.
c. Wait for the client to start the discussion about quitting smoking.
d. Explain that the “cold turkey” method is most effective in stopping smoking.
ANS: A
Current national guidelines indicate that health care providers should urge clients who
smoke to quit smoking at every encounter. The other actions will not help decrease the
client’s health risks related to smoking.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
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4. The nurse is caring for a client admitted to the hospital after an automobile accident who
has a blood alcohol concentration (BAC) of 48 mmol/L (0.22 mg%). The client is alert
and does not appear highly intoxicated. Which of the following nursing actions should the
nurse implement?
a. Maintain the client on NPO status.
b. Avoid the use of intravenous (IV) fluids.
c. Administer acetaminophen for headache.
d. Monitor frequently for anxiety, hyper-reflexia, and sweating.
ANS: D
The client’s assessment data indicate physiological dependence on alcohol, and the client
is likely to develop acute withdrawal such as anxiety, hyper-reflexia, and sweating, which
could be life-threatening. Acetaminophen is not recommended because it is metabolized
by the liver. IV thiamine and IV glucose solutions usually are given to intoxicated clients
to prevent Wernicke’s encephalopathy, and there is no indication that the client should be
NPO.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
5. A client who is alcohol-intoxicated must undergo emergency surgery for abdominal
trauma. Which of the following should the nurse anticipate when caring for the client in
the perioperative period?
a. An increased dose of the general anaesthetic medication.
b. Frequent monitoring for bleeding and respiratory complications.
c. Development of withdrawal symptoms within a few hours after surgery.
d. Stimulation every hour to prevent prolonged postoperative sedation.
ANS: B
Clients who are intoxicated at the time of surgery are at increased risk for problems with
bleeding and respiratory complications such as aspiration. In an intoxicated client, a lower
dose of anesthesia is used because of the synergistic effect of the alcohol. Withdrawal is
likely to occur later in the postoperative course because the medications used for
anesthesia, sedation, and pain will delay withdrawal symptoms. The client should be
monitored frequently for oversedation but does not need to be stimulated.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Planning
6. The nurse is caring for a client with alcohol dependence who has been admitted to the
hospital with chest pain. Twenty-four hours after admission, the client becomes very
tremulous and anxious. Which of the following actions should the nurse implement?
a. Insert an IV line and infuse fluids.
b. Promote oral intake to 3 000 mL/day.
c. Provide a quiet, well-lit environment.
d. Administer opioids to provide sedation.
ANS: C
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The client’s symptoms suggest acute alcohol withdrawal, and a quiet and well-lit
environment will help to decrease agitation, delusions, and hallucinations. There is no
indication that the client is dehydrated. Benzodiazepines, rather than opioids, are used to
prevent withdrawal. IV lines are avoided whenever possible.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
7. A client with a history of heavy alcohol use is seen at the clinic with acute gastritis. Which
statement by the client indicates that the client is in the contemplation stage of change?
a. “I am older and wiser now, and I know I can change my drinking behaviour.”
b. “Alcohol has never bothered my stomach. I think it’s likely that I have the flu.”
c. “I think my drinking is affecting my stomach, but maybe some drugs will help.”
d. “People say that I drink too much, but I really feel pretty good most of the time.”
ANS: C
This statement indicates that the client recognizes that alcohol use is the reason for the
gastritis but is not yet willing to make a change. The statement “I am older and wiser now,
and I know I can change my drinking behaviour” indicates a client at the preparation stage.
The remaining two statements are typical of the precontemplation stage.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Assessment
8. A client who smokes a pack of cigarettes daily develops tachycardia and irritability on the
second day after abdominal surgery. Which of the following actions should the nurse
implement first?
a. Escort the client outside where smoking is allowed.
b. Request a prescription for a nicotine replacement agent.
c. Move the client to a private room and allow smoking.
d. Tell the client that this is a good time to quit smoking.
ANS: B
Nicotine replacement agents should be prescribed for clients who are hospitalized to avoid
withdrawal symptoms. Allowing the client to smoke encourages ongoing smoking. Urging
the client to quit smoking is appropriate, but the first action should be to obtain appropriate
medications to prevent withdrawal symptoms.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
9. The nurse is caring for a client who is admitted to the hospital for treatment of an abscess
on the left thigh and the client tells the nurse that they use fentanyl illegally. Which of the
following symptoms should the nurse anticipate assessing?
a. Nausea and diarrhea
b. Tremors and seizures
c. Lethargy and disorientation
d. Delusions and hallucinations
ANS: A
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Symptoms of opioid withdrawal include gastrointestinal symptoms such as nausea,
vomiting, and diarrhea, similar to a bout of the stomach flu. The other symptoms are seen
during withdrawal from other substances such as alcohol, sedative–hypnotics, or
stimulants.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Assessment
10. The nurse is caring for an adult client who is experiencing acute intoxication. The nurse is
aware that acute intoxication responses usually resolve within which of the following time
frames?
a. 4 hours
b. 12 hours
c. 24 hours
d. 48 hours
ANS: C
Intoxication responses usually last less than 24 hours and are directly related to the
ingestion of psychoactive substances.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
11. During physical assessment of a client who has sinus headaches, the nurse finds nasal
sores and necrosis of the nasal septum. Client use of which of the following substances
should the nurse include in the assessment?
a. Heroin
b. Cocaine
c. Tobacco
d. Marijuana
ANS: B
When cocaine is inhaled, it causes ischemia of the nasal septum, leading to nasal sores and
necrosis. These symptoms are not associated with the use of heroin, tobacco, or
marihuana.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Assessment
12. The nurse is caring for a client admitted to hospital with chest pain who is a pack-a-day
smoker and tells the nurse, “I am just not ready to quit smoking yet.” Which of the
following responses is the most appropriate?
a. “This would be a really good time to quit.”
b. “Your smoking is the cause of your chest pain.”
c. “Do you think that smoking has caused any health problems?”
d. “Are you familiar with the various nicotine replacement options?”
ANS: C
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The client is in the precontemplation stage of change, and the nurse’s role is to assist the
client in identifying motivators to quitting. The current Clinical Practice Guidelines
indicate that the nurse should ask the client to identify any negative consequences from
smoking. The responses “This would be a really good time to quit.” and “Your smoking is
the cause of your chest pain.” express judgemental feelings by the nurse and are not likely
to motivate the client. Providing information about the various nicotine replacement
options would be appropriate for a client who has expressed a desire to quit smoking.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
13. A client who is disoriented and agitated comes to the emergency department after using
methamphetamine. Vital signs are blood pressure 162/98, heart rate 142 and irregular, and
respirations 32. Which of the following actions is priority for the nurse to implement?
a. Reorient the client at frequent intervals.
b. Monitor the client’s ECG and vital signs.
c. Keep the client in a quiet and darkened room.
d. Obtain a health history including prior drug use.
ANS: B
The priority is to ensure physiological stability given that methamphetamine use can lead
to complications such as myocardial infarction. The other actions also are appropriate but
are not of as high a priority.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
14. The nurse is caring for a client who takes methadone daily to prevent a relapse of heroin
addiction and has been admitted for knee surgery. Which of the following actions should
the nurse include in the plan of care to promote effective pain control postoperatively?
a. Use a mixed opioid agonist–antagonist drug for pain relief.
b. Administer opioid analgesics on a regularly scheduled basis.
c. Avoid use of opioids and use alternatives such as NSAIDs.
d. Give prescribed doses of opioid pain medication as needed for pain.
ANS: B
A client addicted to opioids should receive them on an around-the-clock basis to prevent
withdrawal. Normal opioid doses given on a PRN basis will not effectively relieve pain in
a client who has developed tolerance. NSAIDs may be used as adjuncts, but they should
not be the primary analgesic used. Mixed opioid agonist–antagonist drugs can precipitate
withdrawal in clients who have tolerance to opioids.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
15. An older adult has been taking alprazolam and calls the clinic asking for a refill of the
prescription 1 month before it should need to be refilled. Which of the following responses
is most appropriate?
a. “The prescription cannot be refilled for another month. What happened to all of
your pills?”
b. “Do you have any muscle cramps or tremors if you don’t take the medication
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frequently?”
c. “I will ask the doctor to prescribe a few more pills, but you will not be able to get
any more for another month.”
d. “I am concerned that you may be overusing the alprazolam. Let’s make an
appointment for you to see the doctor today.”
ANS: D
The client should be assessed for problems that are causing overuse of the alprazolam,
such as anxiety or memory loss. The other responses by the nurse will not allow for the
needed assessment and possible referral for support services or treatment of drug
dependence.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
16. The nurse is caring for a young adult client who has inhaled cocaine and has been admitted
to the emergency department with palpitations and shortness of breath. Which of the
following actions ordered by the health care provider will the nurse implement first?
a. Obtain a 12-lead ECG.
b. Start O2 at 4 L/minute.
c. Draw blood for drug screening.
d. Infuse normal saline at 100 mL/hour.
ANS: B
The priority here is to ensure that oxygenation is adequate. The other orders also should be
accomplished as soon as possible but are not the first priority.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
17. An agitated individual is brought to the emergency department by friends who state that
the client took a hallucinogenic drug at a party and then tried to jump from a second-story
window. Which of the following nursing diagnoses is priority?
a. Risk for injury related to altered sensation.
b. Ineffective health maintenance related to ineffective coping strategies.
c. Powerlessness related to insufficient knowledge to manage a situation.
d. Ineffective denial related to insufficient sense of control.
ANS: A
Although all the diagnoses may be appropriate for the client, the highest priority is to
address the client’s immediate risk for injury.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Diagnosis
18. A young adult client arrives at the emergency department with severe chest pain and
agitation. Which of the following actions should the nurse take first?
a. Give the PRN naloxone IV.
b. Ask about any use of stimulant drugs.
c. Assess orientation to person, place, and time.
d. Check blood pressure, pulse, and respirations.
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ANS: D
The client has symptoms consistent with the use of cocaine or amphetamines and is at risk
for dysrhythmias, hypotension, heart failure, myocardial infarction, and cardiomyopathy.
The nurse also will ask about drug use and assess orientation, but these are not the priority
actions. Naloxone may be given if the client develops symptoms of CNS depression, but
this client’s current symptoms indicate stimulant use.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
19. All the following medications are ordered for a client admitted with a blood alcohol
concentration of 0.18 mg%. Which of the following should the nurse administer first?
a. Thiamine 100 mg daily
b. Lorazepam 1 mg as needed
c. Folic acid 0.4 mg daily
d. Dextrose 5% in 0.45 saline over 8 hours
ANS: A
Thiamine is given to all clients with alcohol intoxication to prevent Wernicke’s
encephalopathy. Because Wernicke’s encephalopathy can be precipitated by the
administration of glucose solutions, the thiamine should be given before (or concurrently
with) the 5% dextrose solution. Lorazepam would not be appropriate while the client still
has an elevated blood alcohol concentration (BAC). Folic acid also may be administered
but is not as important as thiamine.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
20. Suicide is an overdose effect of which of the following substances?
a. Alcohol
b. Inhalants
c. Opioids
d. Hallucinogens
ANS: B
Suicide is an overdose effect of the use of inhalants. Suicide has not been identified as an
overdose effect of alcohol, opioids, or hallucinogens.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
21. The nurse is caring for a client who has a history of ongoing opioid use and has been
hospitalized for surgery. After a visit by a friend, the nurse assesses that the client is
unresponsive with pinpoint pupils. Which of these prescribed medications will the nurse
administer immediately?
a. Naloxone
b. Diazepam
c. Clonidine
d. Methadone
ANS: A
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The client’s assessment indicates an opioid overdose, and naloxone should be given to
prevent respiratory arrest. The other medications may be used to decrease symptoms
associated with opioid withdrawal but would not be appropriate for an overdose.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
22. The nurse is caring for a young adult who has a cocaine addiction. Which of the following
routes of cocaine administration results in the fastest absorption and the highest “rush”?
a. Smoking
b. Buccal
c. Oral
d. Intranasal
ANS: A
Smoking and intravenous (IV) methods result in the fastest absorption and the highest
“rush.”
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
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Chapter 12: Complementary and Alternative Therapies
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. Which of the following actions if implemented by the nurse indicates that further
education about complementary and alternative therapy is required?
a. Massaging the legs of a client who has a left foot stasis ulcer.
b. Assessing a capillary blood glucose level for a client taking aloe.
c. Recommending the use of acupressure to a client with tension headaches.
d. Teaching family members how to provide a hand massage to a client.
ANS: A
Massage should not be done for a client with open wounds. The other actions by the new
nurse are appropriate.
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
2. The nurse is caring for a client who is experiencing extreme postoperative nausea. Which
of the following therapies should the nurse recommend for this client?
a. Acupuncture
b. Aromatherapy
c. St. John’s wort
d. Magnetic therapy
ANS: A
Acupuncture may be useful in the treatment of postoperative nausea. The other therapies
are not used to treat postoperative nausea.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
3. Which of these complementary and alternative therapies should the nurse suggest to a
client who has elevated triglyceride levels?
Fish oil
Milk thistle
Saw palmetto
Ginkgo biloba
a.
b.
c.
d.
ANS: A
There is evidence that fish oil is helpful in treating hypertriglyceridemia. The other
therapies will not be helpful for this client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
4. Which of the following information obtained by the nurse when admitting a client with
osteoarthritis may indicate a need for client teaching?
a. The client obtains information about herbal therapies online.
b. The client takes glucosamine daily to prevent knee and hip pain.
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c. The client attends a weekly yoga class to improve flexibility and balance.
d. The client states that prayer helps to improve the knee pain and function.
ANS: A
Online information sources are not always reliable and the client may need some teaching
about safe use of herbal remedies. The other information given by the client indicates
appropriate use of complementary and alternative therapies.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
5. A client with chronic headaches seeks treatment from a nurse trained in therapeutic touch
(TT). Which of the following will the nurse perform during the TT session?
a. Realign the client’s energy flow.
b. Manipulate muscles and soft tissues.
c. Apply pressure to body points where energy is obstructed.
d. Passively move stressed joints through the range of motion.
ANS: A
Therapeutic touch involves the use of the practitioner’s hands to realign the client’s energy
flow. The other responses describe other complementary and alternative therapies (CATs)
such as massage, chiropractic therapy, and acupressure.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
6. A client who has nausea associated with chemotherapy asks the nurse whether there are
any complementary and alternative therapies that might be effective. Which of the
following should the nurse discuss with this client?
a. Green tea
b. Acupuncture
c. Black cohosh
d. Chiropractic therapy
ANS: B
Acupuncture is helpful in chemotherapy-induced nausea. The other therapies are
recommended to treat nausea.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
7. A client who develops frequent upper respiratory infections (URIs) asks the nurse whether
any herbal therapies might help. Which of the following should the nurse discuss with this
client?
a. Ginger
b. Echinacea
c. Ginkgo biloba
d. St. John’s wort
ANS: B
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Echinacea may have some benefit in reducing the incidence and duration of the common
cold. Ginkgo biloba, ginger, and St. John’s wort are useful for other conditions, but they
would not be helpful for this client.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
8. Which of the following information should the nurse include when discussing the use of
herbal remedies with a client who uses a variety of herbs for health maintenance?
a. Herbs should be purchased only from manufacturers with a history of quality
control.
b. Most herbs are toxic and carcinogenic and should be used only when proven
effective.
c. Herbs are no better than conventional drugs in maintaining health and may be less
safe.
d. Frequent medical evaluation is required during the use of herbs to avoid adverse
effects.
ANS: A
The quality of herb preparations can vary, so it is important that clients purchase herbal
remedies from reputable manufacturers. When appropriately used, herbs are generally safe
and have fewer adverse effects than conventional medications.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
9. Which of the following data obtained by the nurse during the preoperative assessment of a
client requires further assessment?
a. The client uses several herbal remedies routinely.
b. The client recently visited a chiropractor for back pain.
c. The client has used acupressure to relieve postoperative nausea in the past.
d. The client expresses a wish to use acupuncture for postoperative pain control.
ANS: A
Many herbs prolong bleeding time, so further assessment of the types of herbs that are
used and how recently they were used is needed before the client has surgery. The other
information given by the client also requires further assessment but will not affect the
timing of the client’s surgery.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
10. Which of the following terms is used to describe the study of health as related to a
connection between a deity and the human body?
Distant healing
Petitionary prayer
Theosomatic medicine
Spiritual healing
a.
b.
c.
d.
ANS: C
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The term theosomatic medicine has been developed to describe the study of health as
related to an apparent connection between a deity and the human body. In exploring this
connection, religious involvement has been found to be generally associated with lower
levels of illness and higher levels of wellness. Petitionary prayer involves making a
request for specific needs to be met. Distant healing, mental healing, and spiritual healing
are used to study the outcomes of prayer.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
MULTIPLE RESPONSE
1. A client who uses multiple herbal products is scheduled to undergo knee replacement
surgery. The nurse informs the client that herbs that should be discontinued at least 2–3
weeks before surgery include which of the following? (Select all that apply.)
a. Garlic
b. Ginger
c. Feverfew
d. Echinacea
e. Ginkgo biloba
ANS: A, B, C, E
Feverfew, ginger, garlic, and ginkgo biloba all prolong bleeding time and should be
discontinued before surgery. Echinacea is usually safe to continue.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 13: Palliative Care at the End of Life
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is caring for a terminally ill client who has 20-second periods of apnea followed
by periods of deep and rapid breathing. Which of the following terms should the nurse use
to document this finding?
a. Agonal breathing
b. Apneustic breathing
c. Death rattle respirations
d. Cheyne-Stokes respirations
ANS: D
Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep
and rapid breaths. The “death rattle” is caused by accumulation of mucus in the airways,
causing wet-sounding respirations. Agonal breathing has a very slow and irregular rate and
rhythm. Apneustic respirations are irregular and gasping.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. The nurse is caring for a young adult who is dying after an automobile accident. The
family members want to donate the client’s organs and ask the nurse how the decision
when death has occurred is made. Which of the following is the basis for the nurses’
response to the family in this situation?
a. The client is flaccid and unresponsive.
b. The client is experiencing respiratory acidosis and is on a ventilator.
c. The client is unconscious with no brain stem activity.
d. Respiratory efforts cease and no apical pulse is audible.
ANS: C
Death is the permanent loss of capacity for consciousness and all brain stem functions.
This may result from permanent cessation of circulation or catastrophic brain injury. In the
context of death determination, permanent refers to loss of function that cannot resume
spontaneously and will not be restored through intervention. The other descriptions
describe other clinical manifestations associated with death but are insufficient to declare a
client brain dead.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
3. The nurse is providing hospice care to a client who is manifesting a decrease in all body
system functions except for a heart rate of 124 and a respiratory rate of 28. Which of the
following is the basis for the nurses’ response about these symptoms?
a. They will continue to increase until death finally occurs.
b. They are a normal response before these functions decrease.
c. They indicate a reflex response to the slowing of other body systems.
d. They may be associated with an improvement in the client’s condition.
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ANS: B
An increase in heart and respiratory rate may occur before the slowing of these functions
in the dying client. Heart and respiratory rate typically slow as the client progresses further
toward death. In a dying client, high respiratory and pulse rates do not indicate
improvement, and it would be inappropriate for the nurse to indicate this to the family.
The changes in pulse and respirations are not reflex responses.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
4. The nurse is caring for a client who has been diagnosed with metastatic cancer and plans a
trip across the country “to settle some issues with my sisters and brothers.” Which of the
responses should the nurse recognize that the client is manifesting?
a. Restlessness
b. Yearning and protest
c. Anxiety about unfinished business
d. Fear of the meaninglessness of one’s life
ANS: C
The client’s statement indicates that there is some unfinished family business that the
client would like to address before dying. Restlessness is frequently a behaviour associated
with an inability to express emotional or physical distress, but this client does not express
distress and is able to communicate clearly. There is no indication that the client is
protesting the prognosis, or that there is any fear that the client’s life has been
meaningless.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Assessment
5. The spouse of a client with terminal lung cancer visits daily and cheerfully talks with the
client about vacation plans for the next year. When the nurse asks about any concerns, the
spouse says, “I’m busy at work, but otherwise things are fine.” Which of the following
nursing diagnoses is appropriate?
a. Ineffective denial related to threat of unpleasant reality
b. Anxiety related to threat to current status
c. Caregiver role strain related to inexperience with caregiving
d. Hopelessness related to chronic stress
ANS: A
The spouse’s behaviour and statements indicate the absence of anticipatory grieving,
which may lead to impaired adjustment as the client progresses toward death. The spouse
does not appear to feel overwhelmed, hopeless, or anxious about the partner’s impending
death.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Diagnosis
6. As the nurse admits a client with severe heart failure to the hospital, the client tells the
nurse, “If my heart or breathing stop, I do not want to be resuscitated.” Which of the
following actions should the nurse take?
a. Ask if these wishes have been discussed with the health care provider.
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b. Place a “Do-Not-Resuscitate” (DNR) notation in the client’s care plan.
c. Inform the client that a notarized advance directive must be included in the record
or resuscitation must be performed.
d. Advise the client to designate a person to make health care decisions when the
client is not able to make them independently.
ANS: A
A health care provider’s order should be written describing the actions that the nurses
should take if the client requires CPR, but the primary right to decide belongs to the client
or family. The nurse should document the client’s request but does not have the authority
to place the DNR order in the care plan. A notarized advance directive is not needed to
establish the client’s wishes. The client may need a durable power of attorney for health
care (or the equivalent), but this does not address the client’s current concern with possible
resuscitation.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
7. A client who is very close to death is very restless and keeps repeating, “I am not ready to
die.” Which of the following actions should the nurse take?
a. Remind the client that no one feels ready for death.
b. Sit at the bedside and ask if there is anything the client needs.
c. Insist that family members remain at the bedside with the client.
d. Tell the client that everything possible is being done to delay death.
ANS: B
Staying at the bedside and listening allows the client to discuss any unresolved issues or
physical discomforts that should be addressed. Stating that no one feels ready for death
fails to address the individual client’s concerns. Telling the client that everything is being
done does not address the client’s fears about dying, especially since the client is likely to
die soon. Family members may not feel comfortable staying at the bedside of a dying
client; the nurse should not insist they remain there.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
8. The nurse is caring for a client in a hospice palliative care program who is experiencing
continuous, increasing amounts of pain. Which of the following time schedules should the
nurse implement for the administration of opioid pain medications?
a. Around-the-clock routine administration of analgesics.
b. PRN doses of medication whenever the client requests.
c. Enough pain medication to keep the client sedated and unaware of stimuli.
d. Analgesic doses that provide pain control without decreasing respiratory rate.
ANS: A
The principles of beneficence and nonmaleficence indicate that the goal of pain
management in a terminally ill client is adequate pain relief even if the effect of pain
medications could hasten death. Administration of analgesics on a PRN basis will not
provide the consistent level of analgesia the client needs. Clients usually do not require so
much pain medication that they are oversedated and unaware of stimuli. Adequate pain
relief may require a dosage that will result in a decrease in respiratory rate.
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DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
9. The nurse is caring for a client with lung cancer as part of a home hospice palliative
program. Which of the following interventions should the nurse implement?
a. Discuss cancer risk factors and appropriate lifestyle modifications.
b. Encourage the client to discuss past life events and their meaning.
c. Accomplish a thorough head-to-toe assessment once a week.
d. Educate the client about the purpose of chemotherapy and radiation.
ANS: B
The role of the hospice palliative nurse includes assisting the client with the important
end-of-life task of finding meaning in the client’s life. Frequent head-to-toe assessments
are not needed for hospice clients and may tire the client unnecessarily. Clients admitted to
hospice forego curative treatments such as chemotherapy and radiation for lung cancer;
discussion of cancer risk factors and therapies is not appropriate.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
10. The nurse has been caring for a terminally ill client for the past 10 months. The nurse and
the family are present when the client dies and feels saddened and tearful as the family
members begin to cry. Which of the following actions should the nurse take at this time?
a. Contact a grief counsellor as soon as possible.
b. Cry along with the client’s family members.
c. Leave the home as quickly as possible to allow the family to grieve privately.
d. Consider whether working in hospice is desirable since client losses are common.
ANS: B
It is appropriate for the nurse to cry and express sadness in other ways when a client dies,
and the family is likely to feel that this is therapeutic. Contacting a grief counsellor,
leaving the family to grieve privately, and considering whether hospice continues to be a
satisfying place to work are all appropriate actions as well, but the nurse’s initial action at
this time should be to share the grieving process with the family.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
11. A client who is in the clinic for an immunization tells the nurse, “My mother died 4
months ago, and I just can’t seem to get over it. I’m not sure it is normal to still think
about her every day.” Which of the following nursing diagnoses is most appropriate?
a. Ineffective role performance related to depression
b. Complicated grieving related to emotional disturbance (death of loved one)
c. Anxiety related to unmet needs (lack of knowledge about normal grieving)
d. Impaired mood regulation related to loneliness
ANS: C
The client should be reassured that grieving activities such as frequent thoughts about the
deceased are considered normal for months or years after a death. The other nursing
diagnoses imply that the client’s grief is unusual or pathological, which is not the case.
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DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Diagnosis
12. The family member of a client who is dying tells the nurse, “Mother doesn’t really respond
any more when I visit. I don’t think she knows that I am here.” Which of the following
responses by the nurse is most appropriate?
a. “You may need to cut back your visits for now to avoid overtiring your mother.”
b. “Withdrawal may sometimes be a normal response when preparing to leave life.”
c. “It will be important for you to stimulate your mother as she gets closer to dying.”
d. “Many clients don’t really know what is going on around them at the end of life.”
ANS: B
Withdrawal is a normal psychosocial response to approaching death. Dying clients may
maintain the ability to hear while not being able to respond. Stimulation will tire the client
and is not an appropriate response to withdrawal in this circumstance. Visitors are
encouraged to be “present” with the client, talking softly and making physical contact in a
way that does not demand a response from the client.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
13. Which of the following clients is most appropriate for the nurse to refer to hospice
palliative care?
a. A 60-year-old with lymphoma whose children are unable to discuss issues related
to dying
b. A 72-year-old with chronic severe pain as a result of spinal arthritis and vertebral
collapse
c. A 28-year-old with AIDS-related dementia who needs palliative care and pain
management
d. A 56-year-old with advanced liver failure whose family members can no longer
care for him or her at home
ANS: C
Hospice is designed to provide palliative care such as symptom management and pain
control for clients at the end of life. Clients who require more care than the family can
provide, whose families are unable to discuss important issues related to dying, or who
have severe pain are candidates for other nursing services but are not appropriate hospice
clients.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
14. A terminally ill client is admitted to the hospital. Which of the following actions should
the nurse include in the initial plan of care?
a. Determine the client’s wishes regarding end-of-life care.
b. Emphasize the importance of addressing any family issues.
c. Discuss the normal grief process with the client and family.
d. Encourage the client to talk about any fears or unresolved issues.
ANS: A
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The nurse’s initial action should be to assess the client’s wishes at this time. The other
actions may be implemented if the client or the family express a desire to discuss fears,
understand the grief process, or address family issues, but they should not be implemented
until the assessment indicates that they are appropriate.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Planning
15. The nurse is planning for an end-of-life care discussion with a newly admitted client who
is terminally ill and has decided to use the NURSE protocol during the difficult
conversation to respond to client and/or family emotions. Which of the following terms
describes the “E” in the NURSE protocol?
a. Experimentation
b. Exploration
c. Empathy
d. Emotion
ANS: B
Nurses may use several approaches to difficult conversations that share common features.
Suggested approaches are “ask–tell–ask,” “tell me more,” responding to emotions with the
NURSE protocol (naming, understanding, respecting, supporting, and exploring).
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Planning
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Chapter 14: Inflammation and Wound Healing
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is assessing a client the morning of the first postoperative day and notes redness
and warmth around the incision. Which of the following actions should the nurse
implement?
a. Obtain wound cultures.
b. Document the assessment.
c. Notify the health care provider.
d. Assess the wound every 2 hours.
ANS: B
The incisional redness and warmth are indicators of the normal initial (inflammatory)
stage of wound healing by primary intention; the nurse should document the wound
appearance and continue to monitor the wound. Notification of the health care provider,
assessment every 2 hours, and obtaining wound cultures are not indicated because the
healing is progressing normally.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. A client with an open abdominal wound has a complete blood cell (CBC) count and
differential, which indicate an increase in white blood cells (WBCs) and a shift to the left.
Which of the following actions is priority as a result of this assessment data?
a. Obtain wound cultures.
b. Start antibiotic therapy.
c. Redress the wound with wet-to-dry dressings.
d. Continue to monitor the wound for purulent drainage.
ANS: A
The shift to the left indicates that the client probably has a bacterial infection, and the
nurse will plan to obtain wound cultures. Antibiotic therapy and/or dressing changes may
be started, but cultures should be done first. The nurse will continue to monitor the wound,
but additional actions are needed as well.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
3. The nurse is caring for a client with a systemic bacterial infection that has “goose
pimples,” feels cold, and has a shaking chill. At this stage of the febrile response, which of
the following assessments should the nurse monitor?
a. Skin flushing
b. Muscle cramps
c. Rising body temperature
d. Decreasing blood pressure
ANS: C
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The client’s complaints of feeling cold and shivering indicate that the hypothalamic set
point for temperature has been increased and the temperature is increasing. Because
associated peripheral vasoconstriction and sympathetic nervous system stimulation will
occur, skin flushing and hypotension are not expected. Muscle cramps are not expected
with chills and shivering or with rising temperatures.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
4. The nurse is caring for a young adult client who is receiving antibiotics for an infected leg
wound and has a temperature of 38.8°C (101.8°F). Which of the following actions by the
nurse is most appropriate?
a. Apply a cooling blanket.
b. Notify the health care provider.
c. Give the prescribed PRN Aspirin 650 mg.
d. Check the client’s oral temperature again in 4 hours.
ANS: D
Mild to moderate temperature elevations (less than 39.5°C [103.1°F]) do not harm the
young adult client and may benefit host defence mechanisms. The nurse should continue
to monitor the temperature. Antipyretics are not indicated unless the client is complaining
of fever-related symptoms. There is no need to notify the client’s health care provider or to
use a cooling blanket for a moderate temperature elevation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
5. A client’s 6 ´ 3 cm leg wound has a 2 mm black area surrounded by yellow-green
semiliquid material. Which of the following dressings should the nurse use for wound
care?
a. Dry gauze dressing (Kerlix)
b. Nonadherent dressing (Xeroform)
c. Hydrocolloid dressing (DuoDerm)
d. Transparent film dressing (Tegaderm)
ANS: C
The wound requires debridement of the necrotic areas and absorption of the yellow-green
slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals.
Transparent film dressings are used for red wounds or approximated surgical incisions.
Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb
wound drainage or debride the wound.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
6. The nurse is caring for a client who has an open surgical wound on the abdomen that
contains a creamy exudate and small areas of deep pink granulation tissue. Which of the
following terms should the nurse use to document these findings?
a. Red wound
b. Yellow wound
c. Full-thickness wound
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d. Stage III pressure wound
ANS: B
The description is consistent with a yellow wound. A stage III pressure wound would
expose subcutaneous fat. A red wound would not have any creamy coloured exudate. A
full-thickness wound involves subcutaneous tissue, which is not indicated in the wound
description.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
7. Which of the following nursing actions is most likely to detect early signs of infection in a
client who is taking immuno-suppressive medications?
a. Monitor white blood cell count.
b. Check the skin for areas of redness.
c. Check the temperature every 2 hours.
d. Ask about fatigue or feelings of malaise.
ANS: D
Common clinical manifestations of inflammation and infection are frequently not present
when clients receive immuno-suppressive medications. The earliest manifestation of an
infection may be “just not feeling well.”
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
8. The nurse is planning care for a client and is preparing to complete a wet-to-dry dressing.
Which of the following wound descriptions is appropriate for using this type of dressing?
a. Pressure injury with pink granulation tissue
b. Surgical incision with pink, approximated edges
c. Full-thickness burn filled with dry, black material
d. Wound with purulent drainage and dry brown areas
ANS: D
Wet-to-dry dressings are used when there is minimal eschar to be removed. A
full-thickness wound filled with eschar will require interventions such as surgical
debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on
approximated surgical incisions. Wet-to-dry dressings are not used on uninfected
granulating wounds because of the damage to the granulation tissue.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
9. A client is admitted to the hospital with a pressure injury on the left buttock. The nurse
notes that the base of the wound is yellow and involves subcutaneous tissue. Which of the
following pressure injury wound stages should the nurse document?
a. 1
b. 2
c. 3
d. 4
ANS: C
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A stage 3 pressure injury has full-thickness skin damage and extends into the
subcutaneous tissue. A stage 1 pressure injury has intact skin with some observable
damage such as redness or a boggy feel. Stage 2 pressure injuries have partial-thickness
skin loss. Stage 4 pressure injuries have full-thickness damage with tissue necrosis,
extensive damage, or damage to bone, muscle, or supporting tissues.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
10. A client who is confined to bed and who has a stage 2 pressure injury is being cared for in
the home by family members. To prevent further tissue damage, which of the following
actions should the nurse instruct the family members that it is most important?
a. Change the client’s bedding frequently.
b. Use a hydrocolloid dressing over the injury.
c. Record the size and appearance of the pressure injury weekly.
d. Change the client’s position every 2 hours.
ANS: D
The most important intervention is to avoid prolonged pressure on bony prominences by
frequent repositioning. The other interventions also may be included in family teaching,
but the most important instruction is to change the client’s position every 2–4 hours.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
11. Which nursing action will be included when the nurse is doing a wet-to-dry dressing
change for a client who has a stage III sacral pressure injury?
Administer the ordered PRN oral opioid 30 minutes before the dressing change.
Soak the old dressings with sterile saline a few minutes before removing them.
Pour sterile saline onto the new dry dressings after the wound has been packed.
Apply antimicrobial ointment before repacking the wound with moist dressings.
a.
b.
c.
d.
ANS: A
Mechanical debridement with wet-to-dry dressings is painful, and clients should receive
pain medications before the dressing change begins. The new dressings are moistened with
saline before being applied to the wound. Soaking the old dressings before removing them
will eliminate the wound debridement that is the purpose of this type of dressing.
Application of antimicrobial ointments is not indicated for a wet-to-dry dressing.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
12. The charge nurse observes a new graduate performing a dressing change on a client with a
stage 2 left heel pressure injury. Which of the following actions by the new graduate
indicates a need for further education about pressure injury care?
a. Uses a hydrocolloid dressing (DuoDerm) to cover the injury.
b. Inserts a sterile cotton-tipped applicator into the pressure injury.
c. Irrigates the pressure injury with a 30-mL syringe using sterile saline.
d. Cleans the injury with a sterile dressing soaked in half-strength hydrogen peroxide.
ANS: D
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Pressure injuries should not be cleaned with solutions that are cytotoxic, such as hydrogen
peroxide. The other actions by the new graduate are appropriate.
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
13. A client arrives in the emergency department with a swollen ankle after an injury incurred
while playing soccer. Which of the following actions by the nurse is most appropriate?
a. Elevate the ankle above heart level.
b. Remove the client’s shoe and sock.
c. Apply a warm moist pack to the ankle.
d. Assess the ankle’s range of motion (ROM).
ANS: A
Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation
of the ankle will decrease tissue swelling. Moving the ankle through the ROM will
increase swelling and risk further injury. Cold packs should be applied the first 24 hours to
reduce swelling. The soccer shoe does not need to be removed immediately and will help
to compress the injury if it is left in place.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
14. The nurse is admitting a client with stage 3 pressure injuries on both heels. Which of the
following information obtained by the nurse will have the most impact on wound healing?
a. The client states that the injuries are very painful.
b. The client has had the heel injuries for the last 6 months.
c. The client has several old incisions that have formed keloids.
d. The client takes corticosteroids daily for rheumatoid arthritis.
ANS: D
Chronic corticosteroid use will interfere with wound healing. The persistence of the
pressure injuries over the last 6 months is a concern, but changes in care may be effective
in promoting healing. Keloids are not disabling or painful, although the cosmetic effects
may be distressing for some clients. Actions to reduce the client’s pain will be
implemented, but pain does not impact directly on wound healing.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
15. The nurse has just received change-of-shift report about the following four r. Which client
will the nurse assess first?
a. The client who has multiple black wounds on the feet and ankles.
b. The newly admitted client with a stage IV pressure injury on the coccyx.
c. The client who needs to be medicated with multiple analgesics before a scheduled
dressing change.
d. The client who has been receiving immunosuppressant medications and has a
temperature of 38.9°C (102°F).
ANS: D
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Even a low fever in an immuno-suppressed client is a sign of serious infection and should
be treated immediately with cultures and rapid initiation of antibiotic therapy. The nurse
should assess the other clients as soon as possible after assessing and implementing
appropriate care for the immuno-suppressed client.
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
16. During wound healing, a wound is resistant to infection during which of the following
phases?
a. Initial phase
b. Granulation phase
c. Maturation phase
d. Reoccurrence phase
ANS: B
A wound is resistant to infection during the granulation phase of wound healing.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
17. The nurse is caring for a client with diabetes who had abdominal surgery one week ago,
and obtains the following data. Which of these findings should be reported immediately to
the health care provider?
a. Blood glucose 7.6 mmol/L
b. Oral temperature 38.3°C (100.9°F)
c. Client has increased incisional pain
d. New 5-cm separation of the proximal wound edges
ANS: D
Wound separation at a week postoperatively indicates possible wound dehiscence and
should be immediately reported to the health care provider. The other findings also will be
reported, but do not require intervention as rapidly.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
18. The nurse is caring for a client with diabetes who has been admitted for a laparotomy and
possible release of adhesions. When planning interventions to promote wound healing,
which of the following actions is priority?
a. Maintaining the client’s blood glucose within a normal range
b. Ensuring that the client has an adequate dietary protein intake
c. Giving antipyretics to keep the temperature less than 38.9°C (102°F)
d. Redressing the surgical incision with a dry, sterile dressing twice daily
ANS: A
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Elevated blood glucose will have an impact on multiple factors involved in wound healing.
Ensuring adequate nutrition also is important for the postoperative client, but a higher
priority is blood glucose control. A temperature of 38.9°C (102°F) will not impact wound
healing adversely, although the nurse may administer antipyretics if the client is
uncomfortable. Application of a dry, sterile dressing daily may be ordered, but frequent
dressing changes for a wound healing by primary intention is not necessary to promote
wound healing.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
19. The nurse is caring for an adult client with stage 3 pressure injuries on both heels who has
been in hospital for 6 days. Which of the following timeframes for wound assessment is
accurate when a client is in the acute care setting?
a. Every 4 hours
b. Every 6 hours
c. Every 12 hours
d. Every 24 hours
ANS: D
In acute care, the client should be reassessed every 24 hours. In long-term care, a resident
should be reassessed weekly for the first 4 weeks after admission and at least monthly or
every 3 months thereafter.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
COMPLETION
1. A client’s temperature has been 38.8°C (101.8°F) for several days. The client’s normal
caloric intake to meet nutritional needs is 2 000 calories per day. Knowing that the
metabolic rate increases 13% for every 1°C (33.8°F) increase in temperature above 37.8°C
(100°F) in body temperature, calculate the total calories the client should receive each day.
____________________
ANS: 2 260
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
OTHER
1. A client who has an infected abdominal wound develops a temperature of 40°C (104°F).
All the following interventions are included in the client’s plan of care. In which order
should the nurse perform the following actions?
a. Sponge client with cool water.
b. Administer intravenous antibiotics.
c. Perform wet-to-dry dressing change.
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d. Administer acetaminophen.
ANS:
B, D, A, C
The first action should be to administer the antibiotic because treating the infection that
has caused the fever is the most important aspect of fever management. The next priority
is to lower the high fever, so the nurse should administer acetaminophen to lower the
temperature set point. A cool sponge bath should be done after the acetaminophen is given
to lower the temperature further. The wet-to-dry dressing change will not have an
immediate impact on the infection or fever and should be done last.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
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Chapter 15: Genetics
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. A client whose mother has diagnosed with BRCA gene–related breast cancer asks the
nurse, “Do you think I should be tested for the gene?” Which of the following responses
by the nurse is most appropriate?
a. “In most cases, breast cancer is not caused by the BRCA gene.”
b. “It depends on how you will feel if the test is positive for the BRCA gene.”
c. “There are many things to consider before deciding to have genetic testing.”
d. “You should decide first whether you are willing to have a double mastectomy.”
ANS: C
Although presymptomatic testing for genetic disorders allows clients to take action (such
as mastectomy) to prevent the development of some genetically caused disorders, clients
also need to consider that test results in their medical file may impact other areas of their
life. Telling a client that a decision about mastectomy should be made before testing
implies that the nurse has made a judgement about what the client should do if the test is
positive. Although the client may need to think about her reaction if the test is positive,
other issues (e.g., insurance) also should be considered. Although most breast cancers are
not related to BRCA gene alterations, the client with the gene alteration has a markedly
increased risk for breast cancer.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
2. Which of the following terms describe the process by which the codon sequence is
converted to amino acids?
a. Transcription
b. Mutation
c. Translation
d. Processing
ANS: C
After transcription is complete, translation occurs. Translation is the process through
which the codon sequence is converted into amino acids.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
3. The nurse is counselling a couple in which the man has an autosomal recessive disorder,
and the woman has no gene for the disorder. The nurse uses Punnett squares to show the
couple that the probability of their having a child with the disorder is which of the
following percentages?
a. 0%
b. 25%
c. 50%
d. 75%
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ANS: A
When one parent has no gene for an autosomal recessive disorder, the children will not
display the characteristics of the disorder. However, the children will be carriers of the
autosomal recessive disorder.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
4. The parents of a child with brachydactyly ask if their next child will also be affected.
Which of the following is the basis for the nurses’ response related to autosomal dominant
disorders?
a. There is a 25% chance that the child will be affected.
b. All male off-spring are affected.
c. There is a 50% chance that the child will be affected.
d. All female off-spring will be affected.
ANS: C
Brachydactyly is an autosomal dominant disorder, meaning that there is a 50% chance that
off-spring will be affected. It happens equally in males and females.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
5. The parents of a child with cystic fibrosis ask if their next child will also be affected.
Which of the following is the basis for the nurse’s response related to autosomal recessive
disorders?
a. There is a 25% chance that the child will be affected.
b. All male off-spring are affected.
c. There is a 50% chance that the child will be affected.
d. All female off-spring will be affected.
ANS: A
Cystic fibrosis is an autosomal recessive disorder, meaning that there is a 25% chance that
off-spring will be affected. It happens equally in males and females.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
6. When taking a family history in the genetic clinic, the nurse will ask information about
how many generations in the past?
a. 2
b. 3
c. 4
d. 5
ANS: B
A detailed three-generation family history, or pedigree, offers great insight into possible
genetic conditions within a family.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
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7. A newly pregnant woman asks the nurse what the best time is for a prenatal diagnostic
amniocentesis? Which of the following time frames is the basis for the nurses’ response?
a. 7–10 weeks
b. 11–13 weeks
c. 15–17 weeks
d. 20–24 weeks
ANS: C
A prenatal diagnostic ultrasound should be done between 15 and 17 weeks of gestation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
8. A newly pregnant woman asks the nurse what the best time is for chorionic villus
sampling? Which of the following time frames is the basis for the nurse’s response?
8–10 weeks
11–12 weeks
15–16 weeks
19–20 weeks
a.
b.
c.
d.
ANS: B
Chorionic villus sampling (CVS) is done in the first trimester, usually between 11 and 12
weeks’ gestation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
9. A pregnant client with a family history of cystic fibrosis (CF) asks the emergency
department nurse for information about genetic testing. Which of the following actions is
most appropriate for the nurse to take?
a. Refer the client to a qualified genetic counsellor.
b. Ask the client why genetic testing is important to her.
c. Remind the client that genetic testing has many social implications.
d. Tell the client that cystic fibrosis is an autosomal-recessive disorder.
ANS: A
Although the nurse should understand basic genetics, the emergency department is often
not the ideal environment for genetic counselling. A genetic nurse or counsellor is best
qualified to address the multiple issues involved in genetic testing for a client who is
considering having children. Although genetic testing does have social implications, a
pregnant client will be better served by a genetic counsellor who will have more expertise
in this area. CF is an autosomal-recessive disorder, but the client might not understand the
implications of this statement. Asking why the client feels genetic testing is important may
imply to the client that the nurse is questioning her value system regarding issues such as
abortion.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
10. A male with mild hemophilia asks the nurse, “Will my children be hemophiliacs?” Which
of the following responses by the nurse is most appropriate?
a. “All of your children will be at risk for hemophilia.”
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b. “Hemophilia is a multifactorial inherited condition.”
c. “Only your male children are at risk for hemophilia.”
d. “Your female children will be carriers for hemophilia.”
ANS: D
Because hemophilia is caused by a mutation of the X-chromosome, all female children of
a man with hemophilia are carriers of the disorder and can transmit the mutated gene to
their offspring. Sons of a man with hemophilia will not have the disorder. Hemophilia is
caused by a genetic mutation and is not a multifactorial inherited condition.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
11. When carrying out presymptomatic testing, which of the following diseases has a gene that
is 100% penetrant?
a. Tay–Sachs disease
b. Fragile X syndrome
c. Cystic fibrosis
d. Huntington’s disease
ANS: D
In presymptomatic testing, an individual has genetic testing to determine whether she or he
carries a genetic mutation for a genetic disorder. Typically, individuals electing this testing
are members of a family that exhibits a genetic disorder. An example of this would be
genetic testing for Huntington’s disease, an adult-onset condition characterized by
progressive neurological degeneration. The gene responsible for Huntington’s disease is
100% penetrant; that is, everyone who inherits this mutation will exhibit the disease and,
since there is no cure, will die of the disease.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
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Chapter 16: Altered Immune Response and Transplantation
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. Chickenpox is an example of which of the following types of immunities?
a. Innate
b. Natural active
c. Artificial
d. Cell-mediated
ANS: B
Chickenpox is an example of natural active immunity.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
2. The nurse is caring for a client in the outpatient clinic who has an immune deficiency
involving the T-lymphocytes. Which of the following areas should the nurse teach the
client about the need for more frequent screening?
a. Allergies
b. Malignancy
c. Antibody deficiency
d. Autoimmune disorders
ANS: B
Cell-mediated immunity is responsible for the recognition and destruction of cancer cells.
Allergic reactions, autoimmune disorders, and antibody deficiencies are mediated
primarily by humoral immunity.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
3. Which of the following antibodies is involved with an anaphylactic reaction?
a. IgE
b. IgA
c. IgM
d. IgG
ANS: A
Serum IgE causes the symptoms of allergic reactions and is the antibody involved with an
anaphylactic reaction.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
4. The nurse encourages a new mother to breastfeed her infant, even for a short time, because
colostrum will provide the infant with which of the following types of immunity?
a. Innate
b. Active
c. Passive
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d. Cell-mediated
ANS: C
Colostrum provides passive immunity through antibodies from the mother; these
antibodies protect the infant for a few months. However, memory cells are not retained, so
the protection is not permanent. Innate immunity is present at birth and occurs without
exposure to an antigen. Active immunity requires that the infant manufacture antibodies
after exposure to an antigen. Cell-mediated immunity is acquired through T-lymphocytes
and is a form of active immunity.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
5. The nurse is assessing a client for possible atopic dermatitis. Which of the following
laboratory values should the nurse review?
a. IgE
b. IgA
c. Basophils
d. Neutrophils
ANS: A
Serum IgE causes the symptoms of allergic reactions and is elevated in type 1
hypersensitivity disorders. The eosinophil level will be elevated, rather than neutrophil or
basophil counts. IgA is located in body secretions and would not be tested when
evaluating a client who has symptoms of atopic dermatitis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
6. The nurse is conducting an annual health examination on an older adult client who states,
“I don’t understand why I need to have so many cancer screening tests now. I feel just
fine!” Based upon this statement, which of the following topics will the nurse include in
the clients’ teaching plan?
a. Consequences of aging on cell-mediated immunity
b. Decrease in antibody production associated with aging
c. Impact of poor nutrition on immune function in older people
d. Incidence of cancer-stimulating infections in older individuals
ANS: A
The primary impact of aging on immune function is on the activity of T cells, which are
responsible for tumour immunity. Antibody function is not impacted as much by aging and
does not protect against malignancy. Poor nutrition does contribute to decreased immunity,
but there is no evidence that it is a contributing factor for this client. Although some types
of cancers are associated with specific infections, this client does not have an active
infection.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
7. The nurse discusses the prevention and management of allergic reactions with a client who
is a beekeeper and has developed a hypersensitivity to bee stings. Which of the following
client statements indicates a need for additional teaching?
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a.
b.
c.
d.
“I will plan to take oral antihistamines daily before going to work.”
“I will get a prescription for epinephrine and learn to self-inject it.”
“I should wear a Medic Alert bracelet indicating my allergy to bee stings.”
“I am going to need job retraining so that I can work in a different occupation.”
ANS: A
Since the client is at risk for bee stings and the severity of allergic reactions tends to
increase with added exposure to allergen, taking oral antihistamines will not adequately
control the client’s hypersensitivity reaction. The other client statements indicate a good
understanding of management of the problem.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
8. Which of the following instructions should the nurse include when teaching a client with
possible allergies about intradermal skin testing?
a. “Do not eat anything for about 6 hours before the testing.”
b. “Take an oral antihistamine about an hour before the testing.”
c. “Plan to wait in the clinic for 20–30 minutes after the testing.”
d. “Reaction to the testing will take about 48–72 hours to occur.”
ANS: C
Allergic reactions usually occur within minutes after injection of an allergen, and the client
will be monitored for at least 20 minutes for anaphylactic reactions after the testing.
Medications that might modify the response, such as antihistamines, should be avoided
before allergy testing. There is no reason to be NPO for skin testing. Results with
intradermal testing occur within minutes.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
9. The nurse is caring for a client who receives weekly immunotherapy and has missed the
previous appointment. Which of the following actions should the nurse implement when
the client comes for the next injection?
a. Schedule an additional dose that week.
b. Administer the usual dosage of the allergen.
c. Consult with the health care provider about giving a lower allergen dose.
d. Re-evaluate the client’s sensitivity to the allergen with a repeat skin test.
ANS: C
Because there is an increased risk for adverse reactions after a client misses a scheduled
dose of allergen, the nurse should check with the health care provider before
administration of the injection. A skin test is used to identify the allergen and would not be
used at this time. An additional dose for the week may increase the risk for a reaction.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
10. The nurse is obtaining a health history from a client who works as a laboratory technician
and learns that the client has a history of allergic rhinitis, asthma, and multiple food
allergies. Which of the following actions is most important for the nurse to implement?
a. Encourage the client to carry an epinephrine kit in case a type IV allergic reaction
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to latex develops.
b. Advise the client to use oil-based hand creams to decrease contact with natural
proteins in latex gloves.
c. Document the client’s allergy history and be alert for any clinical manifestations of
a type I latex allergy.
d. Recommend that the client use vinyl gloves instead of latex gloves in preventing
bloodborne pathogen contact.
ANS: C
The client’s allergy history and occupation indicate a risk for development of latex allergy,
and the nurse should be prepared to manage any symptoms that occur. Epinephrine is not
an appropriate treatment for contact dermatitis that is caused by a type IV allergic reaction
to latex. Oil-based creams will increase the exposure to latex from latex gloves. Vinyl
gloves are appropriate to use when exposure to body fluids is unlikely.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
11. A client diagnosed with systemic lupus erythematosus (SLE) is scheduled for
plasmapheresis. Which of the following pathophysiological events should the nurse plan to
teach the client about this procedure?
a. It eliminates eosinophils and basophils from blood.
b. It removes antibody-antigen complexes from circulation.
c. It prevents foreign antibodies from damaging various body tissues.
d. It decreases the damage to organs caused by attacking T-lymphocytes.
ANS: B
Plasmapheresis is used in SLE to remove antibodies, antibody-antigen complexes, and
complement from blood. T-lymphocytes, foreign antibodies, eosinophils, and basophils do
not contribute to the tissue damage in SLE.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
12. Which of the following adverse reactions should the nurse monitor when a client is
undergoing plasmapheresis?
a. Shortness of breath
b. High blood pressure
c. Transfusion reactions
d. Hypotension and paresthesia
ANS: D
Hypotension and paresthesia may occur as the result of plasmapheresis. Citrate is used as
an anticoagulant and may cause hypocalcemia, which may manifest as headache,
paresthesias, and dizziness. The other clinical manifestations are not associated with
plasmapheresis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
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13. The nurse is completing an assessment and health history with a client. Which of the
following statements made by the client should alert the nurse to a possible
immunodeficiency disorder?
a. “I take one baby Aspirin every day to prevent stroke.”
b. “I usually eat eggs or meat for at least two meals a day.”
c. “I had my spleen removed many years ago after a car accident.”
d. “I had a chest x-ray 6 months ago when I had walking pneumonia.”
ANS: C
Splenectomy increases the risk for septicemia from bacterial infections. The client’s
protein intake is good and should improve immune function. Daily Aspirin use does not
impact immune function. A chest x-ray does not have enough radiation to suppress
immune function.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
14. The nurse is caring for a client who had a bone marrow transplant for treatment of
leukemia and has developed a skin rash 10 days after the transplant. The nurse recognizes
this reaction as an indication of which of the following?
a. Donor T cells are attacking the client’s skin cells.
b. The client’s antibodies are rejecting the donor bone marrow.
c. The client is experiencing a delayed hypersensitivity reaction.
d. The client will need treatment to prevent hyperacute rejection.
ANS: A
The client’s history and symptoms indicate that the client is experiencing graft-versus-host
disease, in which the donated T cells attack the client’s tissues. The history and symptoms
are not consistent with rejection or delayed hypersensitivity.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
15. The nurse is caring for a client who has experienced Goodpasture’s syndrome. Which of
the following adverse effects should the nurse be aware of?
a. Thrombocytopenia
b. Leukopenia
c. Angioedema
d. Pulmonary hemorrhage
ANS: D
Goodpasture’s syndrome is a rare disorder involving the lungs and the kidneys. An
antibody-mediated autoimmune reaction occurs involving the glomerular and alveolar
basement membranes. The circulating antibodies combine with tissue antigen to activate
the complement system which causes deposits of IgG to form along the basement
membranes of the lungs or the kidneys. This reaction may result in pulmonary hemorrhage
and glomerulonephritis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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16. The nurse is teaching a client on immunosuppressant therapy after a kidney transplant
about the post-transplant drug regimen. Which of the following statements by the client
should alert the nurse that additional teaching is required?
a. “If I develop an acute rejection episode, I will need to have other types of drugs
given IV.”
b. “I need to be monitored closely because I have a greater chance of developing
malignant tumours.”
c. “After a couple of years, it is likely that I will be able to stop taking the calcineurin
inhibitor.”
d. “The drugs are given in combination because they inhibit different aspects of
transplant rejection.”
ANS: C
The calcineurin inhibitor will need to be continued for life. The other client statements are
accurate and indicate that no further teaching is necessary about those topics.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
17. Which of the following adverse effects is related to cyclosporine administration?
a. Nephrotoxicity
b. Aseptic necrosis
c. Peptic ulcer
d. Leukopenia
ANS: A
Nephrotoxicity is the most severe adverse effect of cyclosporine. Aseptic necrosis, peptic
ulcer, and leukopenia are all adverse effects of the use of corticosteroids, for example,
prednisone.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
18. The nurse is admitting a client to the hospital with a diagnosis of an acute rejection of a
kidney transplant. Which of the following actions should the nurse anticipate
implementing?
a. Administration of immunosuppressant medications
b. Insertion of an arteriovenous graft for hemodialysis
c. Placement of the client on the transplant waiting list
d. Drawing blood for human leukocyte antigen (HLA) and ABO compatibility
matching
ANS: A
Acute rejection is treated with the administration of additional immunosuppressant drugs
such as corticosteroids. Because acute rejection is reversible, there is no indication that the
client will require another transplant, hemodialysis, or HLA/ABO testing.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
19. The nurse is admitting a client to hospital who has an acute rejection of an organ transplant.
Which of the following clients is the most appropriate roommate?
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a.
b.
c.
d.
A client who has viral pneumonia
A client with second-degree burns
A client who is recovering from an anaphylactic reaction to a bee sting
A client with graft-versus-host disease after a recent bone marrow transplant
ANS: C
Treatment for a client with acute rejection includes administration of additional
immunosuppressants, and the client should not be exposed to increased risk for infection
as would occur from clients with viral pneumonia, graft-versus-host disease, and burns.
There is no increased exposure to infection from a client with anaphylaxis.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
20. For early detection of an anaphylactic reaction in a client who has received allergen testing
using the cutaneous scratch method, which of the following actions should the nurse take
first?
a. Check blood pressure and pulse rate.
b. Auscultate the lung sounds bilaterally.
c. Monitor pupil size and reaction to light.
d. Assess the arm at the site of the skin testing.
ANS: D
The initial symptoms of anaphylaxis are itching and edema at the site of the exposure.
Hypotension, tachycardia, dilated pupils, and wheezes occur later. Rapid administration of
epinephrine when excessive itching or swelling at the skin site is observed can prevent the
progression to anaphylaxis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
21. After being stung by a wasp, a client is brought to the clinic by a coworker. Upon arrival
the client is anxious and having difficulty breathing. Which of the following actions is
priority for the nurse to implement?
a. Have the client lie down.
b. Assess the client’s airway.
c. Administer high-flow oxygen.
d. Remove the stinger from the site.
ANS: B
The initial action with any client with difficulty breathing is to assess and maintain the
airway. The other actions also are part of the emergency management protocol for
anaphylaxis, but the priority is airway maintenance.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
22. Immediately after the nurse administers an intradermal injection of an allergen on the
forearm, a client complains of itching at the site and of weakness and dizziness. Which of
the following actions is priority for the nurse to implement?
a. Remind the client to remain calm.
b. Administer subcutaneous epinephrine.
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c. Apply a tourniquet above the injection site.
d. Rub a local anti-inflammatory cream on the site.
ANS: C
Application of a tourniquet will decrease systemic circulation of the allergen and should
be the first reaction. A local anti-inflammatory cream may be applied to the site of a
cutaneous test if the itching persists. Epinephrine will be needed if the allergic reaction
progresses to anaphylaxis. The nurse should assist the client to remain calm, but this is not
an adequate initial nursing action.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
23. The nurse is caring for a client at an outpatient clinic who is experiencing an allergic
reaction to an unknown allergen. Which of the following actions is most appropriate for
the nurse to implement?
a. Perform a focused physical assessment.
b. Obtain the health history from the client.
c. Teach the client about the various diagnostic studies.
d. Administer skin testing by the cutaneous scratch method.
ANS: D
The immediate priority is to administer skin testing by the cutaneous scratch method as the
client is experiencing an allergic reaction. After the allergic reaction is treated, an
assessment of health history, focused physical assessment, and client teaching could
follow.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
24. To determine whether a client’s angioedema has responded to prescribed therapies, which
of the following actions should the nurse take first?
a. Ask about any clear nasal discharge.
b. Obtain blood pressure and heart rate.
c. Check for swelling of the lips and tongue.
d. Assess extremities for wheal and flare lesions.
ANS: C
Angioedema is characterized by swelling of the eyelids, lips, and tongue. Wheal and flare
lesions; clear nasal drainage; and hypotension and tachycardia are characteristics of other
allergic reactions.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
25. Which information about client and donor tissue typing results for a client who needs a
kidney transplant is most important for the nurse to communicate to the health care
provider?
a. Client is Rh positive and donor is Rh negative.
b. Six antigen matches are present in HLA typing.
c. Results of client-donor crossmatching are positive.
d. Panel of reactive antibodies (PRA) percentage is low.
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ANS: C
Positive crossmatching is an absolute contraindication to kidney transplantation, since
hyperacute rejection will occur after the transplant. The other information indicates that
the tissue match between the client and potential donor is acceptable.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
26. Which information about a client who is receiving immunotherapy and has just received
an allergen injection is most important to communicate to the health care provider?
a. The client’s IgG level is increased.
b. The injection site is red and swollen.
c. The client’s allergy symptoms have not improved.
d. There is a 3-cm wheal at the site of the allergen injection.
ANS: D
A local reaction larger than quarter size may indicate that a decrease in the allergen dose is
needed. An increase in IgG indicates that the therapy is effective. Redness and swelling at
the site are not unusual. Because immunotherapy usually takes 1–2 years to achieve an
effect, an improvement in the client’s symptoms is not expected after a few months.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
OTHER
1. The nurse is caring for a client who is receiving an IV antibiotic and develops wheezes and
dyspnea. In which order should the nurse implement these prescribed actions?
a. Discontinue the antibiotic infusion.
b. Give diphenhydramine IV.
c. Inject epinephrine IM or IV.
d. Prepare an infusion of dopamine.
e. Start 100% oxygen using a nonrebreather mask.
ANS:
A, E, C, B, D
The nurse should initially discontinue the antibiotic, since it is the likely cause of the
allergic reaction. Next, oxygen delivery should be maximized, followed by treatment of
bronchoconstriction with epinephrine administered IM or IV. Diphenhydramine will work
more slowly than epinephrine, but will help prevent progression of the reaction. Since the
client currently does not have evidence of hypotension, the dopamine infusion can be
prepared last.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 17: Infection and Human Immunodeficiency Virus Infection
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. A client who has vague symptoms of fatigue and headaches is found to have a positive
enzyme immunoassay (EIA) for human immunodeficiency virus (HIV) antibodies. In
discussing the test results with the client, which of the following information should the
nurse include?
a. The EIA test will need to be repeated to verify the results.
b. A viral culture will be done to determine the progress of the disease.
c. It will probably be 10 or more years before the client develops acquired
immunodeficiency syndrome (AIDS).
d. The Western blot test will be done to determine whether AIDS has developed.
ANS: A
After an initial positive EIA test, the EIA is repeated before more specific testing such as
the Western blot is done. Viral cultures are not part of HIV testing. Because the nurse does
not know how recently the client was infected, it is not appropriate to predict the time
frame for AIDS development. The Western blot tests for HIV antibodies, not for AIDS.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
2. A client is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and HIV
testing is positive. Based on diagnostic criteria established by the World Health
Organization (WHO), which of the following diagnoses should the nurse anticipate?
a. Acute infection
b. Early chronic infection
c. Intermediate chronic infection
d. Late chronic infection or AIDS
ANS: D
Development of PCP pneumonia meets the diagnostic criterion for AIDS. The other
responses indicate an earlier stage of HIV infection than is indicated by the PCP infection.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
3. After having a positive rapid-antibody test for HIV, a client is anxious and does not appear
to hear what the nurse is saying. Which of the following actions should the nurse
implement?
a. Teach the client about the medications available for treatment.
b. Inform the client how to protect sexual and needle-sharing partners.
c. Remind the client about the need to return for retesting to verify the results.
d. Ask the client to notify individuals who have had risky contact with the client.
ANS: C
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After an initial positive antibody test, the next step is retesting to confirm the results. A
client who is anxious is not likely to be able to take in new information or be willing to
disclose information about HIV status of other individuals.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
4. A client who has diagnosed with AIDS tells the nurse, “I have lots of thoughts about dying.
Do you think I am just being morbid?” Which of the following responses by the nurse is
most appropriate?
a. “Thinking about dying will not improve the course of AIDS.”
b. “It is important to focus on the good things about your life now.”
c. “Do you think that taking an antidepressant might be helpful to you?”
d. “Can you tell me more about the kind of thoughts that you are having?”
ANS: D
More assessment of the client’s psychosocial status is needed before taking any other
action. The statements, “Thinking about dying will not improve the course of AIDS.” and
“It is important to focus on the good things in life.” discourage the client from sharing any
further information with the nurse and decrease the nurse’s ability to develop a trusting
relationship with the client. Although antidepressants may be helpful, the initial action
should be further assessment of the client’s feelings.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
5. A pregnant woman with a history of early chronic HIV infection is seen at the clinic.
Which of the following information should the nurse include when teaching the client?
a. The antiretroviral medications used to treat HIV infection are teratogenic.
b. Most infants born to HIV-positive mothers are not infected with the virus.
c. Since she is at an early stage of HIV infection, the infant will not contract HIV.
d. It is likely that her newborn will become infected with HIV unless she uses
antiretroviral drug therapy (ART).
ANS: B
Only 25% of infants born to HIV-positive mothers develop HIV infection, even when the
mother does not use ART during pregnancy. The percentage drops to 2% when ART is
used. Perinatal transmission can occur at any stage of HIV infection (although it is less
likely to occur when the viral load is lower). ART can safely be used in pregnancy,
although some ART drugs should be avoided.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
6. The nurse is caring for a client whose HIV status is unknown. Which of these client
exposures is most likely to require postexposure prophylaxis for the nurse?
a. Needle stick with a needle and syringe used to draw blood
b. Splash into the eyes when emptying a bedpan containing stool
c. Contamination of open skin lesions with client vaginal secretions
d. Needle stick injury with a suture needle during a surgical procedure
ANS: A
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Puncture wounds are the most common means for workplace transmission of bloodborne
diseases, and a needle with a hollow bore that had been contaminated with the client’s
blood would be a high-risk situation. The other situations described would be much less
likely to result in transmission of the virus.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
7. Replication of HIV is enhanced when the client is taking which of the following herbs?
a. Echinacea
b. St. John’s wort
c. Fish oil
d. Saw palmetto
ANS: A
Some herbs (e.g., echinacea, astragalus) should not be used because they can enhance the
replication of HIV. St. John’s wort can interfere with ART rather than enhance replication
of HIV. Saw palmetto does not enhance HIV replication.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
8. The nurse is caring for a client with HIV who has a CD4+ cell count of 400/µL. Which of
the following factors is most important to consider when determining whether
antiretroviral therapy (ART) will be initiated for this client?
a. Client social support system
b. HIV genotype and phenotype
c. Potential medication adverse effects
d. Client ability to comply with ART schedule
ANS: D
Drug resistance develops quickly unless the client takes ART medications on a stringent
schedule, and this endangers both the client and the community. The other information is
also important to consider, but clients who are unable to manage and follow a complex
drug treatment regimen should not be considered for ART.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
9. Which of the following clients will the nurse working in an HIV testing and treatment
clinic anticipate teaching about antiretroviral therapy (ART)?
a. A client who is currently HIV negative but has unprotected sex with multiple
partners
b. A client who was infected with HIV 15 years ago and now has a CD4+ count of
840/µL
c. An HIV-positive client with a CD4+ count of 120/µL who drinks a fifth of whiskey
daily
d. A client who tested positive for HIV 2 years ago and has cytomegalovirus (CMV)
disease
ANS: D
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CMV disease is an AIDS-defining illness and indicates that the client is appropriate for
ART even though the HIV infection period is relatively short. An HIV-negative client
would not be offered ART. A client with a CD4+ count in the normal range would not
typically be started on ART. A client who drinks alcohol heavily would be unlikely to be
able to manage the complex drug regimen and would not be appropriate for ART despite
the low CD4+ count.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
10. When assessing an individual who has diagnosed with early chronic HIV infection and has
a normal CD4+ count, which of the following assessments should the nurse conduct?
a. Check neurological orientation.
b. Ask about problems with diarrhea.
c. Palpate the regional lymph nodes.
d. Examine the oral mucosa for lesions.
ANS: C
Persistent generalized lymphadenopathy is common in the early stage of chronic infection.
Diarrhea, oral lesions, and neurological abnormalities would occur in the later stages of
HIV infection.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
11. Which of the following tests does the Canadian Blood Services use to detect HIV genetic
material in blood?
CD4+ T-cell count
HIV RNA polymerase chain reaction test
Nucleic acid amplification test
CD4 fraction
a.
b.
c.
d.
ANS: C
In 2001, a new, highly sensitive nucleic acid amplification test (NAAT) was implemented
by the Canadian Blood Services to detect HIV genetic material in blood of potential
donors. The NAAT has a much shorter window period than antibody testing and is now
the standard test for donated blood in Canada. CD4+ T-cell count, CD4 fraction, and the
HIV RNA polymerase chain reaction test are not used by Canadian Blood Services.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
12. A young adult who uses injectable illegal drugs asks the nurse about preventing AIDS.
Which of the following information should the nurse inform the client is the best way to
reduce the risk of HIV infection from drug use?
a. Participate in a needle-exchange program.
b. Clean drug injection equipment before use.
c. Ask those who share equipment to be tested for HIV.
d. Avoid sexual intercourse when using injectable drugs.
ANS: A
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Participation in needle and syringe exchange programs has been shown to control the rate
of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not
be consistently practised by individuals in withdrawal. HIV antibodies do not appear for
several weeks to months after exposure, so testing drug users would not be very effective
in reducing risk for HIV exposure. It is difficult to make appropriate decisions about
sexual activity when under the influence of drugs.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
13. Which of the following nursing actions will be most useful in assisting a young adult
college student to adhere to a newly prescribed antiretroviral therapy (ART) regimen?
a. Give the client detailed information about possible medication adverse effects.
b. Remind the client of the importance of taking the medications as scheduled.
c. Encourage the client to join a support group for students who are HIV positive.
d. Check the client’s class schedule to help decide when the ART should be taken.
ANS: D
The best approach to improve adherence is to learn about important activities in the
client’s life and adjust the ART around those activities. The other actions also are useful,
but they will not improve adherence as much as individualizing the ART to the client’s
schedule.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
14. The nurse is caring for a client with HIV infection who has developed Mycobacterium
avium complex infection. Which of the following goals is most appropriate for this client?
a. Be free from injury.
b. Receive immunizations on time.
c. Ensure adequate oxygenation.
d. Maintain intact perineal skin.
ANS: D
The major manifestation of M. avium infection is loose, watery stools, which would
increase the risk for perineal skin breakdown. The other outcomes would be appropriate
for other complications (pneumonia, dementia, influenza, etc.) associated with HIV
infection.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
15. A client who has been treated for HIV infection for 7 years has developed fat
redistribution to the trunk, with wasting of the arms, legs, and face. Which of the
following topics should the nurse include in the client teaching plan?
a. The benefits of daily exercise
b. Foods that are higher in protein
c. Treatment with antifungal agents
d. A change in antiretroviral therapy
ANS: D
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A frequent first intervention for metabolic disorders is a change in ART. Treatment with
antifungal agents would not be appropriate because there is no indication of fungal
infection. Changes in diet or exercise have not proven helpful for this problem.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
16. The nurse is preparing to give the following medications to an HIV-positive client who is
hospitalized with Pneumocystis jiroveci pneumonia (PCP). Which of the following
medications is most important to administer at the right time?
a. Nystatin tablet
b. Oral abacavir
c. Aerosolized pentamidine
d. Oral acyclovir
ANS: B
It is important that antiretrovirals be taken at the prescribed time every day to avoid
developing drug-resistant HIV. The other medications should also be given as close as
possible to the correct time, but they are not as essential to receive at the same time every
day.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
17. Which of the following tests is used to evaluate the effectiveness of ART?
a. Viral load testing
b. Enzyme immunoassay
c. Rapid HIV antibody testing
d. Immuno-fluorescence assay
ANS: A
The effectiveness of ART is measured by the decrease in the amount of virus detectable in
the blood. The other tests are used to detect HIV antibodies, which remain positive even
with effective ART.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
18. Which information about an HIV-positive client who is taking antiretroviral medications is
most important for the nurse to address when planning care?
The client’s blood glucose level is 168 mg/dL.
The client complains of feeling “constantly tired.”
The client is unable to state the adverse effects of the medications.
The client states “sometimes I miss a dose of zidovudine (AZT).”
a.
b.
c.
d.
ANS: D
Since missing doses of ART can lead to drug resistance; this client statement indicates the
need for interventions such as teaching or changes in the drug scheduling. Elevated blood
glucose and fatigue are common adverse effects of ART. The nurse should discuss
medication adverse effects with the client, but this is not as important as addressing the
skipped doses of AZT.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
19. Ten years after seroconversion, an HIV-infected client has a CD4+ cell count of 800 cells
per microlitre and an undetectable viral load. Which of the following actions is the priority
nursing intervention at this time?
a. Monitor for symptoms of AIDS.
b. Teach about the effects of antiretroviral agents.
c. Encourage adequate nutrition, exercise, and sleep.
d. Discuss likelihood of increased opportunistic infections.
ANS: C
The CD4+ level for this client is in the normal range, indicating that the client is the early
chronic stage of infection, when the body is able to produce enough CD4+ cells to
maintain a normal CD4+ count. AIDS and increased incidence of opportunistic infections
typically develop when the CD4+ count is much lower than normal. Although initiation of
ART is highly individual, it would not be likely that a client with a normal CD4+ level
would receive ART.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
20. The nurse is caring for a pregnant client who has recently been diagnosed with HIV. The
client asks the nurse, “How soon after delivery of my baby can ART treatment be started?”
Which of the following provide the basis for the nurse’s response?
a. It can be initiated while you are pregnant.
b. It will start as soon as your baby is born.
c. It depends upon whether you are breastfeeding your baby or not.
d. It cannot begin until 7 days postpartum.
ANS: A
Women infected with HIV should receive optimal ART immediately, regardless of
whether or not they are pregnant.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
21. The nurse is designing a program to teach a community group about decreasing the
incidence of HIV infection in their community. Which of the following information is a
priority that the nurse include in the education session?
a. Methods to prevent perinatal HIV transmission.
b. How to prevent transmission between sexual partners.
c. Ways to sterilize needles used by injectable drug users.
d. Means to prevent transmission through blood transfusions.
ANS: B
Sexual transmission is the most common way that HIV is transmitted. The nurse should
also provide education about perinatal transmission, needle sterilization, and blood
transfusion, but the rate of HIV infection associated with these situations is lower.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
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MULTIPLE RESPONSE
1. The nurse is caring for a client who has just diagnosed with early chronic HIV infection.
Which of the following prophylactic measures should the nurse anticipate being included
in the plan of care? (Select all that apply.)
a. Hepatitis B vaccine
b. Pneumococcal vaccine
c. Influenza virus vaccine
d. Trimethoprim-sulfamethoxazole
e. Varicella-zoster immune globulin
ANS: A, B, C
Prevention of other infections is an important intervention in clients who are HIV positive,
and these vaccines are recommended as soon as the HIV infection is diagnosed.
Antibiotics and immune globulin are used to prevent and treat infections that occur later in
the course of the disease, when the CD4 count has dropped or when infection has
occurred.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
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Chapter 18: Cancer
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is preparing a client for a biopsy of a lump in the right breast and the client asks
the nurse about the difference between a benign tumour and a malignant tumour. Which of
the following responses by the nurse is correct?
a. “Benign tumours do not cause damage to other tissues.”
b. “Benign tumours are likely to recur in the same location.”
c. “Malignant tumours may spread to other tissues or organs.”
d. “Malignant cells reproduce more rapidly than normal cells.”
ANS: C
The major difference between benign and malignant tumours is that malignant tumours
invade adjacent tissues and spread to distant tissues and benign tumours never metastasize.
The other statements are inaccurate. Both types of tumours may cause damage to adjacent
tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumours
do not usually recur.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
2. The nurse is caring for a client who is receiving intravesical bladder chemotherapy. Which
of the following adverse effects should the nurse monitor for in this client?
a. Nausea
b. Alopecia
c. Mucositis
d. Hematuria
ANS: D
The adverse effects of intravesical chemotherapy are confined to the bladder. The other
adverse effects are associated with systemic chemotherapy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
3. The nurse in the outpatient clinic is caring for a client who smokes heavily. To reduce the
client’s risk of dying from lung cancer, which of the following actions will be best for the
nurse to take?
a. Educate the client about the seven warning signs of cancer.
b. Plan to monitor the client’s carcinoembryonic antigen (CEA) level.
c. Discuss the risks associated with cigarettes during every client encounter.
d. Teach the client about the use of annual chest x-rays for lung cancer screening.
ANS: C
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Education about the risks associated with cigarette smoking is recommended at every
client encounter, since cigarette smoking is associated with multiple health problems. A
tumour must be at least 0.5 cm large before it is detectable by current screening methods
and may already have metastasized by that time. Oncofetal antigens such as CEA may be
used to monitor therapy or detect tumour reoccurrence, but are not helpful in screening for
cancer. The seven warning signs of cancer are actually associated with fairly advanced
disease.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
4. After the nurse has finished teaching a client who is scheduled to receive external beam
radiation for abdominal cancer about appropriate diet, which dietary selection by the client
indicates that the teaching has been effective?
a. Fresh fruit salad
b. Roasted chicken
c. Whole wheat toast
d. Cream of potato soup
ANS: B
To minimize the diarrhea that is commonly associated with bowel radiation, the client
should avoid foods high in roughage, such as fruits and whole grains. Lactose intolerance
may develop secondary to radiation, so dairy products also should be avoided.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
5. During a routine health examination, a client tells the nurse about a family history of colon
cancer. Which of the following actions should the nurse take next?
a. Educate the client about the need for a colonoscopy at age 50.
b. Teach the client how to do home testing for fecal occult blood.
c. Obtain more information from the client about the family history.
d. Schedule a sigmoidoscopy to provide baseline data about the client.
ANS: C
The client may be at increased risk for colon cancer, but the nurse’s first action should be
further assessment. The other actions may be appropriate, depending on the information
that is obtained from the client with further questioning.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
6. When reviewing the chart for a client with cervical cancer, the nurse notes that the cancer
is staged as Tis, N0, M0. Which of the following statements is accurate related to this
staging?
a. The cancer is localized to the cervix.
b. The cancer cells are well differentiated.
c. Further testing is needed to determine the spread of the cancer.
d. It is difficult to determine the original site of the cervical cancer.
ANS: A
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Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this
time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ,
the origin is the cervix. Further testing is not indicated given that the cancer has not
spread.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
7. Which statement by a client who is scheduled for a needle biopsy of the prostate indicates
that the nurse’s teaching about the purpose of the biopsy has been effective?
a. “The biopsy will remove the cancer in my prostate gland.”
b. “The biopsy will determine how much longer I have to live.”
c. “The biopsy will help decide the treatment for my enlarged prostate.”
d. “The biopsy will indicate whether the cancer has spread to other organs.”
ANS: C
A biopsy is used to determine whether the prostate enlargement is benign or malignant and
determines the type of treatment that will be needed. Biopsy does not give information
about metastasis, life expectancy, or the impact of cancer on the client’s life; the three
remaining statements indicate a need for client teaching.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
8. The nurse is teaching a client who is postmenopausal and has stage III breast cancer about
the expected outcomes of her cancer treatment. Which client statement indicates that the
teaching has been effective?
a. “After cancer has not recurred for 5 years, it is considered cured.”
b. “The cancer will be cured if the entire tumour is surgically removed.”
c. “Cancer is never considered cured, but the tumour can be controlled with surgery,
chemotherapy, and radiation.”
d. “I will need to have follow-up examinations for many years after I have treatment
before I can be considered cured.”
ANS: D
The risk of recurrence varies by the type of cancer. For breast cancer in postmenopausal
women the client needs at least 20 disease-free years to be considered cured. Some cancers
are considered cured after a shorter time span, or after surgery, but stage III breast cancer
will require additional therapies and ongoing follow-up.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
9. A client with a large stomach tumour that is attached to the liver is scheduled to have a
debulking procedure. When teaching the client, which of the following is the expected
outcome of this surgery?
a. Relief of pain by cutting sensory nerves in the stomach
b. Control of the tumour growth by removal of malignant tissue
c. Decrease in tumour size to improve the effects of other therapy
d. Promotion of better nutrition by relieving the pressure in the stomach
ANS: C
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A debulking surgery reduces the size of the tumour and makes radiation and chemotherapy
more effective. Debulking surgeries do not control tumour growth. The tumour is
debulked because it is attached to the liver, a vital organ (not to relieve pressure on the
stomach). Debulking does not sever the sensory nerves, although pain may be lessened by
the reduction in pressure on the abdominal organs.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
10. External-beam radiation is planned for a client with endometrial cancer. The nurse teaches
the client which of the following important measures to help prevent complications from
the effects of the radiation?
a. Test all stools for the presence of blood.
b. Maintain a high-residue, high-fibre diet.
c. Clean the perianal area carefully after every bowel movement.
d. Inspect the mouth and throat daily for the appearance of thrush.
ANS: C
Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and
cause frequent diarrhea. Careful cleaning of this area will help decrease the risk for skin
breakdown and infection. Stools are likely to have occult blood from the inflammation
associated with radiation, so routine testing of stools for blood is not indicated. Radiation
to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid
irritation of the bowel when clients receive abdominal radiation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
11. The nurse is caring for a client with Hodgkin’s lymphoma who is undergoing external
radiation therapy and tells the nurse, “I am so tired I can hardly get out of bed in the
morning.” Which of the following interventions should the nurse implement?
a. Minimize activity until the treatment is completed.
b. Exercise vigorously when fatigue is not as noticeable.
c. Establish a time to take a short walk almost every day.
d. Consult with a psychiatrist for treatment of depression.
ANS: C
Walking programs are used to keep the client active without excessive fatigue. Vigorous
exercise when the client is less tired may lead to increased fatigue. Fatigue is expected
during treatment and is not an indication of depression. Minimizing activity may lead to
weakness and other complications of immobility.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
12. Which of the following information obtained by the nurse about a client with colon cancer
who is scheduled for external radiation therapy to the abdomen indicates a need for client
teaching?
a. The client swims in a pool 5 days a week.
b. The client has a history of dental caries.
c. The client eats frequently during the day.
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d. The client showers with Dove soap daily.
ANS: A
The client is instructed to avoid swimming in salt water or chlorinated pools during the
treatment period. The client does not need to change the habits of eating frequently or
showering with a mild soap. A history of dental caries will not impact the client who is
scheduled for abdominal radiation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
13. The nurse is caring for a client undergoing external radiation and has developed a dry
desquamation of the skin in the treatment area. Which of the following client statements
indicates that the nurse’s teaching about management of the skin reaction has been
effective?
a. “I can buy some aloe gel to use on the area.”
b. “I will expose the treatment area to a sun lamp daily.”
c. “I can use ice packs to relieve itching in the treatment area.”
d. “I will scrub the area with warm water to remove the scales.”
ANS: A
Aloe gel and cream may be used on the radiated skin area. Ice and sunlamps may injure
the skin. Treatment areas should be cleaned gently to avoid further injury.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
14. A client with metastatic cancer of the colon experiences severe vomiting following each
administration of chemotherapy. Which of the following interventions should the nurse
implement?
a. Teach about the importance of nutrition during treatment.
b. Have the client eat large meals when nausea is not present.
c. Offer dry crackers and carbonated fluids during chemotherapy.
d. Administer prescribed antiemetics 1 hour before the treatments.
ANS: D
Treatment with antiemetics before chemotherapy may help prevent nausea. Although
nausea may lead to poor nutrition, there is no indication that the client needs instruction
about nutrition. The client should eat small, frequent meals. Offering food and beverages
during chemotherapy is likely to cause nausea.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
15. The nurse is caring for a client who is receiving a vesicant chemotherapeutic agent
intravenously. Which of the following actions is most important?
a. Infuse the medication over a short period of time.
b. Stop the infusion if swelling is observed at the site.
c. Administer the chemotherapy through small-bore catheter.
d. Hold the medication unless a central venous line is available.
ANS: B
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Swelling at the site may indicate extravasation, and the IV should be stopped immediately.
The medication generally should be given slowly to avoid irritation of the vein. The size of
the catheter is not as important as administration of vesicants into a running IV line to
allow dilution of the chemotherapeutic drug. These medications can be given through
peripheral lines, although central vascular access devices (CVADs) are preferred.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
16. A chemotherapeutic agent known to cause alopecia is prescribed for a client. Which of the
following actions should the nurse plan to implement to help maintain the client’s
self-esteem?
a. Suggest that the client limit social contacts until regrowth of the hair occurs.
b. Encourage the client to purchase a wig or hat and wear it once hair loss begins.
c. Have the client wash the hair gently with a mild shampoo to minimize hair loss.
d. Inform the client that the hair will grow back once the chemotherapy is complete.
ANS: B
The client is taught to anticipate hair loss and to be prepared with wigs, scarves, or hats.
Limiting social contacts is not appropriate at a time when the client is likely to need a
good social support system. The damage occurs at the hair follicle and will occur
regardless of gentle washing or use of a mild shampoo. The information that the hair will
grow back is not immediately helpful in maintaining the client’s self-esteem.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Planning
17. The nurse is caring for a client with ovarian cancer who is distressed because her husband
rarely visits and tells the nurse, “He just doesn’t care.” The husband indicates to the nurse
that “I never know what to say to help her.” Which of the following nursing diagnoses is
most appropriate?
a. Disabled family coping related to chronically unexpressed feelings by support
person
b. Impaired home maintenance related to insufficient support system
c. Risk for caregiver role strain as evidenced by increase in care needs
d. Dysfunctional family processes related to insufficient problem-solving skills
ANS: D
The data indicate that this diagnosis is most appropriate because poor communication
among the family members is affecting family processes. No data suggest preoccupation
with an outside concern as an etiology. The data do not support impairment in home
maintenance or a burden caused by caregiving responsibilities.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Diagnosis
18. A client receiving head and neck radiation has ulcerations over the oral mucosa and tongue
and thick, ropey saliva. Which of the following actions should the nurse teach the client to
complete?
a. Remove food debris from the teeth and oral mucosa with a stiff toothbrush.
b. Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth.
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c. Gargle and rinse the mouth several times a day with an antiseptic mouthwash.
d. Rinse the mouth before and after each meal and at bedtime with a saline solution.
ANS: D
The client should rinse the mouth with a saline solution frequently. A soft toothbrush is
used for oral care. Hydrogen peroxide may damage tissues. Antiseptic mouthwashes may
irritate the oral mucosa and are not recommended.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
19. Which of the following nursing actions will be most effective in improving oral intake for
a client with the nursing diagnosis of imbalanced nutrition: less than body requirements
related to painful oral ulcers?
a. Offer the client frequent small snacks between meals.
b. Assist the client to choose favourite foods from the menu.
c. Provide education about the importance of nutritional intake.
d. Apply the ordered anaesthetic gel to oral lesions before meals.
ANS: D
Since the etiology of the client’s poor nutrition is the painful oral ulcers, the best
intervention is to apply anaesthetic gel to the lesions before the client eats. The other
actions might be helpful for other clients with impaired nutrition, but would not be as
helpful for this client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
20. The nurse is caring for a client who is a single mother of four school-age children and is
hospitalized with metastatic ovarian cancer. The nurse finds the client crying, and she tells
the nurse that she does not know what will happen to her children when she dies. Which of
the following is the most appropriate response?
a. “Why don’t we talk about the options you have for the care of your children?”
b. “Perhaps the children’s father will take care of them when you aren’t able to.”
c. “For now you need to concentrate on getting well, not worry about your children.”
d. “Many clients with cancer live for a long time, so there is time to plan for your
children.”
ANS: A
This response expresses the nurse’s willingness to listen and recognizes the client’s
concern. The responses beginning “Many clients with cancer live for a long time” and
“For now you need to concentrate on getting well” close off discussion of the topic and
indicate that the nurse is uncomfortable with the topic. In addition, the client with
metastatic ovarian cancer may not have a long time to plan. Although it is possible that the
client’s ex-husband will take the children, more assessment information is needed before
making plans.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
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21. A client who has severe pain associated with terminal liver cancer is being cared for at
home by family members. Which of the following findings indicates that teaching
regarding pain management has been effective?
a. The client agrees to take the medications by the IV route in order to improve
analgesic effectiveness.
b. The client uses the ordered opioid pain medication whenever the pain is greater
than 5 (0–10 scale).
c. The client takes opioids around the clock on a regular schedule and uses additional
doses when breakthrough pain occurs.
d. The client states that nonopioid analgesics may be used when the maximal dose of
the opioid is reached without adequate pain relief.
ANS: C
For chronic cancer pain, analgesics should be taken on a scheduled basis, with additional
doses as needed for breakthrough pain. Taking the medications only when pain reaches a
certain level does not provide effective pain control. Although nonopioid analgesics also
may be used, there is no maximum dose of opioid. Opioids are given until pain control is
achieved. The IV route is not more effective than the oral route, and the oral route is
preferred.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
22. The nurse is caring for a client with metastatic renal cell carcinoma who is receiving
interleukin-2 (IL-2) as an adjuvant therapy. Which of the following mechanisms of action
should the nurse teach the client about this therapy?
a. It enhances immunological response to tumour cells.
b. It stimulates malignant cells in the resting phase to enter mitosis.
c. It prevents the bone marrow depression caused by chemotherapy.
d. It protects normal cells from the harmful effects of chemotherapy.
ANS: A
IL-2 enhances the ability of the client’s own immune response to suppress tumour cells.
IL-2 does not protect normal cells from damage caused by chemotherapy, stimulate
malignant cells to enter mitosis, or prevent bone marrow depression.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
23. The home health nurse is caring for a client who has been receiving interferon therapy for
treatment of cancer. Which statement by the client may indicate a need for a change in
treatment?
a. “I have frequent muscle aches and pains.”
b. “I rarely have the energy to get out of bed.”
c. “I experience chills after I inject the interferon.”
d. “I take acetaminophen every 4 hours.”
ANS: B
Fatigue can be a dose-limiting toxicity of biological therapies. Flulike symptoms, such as
muscle aches and chills, are common adverse effects of interferon use. Clients are advised
to use acetaminophen every 4 hours.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
24. The nurse is caring for a client who is undergoing bone marrow transplantation. Which of
the following information should the nurse include in the client’s teaching plan?
a. Transplant of the donated cells is painful because of the nerves in the tissue lining
the bone.
b. Donor bone marrow cells are transplanted through an incision into the sternum or
hip bone.
c. The transplant procedure takes place in a sterile operating room to minimize the
risk for infection.
d. Hospitalization will be required 2–4 weeks after transplantation.
ANS: D
The client requires strict protective isolation to prevent infection for 2–4 weeks after
marrow transplantation while waiting for the transplanted marrow to start producing cells.
The transplanted cells are infused through an IV line, so the transplant is not painful, nor is
an operating room or incision required.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
25. The nurse teaches a client with cancer of the liver about high-protein, high-calorie diet
choices. Which of the following snack choices by the client indicates that the teaching has
been effective?
a. Orange sherbet
b. Fresh fruit salad
c. Strawberry yogourt
d. Cream cheese bagel
ANS: C
Yogourt has high biological value because of the protein and fat content. Fruit salad does
not have high amounts of protein or fat. Orange sherbet is lower in fat and protein than
yogourt. Cream cheese is low in protein.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
26. The nurse is caring for a client with cancer who has a nursing diagnosis of imbalanced
nutrition: less than body requirements related to altered taste sensation. Which of the
following nursing actions is most appropriate?
a. Add strained baby meats to foods such as casseroles.
b. Teach the client about foods that are high in nutrition.
c. Avoid giving the client foods that are strongly disliked.
d. Put extra spice in the foods that are served to the client.
ANS: C
The client will eat more if disliked foods are avoided and foods that the client likes are
included instead. Additional spice is not usually an effective way to enhance taste. Adding
baby meats to foods will increase calorie and protein levels, but does not address the issue
of taste. The client’s poor intake is not caused by a lack of information about nutrition.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
27. The nurse is teaching a client who has a new diagnosis of acute leukemia about the
complications associated with chemotherapy. The client is restless and is looking away,
never making eye contact. After the teaching, the client asks the nurse to repeat all of the
information. Based on this assessment, which of the following nursing diagnoses is most
likely for this client?
a. Ineffective denial related to ineffective coping strategies (leukemia diagnosis)
b. Acute confusion related to pain (infiltration of leukemia cells into the central
nervous system)
c. Anxiety related to threat of death (leukemia diagnosis)
d. Deficient knowledge (of chemotherapy) related to insufficient interest in learning
ANS: C
The client who has a new cancer diagnosis is likely to have high anxiety, which may
impact learning and require that the nurse repeat and reinforce information. The client’s
history of a recent diagnosis suggests that infiltration of the leukemia is not a likely cause
of the confusion. The client asks for the information to be repeated, indicating that lack of
interest in learning and denial are not etiological factors.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Diagnosis
28. The nurse is caring for a client who is receiving chemotherapy for leukemia. Which of the
following observations require intervention by the nurse?
a. The client ambulates several times a day in the room.
b. The client’s temperature is 38.2°C (100.8°F).
c. The client cleans with a warm washcloth after having a stool.
d. The client uses soap and shampoo to shower every other day.
ANS: B
Any temperature above 38°C (100.4°F) in a client receiving chemotherapy should be
investigated immediately. The client should ambulate in the room rather than the hospital
hallway to avoid exposure to other clients or visitors. Because overuse of soap can dry the
skin and increase infection risk, showering every other day is acceptable. Careful cleaning
after having a bowel movement will help to prevent skin breakdown and infection.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
29. The nurse is caring for a client with tumour lysis syndrome (TLS) who is taking
allopurinol. Which of the following laboratory values should the nurse monitor to
determine the effectiveness of the medication?
a. Uric acid level
b. Serum potassium
c. Serum phosphate
d. Blood urea nitrogen
ANS: A
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Allopurinol is used to decrease uric acid levels. BUN, potassium, and phosphate levels are
also increased in TLS but are not affected by allopurinol therapy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
30. When assessing the need for psychological support after the client has diagnosed with
stage I cancer of the colon, which of the following questions by the nurse will provide the
most information?
a. “How long ago were you diagnosed with this cancer?”
b. “Do you have any concerns about body image changes?”
c. “Can you tell me what has been helpful to you in the past when coping with
stressful events?”
d. “Are you familiar with the stages of emotional adjustment to a diagnosis like
cancer of the colon?”
ANS: C
Information about how the client has coped with past stressful situations helps the nurse
determine usual coping mechanisms and their effectiveness. The length of time since the
diagnosis will not provide much information about the client’s need for support. The
client’s knowledge of typical stages in adjustment to a critical diagnosis does not provide
insight into client needs for assistance. Since surgical interventions for stage I cancer of
the colon may not cause any body image changes, this question is not appropriate at this
time.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Assessment
31. Which of the following findings in a client who is receiving interleukin-2 indicates a need
for rapid action by the nurse?
a. Generalized muscle aches
b. Complaints of nausea and anorexia
c. Oral temperature of 38.1°C (100.6°F)
d. Crackles heard at the lower scapular border
ANS: D
Capillary leak syndrome and acute pulmonary edema are possible toxic effects of
interleukin-2; the client may need oxygen and the nurse should rapidly notify the health
care provider. The other findings are common adverse effects of interleukin-2.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
32. The nurse obtains information about a hospitalized client who is receiving chemotherapy
for cancer of the colon. Which of the following information about the client is most
indicative of a need for a change in therapy?
a. Poor oral intake
b. Increase in carcinoembryonic antigen
c. Frequent loose stools
d. Complaints of nausea
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ANS: B
An increase in carcinoembryonic antigen indicates that the chemotherapy is not effective
for the client’s cancer and may need to be modified. The other client findings are common
adverse effects of chemotherapy. The nurse may need to address these, but they would not
indicate a need for a change in therapy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
33. Which of the following information noted by the nurse reviewing the laboratory results of
a client who is receiving chemotherapy is most important to report to the health care
provider?
a. Hematocrit of 30%
b. Platelets of 150 ´ 109/L
c. Hemoglobin of 161 g/L
d. WBC count of 4 ´ 109/L
ANS: D
The low WBC count places the client at risk for severe infection and is an indication that
the chemotherapeutic drug dose may need to be lower or that white blood cell (WBC)
growth factors such as filgrastim are needed. The other laboratory data do not indicate any
immediate life-threatening adverse effects of the chemotherapy.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
34. Use of dental floss is contraindicated in the client with which of the following assessment
findings?
Halitosis
A decreased platelet count
An increased white blood cell count
Xerostomia
a.
b.
c.
d.
ANS: B
Use of dental floss is contraindicated in the client that has a decreased platelet count but
otherwise critical to use to enhance oral care. Halitosis, xerostomia, and an increased
WBC are not contraindications for the use of dental floss.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
35. When caring for a client with a temporary radioactive cervical implant, which action by
the student nurse indicates that the unit nurse should intervene?
a. The student flushes the toilet once after emptying the client’s bedpan.
b. The student stands by the client’s bed for 30 minutes talking with the client.
c. The student places the client’s bedding in the laundry container in the hallway.
d. The student gives the client an alcohol-containing mouthwash to use for oral care.
ANS: B
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Because clients with temporary implants emit radioactivity while the implants are in place,
exposure to the client is limited. Laundry and urine or feces do not have any radioactivity
and do not require special precautions. Cervical radiation will not affect the oral mucosa,
and alcohol-based mouthwash is not contraindicated.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
36. After receiving change-of-shift report, which of the following clients should the nurse
assess first?
a. 35-year-old who has wet desquamation associated with abdominal radiation
b. 42-year-old who is sobbing after receiving a new diagnosis of ovarian cancer
c. 24-year-old who is receiving neck radiation and has blood oozing from the neck
d. 56-year-old who has a new pericardial friction rub after receiving chest radiation
ANS: C
Since neck bleeding may indicate possible carotid artery rupture in a client who is
receiving radiation to the neck, this client should be seen first. The diagnoses and clinical
manifestations for the other clients are not immediately life threatening.
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. The nurse at the clinic is interviewing an older-adult client who is 160 cm tall and weighs
57 kg. The client has not seen a health care provider for 20 years. She walks 11 km most
days and has a glass of wine two or three times a week. Which topics will the nurse plan to
include in client teaching about cancer screening and decreasing cancer risk? (Select all
that apply.)
a. Pap testing
b. Tobacco use
c. Sunscreen use
d. Mammography
e. Colorectal screening
ANS: A, C, D, E
The client’s age, gender, and history indicate a need for screening or teaching about
colorectal cancer, mammography, Pap smears, and sunscreen. The client does not use
excessive alcohol or tobacco, she is physically active, and her body weight is healthy.
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
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Chapter 19: Fluid, Electrolyte, and Acid–Base Imbalances
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is caring for a client with deficient fluid volume caused by a massive burn
injury. Which of the following assessment data will be of greatest concern to the nurse?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL over the last hour.
c. Oral fluid intake is 100 mL for the last 8 hours.
d. There is prolonged skin tenting over the sternum.
ANS: A
The blood pressure indicates that the client may be developing hypovolemic shock as a
result of fluid loss. This will require immediate intervention to prevent the complications
associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and
skin tenting all indicate the need for increasing the client’s fluid intake but not as urgently
as the hypotension.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. The nurse is caring for a client recently admitted with small cell carcinoma of the lung and
the syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following
assessments should the nurse carefully monitor?
a. Increased total urinary output
b. Elevation of serum hematocrit
c. Decreased serum sodium level
d. Rapid and unexpected weight loss
ANS: C
SIADH causes water retention and hyponatremia—a decrease in serum sodium level.
Weight loss, increased urine output, and elevated serum hematocrit may be associated with
excessive loss of water, but not with SIADH and water retention.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
3. The nurse is evaluating the fluid balance for a client admitted for hypovolemia associated
with multiple draining wounds. Which of the following assessments is the most accurate to
evaluate volume status in this client?
a. Skin turgor
b. Daily weight
c. Presence of edema
d. Hourly urine output
ANS: B
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Daily weight is the most easily obtained and accurate means of assessing volume status.
Skin turgor varies considerably with age. Considerable excess fluid volume may be
present before fluid moves into the interstitial space and causes edema. Hourly urine
outputs do not take account of fluid intake or of fluid loss through insensible loss,
sweating, or loss from the gastrointestinal tract or wounds.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
4. The nurse is caring for an alert and oriented older-adult client with a history of
dehydration. Which of the following information should the home health nurse teach the
client as to when to increase fluid intake?
a. In the late evening hours
b. If the oral mucosa feels dry
c. When the client feels thirsty
d. As soon as changes in level of consciousness (LOC) occur
ANS: B
An alert, elderly client will be able to self-assess for signs of oral dryness such as thick
oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is
not an accurate indicator of volume depletion. Many older clients prefer to restrict fluids
slightly in the evening to improve sleep quality. The client will not be likely to notice and
act appropriately when changes in LOC occur.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
5. The nurse is caring for a client who is taking a potassium-wasting diuretic for treatment of
hypertension. Which of the following assessment data would the nurse include in the
teaching plan?
a. Personality changes
b. Frequent loose stools
c. Facial muscle spasms
d. Lower extremity weakness
ANS: D
Lower extremity weakness progressing to flaccidity is a manifestation of hypokalemia.
Facial muscle spasms might occur with hypocalcemia. Loose stools are associated with
hyperkalemia. Personality changes are not associated with electrolyte disturbances,
although changes in mental status are common manifestations with sodium excess or
deficit.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
6. The nurse is teaching a client about spironolactone as a diuretic. Which statement by the
client indicates that the teaching about this medication has been effective?
a. “I will try to drink at least eight glasses of water every day.”
b. “I will use a salt substitute to decrease my sodium intake.”
c. “I will increase my intake of potassium-containing foods.”
d. “I will drink apple juice instead of orange juice for breakfast.”
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ANS: D
Since spironolactone is a potassium-sparing diuretic, clients should be taught to choose
low potassium foods such as apple juice rather than foods that have higher levels of
potassium, such as citrus fruits. Because the client is using spironolactone as a diuretic, the
nurse would not encourage the client to increase fluid intake. Teach clients to avoid salt
substitutes, which are high in potassium.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
7. The nurse is caring for a client admitted with hyponatremia. Which of the following
actions should the nurse anticipate implementing?
a. Restrict client’s oral free water intake.
b. Avoid use of electrolyte-containing drinks.
c. Infuse a solution of 5% dextrose in 0.45% saline.
d. Administer vasopressin (antidiuretic hormone, [ADH]).
ANS: A
To help improve serum sodium levels, water intake is restricted. Electrolyte-containing
beverages will improve the client’s sodium level. Administration of vasopressin or
hypotonic IV solutions will decrease the serum sodium level further.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
8. The nurse is caring for a client with severe hypokalemia and is preparing to administer
intravenous potassium chloride (KCl) 40 mmol as prescribed by the health care provider.
Which of the following actions should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 20 mEq/hour.
c. Give the KCl only through a central venous line.
d. Add no more than 40 mEq/L to a litre of IV fluid.
ANS: B
Intravenous KCl is administered at a maximal rate of 20 mEq/hour. Rapid IV infusion of
KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more
than 40 mmol, concentrations up to 60 mmol may be used for some clients. KCl can cause
inflammation of peripheral veins, but it can be administered by this route.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
9. The nurse is caring for a client with hyperkalemia and is interpreting the
electrocardiogram (ECG) report. Which of the following ECG changes would the nurse
expect to assess in this client?
a. Ventricular dysrhythmias
b. Bradycardia
c. Flatten T wave
d. Prolonged P-R interval
ANS: D
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ECG changes in a client with hypokalemia include a tall peaked T-wave, prolonged P-R
interval, ST depression, loss of P wave, widening QRS complex, ventricular fibrillation
and standstill. Ventricular dysrhythmias, bradycardia, and flatten T wave are all possible
changes with hypokalemia.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
10. The nurse is caring for a client who has required prolonged mechanical ventilation and has
the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and
HCO3 25 mmol/L. Which of the following interpretations would the nurse document?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
ANS: D
The pH indicates that the client has alkalosis and the low PaCO2 indicates a respiratory
cause. The other responses are incorrect based on the pH and the normal HCO3.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
11. The nurse is caring for a client who was admitted with diabetic ketoacidosis and has rapid,
deep respirations. Which of the following actions should the nurse implement?
a. Notify the client’s health care provider.
b. Give the prescribed PRN lorazepam.
c. Start the prescribed PRN oxygen at 2–4 L/minute.
d. Encourage the client to take deep, slow breaths.
ANS: A
The rapid, deep (Kussmaul’s) respirations indicate a metabolic acidosis and the need for
actions such as administration of sodium bicarbonate, which will require a prescription by
the health care provider. Oxygen therapy is not indicated because there is no indication
that the increased respiratory rate is related to hypoxemia. The respiratory pattern is
compensatory, and the client will not be able to slow the respiratory rate. Lorazepam
administration will slow the respiratory rate and increase the level of acidosis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
12. The home health nurse is visiting an older-adult client who has a low serum protein level.
Which of the following assessment areas should the nurse assess?
Pallor
Edema
Confusion
Restlessness
a.
b.
c.
d.
ANS: B
Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to
remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not
associated with low serum protein levels.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
13. The nurse is caring for a client who is receiving 3% NaCl solution for correction of
hyponatremia. During administration of the solution, which of the following assessments
is a priority for the nurse to monitor?
a. Lung sounds
b. Urinary output
c. Peripheral pulses
d. Peripheral edema
ANS: A
Hypertonic solutions cause water retention, so the client should be monitored for
symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary
edema and are the most serious of the symptoms of fluid excess listed. Bounding
peripheral pulses, peripheral edema, or changes in urine output also are important to
monitor when administering hypertonic solutions, but they do not indicate acute
respiratory or cardiac decompensation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
14. The nurse is caring for a client who has a low serum total protein level and is taking
protein supplements. Which of the following data indicate that the client’s condition has
improved?
a. Hematocrit 28%
b. Good skin turgor
c. Absence of peripheral edema
d. Blood pressure 110/72 mm Hg
ANS: C
Edema is caused by low oncotic pressure in individuals with low serum protein levels; the
absence of edema indicates an improvement in the client’s protein status. Good skin turgor
is an indicator of fluid balance, not protein status. A low hematocrit could be caused by
poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring
protein status.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
15. The nurse is caring for a client who has the following arterial blood gas (ABG) results: pH
7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mmol/L. Which of the following
interpretations would the nurse document?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
ANS: A
The pH and HCO3 indicate that the client has a metabolic acidosis. The ABGs are
inconsistent with the other responses.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
16. The nurse is caring for a client who has been receiving diuretic therapy and is admitted to
the emergency department with a serum potassium level of 3.1 mmol/L. Of the following
medications that the client has been taking at home, which of the following would be of
most concern to the nurse?
a. Oral digoxin 0.25 mg daily
b. Ibuprofen 400 mg every 6 hours
c. Metoprolol 12.5 mg orally daily
d. Lantus insulin 24 U subcutaneously every evening
ANS: A
Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias.
The nurse also will need to do more assessment regarding the other medications, but there
is not as much concern with the potassium level.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
17. The nurse is caring for a client with hypercalcemia. Which of the following actions would
be included in the client’s nursing care plan?
a. Maintain the client on bed rest.
b. Auscultate lung sounds every 4 hours.
c. Monitor for Trousseau’s and Chvostek’s signs.
d. Encourage fluid intake up to 3 000 mL every day.
ANS: D
To decrease the risk for renal calculi, the client should have an intake of 3 000 mL daily.
Ambulation helps decrease the loss of calcium from bone and is encouraged in clients with
hypercalcemia. Trousseau’s and Chvostek’s signs are monitored when there is a possibility
of hypocalcemia. There is no indication that the client needs frequent assessment of lung
sounds, although these would be assessed every shift.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
18. The nurse is teaching a client with renal failure about a low phosphate diet. Which of the
following foods would the nurse teach the client to restrict?
Dairy products
High-fat foods
Fruits and juices
Green, leafy vegetables
a.
b.
c.
d.
ANS: A
Foods high in phosphate include milk and other dairy products, so these are restricted on
low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits or juices are not
high in phosphate and are not restricted.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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19. The nurse is caring for a client in the outpatient clinic who has a decreased serum
magnesium level. Which of the following assessment areas should the nurse include in the
health history?
a. Daily alcohol intake
b. Intake of dietary protein
c. Multivitamin/mineral use
d. Use of over-the-counter (OTC) laxatives
ANS: A
Hypomagnesemia is associated with alcoholism. Protein intake would not have a
significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use
of multivitamin or mineral supplements would tend to increase magnesium level.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
20. The nurse is preparing a client for an intravenous infusion of 50% dextrose and the client
asks the nurse why a peripherally inserted central catheter must be inserted. Which of the
following explanations is the basis for the nurse’s response?
a. The prescribed infusion can be given much more rapidly when the client has a
central line.
b. There is a decreased risk for infection when 50% dextrose is infused through a
central line.
c. The 50% dextrose is hypertonic and will be more rapidly diluted when given
through a central line.
d. The required blood glucose monitoring is more accurate when samples are
obtained from a central line.
ANS: C
Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater
than 10% are administered intravenously. Blood glucose testing is not more accurate when
samples are obtained from a central line. The infection risk is higher with a central catheter
than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given
rapidly.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
21. Which of the following actions would the nurse include in the plan of care for a client who
has a central venous access device (CVAD)?
a. Avoid using friction when cleaning around the CVAD insertion site.
b. Use the push–pause method to flush the CVAD after giving medications.
c. Obtain an order from the health care provider to change CVAD dressing.
d. Have the client turn the head toward the CAVD during injection cap changes.
ANS: B
The push–pause enhances the removal of debris from the CVAD lumen and decreases the
risk for clotting. To decrease infection risk, friction should be used when cleaning the
CVAD insertion site. The dressing should be changed whenever it becomes damp, loose,
or visibly soiled and the client should turn away from the CVAD during cap changes.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
22. The nurse is caring for a client who is receiving iso-osmolar continuous tube feedings who
has developed nausea, vomiting, and tachycardia. Which of the following laboratory
results is most important for the nurse to report to the health care provider?
a. K+ 3.4 mmol/L
b. Ca+2 1.95 mmol/L
c. Na+ 128 mmol/L
d. PO4–3 1.55 mmol/L
ANS: C
The low serum sodium level is consistent with hyponatremia and the client’s symptoms of
nausea, vomiting and tachycardia and indicates a need for immediate action to prevent
further serious complications such as seizures. The potassium and calcium levels vary
slightly from the normal but do not require any immediate action by the nurse. The
phosphate level is within the normal parameters.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
23. The nurse is caring for a client who has been hospitalized for 2 days and is receiving
normal saline IV at 100 mL/hour, has a nasogastric tube to low suction, and is NPO.
Which of the following assessment findings by the nurse is the priority to report to the
health care provider?
a. Serum sodium level of 138 mmol/L
b. Gradually decreasing level of consciousness (LOC)
c. Oral temperature of 37.8°C (100°F) with bibasilar lung crackles
d. Weight gain of 1 kg above the admission weight
ANS: B
The client’s history and change in LOC could be indicative of several fluid and electrolyte
disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia,
hypokalemia, or metabolic alkalosis. Further diagnostic information will be ordered by the
health care provider to determine the cause of the change in LOC and the appropriate
interventions. The weight gain, elevated temperature, crackles, and serum sodium level
also will be reported, but do not indicate a need for rapid action to avoid complications.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
24. The nurse is assessing a client with increased extracellular fluid (ECF) osmolality. Which
of the following assessment areas is the priority assessment for the nurse to obtain?
a. Skin turgor
b. Heart sounds
c. Mental status
d. Capillary refill
ANS: C
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Changes in ECF osmolality lead to swelling or shrinking of cells in the central nervous
system, initially causing confusion, which may progress to coma or seizures. Although
skin turgor, capillary refill, and heart sounds also may be affected by ECF osmolality
changes and resultant fluid shifts, these are signs that occur later and do not have as
immediate an impact on client outcomes.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
25. The nurse is caring for a client with renal failure and has been taking magnesium
hydroxide suspension at home for indigestion. The client is somnolent and has decreased
deep tendon reflexes. Which of the following actions should the nurse take first?
a. Notify the client’s health care provider.
b. Withhold the next scheduled dose of magnesium hydroxide.
c. Review the magnesium level on the client’s chart.
d. Check the chart for the most recent potassium level.
ANS: C
The client has a history and symptoms consistent with hypermagnesemia; the nurse should
check the chart for a recent serum magnesium level. Notification of the health care
provider will be done after the nurse knows the magnesium level. The magnesium
hydroxide should be held, but more immediate action is needed to correct the client’s
decreased deep tendon reflexes (DTRs) and somnolence. Monitoring of potassium levels
also is important for clients with renal failure, but the client’s current symptoms are not
consistent with hyperkalemia.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
26. The nurse is caring for a postoperative client who is receiving nasogastric suction and is
anxious with incisional pain. The client’s respiratory rate is 32 breaths/minute and the
arterial blood gases (ABGs) indicate respiratory alkalosis. Which of the following actions
should the nurse take first?
a. Discontinue the nasogastric suctions for a few hours.
b. Notify the health care provider about the ABG results.
c. Teach the client about the need to take slow, deep breaths.
d. Give the client the PRN morphine sulphate 4 mg intravenously.
ANS: D
The client’s respiratory alkalosis is caused by the increased respiratory rate associated with
pain and anxiety. The nurse’s first action should be to medicate the client for pain.
Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to
discontinue the tube when the client needs gastric suction. The health care provider may
be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The
client will not be able to take slow, deep breaths when experiencing pain.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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27. The nurse is caring for a client with a CVAD who suddenly develops chest pain,
hypotension, and tachycardia. Which of the following positions should the nurse
immediately put the client in?
a. Prone
b. High Fowler’s
c. Left lateral with head down
d. Sims
ANS: C
A client with a CVAD that suddenly develops chest pain, hypotension, and tachycardia is
experiencing an air embolism and the nurse needs to immediately place the client in left
lateral with their head down. Prone is not the correct position in a client with suspected air
emboli. Sims is not the correct position in a client with suspected air emboli. High
Fowler’s is not the correct position in a client with suspected air emboli.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
28. Which assessment finding about a client who has a serum calcium level of 1.58 mmol/L is
most important for the nurse to immediately report to the health care provider?
The client is experiencing laryngeal stridor.
The client complains of generalized fatigue.
The client’s bowels have not moved for 4 days.
The client has numbness and tingling of the lips.
a.
b.
c.
d.
ANS: A
Laryngeal stridor may lead to respiratory arrest and requires rapid action to correct the
client’s calcium level. The other data also are consistent with hypocalcemia, but do not
indicate a need for immediate action.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
29. The nurse is caring for a client postoperative after a thyroidectomy and the client states “I
have a tingling feeling around my mouth.” Which of the following data is priority for the
nurse to assess?
a. An elevated serum potassium level
b. The presence of Chvostek’s sign
c. A decreased thyroid hormone level
d. Bleeding on the client’s dressing
ANS: B
The client’s symptoms indicate possible hypocalcemia, which can occur secondary to
parathyroid injury or removal during thyroidectomy. There is no indication of a need to
check the potassium level, the thyroid hormone level, or for bleeding.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
30. The nurse is caring for a client with advanced lung cancer who has been admitted to the
emergency department with urinary retention caused by renal calculi. Which of the
following laboratory values will require the most immediate action by the nurse?
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a.
b.
c.
d.
Arterial blood pH is 7.32.
Serum calcium is 3.45 mmol/L.
Serum potassium is 5.1 mmol/L.
Arterial oxygen saturation is 91%.
ANS: B
The serum calcium is well above the normal level and puts the client at risk for cardiac
dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care
provider. The potassium, oxygen saturation, and pH also are abnormal, and the nurse
should notify the health care provider about these values as well, but they are not
immediately life threatening.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
31. The nurse obtains the following data when assessing a pregnant client with eclampsia who
is receiving IV magnesium sulphate. Which of the following findings is most important to
report to the health care provider immediately?
a. The bibasilar breath sounds are decreased.
b. The patellar and triceps reflexes are absent.
c. The client has been sleeping most of the day.
d. The client reports feeling “sick to my stomach.”
ANS: B
The loss of the deep tendon reflexes indicates that the client’s magnesium level may be
reaching toxic levels. Nausea and lethargy also are adverse effects associated with
magnesium elevation and should be reported, but they are not as significant as the loss of
deep tendon reflexes. The decreased breath sounds suggest that the client needs to cough
and deep breathe to prevent atelectasis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
32. The nurse has administered 3% saline to a client with hyponatremia. Which of the
following assessment data will require the most rapid response by the nurse?
The client’s radial pulse is 105 beats/minute.
There is sediment and blood in the client’s urine.
The blood pressure increases from 120/80 to 142/94.
There are crackles audible throughout both lung fields.
a.
b.
c.
d.
ANS: D
Crackles throughout both lungs suggest that the client may be experiencing pulmonary
edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate
and blood pressure and the appearance of the urine also should be reported, but they are
not as dangerous as the presence of fluid in the alveoli.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
MULTIPLE RESPONSE
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1. The nurse is caring for a client who is postoperative and has been receiving nasogastric
suction for 3 days. The client’s serum sodium level is 123 mmol/L. Which of the
following prescribed therapies would the nurse implement? (Select all that apply.)
a. Infuse 5% dextrose in water at 125 mL/hour.
b. Administer IV morphine sulphate 4 mg every 4 hours PRN.
c. Give IV metoclopramide 10 mg every 6 hours PRN for nausea.
d. Administer 3% saline if serum sodium drops to less than 128 mmol/L.
e. Withhold opioid prescription related to adverse events with low sodium level.
ANS: B, C, D
It is appropriate to provide pain relief for the postoperative client and treatment for nausea
as required. The serum sodium is low; therefore, serum sodium drops are appropriate for
this client. Because the client’s gastric suction has been depleting electrolytes, the IV
solution should include electrolyte replacement, not dextrose. Solutions such as lactated
Ringer’s solution would usually be ordered for this client. The postoperative pain
medication order would not be withheld.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 20: Nursing Management: Preoperative Care
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is conducting a preoperative interview with a client who is scheduled for an
elective hysterectomy and the client tells the nurse, “I am afraid that I will die in surgery
like my mother did!” Which of the following responses by the nurse is most appropriate?
a. “Tell me more about what happened to your mother.”
b. “You will receive medications to reduce your anxiety.”
c. “You should talk to the doctor again about the surgery.”
d. “Surgical techniques have improved a lot in recent years.”
ANS: A
The client’s statement may indicate an unusually high anxiety level or a family history of
problems such as malignant hyperthermia, which will require precautions during surgery.
The other statements also may address the client’s concerns, but further assessment is
needed first.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
2. A client arrives at the ambulatory surgery centre for a scheduled outpatient surgery. Which
of the following information is of most concern to the nurse?
a. The client has not had outpatient surgery before.
b. The client is planning to drive home after surgery.
c. The client’s insurance does not cover the scheduled procedure.
d. The client had a glass of water a few hours before arriving.
ANS: B
After outpatient surgery, the client should not drive home and will need assistance with
transportation and home care. The client’s experience with outpatient surgery is assessed,
but it does not have as much application to the client’s physiological safety. The client’s
insurance coverage is important to establish, but this is not usually the nurse’s role or a
priority in nursing care. Having clear liquids a few hours before surgery does not usually
increase risk for aspiration as the guideline indicates that clear fluids can be taken up to
two hours before surgery.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
3. The nurse is admitting a female client for an outpatient surgery procedure. Which of the
following information is most important to report to the anaesthesiologist before surgery?
a. The client’s lack of knowledge about postoperative pain control measures
b. The client’s statement that her last menstrual period was 8 weeks previously
c. The client’s history of a postoperative infection following a prior cholecystectomy
d. The client’s concern that she will be unable to care for her children postoperatively
ANS: B
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This statement suggests that the client may be pregnant, and pregnancy testing is needed
before administration of anaesthetic agents. Although the other data also may be
communicated with the surgeon and anaesthesiologist, they will affect postoperative care
and do not indicate a need for further assessment before surgery.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
4. A client who is scheduled for surgery in a week tells the nurse doing the preoperative
assessment about an allergy to bananas, kiwifruit, and latex products. Which of the
following actions is most important for the nurse to take?
a. Notify the dietitian about the food allergies.
b. Alert the surgery centre about the latex allergy.
c. Reassure the client that all allergies are noted on the medical record.
d. Ask whether the client uses antihistamines to reduce allergic reactions.
ANS: B
When a client is allergic to latex, special nonlatex materials are used during surgical
procedures and the staff will need to know about the allergy in advance to obtain
appropriate nonlatex materials and have them available on the surgical date. The other
actions also may be appropriate, but prevention of allergic reaction (either contact
dermatitis or anaphylaxis) during surgery is the most important action.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
5. According to the ASA Physical Status Classification System, which of the following
assessments is consistent with a rating of ASA III?
a. Chronic asthma, controlled with an inhaler and corticosteroids
b. Poorly controlled asthma and is wheezing
c. Is in status asthmaticus and on a ventilator
d. Has no significant health problems
ANS: A
A client assessed as a rating of III on the ASA Physical Status Classification System has a
history of chronic asthma controlled with b-adrenergic agonist inhaler and inhaled
corticosteroids and is not wheezing. Poorly controlled asthma and wheezing is a rating of
IV. No significant health problems, past or present, is a rating of I. A client in status
asthmaticus, intubated and on a ventilator, receiving corticosteroids intravenously, is rated
as a V.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
6. The nurse is completing a preoperative assessment of a client scheduled for a colon
resection and the client tells the nurse about using St. John’s wort to prevent depression.
Which of the following information should the nurse alert the staff in the postanaesthesia
recovery area about?
a. Increased pain
b. Hypertensive episodes
c. Increased postanaesthesia waking time
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d. Increased postoperative bleeding
ANS: C
St. John’s wort may prolong the effects of anaesthetic agents and increase the time to
waken completely after surgery. It is not associated with increased bleeding risk,
hypertension, or increased pain.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
7. On the day of surgery, the nurse is admitting a client with a history of cigarette smoking.
Which of the following actions is most important at this time?
Auscultate for adventitious breath sounds.
Ask whether the client has smoked recently.
Remind the client about harmful effects of smoking.
Calculate the cigarette smoking history in pack-years.
a.
b.
c.
d.
ANS: A
Abnormal breath sounds may indicate the presence of an acute respiratory infection or
chronic lung disease that will affect the choice of anaesthesia or proceeding with the
scheduled surgery. The other nursing actions also are appropriate but will not affect the
immediate surgical procedure as much as the presence of abnormal breath sounds.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
8. A client is seen at the health care provider’s office several weeks before hip surgery for
preoperative assessment. The client reports use of Echinacea, ginseng, glucosamine, and
chondroitin. Which of the following actions should the nurse take?
a. Ascertain that there will be no interactions with anaesthetic agents.
b. Discuss the supplement use with the client’s health care provider.
c. Teach the client that these products may be continued preoperatively.
d. Advise the client to stop the use of all herbs and supplements at this time.
ANS: B
The nurse should discuss the medication use with the client’s health care provider because
ginseng may increase bleeding, heart rate, and blood pressure. The nurse should not advise
the client to stop the supplements or to continue them without consulting with the health
care provider. Determining the interactions between the supplements and anaesthetics is
not within the nurse’s scope of practice.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
9. Before the administration of preoperative medications, the nurse is preparing to witness
the client signing the operative consent form when the client says, “I do not really
understand what the doctor said.” Which of the following actions is best for the nurse to
take?
a. Provide an explanation of the planned surgical procedure.
b. Notify the surgeon that the informed-consent process is not complete.
c. Administer the prescribed preoperative antibiotics and withhold any ordered
sedative medications.
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d. Notify the operating room staff that the surgeon needs to give a more complete
explanation of the procedure.
ANS: B
The surgeon is responsible for explaining the surgery to the client, and the nurse should
wait until the surgeon has clarified the surgery before having the client sign the consent
form. The nurse should communicate directly with the surgeon about the consent form
rather than asking other staff to pass on the message. It is not within the nurse’s legal
scope of practice to explain the surgical procedure. No preoperative medications should be
administered until the client signs the consent form.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
10. Which of the following topics is most important for the nurse to discuss preoperatively
with a client who is scheduled for a colon resection?
a. Care for the surgical incision
b. Medications used during surgery
c. Deep-breathing and coughing techniques
d. Oral antibiotic therapy after discharge home
ANS: C
Preoperative teaching, demonstration, and redemonstration of deep breathing and
coughing are needed on clients having abdominal surgery to prevent postoperative
atelectasis. Incisional care and the importance of completing antibiotics are better
discussed after surgery, when the client will be more likely to retain this information. The
client does not usually need information about medications that are used intraoperatively.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
11. Ten minutes after the nurse administered the ordered preoperative opioid by intravenous
(IV) injection, the client asks to get up to go to the bathroom to urinate. Which of the
following actions is best for the nurse to implement?
a. Assist the client to the bathroom and ensure a call bell is within reach.
b. Offer a urinal or bedpan and position the client in bed to promote voiding.
c. Allow the client up to the bathroom because the onset of the medication takes
more than 10 minutes.
d. Ask the client to wait because catheterization is performed at the beginning of the
surgical procedure.
ANS: B
The client will be at risk for a fall after receiving the opioid, so the best nursing action is to
have the client use a bedpan or urinal. Having the client get up either with assistance or
independently increases the risk for a fall. The client will be uncomfortable and risk
involuntary incontinence if the bladder is full during transport to the operating room.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
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12. The nurse is providing preoperative teaching to an older-adult client who has poor hearing
and vision. The partner answers most questions directed to the client. Which of the
following actions should the nurse take when implementing client teaching?
a. Use printed materials for instruction so that the client will have more time to
review the material.
b. Direct the teaching toward the partner as the client’s support person and caregiver.
c. Provide additional time for the client to understand preoperative instructions and
carry out procedures.
d. Ask the partner to wait in the hall in order to focus preoperative teaching with the
client.
ANS: C
The nurse should allow more time when doing preoperative teaching and preparation for
older clients with sensory deficits. Because the client has visual deficits, he will not be
able to use written material for learning. The teaching should be directed toward both the
client and the wife because both will need to understand preoperative procedures and
teaching.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
13. The nurse is caring for a client with diabetes who is scheduled for a mastectomy at 1:00
PM today and it is now 8:30 AM. The client uses insulin to control blood glucose and has
been NPO since midnight. Which of the following actions should the nurse take?
a. Withhold the usual scheduled insulin dose because the client is NPO.
b. Obtain a blood glucose measurement before any insulin administration.
c. Administer the usual insulin dose because stress will increase the blood glucose.
d. Administer a lower dose of insulin because there will be no oral intake before
surgery.
ANS: B
Preoperative insulin administration is individualized to the client, and the current blood
glucose will provide the most reliable information about insulin needs. It is not possible to
predict whether the client will require no insulin, a lower dose, or a higher dose without
blood glucose monitoring.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
14. The clinic nurse is reviewing the complete blood cell count (CBC) results for a client who
is scheduled for surgery in a few days. The results are white blood cell count (WBC)
10.2 ´ 109/L; hemoglobin 150 g/L; hematocrit 45%; platelets 150 ´ 109/L. Which of the
following actions should the nurse take?
a. Send the CBC results to the surgery facility.
b. Call the surgeon and anaesthesiologist immediately.
c. Ask the client about any symptoms of a recent infection.
d. Discuss the possibility of blood transfusion with the client.
ANS: A
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The nurse should be sure that the CBC results, which are normal, are available at the
surgical facility to avoid delay of the procedure. With normal results, there is no need to
notify the surgeon or anaesthesiologist, discuss blood transfusion, or ask about recent
infection.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
15. The nurse is preparing a client the morning of surgery and the client refuses to remove a
wedding ring, saying, “I have never taken it off since the day I was married.” Which of the
following actions should the nurse implement?
a. Have the client sign a release and leave the ring on.
b. Tape the wedding ring securely to the client’s finger.
c. Tell the client that the hospital is not liable for loss of the ring.
d. Suggest that the client give the ring to a family member to keep.
ANS: B
The ring can be taped to the client’s finger and noted on the preoperative checklist. There
is no need for a release form or to discuss liability with the client. Wearing the ring is
obviously important to the client, so the nurse should tape the ring in place rather than
have a family member keep the ring for the client.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
16. The nurse is preparing to administer atropine to a client before surgery. Which of the
following symptoms should the nurse teach the client to expect?
a. Dizziness
b. Weakness
c. Dry mouth
d. Forgetfulness
ANS: C
Anticholinergic medications decrease oral and respiratory secretions, so the client is taught
that a dry mouth is an expected adverse effect. Weakness, forgetfulness, and dizziness are
adverse effects associated with other preoperative medications such as opioids and
benzodiazepines.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
17. The nurse is obtaining the health history for a client who is scheduled for outpatient knee
surgery. Which of the following statements by the client is most important for the nurse to
report to the health care provider?
a. “I had a heart valve replacement last year.”
b. “I had bacterial pneumonia 6 months ago.”
c. “I have knee pain whenever I walk or jog.”
d. “I have a strong family history of breast cancer.”
ANS: A
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A client with a history of valve replacement is at risk for endocarditis associated with
invasive procedures and may need antibiotic prophylaxis. A current respiratory infection
may affect whether the client should have surgery, but a history of pneumonia is not a
reason to postpone surgery. The client’s knee pain is the likely reason for the surgery. A
family history of breast cancer does not have any implications for the current surgery.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
18. The nurse is interviewing a client who is to have outpatient surgery using a general
anaesthetic. Which of the following information is most important to communicate to the
surgeon and anaesthesiologist before surgery?
a. The client drinks three or four cups of coffee every morning before going to work.
b. The client takes a baby Aspirin daily but stopped taking aspirin 2 weeks ago.
c. The client drank 120 mL of apple juice 3 hours before coming to the hospital.
d. The client’s father died after receiving general anaesthesia for abdominal surgery.
ANS: D
The information about the client’s father suggests that there may be a family history of
malignant hyperthermia and that precautions may need to be taken to prevent this
complication. Current research indicates that having clear liquids 3 hours before surgery
does not increase the risk for aspiration in most clients. Clients are instructed to
discontinue Aspirin 1–2 weeks before surgery. The client should be offered caffeinated
beverages postoperatively to prevent a caffeine-withdrawal headache, but this does not
have preoperative implications.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
19. The nurse is preparing a client for surgery. Which of the following information about
medication use is most important for the nurse to communicate to the health care provider?
a. The client uses acetaminophen occasionally for aches and pains.
b. The client takes garlic capsules daily but did not take any on the surgical day.
c. The client has a history of cocaine use but quit using the drug over 10 years ago.
d. The client took a sedative medication the previous night to assist in falling asleep.
ANS: B
Chronic use of garlic may predispose to intraoperative and postoperative bleeding. The use
of a sedative the previous night, occasional acetaminophen use, and a distant history of
cocaine use will not usually affect the surgical outcome.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
20. The nurse is preparing a client for abdominal surgery who takes a diuretic and a b-blocker
pill to control blood pressure. Which of the following client information is most important
for the nurse to communicate to the health care provider before surgery?
a. Pulse rate 59 beats/minute
b. Hematocrit 35%
c. Blood pressure 142/78 mm Hg
d. Serum potassium 3.3 mmol/L
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ANS: D
The low potassium level may increase the risk for intraoperative complications such as
dysrhythmias. Slightly elevated blood pressure is common before surgery because of client
anxiety. The heart rate would be expected in a client taking a b-blocker. The hematocrit is
in the low normal range but does not require any intervention before surgery.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
MULTIPLE RESPONSE
1. The nurse is analyzing a client’s preoperative blood studies. Which of the following blood
studies should the nurse review to assess for anemia and infection in a client with no
known health problems? (Select all that apply.)
a. Red blood cell count
b. White blood cell count
c. Serum potassium
d. Hematocrit
e. Prothrombin (INR) time
ANS: A, B, D
Preoperative blood studies for assessing anemia, immune status, and infection include
RBC, Hgb, Hct, platelets, WBC, and WBC differential. Prothrombin (INR) time would be
used to assess bleeding tendencies. Serum potassium would not be assessed as part of
anemia or infection but would be assessed in a client who is taking a diuretic.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. The nurse is providing preoperative teaching to a client who is scheduled for surgery in 3
days. Which of the following information should the nurse include when addressing
preoperative sensory information? (Select all that apply.)
a. Warming blankets are available as the operating room is often cold.
b. Lighting in the operating room is low that may cause the client to have blurred
vision.
c. The operating room bed is narrow and a safety strap is used to secure the client to
the bed.
d. Not to be alarmed by the quiet environment as there is no conversation in the
operating room.
e. Machines may be making “ticking and pinging noises” that can be heard.
ANS: A, C, E
When providing preoperative teaching related to sensory information the nurse should
include that warming blankets will be available as the operating room is often cold, a
safety strap will be applied over the clients knees as the operating room bed is narrow, and
the operating room machines make noises that the client may hear when they are awake.
Lighting in the OR is very bright, not dull although the client may have blurred vision
related to the preoperative medication it would not be related to the OR lighting. Talking
may be heard in the OR but is often distorted because of the masks and clients should be
directed to ask any questions that they may have.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 21: Nursing Management: Intraoperative Care
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The perioperative nurse is encouraging a family member to remain with a client in the
preoperative holding area until the client is taken into the operating room. Which of the
following reasons is the primary reason for this encouragement?
a. Ensure proper identification of the client before surgery.
b. Protect client from cross-contamination with other clients.
c. Assist perioperative nurse to obtain a complete client history.
d. Help relieve the stress of surgery for the client and family member.
ANS: D
The presence of a family member or friend reduces the client’s anxiety and stress
associated with the preoperative period. Although the family may give information about
the client’s name and history, this information is obtained and confirmed by the nurse in
other ways. Nursing staff, rather than family members, are responsible for prevention of
cross-contamination.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
2. Which of the following descriptions best define the role of the nurse anaesthetist as a
member of the surgical team?
a. Is able to administer anaesthetics
b. Has the same credentials and responsibilities as an anaesthesiologist
c. Is responsible for intraoperative administration of anaesthetics ordered by the
anaesthesiologist
d. Does not require supervision by the anaesthesiologist while administering
anaesthesia to a client
ANS: A
The registered nurse anaesthesia assistant (RNAA) is able to administer anaesthetic
agents. Although the responsibilities of a RNAA and an anaesthesiologist have some
overlap, the credentialing and roles are different. Supervision by an anaesthesiologist is
necessary during anaesthetic administration by a RNAA as the RNAA works in
collaboration with and under the supervision of an anaesthesiologist.
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
3. Which of the following outcome measures is best for the operating room (OR) nurse
manager to use in determining the effectiveness of the physical environment and traffic
control measures in the operating room?
a. Smooth functioning of the OR team
b. Effective protection of client privacy
c. Rapid completion of surgical procedure
d. Low incidence of perioperative infection
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ANS: D
The primary focus when setting up the OR is the prevention of cross-contamination and
transmission of infection to the client. Client privacy, efficient completion of procedures,
and smooth functioning of the OR team are also important, but the priority is protection of
the client from infection.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
4. Which of the following actions should the scrub nurse use to maintain aseptic technique
during surgery?
a. Use waterproof shoe covers.
b. Wear personal protective equipment.
c. Insist that all operating room (OR) staff perform a surgical scrub.
d. Change gloves after touching the thigh of a surgeon’s sterile gown.
ANS: D
Once gloved, a nurse’s hands are not to go below his or her waist; therefore, touching the
surgeon’s thigh would contaminate the nurse’s gloves. Hands are always to be kept above
waist level. Shoe covers are not sterile. Personal protective equipment is designed to
protect caregivers, not the client, and is not part of aseptic technique. Staff members such
as the circulating nurse do not have to perform a surgical scrub before entering the OR.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
5. After orienting a new staff member to the scrub nurse role, the nurse preceptor will know
that the teaching was effective if the new staff member implements which of the following
actions?
a. Documents all client care accurately.
b. Labels all specimens to send to the laboratory.
c. Keeps both hands above the operating table level.
d. Takes the client to the postanaesthesia recovery area.
ANS: C
The scrub nurse role includes maintaining asepsis in the operating field and both hands
must stay above waist level to ensure that they are above the operating table level. The
other actions would be appropriate to the circulating nurse role.
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
6. Data that were obtained during the perioperative nurse is assessing a client in the
preoperative holding area. Which of the following findings would indicate a need for
special protection techniques during surgery?
a. A stated allergy to cats and dogs
b. A history of spinal and hip arthritis
c. Verbalization of anxiety by the client
d. Having a sip of water 2 hours previously
ANS: B
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The client with arthritis may require special positioning to avoid injury and postoperative
discomfort. Preoperative anxiety and having a sip of water 2–3 hours before surgery are
not unusual for the preoperative client. An allergy to cats and dogs will not impact the care
needed during the intraoperative phase.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
7. The nurse from the general surgical unit is asked to bring the client’s hearing aid to the
surgical suite. The nurse will take the hearing aid to which one of the following areas?
a. Clean core
b. Scrub sink area
c. Nursing station or communication centre
d. Corridors of the operating room area
ANS: C
The nurse from the general unit would not be wearing surgical scrub attire or a head
covering and would be restricted to the nursing station or communication centre, which are
unrestricted areas. The clean care, scrub sink area, and corridors are semirestricted areas
that require staff members wear surgical scrub attire and head coverings.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
8. The nurse is caring for a preoperative adult client who is scheduled for a routine surgery
and is in the holding area. The client asks the nurse, “Will the doctor put me to sleep with
a mask over my face?” Which of the following responses is most appropriate?
a. “A drug will be given to you through your IV line, which will cause you to go to
sleep almost immediately.”
b. “Only your surgeon can tell you for sure what method of anaesthesia will be used.
Should I ask your surgeon?”
c. “General anaesthesia is now given by injecting medication into your veins, so you
will not need a mask over your face.”
d. “Masks are not used anymore for anaesthesia. A tube will be inserted into your
throat to deliver a gas that will put you to sleep.”
ANS: A
The first step in virtually all routine surgeries for general anaesthesia is the injection of an
intravenous (IV) induction agent, which rapidly induces sleep. The anaesthesiologist (not
the surgeon) determines the method of anaesthesia used. Masks may still be used for
inhalation, although many clients are intubated. Total IV anaesthesia may be used for
some clients but inhalation anaesthetics also are commonly used. The client will have a
face mask even if the medication is injected into client veins so telling the client that they
will not have a face mask is not accurate.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
9. A surgical client received a volatile liquid as an inhalation anaesthetic during surgery.
Which of the following symptoms should the nurse monitor for in the immediate
postoperative period?
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a.
b.
c.
d.
Tachypnea
Myoclonia
Hypertension
Incisional pain
ANS: D
Because volatile liquid inhalation agents are rapidly metabolized, postoperative pain
occurs soon after surgery. Hypertension and tachypnea are not associated with general
anaesthetics. Myoclonia may occur with nonbarbiturate hypnotics but not with the inhaled
inhalation agents.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
10. The nurse is caring for a client before surgery who has a question about the preoperative
medication. Which of the following people will the nurse communicate this information
to?
a. Scrub nurse
b. Anaesthesiologist
c. Circulating nurse
d. Registered nurse first assistant (RNFA)
ANS: B
The anaesthesiologist is responsible for prescribing and answering questions about
preoperative medications. The RNFA and surgeon are responsible for the surgery, but not
for the preoperative sedation. The circulating nurse does not have authority to make a
change in any medication.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
11. The nurse is preparing a client with a dislocated shoulder for a closed, manual reduction of
the dislocation with procedural sedation. Which of the following medications should the
nurse anticipate administering for this procedure?
a. IV midazolam
b. Inhaled desflurane
c. Epidural lidocaine
d. Eutectic mixture of local anaesthetics (EMLA)
ANS: A
IV sedatives, such as the benzodiazepines, are administered for procedural sedation.
Inhaled, epidural, and topical agents are not included in procedural sedation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
12. Which of the following actions should the nurse include in the plan of care immediately
after surgery for a client who received ketamine as an anaesthetic agent?
Administer larger doses of analgesic agents.
Monitor for severe slowing of the heart rate.
Provide a quiet environment in the postanaesthesia care unit.
Avoid the use of benzodiazepines in the postoperative period.
a.
b.
c.
d.
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ANS: C
Hallucinations are an adverse effect associated with the dissociative anaesthetics such as
ketamine, so the postoperative environment should be kept quiet to decrease the risk of
hallucinations. Since ketamine causes profound analgesia lasting into the postoperative
period, larger doses of analgesics are not needed. Ketamine causes an increase in heart rate.
Benzodiazepine use with ketamine may be used to decrease the incidence of hallucinations
and nightmares.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
13. A client’s family history reveals that the client may be at risk for malignant hyperthermia
(MH) during anaesthesia. Which of the following information should the nurse include
when providing preoperative client teaching?
a. Anaesthesia can be administered with minimal risks with the use of appropriate
precautions and medications.
b. As long as succinylcholine is not administered as a muscle relaxant, the reaction
should not occur.
c. Surgery must be performed under local anaesthetic to prevent development of a
sudden, extreme increase in body temperature.
d. Surgery will be delayed until the client is genetically tested to determine
susceptibility to malignant hyperthermia.
ANS: A
General anaesthesia can be administered to clients with MH as long as precautions to
avoid MH are taken and preparations are made to treat MH if it does occur. Other factors
besides succinylcholine administration are associated with MH. Predictions about whether
MH will occur based on family history are inconsistent, and it may not be possible to
delay surgery.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
14. A client in surgery receives a neuro-muscular blocking agent as an adjunct to general
anaesthesia. At completion of the surgery, it is most important that the nurse monitor the
client for which of the following adverse effects?
a. Nausea
b. Confusion
c. Bronchospasm
d. Weak chest-wall movement
ANS: D
The most serious adverse effect of the neuro-muscular blocking agents is weakness of the
respiratory muscles leading to postoperative hypoxemia. Nausea and confusion are
possible adverse effects of these drugs, but they are as great a concern as respiratory
depression. Because these medications decrease muscle contraction, laryngospasm and
bronchospasm are not concerns.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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15. Which of the following actions by a member of the surgical team requires rapid
intervention by the charge nurse?
a. Wearing street clothes into the nursing station
b. Wearing a surgical mask into the holding room
c. Walking into the hallway outside an operating room without the hair covered
d. Putting on a surgical mask, cap, and scrubs before entering the operating room
ANS: C
The corridors outside the OR are part of the semirestricted area where personnel must
wear surgical attire and head coverings. Surgical masks may be worn in the holding room,
although they are not necessary. Street clothes may be worn at the nursing station, which
is part of the unrestricted area. Wearing a mask and scrubs is essential when going into the
OR.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
16. Which of the following nursing actions should the preoperative nurse perform to prepare a
client for cranial surgery that requires hair removal?
a. Consult with the surgeon to consider cancellation of the surgery.
b. Use a depilatory agent to remove hair from the surgical area.
c. Shave the scalp surgical area with a 1 cm border.
d. No special preoperative action is required.
ANS: B
For surgeries that require hair removal, the hair is either clipped or a depilatory agent is
used for hair removal. There is no need to consider cancelling the surgery. Shaving the
hair is contraindicated.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
17. The nurse is positioning a client in the operating room for a transurethral resection of the
prostate. Which of the following client positions should the nurse place this client in?
a. Prone
b. Supine
c. Trendelenburg
d. Lithotomy
ANS: D
The lithotomy position is used for genito-urinary procedures such as vaginal hysterectomy
and transurethral resection of the prostate. Although supine is the most common position,
it is not used for this surgery; rather it is appropriate for abdominal, cardiac, and breast
surgeries. A variation of the supine is the Trendelenburg position, used in lower abdominal
or pelvic surgery, for which it is necessary to see the pelvic organs. The prone position
allows easy access for back surgeries (e.g., laminectomies).
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
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1. The nurse is preparing a client for surgery. Which of the following actions should the
nurse include in the surgical time-out procedure? (Select all that apply.)
a. Check for placement of IV lines.
b. Have the surgeon identify the client.
c. Confirm the hospital chart identification (ID) number.
d. Have the client state name and date of birth.
e. Ask the client to state the surgical procedure.
f. Verify the client ID band number.
ANS: C, D, E, F
These actions are included in surgical time out. IV line placement and identification of the
client by the surgeon are not included in the surgical time-out procedure.
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
2. The nurse is completing an inventory of medications on the unit. Which of the following
anaesthesia medications should the nurse expect to observe under refrigeration? (Select all
that apply.)
a. Atracurium
b. Pancuronium
c. Rocuronium
d. Neostigmine bromide
e. Succinylcholine
ANS: A, E
Succinylcholine and atracurium both require refrigeration. The other medications listed
did not require refrigeration.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
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Chapter 22: Nursing Management: Postoperative Care
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is caring for a client who is recovering from anaesthesia in the
postanaesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP)
is 124/70. Thirty minutes after admission, the blood pressure is 112/60, with a pulse of
72 and warm, dry skin. Which of the following actions is the most appropriate for the
nurse to implement at this time?
a. Increase the rate of the IV fluid replacement.
b. Continue to take vital signs every 15 minutes.
c. Administer oxygen therapy at 100% per mask.
d. Notify the anaesthesia care provider (ACP) immediately.
ANS: B
A slight drop in postoperative BP with a normal pulse and warm, dry skin indicates
normal response to the residual effects of anaesthesia and requires only ongoing
monitoring. Hypotension with tachycardia and/or cool, clammy skin would suggest
hypovolemic or hemorrhagic shock and the need for notification of the ACP, increased
fluids, and high-concentration oxygen administration.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
2. The nurse is caring for a client who is recovering from anaesthesia in the
postanaesthesia care unit (PACU), and the vital signs are blood pressure 118/72, pulse
76, respirations 12, and SpO2 91%. The client is sleepy but awakens easily. Which of the
following actions should the nurse take at this time?
a. Place the client in a side-lying position.
b. Encourage the client to take deep breaths.
c. Prepare to transfer the client from the PACU.
d. Increase the rate of the postoperative IV fluids.
ANS: B
The client’s borderline SpO2 and sleepiness indicate hypoventilation. The nurse should
stimulate the client and remind the client to take deep breaths. Placing the client in a
lateral position is needed when the client first arrives in the PACU and is unconscious.
The stable BP and pulse indicate that no changes in fluid intake are required. The client
is not fully awake and has a low SpO2, indicating that transfer from the PACU is not
appropriate.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
3. After a new nurse has been oriented to the postanaesthesia care unit (PACU), the charge
nurse will evaluate that the orientation has been successful when the new nurse does
which of the following actions?
a. Places a client in the Trendelenburg position when the blood pressure (BP) drops.
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b. Assists a client to the prone position when the client is nauseated.
c. Turns an unconscious client to the side when the client arrives in the PACU.
d. Positions a newly admitted unconscious client supine with the head elevated.
ANS: C
The client should initially be positioned in the lateral “recovery” position to keep the
airway open and avoid aspiration. The prone position is not usually used and would
make it difficult to assess the client’s respiratory effort and cardiovascular status. The
Trendelenburg position is avoided because it increases the work of breathing. The client
is placed supine with the head elevated after regaining consciousness.
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
4. The nurse is preparing an older-adult client for discharge from the ambulatory surgical
unit following left eye surgery. The client tells the nurse, “I do not know if I can take
care of myself with this patch over my eye.” Which of the following actions is the most
appropriate for the nurse to implement?
a. Refer the client for home health care services.
b. Discuss the specific concerns regarding self-care.
c. Give the client written instructions regarding care.
d. Assess the client’s support system for care at home.
ANS: B
The nurse’s initial action should be to assess exactly the client’s concerns about self-care.
Referral to home health care and assessment of the client’s support system may be
appropriate actions but will be based on further assessment of the client’s concerns.
Written instructions should be given to the client, but these are unlikely to address the
client’s stated concern about self-care.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
5. After removal of the nasogastric (NG) tube on the second postoperative day, the client is
placed on a clear liquid diet. Four hours later, the client complains of sharp, cramping
gas pains. Which of the following actions should the nurse take?
a. Reinsert the NG tube.
b. Give the PRN IV opioid.
c. Assist the client to ambulate.
d. Place the client on NPO status.
ANS: C
Ambulation encourages peristalsis and the passing of flatus, which will relieve the
client’s discomfort. If distension persists, the client may need to be placed on NPO status,
but usually this is not necessary. Morphine administration will further decrease intestinal
motility. Gas pains are usually caused by trapping of flatus in the colon, and reinsertion
of the NG tube will not relieve the pains.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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6. The nurse is caring for a client following gallbladder surgery, and the client’s T-tube is
draining dark green fluid. Which of the following actions should the nurse take?
a. Place the client on bed rest.
b. Notify the client’s surgeon.
c. Document the colour and amount of drainage.
d. Irrigate the T-tube with sterile normal saline.
ANS: C
A T-tube normally drains dark green to bright yellow drainage, so no action other than to
document the amount and colour of the drainage is needed. The other actions are not
necessary.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
7. In intervening to promote ambulation, coughing, deep breathing, and turning by a
postoperative client on the first postoperative day, which of the following actions by the
nurse is most helpful?
a. Discuss the complications of immobility and poor cough effort.
b. Teach the client the purpose of respiratory care and ambulation.
c. Administer ordered analgesic medications before these activities.
d. Give the client positive reinforcement for accomplishing these activities.
ANS: C
The most essential nursing action in encouraging these postoperative activities is
administration of adequate analgesia to allow the client to accomplish the activities with
minimal pain. Even with motivation provided by proper teaching, positive reinforcement,
and concern about complications, clients will have difficulty if there is a great deal of
pain involved with these activities.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
8. The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway
clearance in a postoperative client have been successful when which of the following
goals has been met?
a. Client drinks 2–3 L of fluid in 24 hours.
b. Client uses the spirometer 10 times every hour.
c. Client’s breath sounds are clear to auscultation.
d. Client’s temperature is less than 38°C (100.4°F) orally.
ANS: C
One characteristic of ineffective airway clearance is the presence of adventitious breath
sounds such as rhonchi or wheezes, so clear breath sounds are an indication of resolution
of the problem. Spirometer use and increased fluid intake are interventions for
ineffective airway clearance but may not improve breath sounds in all clients. Elevated
temperature may occur with atelectasis, but a normal or near-normal temperature does
not always indicate resolution of respiratory problems.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
9. The nurse is caring for a client who has begun to awaken after 30 minutes in the
postanaesthesia care unit (PACU), who is restless and shouting at the nurse. The client’s
oxygen saturation is 99%, and recent laboratory results are all normal. Which of the
following actions by the nurse is most appropriate?
a. Insert an oral or nasal airway.
b. Notify the anaesthesia care provider.
c. Orient the client to time, place, and person.
d. Be sure that the client’s IV lines are secure.
ANS: D
Because the client’s assessment indicates physiological stability, the most likely cause of
the client’s agitation is emergence delirium, which will resolve as the client wakes up
more fully. The nurse should ensure client safety through interventions such as raising
the bed rails and securing IV lines. Emergence delirium is common in clients recovering
from anaesthesia, so there is no need to notify the anaesthesiologist. Insertion of an
airway is not needed because the oxygen saturation is good. Orientation of the client is
needed but is not likely to be effective until the effects of anaesthesia have resolved
more completely.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
10. The nurse is caring for an older adult in the postanaesthesia unit. Which of the following
age-related considerations may impact postoperative recovery?
a. Increased thoracic compliance
b. Decreased ability to cough
c. Increased lung tissue
d. Decreased compliance with deep breathing and coughing
ANS: B
The older adult has a decrease in respiratory function, including decreased ability to
cough, decreased thoracic compliance (not increased), and decreased (not increased)
lung tissue. There is no noted decrease in compliance related to postoperative deep
breathing and coughing.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
11. The nurse is caring for a client who is being transferred from the postanaesthesia care
unit (PACU) to the clinical surgical unit. Which of the following actions should the
nurse implement first on the clinical surgical unit?
a. Assess the client’s pain.
b. Take the client’s vital signs.
c. Read the postoperative orders.
d. Check the rate of the IV infusion.
ANS: B
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Because the priority concerns after surgery are airway, breathing, and circulation, the
vital signs are assessed first. The other actions should take place after the vital signs are
obtained and compared with the vital signs before transfer.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
12. The nurse is caring for an older-adult client who had a surgical repair of a hip fracture 2
days previously and has restrictions on ambulation. Based on this information, which of
the following collaborative problems is priority for the client?
a. Potential complication: hypovolemic shock
b. Potential complication: venous thrombo-embolism
c. Potential complication: fluid and electrolyte imbalance
d. Potential complication: impaired surgical wound healing
ANS: B
The client is older and relatively immobile, two risk factors for development of deep
vein thrombosis. The other potential complications are possible postoperative problems,
but they are not supported by the data about this client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Diagnosis
13. The nurse is caring for a client who is just waking up after having a general anaesthetic
and the client is agitated and confused. Which of the following actions should the nurse
take first?
a. Check the O2 saturation.
b. Administer the ordered opioid.
c. Take the blood pressure and pulse.
d. Notify the anaesthesia care provider.
ANS: A
Emergence delirium may be caused by a variety of factors. However, the nurse should
first assess for hypoxemia. The other actions also may be appropriate, but are not the
best initial action.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
14. The nurse is caring for a postoperative client who has not voided for 7 hours after return
to the postsurgical unit. Which of the following actions should the nurse take first?
a. Notify the surgeon.
b. Assess for bladder distension.
c. Assist the client to ambulate to the bathroom.
d. Insert a straight catheter as indicated on the PRN order.
ANS: B
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The initial action should be to assess the bladder for distension. If the bladder is
distended, providing the client with privacy (by walking with them to the bathroom) will
be helpful. Catheterization should only be done after other measures have been tried
without success because of the risk for urinary tract infection. There is no indication to
notify the surgeon about this common postoperative problem unless all measures to
empty the bladder are unsuccessful.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
15. The nurse is caring for a client with abdominal surgery and on the first postoperative day,
the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. Which
of the following actions should the nurse implement first?
a. Reinforce the dressing.
b. Take the client’s vital signs.
c. Recheck the dressing in 1 hour for increased drainage.
d. Notify the client’s surgeon of a potential hemorrhage.
ANS: B
New bright-red drainage may indicate hemorrhage, and the nurse should initially assess
the client’s vital signs for tachycardia and hypotension. The surgeon should then be
notified of the drainage and the vital signs. The dressing may be changed or reinforced,
based on the surgeon’s orders or institutional policy. The nurse should not wait an hour
to recheck the dressing.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
16. The nurse is caring for a client and during the second postoperative day after abdominal
surgery, the nurse obtains an oral temperature of 38.2°C (100.8°F). Which of the
following actions should the nurse take first?
a. Have the client use the incentive spirometer.
b. Assess the surgical incision for redness and swelling.
c. Administer the ordered PRN acetaminophen.
d. Notify the client’s health care provider about the fever.
ANS: A
A temperature of 38.2°C (100.8°F) in the first 48 hours is usually caused by atelectasis,
and the nurse should have the client cough and deep breathe. This problem may be
resolved by nursing intervention, and therefore notifying the health care provider is not
necessary. Acetaminophen will reduce the temperature, but it will not resolve the
underlying respiratory congestion. Because evidence of wound infection does not
usually occur before the third postoperative day, assessment of the incision is not likely
to be useful.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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17. The nurse is caring for an unconscious client who was transferred to the postanaesthesia
care unit (PACU) 10 minutes previously and has an oxygen saturation of 88%. Which of
the following actions should the nurse take first?
a. Elevate the client’s head.
b. Suction the client’s mouth.
c. Increase the oxygen flow rate.
d. Perform the jaw-thrust manoeuvre.
ANS: D
In an unconscious postoperative client, a likely cause of hypoxemia is airway obstruction
by the tongue, and the first action is to clear the airway by manoeuvres such as the jaw
thrust or chin lift. Increasing the oxygen flow rate and suctioning are not helpful when
the airway is obstructed by the tongue. Elevating the client’s head will not be effective in
correcting the obstruction but may help with oxygenation after the client is awake.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
18. The nurse is caring for a client who had abdominal surgery two days previously. Which
of the following information about the client is most important to communicate to the
health care provider?
a. The right calf is swollen, warm, and painful.
b. The client’s temperature is 37.9°C (100.2°F).
c. The 24-hour oral intake is 600 mL greater than the total output.
d. The client complains of abdominal pain at level 6 (0–10 scale).
ANS: A
The calf pain, swelling, and warmth suggest that the client has a deep vein thrombosis,
which will require health care provider orders for diagnostic tests and anticoagulants.
Because the stress response causes fluid retention for the first 2–5 days postoperatively,
the difference between intake and output is expected. A temperature elevation to 37.9°C
(100.2°F) on the second postoperative day suggests atelectasis, and the nurse should
have the client deep breathe and cough. Pain with ambulation is normal, and the nurse
should administer the ordered analgesic before client activities.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
19. The nurse is caring for a client in the postoperative period who is on bed rest. Which of
the following actions should the nurse implement?
a. Assist the client to the bathroom when required.
b. Implement active ROM exercise every 1–2 hours.
c. Place the client in a chair for 20 minutes TID.
d. Complete passive ROM exercises once per 12 hour shift.
ANS: B
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When confined to bed, clients should alternately flex and extend all joints 10–12 times
every 1–2 hours while awake. The muscular contraction produced by these exercises and
by ambulation facilitates venous return from the lower extremities. A client on bed rest
is not to be assisted up to the bathroom or placed in a chair. If passive ROM exercise
were to be completed, the frequency would be every 1–2 hours, not once per 12 hour
shift.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
OTHER
1. The nurse is caring for a client on the first postoperative day who is dizzy when
ambulating in the room. In what order will the nurse accomplish the following activities?
(All the activities are appropriate.)
a. Take the client’s blood pressure (BP).
b. Place the client in the supine position.
c. Assist the client to sit.
d. Record the results.
ANS:
B, A, C, D
The first priority for the client with syncope is to prevent a fall, so the client should be
placed in the supine position. Assessment of the BP will determine whether the dizziness
is due to orthostatic hypotension, which occurs because of hypovolemia. After taking BP,
the client is assisted to the sitting position and the BP is rechecked in 1–3 minutes.
Because this is a common postoperative problem that is usually resolved through nursing
measures such as increasing fluid intake and making position changes more slowly, there
is no need to notify the health care provider and the nurse is to record the results of the
assessment.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
2. The nurse is caring for a client in the PACU and the client’s blood pressure has dropped
from an admission blood pressure of 138/84 to 100/58 with a pulse change of 68–94.
SpO2 is 98% on 3L of oxygen. In which order should the nurse take these actions?
a. Raise the IV infusion rate.
b. Assess the client’s dressing.
c. Increase the oxygen flow rate.
d. Check the client’s temperature.
ANS:
C, A, B, D
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The first nursing action should be to increase the oxygen flow rate. Since the most
common cause of hypotension is volume loss, the IV rate should be increased next.
Because hemorrhage is a common cause of postoperative volume loss, the nurse should
check the dressing. Finally, the client should be assessed for vasodilation caused by
rewarming.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 23: Nursing Assessment: Visual and Auditory Systems
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is teaching a client about routine glaucoma testing. Which of the following
information should the nurse include in the teaching plan?
a. The test involves reading a Snellen chart at a distance of 6 m.
b. Application of a Tono-pen to the surface of the eye will be needed.
c. The examination includes checking the pupil’s reaction to a bright light.
d. Medications to dilate the pupil will be used before testing for glaucoma.
ANS: B
Glaucoma is caused by an increase in intraocular pressure, which would be measured
using the Tono-pen. The other techniques are used in testing for other eye disorders.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
2. Which assessment information obtained by the nurse when performing an eye
examination for an older-adult client indicates that more extensive examination of the
eyes is needed?
a. The client’s sclerae are light yellow in colour.
b. The client complains of persistent photophobia.
c. The pupil recovers slowly after being stimulated by a penlight.
d. There is a whitish gray ring encircling the periphery of the iris.
ANS: B
Photophobia is not a normally occurring change with aging and would require further
assessment. The other assessment data are common age-related differences and would
not be unusual in an older-adult client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
3. The nurse is performing an eye examination on a client and is assessing for
accommodation. Which of the following actions should the nurse implement?
a. Cover one eye for 1 minute and note the pupil reaction when the cover is removed.
b. Shine a light into the client’s eye and assess the pupil response in the opposite eye.
c. Observe the pupils when the client focuses on a close object and then on a distant
object.
d. Touch the client’s pupil with a small piece of sterile cotton and watch for a blink
reaction.
ANS: C
Accommodation is defined as the ability of the lens to adjust to various distances. The
other nursing actions also may be part of the eye examination, but they do not test for
accommodation.
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DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
4. The nurse is delivering a health-promotion session at the eye clinic and advises all
clients to wear sunglasses that protect the eyes from ultraviolet light. Which of the
following conditions is associated with ultraviolet sunlight exposure?
a. Cataracts
b. Glaucoma
c. Anisocoria
d. Exophthalmos
ANS: A
Ultraviolet light exposure is associated with the accelerated development of cataracts.
Glaucoma is caused by increased intraocular pressure, exophthalmos is associated with
hyperthyroidism, and anisocoria can occur normally in a small percentage of the
population or may be caused by injury or central nervous system disorders.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
5. The nurse’s assessment of a client’s visual acuity reveals that the left eye can see at 20
feet what a person with normal vision can see at 40 feet and the right eye can see at 20
feet what a person with normal vision can see at 50 feet. Which of the following findings
should the nurse document?
a. Left eye 20/40; right eye 20/50
b. OU 20/40; OS 50/20
c. Right eye 20/40; left eye 20/50
d. OS 20/40; OD 20/50
ANS: A
When documenting visual acuity, the first number indicates the standard (for normal
vision) of 20 feet and the second number indicates the line that the client is able to read
when standing 20 feet from the Snellen chart. Nurses should avoid using the
abbreviations OS for left eye, OD for right eye, and OU for both eyes when documenting
in client charts. The remaining three answers do not correctly describe the client’s visual
acuity.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
6. The nurse is conducting a vision assessment on a client and is assessing the client’s
visual field. Which of the following actions should the nurse include?
a. Position the client 20 feet from the Snellen chart.
b. Have the client cover one eye while facing the nurse.
c. Instruct the client to follow a moving object using only the eyes.
d. Shine a light into one pupil and observe the response for both pupils.
ANS: B
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To perform confrontation visual field testing, the client faces the examiner and covers
one eye, then counts the number of fingers that the examiner brings into the visual field.
The other actions are needed to test for visual acuity, extraocular movements, and
consensual pupil response.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
7. The nurse is observing a student who is preparing to perform an ear examination of an
adult client. Which of the following actions by the student should cause the nurse to
intervene in the assessment?
a. Chooses a speculum smaller than the ear canal
b. Pulls the auricle of the ear down and backward
c. Stabilizes the hand holding the otoscope on the client’s head
d. Stops inserting the otoscope after observing impacted cerumen
ANS: B
The auricle should be pulled up and back when assessing an adult. The other actions are
appropriate when performing an ear examination.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
8. The nurse is obtaining a health history from a middle-aged adult client. Which of the
following client statements is most important to communicate to the health care
provider?
a. “My vision seems blurry now when I read.”
b. “I have noticed that my eyes are drier now.”
c. “It is hard for me to see when I drive at night.”
d. “The peripheral part of my vision is decreased.”
ANS: D
The decrease in peripheral vision may indicate glaucoma, which is not a normal visual
change associated with aging and requires rapid treatment. The other client statements
indicate visual problems (presbyopia, dryness, and lens opacity) that are considered a
normal part of aging.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
9. The nurse is obtaining a health history from an older-adult client, who is new to the eye
clinic and who has glaucoma. Which of the following information given by the client
will have the most implications for the client’s treatment?
a. “I use aspirin when I have a sinus headache.”
b. “I have had frequent episodes of conjunctivitis.”
c. “I take metoprolol daily for angina.”
d. “I have not had an eye examination for 10 years.”
ANS: C
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It is important to note whether the client takes any â-adrenergic blockers because this
category of medications also is used to treat glaucoma, and there may be an increase in
adverse effects. The use of aspirin does not increase intraocular pressure and is safe for
clients with glaucoma. Although older clients should have yearly eye examinations, the
treatment for this client will not be affected by the 10-year gap in eye care.
Conjunctivitis does not increase the risk for glaucoma.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
10. The nurse is preparing to assess the visual acuity for a client in the outpatient clinic.
Which of the following supplies should the nurse obtain to prepare for this assessment?
a. Penlight
b. Amsler grid
c. Snellen chart
d. Ophthalmoscope
ANS: C
The Snellen chart is used to check visual acuity. An ophthalmoscope, penlight, and
Amsler grid also may be used during an eye examination, but they are not helpful in
assessing visual acuity.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
11. The nurse is admitting a client to the hospital who has an eye patch in place and tells the
nurse “I had a recent eye injury, so I need to wear this patch for a few weeks.” Which of
the following nursing diagnoses will the nurse include in the plan of care?
a. Risk for falls as evidenced by impaired vision (decrease in stereoscopic vision)
b. Ineffective health maintenance related to impaired decision-making (inability to
see surroundings)
c. Disturbed body image related to alteration in self-perception
d. Ineffective denial related to threat of unpleasant reality
ANS: A
The loss of stereoscopic vision created by the eye patch impairs the client’s ability to see
in three dimensions and to judge distances. It also increases the risk for falls. There is no
evidence in the assessment data for ineffective denial, disturbed body image, or
ineffective health maintenance.
DIF: Cognitive Level: Application
TOP: Nursing Process: Diagnosis
MSC: NCLEX: Safe and Effective Care Environment
12. The nurse is preparing a client in the eye clinic for refractometry. Which of the
following information should the nurse include in client teaching?
a. “You will need to wear sunglasses for a few hours after the exam.”
b. “The surface of your eye will be numb while the doctor does the exam.”
c. “You should not take any of your eye medicines before the examination.”
d. “The doctor will shine a bright light into your eye during the examination.”
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ANS: A
The pupil is dilated by using cycloplegic medications during refractometry. This effect
will last several hours and cause photophobia. The other teaching would not be
appropriate for a client who was having refractometry.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
13. The nurse is assessing an older-adult client for the presence of presbyopia. Which of the
following equipment will the nurse need to obtain before the examination?
a. Penlight
b. Tono-pen
c. Jaeger chart
d. Snellen chart
ANS: C
Presbyopia is the normal loss of near vision that occurs with age and is assessed using a
Jaeger chart. This assessment should begin after 40 years of age. The Snellen chart,
penlight, and the Tono-pen are used when assessing for other visual disorders.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
14. The nurse is caring for a client in the emergency department with symptoms of eye
itching and pain caused by sleeping with contact lenses in place. Which of the following
equipment should the nurse anticipate preparing to facilitate further examination of the
client’s eye?
a. Tonometer
b. Eye patch
c. Refractometer
d. Fluorescein dye
ANS: D
Eye itching and pain suggest a possible corneal abrasion or ulcer, which can be
visualized using fluorescein dye. The other items listed would not be helpful in
determining the cause of this client’s symptoms.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
15. The nurse is obtaining a nursing history from a client when the client indicates
symptoms of dizziness when bending over and nausea and dizziness associated with
physical activities. Which of the following topics should the nurse include in this client’s
teaching plan?
a. Tympanometry
b. Rotary chair testing
c. Pure-tone audiometry
d. Bone-conduction testing
ANS: B
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The client’s clinical manifestations of dizziness and nausea suggest a disorder of the
labyrinth, which controls balance and contains three semicircular canals and the
vestibule. Rotary chair testing is used to test vestibular function. The other tests are used
to test for problems with hearing.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
16. The nurse is taking a health history of a new client at the ear clinic and the client states,
“I always sleep with the radio on.” Which of the following questions is most appropriate
to obtain more information about possible hearing problems?
a. “Do you grind your teeth at night?”
b. “What time do you usually fall asleep?”
c. “Have you noticed any ringing in your ears?”
d. “Are you ever dizzy when you are lying down?”
ANS: C
Clients with tinnitus may use masking techniques, such as playing a radio, to block out
the ringing in the ears. The responses “Do you grind your teeth at night?” and “Have you
noticed any ringing in your ears?” would be used to obtain information about other ear
problems, such as vestibular disorders and referred temporo-mandibular joint (TMJ)
pain. The response “What time do you usually fall asleep?” would not be helpful in
assessing problems with the client’s ears.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
17. The nurse is admitting a client to the hospital preoperatively. Which of the following
findings may indicate that the client is at risk for falls while hospitalized?
a. Lateralization with Weber’s test
b. Positive result for Rinne’s testing
c. Inability to hear a low-pitched whisper
d. Nystagmus when head is turned rapidly
ANS: D
Nystagmus suggests that the client may have problems with balance related to disease of
the vestibular system. The other tests are used to check hearing; abnormal results for
these do not indicate potential problems with balance.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
18. The nurse is conducting a health history with a new client in the outpatient clinic. Which
of the following medications in the health history may indicate the need to perform a
focused hearing assessment?
a. Salbutamol for acute asthma
b. Atenolol to prevent angina
c. Acetaminophen frequently for headaches
d. Ibuprofen for 20 years to treat arthritis
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ANS: D
Nonsteroidal anti-inflammatory drugs (NSAIDs) are potentially ototoxic.
Acetaminophen, atenolol, and salbutamol are not associated with hearing loss. Other
drugs that are potentially ototoxic include aminoglycosides, any other antibiotics,
salicylates, antimalarial agents, chemotherapeutic drugs, and diuretics.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
19. Which of the following actions should the nurse include in the plan of care for a client
who has vestibular disease?
a. Check Rinne’s and Weber’s tests.
b. Face the client when speaking.
c. Enunciate clearly when speaking.
d. Monitor the client’s ability to ambulate safely.
ANS: D
Vestibular disease affects balance so the nurse should monitor the client during activities
that require balance. The other action might be used for clients with hearing disorders.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
20. The nurse in the eye clinic is examining an older-adult client who says “I see small spots
that move around in front of my eyes.” Which of the following actions should the nurse
take first?
a. Immediately have the ophthalmologist evaluate the client.
b. Explain that spots and “floaters” are a normal part of aging.
c. Inform the client that these spots may indicate damage to the retina.
d. Use an ophthalmoscope to examine the posterior chamber of the eyes.
ANS: D
Although “floaters” are usually caused by vitreous liquefaction and are common in aging
clients, they can be caused by hemorrhage into the vitreous humur or by retinal tears, so
the nurse’s first action will be to examine the retina and posterior chamber. Although the
ophthalmologist will examine the client, the presence of spots or floaters in a
65-year-old is not an emergency. The spots may indicate retinal damage, but the nurse
should assess the eye further before discussing this with the client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
21. The nurse is assessing a client’s auditory canal and tympanic membrane. Which of the
following findings is a priority to report to the health care provider?
a. There is a cone of light visible.
b. The tympanum is bluish-tinged.
c. Cerumen is present in the auditory canal.
d. The skin in the ear canal is dry and scaly.
ANS: B
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A bluish-tinged tympanum can occur with acute otitis media, which requires immediate
care to prevent perforation of the tympanum. Cerumen in the ear canal may need to be
removed before proceeding with the examination but is not unusual or pathological. The
presence of a cone of light on the eardrum is normal. Dry and scaly skin in the ear canal
may need further assessment but does not require urgent care.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
MULTIPLE RESPONSE
1. The nurse is caring for a child who has a perforated eardrum. Which of the following are
possible causes? (Select all that apply.)
a. Chronic otitis media
b. Mastoiditis
c. Eustachian tube blockage
d. Serous otitis media
e. Acute otitis media
ANS: A, B, E
Perforation of the eardrum, central or marginal, can be caused by chronic otitis media
and mastoiditis. Acute otitis media may also be the cause of a perforation, but more
commonly it is bulging red or blue with an acute infection. Eustachian tube blockage
could be the cause of a retracted eardrum. Serous otitis media presents as hairline fluid
level, yellow-amber bubbles above the fluid line.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. The nurse is conducting an auditory assessment with a client. Which of the following
findings should the nurse document as normal? (Select all that apply.)
a. Ability to hear low whisper at 30 cm
b. Rinne’s test results: bone conduction is better than air conduction
c. Weber’s test results- no lateralization
d. Curved cone light reflex
e. Symmetrical location of ears
ANS: A, C, E
Normal findings in the physical assessment of the auditory system include ears
symmetrical in location and shape; auricles and tragus nontender, without lesions; clear
canal and tympanic membrane intact, landmarks and light reflect intact; ability to hear
low whispers at 30 cm and no lateralization Weber’s test result. Rinne’s test result for a
normal finding is that air conduction is better than bone conduction.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 24: Nursing Management: Visual and Auditory Problems
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is assessing a client in the outpatient eye clinic who has myopia and presbyopia.
Which of the following assessments should the nurse implement to evaluate the
effectiveness of the prescribed bifocals?
a. Strength of the eye muscles
b. Both near and distant vision
c. Cloudiness in the eye lenses
d. Intraocular pressure changes
ANS: B
The lenses are prescribed to correct the client’s near and distant vision. The nurse also may
assess for cloudiness of the lenses, increased intraocular pressure, and eye movement, but
these data will not evaluate whether the client’s bifocals are effective.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
2. A client is seen in the ophthalmology clinic and diagnosed with recurrent staphylococcal
and seborrheic blepharitis. Which of the following topics should the nurse include in the
teaching plan?
a. Saline irrigation of the eyes
b. Surgical removal of the lesion
c. Using baby shampoo to clean the lids
d. The use of cool compresses to the eyes
ANS: C
Baby shampoo is used to soften and remove crusts associated with blepharitis. The other
interventions are not used in treating this disorder.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
3. Which of the following actions should the nurse take when assisting a totally blind client
to walk to the bathroom?
a. Take the client by the arm and lead the client slowly to the bathroom.
b. Have the client place a hand on the nurse’s shoulder and guide the client.
c. Stay beside the client and describe any obstacles on the path to the bathroom.
d. Walk slightly ahead of the client and allow the client to hold the nurse’s elbow.
ANS: D
When using the sighted-guide technique, the nurse walks slightly in front and to the side of
the client and has the client hold the nurse’s elbow. The other techniques are not as safe in
assisting a blind client.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
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4. A client has been seen at a clinic for repeated hordeolum of the eyes during the last 6
months. Which of the following actions should the nurse recommend to the client to help
prevent further infection?
a. Apply cold compresses at the first sign of recurrence.
b. Discard all open or used cosmetics used near the eyes.
c. Wash the scalp and eyebrows with an anti-seborrheic shampoo.
d. Seek evaluation for the presence of sexually transmitted infections (STIs).
ANS: B
Hordeolum (stye) is commonly caused by Staphylococcus aureus, which may be present
in cosmetics that the client is using. Warm compresses are recommended to treat
hordeolum. Anti-seborrheic shampoos are recommended for seborrheic blepharitis. Clients
with adult inclusion conjunctivitis, which is caused by Chlamydia trachomatis, should be
referred for STD testing.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
5. Which of the following topics should the nurse plan to include when teaching the client
with herpes simplex keratitis of the left eye about management of the infection?
How to apply an occlusive dressing to the affected eye
Need for frequent handwashing and avoiding touching the eyes
Application of antibiotic drops to the left eye several times daily
Use of corticosteroid ophthalmic ointment to decrease inflammation
a.
b.
c.
d.
ANS: B
The best way to avoid the spread of infection from one eye to another is to avoid rubbing
or touching the eyes and to use careful handwashing when touching the eyes is
unavoidable. Occlusive dressings are not used for herpes keratitis. Herpes simplex is a
virus and antibiotic drops will not be prescribed. Topical corticosteroids typically are not
ordered because they can contribute to a longer course of infection and more
complications.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
6. The nurse is caring for a client in the eye clinic who has 20/200 vision with the use of
corrective lenses. Which of the following information should the nurse include when
providing client teaching?
a. How to use a cane safely
b. How to access audio books
c. Where Braille instruction is available
d. Where to obtain specialized magnifiers
ANS: D
Various types of magnifiers can enhance the remaining vision enough to allow the
performance of many tasks and activities of daily living (ADLs). Audio books, Braille
instruction, and canes usually are reserved for clients with no functional vision.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
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7. The nurse is caring for a client with adult inclusion conjunctivitis (AIC) caused by
Chlamydia trachomatis. Which of these actions should be included in the plan of care?
a. Discussing the need for sexually transmitted infection testing
b. Applying topical corticosteroids to prevent further inflammation
c. Assisting with applying for community visual rehabilitation services
d. Educating about the use of antiviral eye drops to treat the infection
ANS: A
Clients with AIC have a high risk for concurrent genital Chlamydia infection and should
be referred for STI testing. AIC is treated with antibiotics; antiviral and corticosteroid
medications are not appropriate therapies. Although some types of Chlamydia infection do
cause blindness, AIC does not lead to blindness, so referral for visual rehabilitation is not
appropriate.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
8. Which of the following topics will the nurse include in client teaching following outpatient
cataract surgery and lens implantation?
a. Use of oral opioids for pain control
b. Administration of antibiotic eye drops
c. Importance of coughing and deep-breathing exercises
d. Need for bed rest for the first 24 hours after the surgery
ANS: B
Antibiotic and corticosteroid eye drops are commonly prescribed after cataract surgery,
and the client should be able to administer them using safe technique. Pain is not expected
after cataract surgery and opioids will not be needed. Coughing and deep-breathing
exercises are not needed since a general anaesthetic agent is not used. There is no bed rest
restriction after cataract surgery.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
9. The nurse is reviewing a client’s medical record and notes that the last eye examination
revealed an intraocular pressure of 28 mm Hg. Which of the following parameters should
the nurse assess?
a. Visual acuity
b. Pupil reaction
c. Colour perception
d. Peripheral vision
ANS: D
The client’s increased intraocular pressure indicates glaucoma, which decreases peripheral
vision. Because central visual acuity is unchanged by glaucoma, assessment of visual
acuity could be normal even if the client has worsening glaucoma. Colour perception and
pupil reaction to light are not affected by glaucoma.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
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10. The nurse is caring for a client with a left retinal detachment who had a pneumatic
retinopexy procedure. Which of the following information should be included in the
discharge teaching plan?
a. The use of bilateral eye patches to reduce movement of the operative eye
b. The need to wear dark or tinted glasses to protect the eyes from bright light
c. The procedure for sterile dressing changes when the eye dressing is saturated
d. The purpose of maintaining the head in a prescribed position for several weeks
ANS: D
Following pneumatic retinopexy, the client will need to position the head so the air bubble
remains in contact with the retinal tear. The dark lenses and bilateral eye patches are not
required after this procedure. Saturation of any eye dressings would not be expected
following this procedure.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
11. The nurse is caring for a client with age-related macular degeneration who has just had
photodynamic therapy. Which of the following statements by the client indicates that the
discharge teaching has been effective?
a. “I will need to use bright lights to read for at least the next week.”
b. “I will use drops to keep my pupils dilated until my appointment.”
c. “I will not use facial lotions near my eyes during the recovery period.”
d. “I will keep covered with long-sleeved shirts and pants for the next 5 days.”
ANS: D
The photosensitizing drug used for photodynamic therapy is activated by exposure to
bright light and can cause burns in areas exposed to light for 5 days after the treatment.
There are no restrictions on use of facial lotions, medications to keep the pupils dilated
would not be appropriate, and bright lights would increase the risk for damage caused by
the treatment.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
12. The nurse is assessing a client with primary open-angle glaucoma (POAG) to evaluate if
the treatment has been effective. Which of the following parameters should the nurse
assess to determine if there has been improvement?
a. Eye pain
b. Visual field
c. Blurred vision
d. Depth perception
ANS: B
POAG develops slowly and without symptoms except for a gradual loss of visual field.
Acute closed-angle glaucoma may present with excruciating pain, coloured halos, and
blurred vision. Problems with depth perception are not associated with POAG.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
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13. A client with glaucoma who has been using timolol drops for several days tells the nurse
that the eye drops cause eye burning and visual blurriness for a short time after
administration. Which of the following responses by the nurse is most appropriate?
a. “These are normal adverse effects of the drug, which should become less
noticeable with time.”
b. “If you occlude the puncta after you administer the drops, it will help relieve these
adverse effects.”
c. “The drops are uncomfortable, but it is very important for you to use them as
prescribed to retain your vision.”
d. “These symptoms are caused by glaucoma and may indicate a need for an
increased dosage of the eye drops.”
ANS: C
Clients should be instructed that eye discomfort and visual blurring are expected adverse
effects of the ophthalmic drops but that the drops must be used to prevent further
visual-field loss. The temporary burning and visual blurriness might not lessen with
ongoing use, are not relieved by avoiding systemic absorption, and are not symptoms of
glaucoma.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
14. The nurse is admitting a client to the hospital with severe COPD and a history of glaucoma.
Which of the following prescribed medications should the nurse question?
Morphine sulphate 4 mg IV
Diazepam 5 mg IV
Betaxolol 0.25% eye drops
Levobunolol 0.5% eye drops
a.
b.
c.
d.
ANS: D
Levobunolol is a noncardioselective b2-blocker and is contraindicated for use in clients
with asthma or severe COPD. The other medications are appropriate for this client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
15. The nurse is caring for a client who has bacterial endophthalmitis in the left eye, is restless,
frequently asking whether the eye is healing and whether removal of the eye will be
necessary. Based on the assessment data, which of the following nursing diagnoses is
appropriate?
a. Hopelessness related to stressors (current loss of functional vision)
b. Anxiety related to threat to current status (uncertainty of outcome of treatment)
c. Situational low self-esteem related to decrease in control over environment (loss of
visual function)
d. Risk for falls as evidenced by impaired vision
ANS: B
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The client’s restlessness and questioning of the nurse indicate anxiety about the
uncertainty of the outcome of treatment, including the future possible loss of vision.
Because the client can see with the right eye, functional vision is relatively intact and the
client is not at a high risk for falls. There is no indication of impaired self-esteem at this
time.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Diagnosis
16. To decrease the risk for future hearing loss, which of the following actions should the
nurse working with college students at the on-campus health clinic implement?
Arrange to include otoscopic examinations for all clients.
Administer rubella immunizations to all students at the clinic.
Discuss the importance of limiting exposure to very high amplified music.
Teach clients to regularly irrigate the ear to decrease cerumen impaction.
a.
b.
c.
d.
ANS: C
The nurse should discuss the impact of amplified music on hearing with young adults and
discourage listening to very high amplified music (greater than 50% of maximum volume),
especially for prolonged periods. Cerumen may need to be regularly removed for older
clients, but this is not a routine need for younger adults. Only women of childbearing age
who have not been previously vaccinated or exposed to rubella will require immunization.
Otoscopic examinations are not necessary for all clients.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
17. A client with external otitis has an ear wick placed and a new prescription for antibiotic
otic drops. After the nurse provides client teaching, which of the following client
statements indicates that more instruction is needed?
a. “I may use aspirin or acetaminophen for pain relief.”
b. “I should apply the eardrops to the cotton wick in my ear canal.”
c. “I should clean my ear canal daily with a cotton-tipped applicator.”
d. “I may use warm compresses to the outside of my ear for comfort.”
ANS: C
Insertion of instruments such as cotton-tipped applicators into the ear should be avoided.
The other client statements indicate that the teaching has been successful.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
18. The nurse is preparing a client with chronic otitis media for a tympanoplasty. Which of the
following information should the nurse include in preoperative teaching related to
postoperative expectations?
a. Keeping the head elevated
b. The need for prolonged bed rest
c. Avoidance of coughing or blowing the nose
d. Continuous antibiotic irrigation of the ear canal
ANS: C
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Coughing or blowing the nose increases pressure in the Eustachian tube and middle ear
cavity and disrupts postoperative healing. There is no postoperative need for prolonged
bed rest, elevation of the head, or continuous antibiotic irrigation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
19. The nurse is assessing a client who has recently been treated with amoxicillin for acute
otitis media of the right ear. Which of the following assessment data obtained by the nurse
is of most concern?
a. The client has a temperature of 38.1°C (100.6°F).
b. The client complains of “popping” in the ear.
c. The client frequently asks the nurse to repeat information.
d. The client states that the right ear has a feeling of fullness.
ANS: A
The fever indicates that the infection may not be resolved and the client might need further
antibiotic therapy. A feeling of fullness, “popping” of the ear, and decreased hearing are
symptoms of otitis media with effusion. These symptoms are normal for weeks to months
after an episode of acute otitis media and usually resolve without treatment.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
20. The nurse is admitting a client with Ménière’s disease who has vertigo, nausea, and
vomiting. Which of the following nursing interventions should be included in the care
plan?
a. Keep the client’s room darkened.
b. Encourage oral fluids to 3 000 mL daily.
c. Change the client’s position every 2 hours.
d. Keep the head of the bed elevated 30 degrees.
ANS: A
A darkened, quiet room will decrease the symptoms of the acute attack of Ménière’s
disease. Since the client will be nauseated during an acute attack, fluids are administered
intravenously. Position changes will cause vertigo and nausea. The head of the bed can be
positioned for client comfort.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
21. The home health nurse observes a client taking these actions when self-administering
eardrops. Which of the following client actions indicates a need for more teaching?
a. The client leaves the ear wick in place while administering the drops.
b. The client lies down before and for 2 minutes after administering the drops.
c. The client gets the eardrops out of the refrigerator just before administering the
drops.
d. The client holds the tip of the dropper 1 cm above the ear while administering the
drops.
ANS: C
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Administration of cold eardrops can cause dizziness because of stimulation of the
semicircular canals. The other client actions are appropriate.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
22. The nurse is admitting an older-adult client and the client repeatedly asks the nurse to
“speak up so that I can hear you.” Which of the following actions should the nurse take?
a. Overenunciate while speaking.
b. Speak normally but more slowly.
c. Increase the volume when speaking.
d. Use more facial expressions when talking.
ANS: B
Client understanding of the nurse’s speech will be enhanced by speaking at a normal tone,
but more slowly. Increasing the volume, overenunciating, and exaggerating facial
expressions will not improve the client’s ability to comprehend the nurse.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
23. An older-adult client with presbycusis is fitted with binaural hearing aids. Which of the
following information should the nurse include when teaching the client how to use the
hearing aids?
a. Experiment with volume and hearing ability in a quiet environment initially.
b. Keep the volume low on the hearing aids for the first week while adjusting to
them.
c. Add the second hearing aid after making the initial adjustment to the first hearing
aid.
d. Wear the hearing aids for about an hour a day at first, gradually increasing the time
of use.
ANS: A
Initially the client should use the hearing aids in a quiet environment like the home,
experimenting with increasing and decreasing the volume as needed. There is no need to
gradually increase the time of wear. The client should experiment with the level of volume
to find what works well in various situations. Both hearing aids should be used.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
24. A client with hearing loss asks the nurse about the use of a cochlear implant. Which of the
following information will the nurse include when replying to the client?
a. Cochlear implants require training in order to receive the full benefit.
b. Cochlear implants are not useful for clients with congenital deafness.
c. Cochlear implants are most helpful as an early intervention for presbycusis.
d. Cochlear implants improve hearing in clients with conductive hearing loss.
ANS: A
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Extensive rehabilitation is required after cochlear implants in order for clients to receive
the maximum benefit. Hearing aids, rather than cochlear implants, are used initially for
presbycusis. Cochlear implants are used for sensorineural hearing loss and would not be
helpful for conductive loss. They are appropriate for some clients with congenital
deafness.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
25. Which of the following interventions should the nurse implement for a client who has just
been diagnosed with viral conjunctivitis?
a. Explain the purpose of antiviral eye drops.
b. Show how to perform eye irrigation safely.
c. Instruct about how to insert soft contact lenses.
d. Demonstrate appropriate handwashing technique.
ANS: D
Good hand hygiene is the major means to prevent the spread of conjunctivitis. Antiviral
drops and eye irrigation will not be helpful in shortening the disease process. Contact
lenses should not be used when clients have conjunctivitis because they can further irritate
the conjunctiva.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
26. Which of the following information should the nurse include when teaching a client with
keratitis caused by herpes simplex type 1?
a. Application of corticosteroid ophthalmic ointment to the eyes
b. Application of povidone-iodine gel around the eye
c. Avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs)
d. Importance of taking all of the ordered oral acyclovir
ANS: D
Oral acyclovir may be ordered for herpes simplex infections. Corticosteroid ointments are
usually contraindicated because they prolong the course of the infection. Although
povidone-iodine gel may be applied to the skin around the eyes for herpes zoster (varicella)
infections, it is not used for herpes simplex infections. NSAIDs can be used to treat the
pain associated with keratitis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
27. The nurse is admitting a client to the outpatient surgery unit who is scheduled for cataract
extraction and implantation of an intraocular lens. Which of the following information has
the most immediate implications for the client’s care?
a. The client has not eaten anything for 8 hours.
b. The client takes three antihypertensive medications.
c. The client gets nauseated with general anaesthesia.
d. The client has had blurred vision for several years.
ANS: B
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Mydriatic medications used for pupil dilation are sympathetic nervous system stimulants
and may increase heart rate and blood pressure. Using punctal occlusion when
administering the mydriatic to minimize systemic effects and monitoring of blood pressure
are indicated for this client. Clients are expected to be NPO for 6–8 hours before the
surgical procedure. Blurred vision is an expected finding with cataracts. Cataract
extraction and intraocular lens implantation are done using local anaesthesia.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
28. The nurse is caring for a client with neural presbycusis. Which of the following hearing
changes should the nurse expect with this type of presbycusis?
a. Loss of high-pitched sounds
b. Loss of speech discrimination
c. Uniform loss for all frequencies
d. Range of hearing loss with low frequencies
ANS: B
The hearing change with a neural presbycusis is a loss of speech discrimination. Loss of
high-pitched sounds accompanies a sensory presbycusis. A metabolic presbycusis has a
hearing change that is uniform for all frequencies, accompanied by recruitment. A
cochlear presbycusis has a hearing change that is a range of hearing loss that increases
from low to high frequencies.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
29. The nurse is admitting a client for surgery who has functional blindness for several years
and is cared for by the client’s spouse. Which of the following actions is most important to
implement during the initial assessment?
a. Obtain more information about the cause of the client’s vision loss.
b. Obtain information from the spouse about the client’s special needs.
c. Make eye contact with the client and ask about any need for assistance.
d. Perform an evaluation of the client’s visual acuity using a Snellen chart.
ANS: C
Making eye contact with a partially sighted client allows the client to hear the nurse more
easily and allows the nurse to assess the client’s facial expressions. The client (rather than
the spouse) should be asked about any need for assistance. The information about the
cause of the vision loss and assessment of the client’s visual acuity are not priorities
during the initial assessment.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
30. Which of the following actions is an example of an approach magnification?
a. Using a telescopic lens
b. Sitting closer to a television while watching it
c. Using a black-tipped felt marker when writing
d. Reading books with large-type print
ANS: B
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Approach magnification is a simple but sometimes overlooked technique for enhancing
the client's residual vision. The nurse can recommend that the client sit closer to the
television or hold books closer to the eyes, which the client may be reluctant to do unless
encouraged. Using a telescopic lens is an optical device. Using a black-tipped marker to
write is a contrast enhancement technique. Reading large-type print books may be helpful
but is not an approach magnification action unless the book was brought close to the eyes,
which is not indicated in the answer choice.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
31. The camp nurse is caring for a client who is complaining of bilateral eye pain after a
campfire log exploded, sending sparks into the client’s eyes. Which of the following
actions should the nurse take first?
a. Apply ice packs to the eyes.
b. Flush the eyes with sterile saline.
c. Cover the eyes with dry sterile patches and protective eye shields.
d. Apply antiseptic ophthalmic ointment from the first-aid kit to the eyes.
ANS: C
Emergency treatment of a burn or foreign-body injury to the eyes includes protecting the
eyes from further injury by covering them with dry sterile dressings and protective shields.
Flushing of the eyes immediately is indicated only for chemical exposure. Except in the
case of chemical exposure, the nurse should not begin treatment until the client has been
assessed by a health care provider and orders are available.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
32. The nurse is caring for a client with an acute attack of Ménière’s disease. Which of the
following actions carried out by a family member that is visiting the client should the
nurse intervene?
a. Raises the side rails on the bed
b. Turns on the client’s television
c. Turns the client to the right side
d. Places an emesis basin at the bedside
ANS: B
Watching television may exacerbate the symptoms of an acute attack of Ménière’s disease.
The other actions are appropriate.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
33. A client who had cataract extraction and intraocular lens implantation the previous day
calls the eye clinic and gives the nurse all of this information. Which of the following
information is the priority to communicate to the health care provider?
a. The client has eye pain rated at a 5 (on a 0–10 scale).
b. The client has questions about the ordered eye drops.
c. The client has poor depth perception when wearing an eye patch.
d. The client complains that the vision has “not improved very much.”
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ANS: A
Postoperative cataract surgery clients usually experience little or no pain, so pain at a 5 on
a 10-point pain level may indicate complications such as hemorrhage, infection, or
increased intraocular pressure. The other information given by the client indicates a need
for client teaching but does not indicate that complications of the surgery may be
occurring.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
34. Which of the following assessment findings in a client who was struck in the right eye
with a baseball is a priority for the nurse to communicate to the health care provider in the
emergency department?
a. The client complains of a right-sided headache.
b. The sclerae on the right eye have broken blood vessels.
c. The area around the right eye is bruised and tender to the touch.
d. The client complains of “a curtain” blocking part of the visual field.
ANS: D
The client’s sensation that a curtain is coming across the field of vision suggests retinal
detachment and the need for rapid action to prevent blindness. The other findings would
be expected with the client’s history of being hit in the eye with a ball.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
35. The charge nurse observes a newly hired nurse caring for a client who has just arrived in
the postanaesthesia care unit after having right cataract removal and an intraocular lens
implant. Which of the following interventions requires that the charge nurse intervene?
a. The nurse leaves the eye shield in place.
b. The nurse encourages the client to cough.
c. The nurse elevates the client’s head to 45 degrees.
d. The nurse applies corticosteroid drops to the right eye.
ANS: B
Because coughing will increase intraocular pressure, clients are generally taught to avoid
coughing during the acute postoperative time. The other actions are appropriate for a client
after having this surgery.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
36. The nurse is assessing the presence or absence of contact lenses in an unconscious client.
Which of the following directions should the nurse shine a pen light?
a. Parallel to the eye
b. At a 90-degree angle to the eye
c. Obliquely into the eye
d. Toward the centre of the nasal bridge
ANS: C
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The nurse must know whether the client has contact lenses in and assesses the eye by
shining a light obliquely on the eyeball to help the nurse visualize a contact lens.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
37. The nurse is admitting a client with a head injury after a motor vehicle accident who has
shortness of breath and severe eye pain. Which of the following actions should the nurse
take first?
a. Elevate the head to 45 degrees.
b. Administer the ordered analgesic.
c. Check the client’s oxygen saturation.
d. Examine the eye for evidence of trauma.
ANS: C
The priority action for a client after a head injury is to assess and maintain airway and
breathing. Because the client is complaining of shortness of breath, it is essential that the
nurse assess the oxygen saturation. The other actions also are appropriate but are not the
first action the nurse will take.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
38. These medications are prescribed by the health care provider for a client who has just been
admitted to hospital with acute angle-closure glaucoma. Which of the following
medications should the nurse give first?
a. Morphine sulphate 4 mg intravenously
b. Betaxolol 1 drop in each eye
c. Acetazolamide 250 mg orally
d. Mannitol 100 mg intravenously
ANS: D
The most immediate concern for the client is to lower intraocular pressure, which will
occur most rapidly with IV administration of a hyperosmolar diuretic such as mannitol.
The other medications also are appropriate for a client with glaucoma but would not be the
first medication administered.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
39. Which of the following nursing diagnoses is priority when caring for a client who is
experiencing an acute attack of Ménière’s disease?
a. Risk for falls as evidenced by impaired balance
b. Impaired verbal communication related to vulnerability (tinnitus)
c. Bathing self-care deficit related to weakness (vertigo)
d. Imbalanced nutrition: less than body requirements related to insufficient dietary
intake (nausea)
ANS: A
All the nursing diagnoses are appropriate, but because sudden acute attacks of vertigo, the
major focus of nursing care is to prevent injuries associated with impaired balance.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Diagnosis
40. The nurse is caring for a client who had a stapedotomy yesterday. Which of the following
findings is most important for the nurse to communicate to the health care provider?
a. The client complains of “congestion” in the ear.
b. The client’s oral temperature is 38.1°C (100.6°F).
c. The client says “My hearing is worse now than it was right after surgery.”
d. There is a small amount of dried bloody drainage on the client’s dressing.
ANS: B
An elevated temperature following any surgery may indicate a postoperative infection.
Although the nurse would report all the data, a temporary decrease in hearing, bloody
drainage on the dressing, and a feeling of congestion because of the accumulation of blood
and drainage in the ear are common after this surgery.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
MULTIPLE RESPONSE
1. The nurse is caring for a client with chronic otitis media. Which of the following findings
should the nurse expect to assess? (Select all that apply.)
a. Pinked-tinged exudate
b. Pain
c. Nausea
d. Dizziness
e. Hearing loss
ANS: C, D, E
Chronic otitis media is characterized by a purulent exudate and inflammation that can
involve the ossicles, Eustachian tube, and mastoid bone. It is often painless and may be
accompanied by hearing loss, nausea, and episodes of dizziness. Hearing loss is a
complication from inflammatory destruction of the ossicles, a TM perforation, or
accumulation of fluid in the middle ear space.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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Chapter 25: Nursing Assessment: Integumentary System
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. Which assessment information documented in a client’s chart indicates that the nurse
may need to continue to monitor the skin condition of an 82-year-old client admitted
with bacterial pneumonia?
a. “Scattered macular brown areas on extremities”
b. “Skin brown and wrinkled, skin tenting on forearm”
c. “Longitudinal nail bed ridges noted, sparse scalp hair”
d. “Skin moist and intact, states history of allergic rashes”
ANS: D
Because the client will be receiving antibiotics, the nurse should monitor the client for
the presence of an allergic rash. The assessment data in the other response would be
normal for an elderly client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. The nurse is caring for a client who has a circular, flat, reddened lesion about 5 cm in
diameter on his ankle. Which of the following actions would the nurse implement to
determine whether the lesion is related to blood vessel dilation?
a. Elevate the client’s leg
b. Press firmly on the lesion
c. Check the temperature of the skin around the lesion
d. Palpate the dorsalis pedis and posterior tibial pulses
ANS: B
If the lesion is caused by blood vessel dilation, blanching will occur with direct pressure.
The other assessments will assess circulation to the leg, but will not be helpful in
determining the etiology of the lesion.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
3. The nurse is preparing for a teaching session with older-adult clients. Which of the
following changes is an age-related change in the hair?
a. Increased melanocytes
b. Decreased oils
c. Increased density
d. Increased estrogen
ANS: B
Age-related changes to the hair include decreased oils, density, estrogen, and
melanocytes.
DIF:
Cognitive Level: Application
TOP: Nursing Process: Implementation
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MSC: NCLEX: Health Promotion and Maintenance
4. The nurse is caring for a client who is dark-skinned and has been admitted to the hospital
in severe respiratory distress. Which of the following actions should the nurse implement
to determine whether the client is cyanotic?
a. Assess the skin colour of the earlobes.
b. Apply pressure to the palms of the hands.
c. Check the lips and oral mucous membranes.
d. Examine capillary refill time of the nail beds.
ANS: C
Cyanosis in dark-skinned individuals is more easily seen in the mucous membranes.
Earlobe colour may change in light-skinned individuals, but this change in skin colour is
difficult to detect on darker skin. Application of pressure to the palms of the hands and
nail bed assessment would check for adequate circulation, but not for skin colour.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
5. A client asks the nurse why a potassium hydroxide test needs to be done. The nurse’s
response is based upon the knowledge that which of the following is the purpose of this
test?
a. Examine a lesion via a biopsy.
b. Obtain fluids from vesicles for assessment.
c. Assess for fungal infection.
d. Scrap exudate from a lesion for microscopic examination.
ANS: C
A potassium hydroxide test is done to examine hair, nails, or scales for superficial fungal
infection. Scraping exudate from a lesion for examination is used with mineral oil slides.
A Tzanck test is used when fluid is obtained from vesicles for assessment.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
6. The nurse is caring for a client who has several angiomas on their legs. Which of the
following actions should the nurse take next?
a. Assess the client for evidence of liver disease.
b. Discuss the adverse effects of sun exposure on the skin.
c. Educate the client about possible skin changes with aging.
d. Suggest that the client make an appointment with a dermatologist.
ANS: A
Angiomas are a common occurrence as client’s age, but they may occur with systemic
problems such as liver disease. The client may want to see a dermatologist to have the
angiomas removed, but this is not the initial action by the nurse. The nurse may need to
educate the client about the effects of aging on the skin and about the effects of sun
exposure, but the initial action should be further assessment.
DIF:
Cognitive Level: Application
TOP: Nursing Process: Implementation
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MSC: NCLEX: Health Promotion and Maintenance
7. The nurse is caring for a client in the dermatology clinic who is scheduled for removal of
a 15-mm multicoloured and irregular mole from the upper back. Which of the following
biopsies would the nurse teach to this client?
a. Shave
b. Punch
c. Incisional
d. Excisional
ANS: C
An incisional biopsy would remove the entire mole and the tissue borders. The
appearance of the mole indicates that it may be malignant; a shave biopsy would not
remove the entire mole. The mole is too large to be removed with punch biopsy.
Excisional biopsies are done for smaller lesions and where a good cosmetic effect is
desired, such as on the face.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
8. The nurse is conducting an assessment of the client’s skin and observes a ring of small,
raised, discrete lesions filled with serous fluid on the client’s right temple. Which of the
following descriptions would the nurse use when documenting the lesions?
a. Grouped
b. Confluent
c. Zosteriform
d. Generalized
ANS: A
The description of the lesions indicates that they are grouped. The other terms are
inconsistent with the description of the lesions.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
9. The nurse is caring for a client who reports chronic itching of the ankles and cannot keep
from continuously scratching them. The nurse will plan to implement interventions to
decrease the risk for which of the following conditions?
a. Skin atrophy
b. Lichenification
c. Skin varicosity
d. Keloid formation
ANS: B
Lichenification is likely to occur in areas where the client scratches the skin frequently.
Scratching is not a risk factor for skin atrophy, keloid formation, and varicosities.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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10. The nurse is admitted an older-adult client to an assisted-living facility and notes
abnormalities on the skin. Which of the following abnormalities is the priority to discuss
immediately with the health care provider?
a. Several dry, scaly patches on the face
b. Numerous varicosities noted on both legs
c. Dilation of small blood vessels on the face
d. Petechiae present on the chest and abdomen
ANS: D
Petechiae are caused by pinpoint hemorrhages and are associated with inflammation,
marked dilation, blood vessel trauma, and blood dyscrasia that results in bleeding
tendencies (e.g., thrombo-cytopenia). The nurse should contact the client’s health care
provider about this finding for further diagnostic follow-up. The other skin changes are
associated with aging. Although the other changes also will require ongoing monitoring
or intervention by the nurse, they do not indicate a need for urgent action.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
MULTIPLE RESPONSE
1. The nurse is conducting a health history with a client and the nurse discovers that the
client works as a roofer. The nurse will plan to teach the client about how to self-assess
for clinical manifestations of which of the following integument conditions? (Select all
that apply.)
a. Alopecia
b. Intertrigo
c. Wrinkling
d. Erythema
e. Actinic keratosis
ANS: C, D, E
A client who works as a roofer is at risk for integumentary lesions caused by sun
exposure such as wrinkling, erythema, and actinic keratoses. Alopecia and intertrigo are
not associated with excessive sun exposure.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
2. The nurse is conducting a health assessment on an older-adult client and is assessing the
client’s nails. Which of the following assessments are age-related changes? (Select all
that apply.)
a. Longitudinal ridging
b. Decreased keratin
c. Decreased circulation
d. Thick, brittle nails
e. Increased peripheral blood supply
ANS: A, C, D
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Age-related changes to the nails include a decreased peripheral blood supply and
circulation, increased keratin, thick, brittle nails, longitudinal ridging and a prolonged
return of blood to nails on blanching.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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Chapter 26: Nursing Management: Integumentary Problems
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. To decrease the risk for sun damage to the skin, which information should the nurse
include when teaching clients?
a. Waterproof sunscreens will provide good protection when swimming.
b. Use a sunscreen with an SPF of at least 8–10 for adequate protection.
c. Try to stay out of the sun between the hours of 1 000 and 1 600.
d. Increase sun exposure by no more than 10 minutes a day to avoid skin damage.
ANS: C
The risk for skin damage from the sun is highest with exposure between 1 000 and 1 500
during regular time and 1 100–1 600 during daylight savings time. The term waterproof
is misleading; no sunscreen is completely waterproof. Sunscreen with an SPF of at least
15 is recommended for people at normal risk for skin cancer. Although gradually
increasing sun exposure may decrease the risk for burning, the risk for skin cancer is not
decreased.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
2. The nurse is caring for a client with a urinary tract infection and has been prescribed
ciprofloxacin. Which of the following information should the nurse include when
teaching this client?
a. Use a sunscreen with a high SPF when exposed to the sun.
b. Sun exposure may decrease the effectiveness of the medication.
c. Photosensitivity may result in an artificial-looking tan appearance.
d. Wear sunglasses to avoid eye damage while taking ciprofloxacin.
ANS: A
The client should wear sunscreen when taking medications that can cause
photosensitivity. The other statements are not accurate.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
3. The nurse is caring for a client who has basal cell carcinoma (BCC) of the face. Which
of the following information should the nurse include when teaching this client?
a. Treatment plans include watchful waiting.
b. Screening for metastasis will be important.
c. Low-dose systemic chemotherapy is used to treat BCC.
d. Minimizing sun exposure will reduce risk for future BCC.
ANS: D
BCC is frequently associated with sun exposure. BCC spread locally, but do not
metastasize to distant tissues. Since BCC can cause local tissue destruction, treatment is
indicated. Local chemotherapy may be used to treat BCC.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
4. The nurse is caring for a client in the dermatology clinic who has a small, slow-growing
papule with ulceration and a depression in the centre of the lesion on the right cheek.
Which of the following nursing interventions will the nurse anticipate performing for
this client?
a. Prepare the client for a biopsy.
b. Teach about the use of corticosteroid creams.
c. Educate the client about use of tretinoin (Retin-A).
d. Discuss the need for topical application of antibiotics.
ANS: A
Because the appearance of the lesion is consistent with a possible basal cell carcinoma
(BCC), the appropriate treatment would be excision and biopsy. Over-the-counter (OTC)
corticosteroids, topical antibiotics, and Retin-A would not be used for this lesion unless
the biopsy indicated that the lesion was nonmalignant.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
5. After the nurse determines that a client has the following risk factors for melanoma,
which risk factor should be the focus of client teaching related to prevention?
a. The client has multiple dysplastic nevi.
b. The client is fair-skinned and has blue eyes.
c. The client’s mother died of a malignant melanoma.
d. The client uses a tanning booth throughout the winter.
ANS: D
Since the only risk factor that the client can change is the use of a tanning booth, the
nurse should focus teaching about melanoma prevention on this factor. The other factors
also will contribute to increased risk.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
6. The health care provider diagnoses impetigo for a client who has crusty vesicopustular
lesions on the lower face. Which of the following topics would the nurse include in the
teaching plan for this client?
a. Avoidance of antibiotic ointments on the lesions
b. How to clean the infected areas with soap and water
c. Use of petroleum jelly (Vaseline) to soften crusty areas
d. Appropriate use of alcohol-based cleansers on the lesions
ANS: B
The treatment for impetigo includes softening of the crusts with warm saline soaks and
then soap-and-water removal. Alcohol-based cleansers and use of petroleum jelly are not
recommended for impetigo. Antibiotic ointments may be applied to the lesions.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
7. The nurse is teaching the client how to use wet compresses at home for treatment of
poison ivy. Which of the following instructions would the nurse include in the teaching
plan?
a. Use only sterile water as the solution for the dressing.
b. The material for the compress is to be 4–8 layers thick.
c. The compress should meet the edge of the area that is to be treated.
d. Use abdominal pads (gauze sponges) when covering odd-shaped body parts.
ANS: B
The material for wet compresses should be 4–8 layers thick and slightly larger than the
area that is being treated. Abdominal pads are to be avoided as they hold too much fluid
as well as fibres may be left in the wound if the skin is not intact. It is not necessary to
use sterile water; tap water at room temperature is acceptable.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
8. The nurse is assessing a client’s scalp and suspects the presence of pediculosis when
which of the following assessment findings are observed?
a. Ringlike rashes with red, scaly borders over the entire scalp
b. Papular, wheal-like lesions with white deposits on the hair shaft
c. Patchy areas of alopecia with small vesicles and excoriated areas
d. Red, hive-like papules and plaques with sharply circumscribed borders
ANS: B
Pediculosis is characterized by wheal-like lesions with parasites that attach eggs to the
base of the hair shaft. The other descriptions are more characteristic of other types of
skin disorders.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
9. The health care provider prescribes topical 5-fluorouracil (5-FU) for a client with actinic
keratosis on the nose. Which of the following information would the nurse include in the
client teaching plan?
a. You may develop nausea and anorexia, but good nutrition is important during
treatment.
b. You will need to avoid crowds because of the risk for infection caused by
chemotherapy.
c. The nose will develop painful, eroded areas that will take weeks before completely
healing.
d. 5-FU is needed to shrink the lesion so that less scarring occurs once the lesion is
excised.
ANS: C
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Topical 5-FU causes an initial reaction of erythema, itching, and erosion, which lasts 4
weeks after application of the medication is stopped. The medication is topical, so there
are no systemic effects such as increased infection risk, anorexia, or nausea. Actinic
keratosis is not usually treated with excision.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
10. A client with atopic dermatitis has been using a high-potency topical corticosteroid
ointment for several weeks. Which of the findings by the nurse indicates a possible
adverse effect of the medication?
a. Thinning of the affected skin
b. Alopecia of the affected areas
c. Reddish-brown discoloration of the skin
d. Dryness and scaling in the areas of treatment
ANS: A
Thinning of the skin indicates that atrophy, a possible adverse effect of topical
corticosteroids, is occurring. The health care provider should be notified so that the
medication can be changed or tapered. Alopecia, red-brown discoloration, and dryness
or scaling of the skin are not adverse effects of topical corticosteroid use.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
11. The nurse is caring for a client who is undergoing psoralen plus ultraviolet A light
(PUVA) therapy for treatment of psoriasis. Which of the following actions would the
nurse plan to implement to minimize complications from this procedure?
a. Cleanse the skin carefully with an antiseptic soap.
b. Shield any unaffected areas with lead-lined drapes.
c. Have the client use protective eyewear while receiving PUVA.
d. Apply petroleum jelly to the areas surrounding the psoriatic lesions.
ANS: C
The eyes should be shielded from UV light (UVL) during and after PUVA therapy to
prevent the development of cataracts. The client should be taught about the effects of
UVL on unaffected skin, but lead-lined drapes, use of antiseptic soap, and petroleum
jelly are not used to prevent skin damage.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
12. A client with an enlarging, irregular mole that is 6 mm in diameter is scheduled for
outpatient treatment. Which of the following procedures would the nurse include in the
teaching plan for this client?
a. Curettage
b. Cryosurgery
c. Punch biopsy
d. Surgical excision
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ANS: D
The description of the mole is consistent with malignancy, so excision and biopsy are
indicated. Curettage and cryosurgery are not used if malignancy is suspected. A punch
biopsy would not be done for a lesion greater than 5 mm in diameter.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
13. Which of the following information would the nurse include when teaching an
older-adult client about skin care?
a. Dry the skin thoroughly before applying lotions.
b. Bathe and shampoo daily with soap and shampoo.
c. Use warm water and a moisturizing soap when bathing.
d. Use antibacterial soaps when bathing to avoid infection.
ANS: C
Warm water and moisturizing soap will avoid overdrying of the skin. Since older clients
have dryer skin, daily bathing and shampooing are not necessary and may dry the skin
unnecessarily. Antibacterial soaps are not necessary. Lotions should be applied while the
skin is still damp to seal moisture in.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
14. Which of the following actions would the nurse take when applying a wet dressing to an
inflamed and pruritic area of skin on a client’s ankle?
a. Use a cool solution to wet the dressing.
b. Change the dressing using sterile gloves.
c. Soak the dressing in sterile normal saline.
d. Apply the dressing from the knee to the foot.
ANS: A
Cool solutions are used when wet dressings are applied to inflamed areas. Wet dressings
do not require sterile technique; tap water is the most common solution used. To avoid
maceration of healthy skin, wet dressings should only be applied over the affected area.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
15. The nurse is caring for a client who has just received a diagnosis of a fungal infection
and the client asks the nurse how this will be treated. The nurses’ response is based upon
knowledge that which of the following bases is the most common for antifungal
treatment?
a. Gel
b. Paste
c. Lotion
d. Powder
ANS: D
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Powder is the most common base for antifungal preparations. Gels are used for acute
exudative inflammation. The paste is used when a drying effect is necessary because
moisture is absorbed. A lotion is useful in treating subacute pruritic eruptions.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
16. The nurse notes darker skin pigmentation in the skin folds of a client who has a body
mass index of 40 kg/m2. Which of the following topics would the nurse include in client
teaching?
a. Teach the client about the risk for type 2 diabetes.
b. Educate the client about treatment of fungal infection.
c. Discuss the use of drying agents to minimize infection risk.
d. Instruct the client about use of mild soap to clean skin folds.
ANS: A
Obesity and the presence of acanthosis nigricans in skin folds suggest an increased risk
for type 2 diabetes. The description of the client’s skin does not indicate problems with
fungal infection, poor hygiene, or the need to dry the skin folds better.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
17. The nurse is assessing a new client at the outpatient clinic and notes dry, scaly skin; thin
hair; and thick, brittle nails. Which of the following actions is best for the nurse to take
at this time?
a. Instruct the client about the importance of nutrition in skin heath.
b. Make a referral to a podiatrist so that the nails can be safely trimmed.
c. Consult with the health care provider about the need for further diagnostic testing.
d. Teach the client about using moisturizing creams and lotions to decrease dry skin.
ANS: C
The client has clinical manifestations that could be caused by systemic problems or
interferences with nutrition (e.g., protein deficiency) so further diagnostic evaluation is
indicated. Client teaching about nutrition, addressing the client’s dry skin, and referral to
a podiatrist also may be needed, but the priority is to rule out underlying disease that
may be causing these manifestations.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
18. The nurse is providing care to a client with a squamous cell carcinoma (SCC) that had a
Mohs procedure in the dermatology clinic. Which of the following nursing actions
would be included in the postoperative plan of care?
a. Describe the use of topical fluorouracil on the incision.
b. Teach how to use sterile technique to clean the suture line.
c. Schedule daily appointments for wet-to-dry dressing changes.
d. Educate about use of cold packs to reduce bruising and swelling.
ANS: D
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Application of cold packs to the incision after the surgery will help decrease bruising
and swelling at the site. Since the Mohs procedure results in complete excision of the
lesion, topical fluorouracil is not needed after surgery. The suture line is cleaned with tap
water. No debridement with wet-to-dry dressings is indicated.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
19. A client with atopic dermatitis has a new prescription for tacrolimus. After teaching the
client about the medication, which statement by the client indicates that further teaching
is needed?
a. “After I apply the medication, I can go ahead and get dressed as usual.”
b. “I will rub the medication gently onto the skin every morning and night.”
c. “I will need to minimize my time in the sun while I am using the tacrolimus.”
d. “If the medication burns when I apply it, I will wipe it off and call the doctor.”
ANS: D
The client should be taught that transient burning at the application site is an expected
effect of tacrolimus and that the medication should be left in place. The other statements
by the client are accurate and indicate that client teaching has been effective.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
20. After the nurse has finished teaching a client about application of corticosteroid cream to
an area of contact dermatitis on the right leg, which of the following client actions
indicates that more teaching is needed?
a. The client spreads the cream using a downward motion.
b. The client takes a tepid bath before applying the cream.
c. The client applies a thick layer of the cream to the affected skin.
d. The client covers the area with a dressing after applying the cream.
ANS: C
Creams and ointments should be applied in a thin layer to avoid wasting the medication.
The other actions by the client indicate that the teaching has been successful.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
21. The nurse is teaching a client about the use of a wet dressing to reduce pruritus. Which
of the following time frames would the nurse instruct the client to leave the dressing on
for?
a. 5–15 minutes
b. 10–30 minutes
c. 30–45 minutes
d. 45–60 minutes
ANS: B
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Wet dressings can be used effectively to relieve pruritus. Thin cotton sheets or thermal
underwear is placed in warm water, wrung out, and placed over the pruritic area. After
10–30 minutes, the dressing is removed and the skin is patted dry (not rubbed) and a
lubricant or medication applied. This can be done two to four times per day.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
22. The nurse is assessing a client who has just arrived in the postanaesthesia recovery area
(PACU) after a blepharoplasty. Which of the following assessment data is a priority?
a. The client complains of incisional pain.
b. The client’s heart rate is 110 beats/minute.
c. The client is unable to detect when the eyelids are touched.
d. The skin around the incision is pale and cold when palpated.
ANS: D
Pale, cool skin indicates a possible decrease in circulation, so the surgeon should be
notified immediately. Warm, pink skin that blanches with pressure indicates that
adequate circulation is present in the surgical area. The other assessment data indicate a
need for ongoing assessment or nursing action. A heart rate of 110 may be related to the
stress associated with surgery; assessment of other vital signs and continued monitoring
are appropriate. Because local anaesthesia would be used for the procedure, numbness of
the incisional area is expected immediately after surgery. The nurse should monitor for
return of feeling.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
23. A client who has severe refractory psoriasis on the face, neck, and extremities has quit
working and withdrawn from social activities because of the appearance of the lesions.
Which of the following actions should the nurse take first?
a. Discuss the possibility of enrolling in a worker-retraining program.
b. Encourage the client to volunteer to work on community projects.
c. Suggest that the client use cosmetics to cover the psoriatic lesions.
d. Ask the client to describe the impact of psoriasis on quality of life.
ANS: D
The nurse’s initial actions should be to assess the impact of the disease on the client’s
life and to allow the client to verbalize feelings about the psoriasis. Depending on the
assessment findings, other actions may be appropriate.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
MULTIPLE RESPONSE
1. The nurse is teaching a client with contact dermatitis of the arms and lower legs about
ways to decrease pruritus. Which of the following information would the nurse include
in the teaching plan? (Select all that apply.)
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a.
b.
c.
d.
e.
Cool, wet cloths or dressings can be used to reduce itching.
Take cool or tepid baths several times daily to decrease itching.
Add oil to your bath water to aid in moisturizing the affected skin.
Rub yourself dry with a towel after bathing to prevent skin maceration.
Use of an over-the-counter (OTC) antihistamine with sedative effects can reduce
scratching.
ANS: A, B, E
Cool or tepid baths, cool dressings, and OTC antihistamines all help reduce pruritus and
scratching. Adding oil to bath water is not recommended because of the increased risk
for falls. The client should use the towel to pat (not rub) the skin dry.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 27: Nursing Management: Burns
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is assessing a client who spilled hot oil on the right leg and foot and notes that
the skin is red, swollen, and covered with large blisters. The client states that they are very
painful. Which of the following burn descriptions should the nurse document?
a. Full-thickness skin destruction
b. Deep full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction
ANS: C
The erythema, swelling, and blisters point to a deep partial-thickness burn. With
full-thickness skin destruction, the appearance is pale and dry or leathery and the area is
painless because of the associated nerve destruction. With superficial partial-thickness
burns, the area is red, but no blisters are present.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. The nurse is admitting a client to the burn unit who has an approximate 25% total body
surface area (TBSA) burn and the following initial laboratory results: Hct 56%, Hb 172
g/L, serum K+ 4.8 mmol/L, and serum Na+ 135 mmol/L. Which of the following actions
should the nurse anticipate implementing?
a. Continue to monitor the laboratory results.
b. Increase the rate of the ordered IV solution.
c. Type and crossmatch for a blood transfusion.
d. Document the findings in the client’s record.
ANS: B
The client’s laboratory data show hemoconcentration, which may lead to a decrease in
blood flow to the microcirculation unless fluid intake is increased. Documentation and
continuing to monitor are inadequate responses to the data. Since the hematocrit and
hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be
needed after the emergent phase.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
3. The nurse is admitting a client to the burn unit who has burns to the upper body and head
after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are
decreased and no wheezes are audible. Which of the following actions should the nurse
implement first?
a. Encourage the client to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal intubation.
c. Document the results and continue to monitor the client's respiratory rate.
d. Reposition the client in high-Fowler’s position and reassess breath sounds.
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ANS: B
The client’s history and clinical manifestations suggest airway edema and the health care
provider should immediately be notified so that intubation can rapidly be done. Placing the
client in a more upright position or having the client cough will not address the problem of
airway edema. Continuing to monitor is inappropriate because immediate action should
occur.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
4. The nurse is caring for a client with severe burns who is receiving crystalloid fluid
replacement IV, ordered using the Parkland formula. The initial volume of fluid to be
administered in the first 24 hours is 30 000 mL. The initial rate of administration is 1 875
mL/hour. Which of the following infusion rates is accurate after the first 8 hours?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1 250 mL/hour
ANS: C
Half of the fluid replacement using the Parkland formula is administered in the first 8
hours and the other half over the next 16 hours (25% per each 8 hour period, respectively).
In this case, the client should receive half of the initial rate, or 938 mL/hour.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
5. The nurse is caring for a client who is in the emergent phase of burn care. Which of the
following nursing actions will be most useful in determining whether the client is
receiving adequate fluid infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output.
ANS: D
When fluid intake is adequate, the urine output will be at least 0.5–1 mL/kg/hour. The
client’s weight is not useful in this situation because of the effects of third spacing and
evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used,
but they are not as adequate in determining that fluid infusions are maintaining adequate
perfusion.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
6. The nurse is caring for a client who has just been admitted with a 40% total body surface
area (TBSA) burn injury. Which of the following interventions should the nurse include in
the plan of care to maintain adequate nutrition?
a. Insert a feeding tube and initiate enteral feedings.
b. Infuse total parenteral nutrition via a central catheter.
c. Encourage an oral intake of at least 5 000 kcal/day.
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d. Administer multiple vitamins and minerals in the IV solution.
ANS: A
Enteral feedings can usually be initiated during the emergent phase at low rates and
increased over 24–48 hours to the goal rate. During the emergent phase, the client will be
unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that
prevents adequate nutrient absorption. Vitamins and minerals may be administered during
the emergent phase, but these will not assist in meeting the client’s caloric needs.
Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal
function, and is not routinely used in burn clients.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
7. The nurse is caring for a client who has deep partial-thickness and full-thickness burns of
the face and chest and is having the wounds treated with the open method. Which of the
following nursing actions should be included in the plan of care?
a. Restrict all visitors to prevent cross-contamination of wounds.
b. Wear gowns, caps, masks, and gloves during all care of the client.
c. Turn the room temperature up to at least 20°C (68°F) during dressing changes.
d. Administer prophylactic antibiotics to prevent bacterial colonization of wounds.
ANS: B
Use of gowns, caps, masks, and gloves during all client care will decrease the possibility
of wound contamination for a client whose burns are not covered. Restricting all visitors is
not necessary and will have adverse psychosocial consequences for the client. The room
temperature should be kept at approximately 30°C (86°F) for clients with open burn
wounds. Systemic antibiotics are not well absorbed into deep burns because of the lack of
circulation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
8. Which of the following actions should be included in the plan of care for a client who has
burns of the ears, head, neck, and right arm and hand?
a. Place the right arm and hand flexed in a position of comfort.
b. Elevate the right arm and hand on pillows and extend the fingers.
c. Assist the client to a supine position with a small pillow under the head.
d. Position the client in a side-lying position with rolled towel under the neck.
ANS: B
The right hand and arm should be elevated to reduce swelling and the fingers extended to
avoid flexion contractures (even though this position may not be comfortable for the
client). The client with burns of the ears should not use a pillow since this will put pressure
on the ears and may stick to the ears. Clients with neck burns should not use a pillow,
since the head should be maintained in an extended position in order to avoid contractures.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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9. The nurse is caring for a client who has circumferential burns of both arms and develops a
decrease in radial pulse strength and numbness in the fingers. Which of the following
actions should the nurse take?
a. Notify the health care provider.
b. Monitor the pulses every 2 hours.
c. Elevate both arms above heart level with pillows.
d. Encourage the client to flex and extend the fingers.
ANS: A
The decrease in pulse in a client with circumferential burns indicates decreased circulation
to the arms and the need for escharotomy. Monitoring the pulses is not an adequate
response to the decrease in circulation. Elevating the hands or increasing hand movement
will not improve the client’s circulation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
10. The nurse is caring for a client who incurred extensive burn injuries 5 days ago and has
been prescribed ranitidine. Which of the following assessments should the nurse use to
evaluate the effectiveness of the medication?
a. Bowel sounds
b. Stool frequency
c. Abdominal distention
d. Stools for occult blood
ANS: D
H2 blockers are given to prevent Curling’s ulcer in the client who has suffered burn
injuries. H2 blockers do not impact bowel sounds, stool frequency, or appetite.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
11. The nurse is caring for a client who has partial-thickness burns. Which of the following
prescribed medications will be best for the nurse to use before wound debridement?
Ketorolac
Lorazepam
Gabapentin
Hydromorphone
a.
b.
c.
d.
ANS: D
Opioid pain medications are the best choice for pain control. The other medications are
used as adjuvants to enhance the effect of opioids.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
12. The nurse is caring for a client who is in the rehabilitation phase after having deep
partial-thickness face and neck burns and has a nursing diagnosis of disturbed body image.
Which of the following actions by the client indicates that the problem is resolving?
a. Stating that the scarring will only be temporary
b. Avoiding using a pillow to prevent neck contractures
c. Asking about how to use make-up to cover up the scars
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d. Expressing sadness and anger about the scar appearance
ANS: C
The willingness to use strategies to enhance appearance is an indication that the disturbed
body image is resolving. Expressing feelings about the scars indicates a willingness to
discuss appearance, but not resolution of the problem. Because deep partial-thickness
burns leave permanent scars, a statement that the scars are temporary indicates denial
rather than resolution of the problem. Avoiding using a pillow will help prevent
contractures, but it does not address the problem of disturbed body image.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Evaluation
13. The nurse is caring for a client who has burns over 30% of the body surface. Which of the
following events indicates that the client has moved from the emergent to the acute phase
of the burn injury?
a. White blood cell levels decrease.
b. Blisters and edema have subsided.
c. The client has large quantities of pale urine.
d. The client has been hospitalized for 48 hours.
ANS: C
At the end of the emergent phase, capillary permeability normalizes and the client begins
to diurese large amounts of urine with a low specific gravity. Although this may occur at
about 48 hours, it may be longer in some clients. Blisters and edema begin to resolve, but
this process requires more time. White blood cells may increase or decrease, based on the
client’s immune status and any infectious processes.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Application
14. Which of the following snacks will be best for the nurse to offer to a client with burns
covering 40% total body surface area (TBSA) who is in the acute phase of burn
treatment?
a. Strawberry gelatin
b. Whole wheat bagel
c. Chunky applesauce
d. Chocolate milkshake
ANS: D
A client with a burn injury needs high protein and calorie food intake, and the milkshake is
the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
15. Which of the following assessment parameters is the priority nursing assessment when
caring for a client who has just arrived in the emergency department after suffering an
electrical burn from exposure to a high-voltage current?
a. Oral temperature
b. Peripheral pulses
c. Extremity movement
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d. Pupil reaction to light
ANS: C
All clients with electrical burns should be considered at risk for cervical spine injury, and
assessments of extremity movement will provide baseline data. The other assessment data
also are necessary but not as essential as determining cervical spine status.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
16. The occupational health nurse is assessing an employee who has just spilled industrial
acids on the arms and legs. Which of the following actions is priority for the nurse to
implement?
a. Apply an alkaline solution to the affected area.
b. Place cool compresses on the area of exposure.
c. Cover the affected area with dry, sterile dressings.
d. Flush the burned area with large amounts of water.
ANS: D
With chemical burns, the initial action is to remove the chemical from contact with the
skin as quickly as possible. Covering the affected area or placing cool compresses on the
area will leave the chemical in contact with the skin. Application of an alkaline solution is
not recommended.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
17. The nurse is caring for a client who has burns on the back and chest from a house fire and
has become agitated and restless 9 hours after being admitted to the hospital. Which of the
following actions should the nurse take first?
a. Stay at the bedside and reassure the client.
b. Administer the ordered morphine sulphate IV.
c. Assess orientation and level of consciousness.
d. Use pulse oximetry to check the oxygen saturation.
ANS: D
Agitation in a client who may have suffered inhalation injury might indicate hypoxemia,
and this should be assessed by the nurse first. Administration of morphine may be
indicated if the nurse determines that the agitation is caused by pain. Assessing level of
consciousness and orientation also is appropriate but not as essential as determining
whether the client is hypoxemic. Reassurance is not helpful to reduce agitation in a
hypoxemic client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
18. Which of the following actions should the nurse take first when a client arrives in the
emergency department with facial and chest burns caused by a house fire?
Infuse the ordered IV solution.
Auscultate the client’s lung sounds.
Determine the extent and depth of the burns.
Administer the ordered opioid pain medications.
a.
b.
c.
d.
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ANS: B
A client with facial and chest burns is at risk for inhalation injury, and assessment of
airway and breathing is the priority. The other actions will be completed after airway
management is assured.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
19. The nurse is admitting a client with extensive electrical burn injuries. Which of the
following prescribed interventions should the nurse implement first?
a. Start two large bore IVs.
b. Place on cardiac monitor.
c. Apply dressings to burned areas.
d. Assess for pain at contact points.
ANS: B
After an electrical burn, the client is at risk for fatal dysrhythmias and should be placed on
a cardiac monitor. The other actions should be accomplished in the following order: Start
two IVs, assess for pain, and apply dressings.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
20. Six hours after a thermal burn covering 50% of a client’s total body surface area (TBSA),
the nurse obtains these data when assessing a client. Which of the following information is
priority for the nurse to communicate to the health care provider?
a. Blood pressure is 94/46 per arterial line.
b. Serous exudate is leaking from the burns.
c. Cardiac monitor shows a pulse rate of 104.
d. Urine output is 20 mL/hour for the past 2 hours.
ANS: D
The urine output should be at least 0.5–1.0 mL/kg/hour during the emergent phase, when
the client is at great risk for hypovolemic shock. The nurse should notify the health care
provider because a higher IV fluid rate is needed. BP during the emergent phase should be
greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from
the burns is expected during the emergent phase.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
21. After receiving change-of-shift report, which of the following clients should the nurse
assess first?
a. A client with 40% total body surface area (TBSA) burns who is receiving IV
fluids at 500 mL/hour
b. A client with smoke inhalation who has wheezes and altered mental status
c. A client with full-thickness leg burns who has a dressing change scheduled
d. A client with abdominal burns who is complaining of level 8 (0–10 scale) pain
ANS: B
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This client has evidence of lower airway injury and hypoxemia and should be assessed
immediately to determine need for oxygen or intubation. The other clients also should be
assessed as rapidly as possible, but they do not have evidence of life-threatening
complications.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
22. Which of the following frequencies of multiple-dressing method burn treatment dressing
changes should the nurse should question?
a. Every 6 hours
b. Every 12 hours
c. Once a day
d. Once a week
ANS: A
These dressings are changed at various intervals, from every 12 to 24 hours to once every
14 days, depending on the product. However, the dressing should not be changed 6 hours
from application.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
23. The nurse notes a bright red skin colour for a client who was found unconscious from
smoke inhalation in a burning house. Which of the following actions should the nurse take
first?
a. Insert two large-bore IV lines.
b. Check the client’s orientation.
c. Place the client on 100% oxygen using a non-rebreather mask.
d. Assess for singed nasal hair and dark oral mucous membranes.
ANS: C
The client’s history and skin colour suggest carbon monoxide poisoning, which should be
treated by rapidly starting oxygen at 100%. The other actions can be taken after the actions
to correct gas exchange.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
24. Which of the following laboratory results requires the most rapid action by the nurse who
is caring for a client who suffered a large burn 48 hours ago?
Hct 52%
BUN 13.8 mmol/L
Serum sodium 146 mmol/L
Serum potassium 6.2 mmol/L
a.
b.
c.
d.
ANS: D
Hyperkalemia can lead to fatal bradycardia and indicates that the client requires cardiac
monitoring and immediate treatment to lower the potassium level. The other laboratory
values also are abnormal and require changes in treatment, but they are not as immediately
life threatening as the elevated potassium level.
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DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
25. The staff nurse is supervising a student nurse on the burn unit. Which of the following
actions by the student nurse require that the staff nurse intervene?
a. The student nurse uses clean latex gloves when applying antibacterial cream to a
burn wound.
b. The student nurse obtains burn cultures when the client has a temperature of
35.1°C (95.1°F).
c. The student nurse administers PRN fentanyl IV to a client 5 minutes before a
dressing change.
d. The student nurse calls the health care provider for an insulin order when a
nondiabetic client has an elevated serum glucose.
ANS: A
Sterile gloves should be worn when applying medications or dressings to a burn.
Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic
clients may require insulin because stress and high calorie intake may lead to temporary
hyperglycemia. Fentanyl peaks 5 minutes after IV administration and should be used just
before and during dressing changes for pain management.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
26. Which of the following nursing actions should be done first for a client who has suffered a
burn injury while working on an electrical power line?
Obtain the blood pressure.
Stabilize the cervical spine.
Assess for the contact points.
Check alertness and orientation.
a.
b.
c.
d.
ANS: B
Cervical spine injuries are commonly associated with electrical burns. Therefore
stabilization of the cervical spine takes precedence after airway management. The other
actions also are included in the emergent care after electrical burns, but the most important
action is to avoid spinal cord injury.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
COMPLETION
1. The nurse is admitting a client with burns over 30% of total body surface area (TBSA)
and who weighs 70 kg. Using the Parkland formula, calculate the volume of lactated
Ringer’s solution that the nursing staff will administer during the first 24 hours.
__________________
ANS:
8 400 mL
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The Parkland formula states that clients should receive 4 mL/kg/%TBSA burned during
the first 24 hours.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
2. The nurse is estimating the extent of a burn using the rule of nines for a client who has
been admitted with deep partial-thickness burns of the posterior trunk and right arm. What
percentage of the client’s total body surface area (TBSA) has been injured?
__________________
ANS:
27%
When using the rule of nines, the posterior trunk is considered to cover 18% of the client’s
body and each arm is 9%.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
OTHER
1. In which order should the nurse take these actions when doing a dressing change for a
partial-thickness burn wound on a client’s back?
a. Apply sterile gauze dressing.
b. Document wound appearance.
c. Apply silver sulphadiazine cream.
d. Administer IV fentanyl.
e. Clean wound with saline-soaked gauze.
ANS:
D, E, C, A, B
Since partial-thickness burns are very painful, the nurse’s first action should be to
administer pain medications. The wound will then be cleaned, antibacterial cream applied,
and covered with a new sterile dressing. The last action should be to document the
appearance of the wound.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 28: Nursing Assessment: Respiratory System
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is admitting a client with acute shortness of breath. Which of the following
actions should the nurse take during the initial assessment of the client?
a. Complete a full physical examination to determine the systemic effect of the
respiratory distress.
b. Obtain a comprehensive health history to determine the extent of any prior
respiratory problems.
c. Delay the physical assessment and ask family members about any history of
respiratory problems.
d. Perform a respiratory system assessment and ask specific questions about this
episode of respiratory distress.
ANS: D
When a client has severe respiratory distress, only information pertinent to the current
episode is obtained, and a more thorough assessment is deferred until later. Obtaining a
comprehensive health history or full physical examination is unnecessary until the acute
distress has resolved. A focused physical assessment should be done rapidly to help
determine the cause of the distress and suggest treatment. Although family members may
know about the client’s history of medical problems, the client is the best informant for
these data.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. The nurse is preparing a client with a right-sided pleural effusion for a thoracentesis.
Which of the following positions should the nurse position the client?
a. Supine with the head of the bed elevated 45 degrees
b. In the Trendelenburg position with both arms extended
c. On the left side with the right arm extended above the head
d. Sitting upright with the arms supported on an over bed table
ANS: D
The upright position with the arms supported increases lung expansion, allows fluid to
collect at the lung bases, and expands the intercostal space so that access to the pleural
space is easier. The other positions would increase the work of breathing for the client and
make it more difficult for the health care provider performing the thoracentesis.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
3. The nurse is caring for a client with a metabolic acidosis of unknown origin. Which of the
following findings should the nurse expect based on this diagnosis?
Intercostal retractions
Kussmaul’s respirations
Low oxygen saturation (SpO2)
Decrease in venous O2 pressure
a.
b.
c.
d.
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ANS: B
Kussmaul’s (deep and rapid) respirations are a compensatory mechanism for metabolic
acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in PvO2
would not be caused by acidosis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
4. The nurse is auscultating a client’s lungs and hears short, high-pitched sounds during
exhalation in the lower 1/3 of both lungs. Which of the following information should the
nurse document?
a. Expiratory crackles at the bases
b. Expiratory wheezes in both lungs
c. Abnormal lung sounds in the bases of both lungs
d. Pleural friction rub in the right and left lower lobes
ANS: B
Wheezes are high-pitched sounds. In this case they are heard during the expiratory phase
of the respiratory cycle. Abnormal breath sounds are either bronchial or bronchovesicular
sounds heard in the peripheral lung fields. Crackles are low-pitched, “bubbling” sounds.
Pleural friction rubs are grating sounds that are usually heard during both inspiration and
expiration.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
5. The nurse is palpating the posterior chest of a client while the client says “99” and notes
that no vibration is felt. Which of the following information should the nurse document?
Diminished expansion
Dullness to percussion
Absent tactile fremitus
Decreased breath sounds
a.
b.
c.
d.
ANS: C
To assess for tactile fremitus, the nurse should use the palms of the hands to assess for
vibration when the client repeats a word or phrase such as “99.” Different techniques are
used to assess for dullness to percussion, decreased breath sounds, and diminished
expansion.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
6. The nurse is caring for a client with a chronic cough who has had a bronchoscopy. Which
of the following actions should the nurse include in the nursing care plan after the
procedure?
a. Elevate the head of the bed to 80–90 degrees.
b. Keep the client NPO until the gag reflex returns.
c. Place on bed rest for at least 4 hours postbronchoscopy.
d. Notify the health care provider about blood-tinged mucus.
ANS: B
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Because a local anaesthetic is used to suppress the gag or cough reflexes during
bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the
client to take oral fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy.
The client does not need to be on bed rest, and the head of the bed does not need to be in
the high Fowler’s position.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
7. The nurse is auscultating a client’s chest while the client takes a deep breath and hears
loud, high-pitched, “blowing” sounds at both lung bases. Which of the following
information should the nurse document?
a. Normal sounds
b. Vesicular sounds
c. Abnormal sounds
d. Adventitious sounds
ANS: C
The description indicates that the nurse hears bronchial breath sounds that are abnormal
when heard in the peripheral lung fields. Adventitious sounds are extra breath sounds such
as crackles, wheezes, rhonchi, and friction rubs. Vesicular sounds are low-pitched, soft
sounds heard over all lung areas except the major bronchi.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
8. The nurse is caring for a client with respiratory disease and observes that the client’s SpO2
drops from 92% to 88% while the client is ambulating in the hallway. Which of the
following actions should the nurse take next?
a. Notify the health care provider.
b. Document the response to exercise.
c. Administer the PRN supplemental O2.
d. Encourage the client to pace activity.
ANS: C
The drop in SpO2 to 85% indicates that the client is hypoxemic and needs supplemental
oxygen when exercising. The other actions also are appropriate, but the first action should
be to correct the hypoxemia.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
9. Which of the following actions should the nurse plan to take for a client who is scheduled
for pulmonary function testing (PFT)?
a. Explain reasons for NPO status.
b. Administer sedative drug before PFT.
c. Assess pulse and BP after the procedure.
d. Teach deep inhalation and forceful exhalation.
ANS: D
For PFT, the client should inhale deeply and exhale as long, hard, and fast as possible. The
other actions are not needed with PFT.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
10. The nurse is observing a student who is listening to a client’s lungs. Which of the
following actions by the student indicates a need to review respiratory assessment skills?
a. The student compares breath sounds from side to side.
b. The student listens only over the posterior part of the chest.
c. The student places the stethoscope over the scapulae and then auscultates.
d. The student starts at the base of the posterior lung and moves to the apices.
ANS: C
The stethoscope should be placed over lung tissue, not over bony structures. Breath sounds
should be compared from side to side. The techniques of starting at the lung base and then
moving toward the apices and listening only over the posterior chest are acceptable.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
11. The nurse is reviewing a client’s laboratory results and identifies which of the following
values as a normal tidal volume?
a. 100 mL
b. 250 mL
c. 500 mL
d. 1 000 mL
ANS: C
The normal tidal volume is 500 mL.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
12. The nurse is admitting a client to the emergency department who has sudden onset
shortness of breath and diagnosed with a possible pulmonary embolus. To confirm the
diagnosis, which of the following diagnostic measures should the nurse anticipate?
a. Positron emission tomography (PET) scan
b. Chest x-ray
c. Bronchoscopy
d. Spiral computed tomography (CT) scan
ANS: D
Spiral CT scans are the most commonly used test to diagnose pulmonary emboli. A chest
x-ray may be ordered but will not be diagnostic for a pulmonary embolus. Bronchoscopy
is used to inspect for changes in the bronchial tree, not to assess for vascular changes. PET
scans are most useful in determining the presence of malignancy.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
13. Which of the following lung structures has the most generations?
a. Segmental bronchi
b. Subsegmental bronchi
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c. Bronchioles
d. Alveoli
ANS: D
The lung structure that has the most generations is the alveoli with 28. Segmental bronchi,
subsegmental bronchi, and bronchioles have less than 28 generations.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
14. Which of the following pH values is abnormal for a pH when assessing blood results of a
mixed venous blood sample?
7.31
7.35
7.40
7.42
a.
b.
c.
d.
ANS: D
The normal pH of a mixed venous sample is 7.31–7.41. The normal pH of an arterial
blood sample is 7.35–7.45.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
15. The nurse is analyzing the results of a client’s arterial blood gases (ABGs). Which of the
following findings require the most immediate action?
a. The arterial oxygen saturation (SaO2) is 92%.
b. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg.
c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg.
d. The bicarbonate level (HCO3–) is 29 mmol/L.
ANS: B
All the values are abnormal, but the low PaO2 indicates that the client is at the point on the
oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large
drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene
immediately to improve the client’s oxygenation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
16. The nurse is assessing the respiratory system of an older-adult client. Which of the
following findings indicate that the nurse should take immediate action?
a. The chest appears barrel shaped.
b. The client has a weak cough effort.
c. Crackles are heard from the lung bases to the midline.
d. Hyperresonance is present across both sides of the chest.
ANS: C
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Crackles in the lower half of the lungs indicate that the client may have an acute problem
such as heart failure. The nurse should immediately accomplish further assessments, such
as oxygen saturation, and notify the health care provider. A barrel-shaped chest,
hyper-resonance to percussion, and a weak cough effort are associated with aging. Further
evaluation may be needed, but immediate action is not indicated.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
17. The nurse is admitting a client who is hypothermic with a O2 saturation of 96%. Which of
the following actions should the nurse take next?
a. Initiate rewarming of the client.
b. Complete a head-to-toe assessment.
c. Obtain arterial blood gases (ABGs).
d. Place the client on high-flow oxygen.
ANS: D
Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation
curve will decrease the amount of oxygen delivered to tissues, so high oxygen
concentrations should be given until the client is normothermic. The other actions also are
appropriate, but the initial action should be to administer oxygen.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
18. After the nurse has received change-of-shift report, which of the following clients should
be assessed first?
a. A client with pneumonia who has crackles in the right lung base
b. A client with chronic obstructive pulmonary disease (COPD) and pulmonary
function testing (PFT) that indicates low forced vital capacity
c. A client with possible lung cancer who has just returned after bronchoscopy
d. A client with hemoptysis and a 16-mm induration with tuberculin skin testing
ANS: C
Since the cough and gag are decreased after bronchoscopy, this client should be assessed
for airway maintenance. The other clients do not have clinical manifestations or
procedures that require immediate assessment by the nurse.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
19. The nurse has just received arterial blood gas (ABG) results on four clients. Which of the
following results is considered normal?
a. pH 7.32, PaO2 85 mm Hg, PaCO2 55 mm Hg, and O2 saturation 90%
b. pH 7.38, PaO2 75 mm Hg, PaCO2 40 mm Hg, and O2 saturation 92%
c. pH 7.42, PaO2 80 mm Hg, PaCO2 33 mm Hg, and O2 saturation 98%
d. pH 7.52, PaO2 90 mm Hg, PaCO2 30 mm Hg, and O2 saturation 94%
ANS: B
These ABGs indicate normal values.
DIF:
Cognitive Level: Application
TOP: Nursing Process: Implementation
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MSC: NCLEX: Physiological Integrity
20. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) with
increasing dyspnea over the last 3 days. Which of the following findings is most important
to report to the health care provider?
a. Respirations are 36 breaths/minute.
b. Anterior–posterior chest ratio is 1:1.
c. Lung expansion is decreased bilaterally.
d. Hyperresonance to percussion is present.
ANS: A
The increase in respiratory rate indicates respiratory distress and a need for rapid
interventions such as administration of oxygen or medications. The other findings are
common chronic changes occurring in clients with COPD.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
21. The nurse is performing an assessment of the client’s respiratory system. Which of the
following parameters is the nurse assessing when using the following illustrated
technique?
a.
b.
c.
d.
Bronchophony
Chest expansion
Accessory muscle use
Diaphragmatic excursion
ANS: B
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
MULTIPLE RESPONSE
1. Which of the following respiratory assessments are not normal? (Select all that apply.)
a. Respirations 23 breaths/minute
b. Outward movement of abdomen during inspiration
c. Increase in vibrations with tactile fremitus
d. Tripod position
e. Symmetrical chest expansion
ANS: A, C, D
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Respirations greater than 20 breaths/minute indicate tachypnea. Tactile fremitus is often
increased in pneumonia and pulmonary edema. The tripod position is assumed in clients
with COPD, asthma in exacerbation and pulmonary edema. Outward movement of the
abdomen during inspiration is normal. Symmetrical chest expansion is normal.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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Chapter 29: Nursing Management: Upper Respiratory Problems
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is caring for a client who has had an anterior packing for severe epistaxis.
Which of the following nursing interventions should be included in the plan of care?
a. Educate the client to return in 3 days to have the nasal packing removed.
b. Reassure the client that the nose will look normal when the swelling subsides.
c. Instruct the client to keep the head elevated for 48 hours to minimize pain.
d. Teach the client to use nonsteroidal anti-inflammatory drugs (NSAIDs) for pain
control.
ANS: A
The client should be instructed to return in 48–72 hours to have the anterior packing
removed. Maintaining the head in an elevated position is not required. NSAIDs increase
the risk for bleeding and should not be used. Although return to a preinjury appearance is
the goal, it is not always possible to achieve this result and the nurse should not provide
false reassurance.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
2. The nurse is teaching a client with allergic rhinitis about management of the condition.
Which of the following information should the nurse include in the teaching plan?
a. Over-the-counter (OTC) antihistamines cause sedation, so prescription
antihistamines are usually ordered.
b. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit
their use.
c. Use of oral antihistamines for a few weeks before the allergy season may prevent
reactions.
d. Identification and avoidance of environmental triggers are the best ways to avoid
symptoms.
ANS: D
The most important intervention is to assist the client in identifying and avoiding potential
allergens. Intranasal corticosteroids (not oral antihistamines) should be started several
weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic
absorption. Nonsedating antihistamines are available OTC.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
3. The nurse is providing teaching to a client who has acute viral rhinitis about management
of upper respiratory infections (URI). Which of the following client statements indicate
that additional teaching is needed?
a. “I can take acetaminophen to treat discomfort.”
b. “I will drink lots of juices and other fluids to stay hydrated.”
c. “I can use my nasal decongestant spray until the congestion is all gone.”
d. “I will watch for changes in nasal secretions or the sputum that I cough up.”
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ANS: C
The nurse should clarify that nasal decongestant sprays should be used for no more than 5
days to prevent rebound vasodilation and congestion. The other responses indicate that the
teaching has been effective.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
4. An RN is observing a nursing student who is suctioning a hospitalized client with a
tracheostomy in place. Which of the following actions by the student requires the RN to
intervene?
a. The student preoxygenates the client for 1 minute before suctioning.
b. The student puts on clean gloves and uses a sterile catheter to suction.
c. The student inserts the catheter about 15 cm into the tracheostomy tube.
d. The student applies suction for 10 seconds while withdrawing the catheter.
ANS: B
Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. The other
student actions do not require intervention by the RN. Although the client may not need 1
minute of preoxygenation, this would not be unsafe. Suctioning for 10 seconds is
appropriate. The length of catheter that should be inserted depends on the length of the
tracheostomy tube, but the range is 13–15 cm for most adult clients.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
5. The nurse is deflating the cuff of a tracheostomy tube to evaluate the client’s ability to
swallow. Which of the following actions should the nurse implement?
a. Clean the inner cannula of the tracheostomy tube before deflation.
b. Deflate the cuff during the inhalation phase of the respiratory cycle.
c. Suction the client’s mouth and trachea before deflation of the cuff.
d. Insert exactly the same volume of air into the cuff during reinflation.
ANS: C
The client’s mouth and trachea should be suctioned before the cuff is deflated to prevent
aspiration of oral secretions. The amount of air needed to inflate the cuff varies and is
adjusted by measuring cuff pressure or using the minimal leak technique, not by
measuring the volume of air removed from the cuff. The cuff is deflated during client
exhalation so that secretions will be forced into the mouth rather than aspirated. There is
no need to clean the inner cannula before cuff deflation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
6. Which of the following causes is the most common cause of acute pharyngitis?
a. Fungal
b. Viral
c. Acute follicular
d. Peritonsillar
ANS: B
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Viral pharyngitis accounts for approximately 70% of all cases of acute pharyngitis.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
7. The nurse is caring for a client with a tracheostomy who has a new prescription for a
fenestrated tracheostomy tube. Which of the following actions should be included in the
plan of care?
a. Leave the tracheostomy inner cannula inserted at all times.
b. Place the decannulation cap in the tube before cuff deflation.
c. Assess the ability to swallow before using the fenestrated tube.
d. Inflate the tracheostomy cuff during use of the fenestrated tube.
ANS: C
Because the cuff is deflated when using a fenestrated tube, the client’s risk for aspiration
should be assessed before changing to a fenestrated tracheostomy tube. The decannulation
cap is never inserted before cuff deflation because to do so would obstruct the client’s
airway. The cuff is deflated and the inner cannula removed to allow air to flow across the
client’s vocal cords when using a fenestrated tube.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
8. The nurse is caring for a client with a tracheostomy tube and is inflating the cuff to the
appropriate level. Which of the following actions is best for the nurse to implement?
Check the pilot balloon after inflation to ensure that it is firm.
Use a manometer to ensure cuff pressure is at an appropriate level.
Check the amount of cuff pressure ordered by the health care provider.
Fill the balloon until minimal air leakage around the cuff is auscultated.
a.
b.
c.
d.
ANS: B
Measurement of cuff pressure using a manometer to ensure that cuff pressure is 20 mm Hg
or lower will avoid compression of the tracheal capillaries. A firm pilot balloon indicates
that the cuff is inflated but does not assess for over-inflation. A health care provider’s
order is not required to determine safe cuff pressure. A minimal leak technique is an
alternate means for cuff inflation, but this technique does allow a small air leak around the
cuff and increases the risk for aspiration.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
9. The nurse is teaching a client with laryngeal cancer about radiation therapy. Which of the
following client statements indicate that the teaching has been effective?
“I will need to buy a water bottle to carry with me.”
“I should not use any lotions on my neck and throat.”
“Until the radiation is complete, I may have diarrhea.”
“Alcohol-based mouthwashes will help clean oral ulcers.”
a.
b.
c.
d.
ANS: A
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Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation
will damage tissues at the site being radiated but should not affect the abdominal organs,
so loose stools are not a usual complication of head and neck radiation therapy. Frequent
oral rinsing with non–alcohol-based rinses is recommended. Prescribed lotions and
sunscreen may be used on irradiated skin, although they should not be used just before the
radiation therapy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
10. The nurse is obtaining a health history from a client with a 40 year, pack a day smoking
history, symptoms of hoarseness and tightness in the throat, and difficulty swallowing.
Which of the following questions is most important for the nurse to ask?
a. “How much alcohol do you drink in an average week?”
b. “Do you have a family history of head or neck cancer?”
c. “Have you had frequent streptococcal throat infections?”
d. “Do you use antihistamines for upper airway congestion?”
ANS: A
Prolonged alcohol use and smoking are associated with the development of laryngeal
cancer, which the client’s symptoms and history suggest. Family history is not a risk factor
for head or neck cancer. Frequent antihistamine use would be asked about if the nurse
suspected allergic rhinitis, but the client’s symptoms are not suggestive of this diagnosis.
Streptococcal throat infections also may cause these clinical manifestations, but clients
also will complain of pain and fever.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
11. The nurse is caring for a client who is scheduled for a total laryngectomy and radical neck
dissection for cancer of the larynx. The client asks the nurse, “How will I talk after the
surgery?” Which of the following responses by the nurse is best?
a. “You will breathe through a permanent opening in your neck, but you will not be
able to communicate orally.”
b. “You won’t be able to talk right after surgery, but you will be able to speak again
after the tracheostomy tube is removed.”
c. “You won’t be able to speak as you used to, but there are artificial voice devices
that will give you the ability to speak normally.”
d. “You will have a permanent opening into your neck, and you will need to have
rehabilitation for some type of voice restoration.”
ANS: D
Voice restoration is planned after a total laryngectomy, and a variety of assistive devices
are available to restore communication. Although the ability to communicate orally is
changed, it would not be appropriate to tell a client that this ability would be lost. Artificial
voice devices do not permit normal-sounding speech. In a total laryngectomy, the vocal
cords are removed, so normal speech is impossible.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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12. The nurse is caring for a client who had a total laryngectomy and has a nursing diagnosis
of hopelessness related to loss of control of personal care. Which of the following
information obtained by the nurse is the best indicator that the problem identified in this
nursing diagnosis is resolving?
a. The client lets the spouse provide tracheostomy care.
b. The client allows the nurse to suction the tracheostomy.
c. The client asks how to clean the tracheostomy stoma and tube.
d. The client uses a communication board to request “No Visitors.”
ANS: C
Independently caring for the laryngectomy tube indicates that the client has regained
control of self-care and hopelessness is at least partially resolved. Letting the nurse and
spouse provide care and requesting no visitors may indicate that the client is still
experiencing hopelessness.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Evaluation
13. The nurse is providing discharge instructions for a client with a total laryngectomy. Which
of the following client statements indicate that additional instruction is required?
a. “I must keep the stoma covered with a loose sterile dressing at all times.”
b. “I can participate in most of my prior fitness activities except swimming.”
c. “I should wear a Medic Alert bracelet that identifies me as a neck breather.”
d. “I need to be sure that I have smoke and carbon monoxide detectors installed.”
ANS: A
The stoma may be covered with clothing or a loose dressing, but this is not essential. The
other client comments are all accurate and indicate that the teaching has been effective.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
14. Which of the following actions should the nurse take first when a client develops a
nosebleed?
a. Pack both nares tightly with 1 cm ribbon gauze.
b. Pinch the lower portion of the nose for 10 minutes.
c. Prepare supplies that will be needed for cauterization.
d. Apply ice compresses over the client’s nose and cheeks.
ANS: B
The first nursing action for epistaxis is to apply direct pressure by pinching the nostrils.
Application of cold packs may decrease blood flow to the area somewhat, but will not be
sufficient to stop bleeding. Cauterization or nasal packing may be needed if pressure to the
nares does not stop bleeding, but these are not the first actions to take for nosebleed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
15. The nurse is caring for a client who has had a total laryngectomy and radical neck
dissection. During the first 24 hours after surgery, which of the following actions is
priority?
a. Monitor for bleeding.
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b. Assess breath sounds.
c. Clean the inner cannula every 8 hours.
d. Avoid changing the tracheostomy ties.
ANS: B
The most important goals posttracheotomy are to maintain the airway and ensure adequate
oxygenation. Assessment of the breath sounds is the priority action. Maintenance of the
tracheostomy ties, cleaning the inner cannula, and checking for bleeding also are
appropriate nursing actions but are not of as high a priority.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
16. The nurse is caring for a client with an uncuffed tracheostomy tube who coughs violently
during suctioning and dislodges the tracheostomy tube. Which of the following actions
should the nurse take first?
a. Insert the obturator and attempt to reinsert the tracheostomy tube.
b. Position the client in an upright position with the neck extended.
c. Assess the client’s oxygen saturation and notify the health care provider.
d. Ventilate the client with a manual bag until the health care provider arrives.
ANS: A
The first action should be to attempt to reinsert the tracheostomy tube to maintain the
client’s airway. Assessing the client’s oxygenation is an important action, but it is not the
most appropriate first action in this situation. Covering the stoma with a dressing and
manually ventilating the client may be an appropriate action if the nurse is unable to
reinsert the tracheostomy tube. The client should be placed in a semi-Fowler’s position if
reinsertion of the tracheostomy tube is not successful.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
17. Which of the following clients in the respiratory disease clinic should the nurse assess
first?
A 23-year-old, complaining of a sore throat, who has stridor
A 34-year-old who has a “scratchy throat” and a positive rapid strep antigen test
A 55-year-old who is receiving radiation for throat cancer and has severe fatigue
A 72-year-old with a history of a total laryngectomy whose stoma is red and
inflamed
a.
b.
c.
d.
ANS: A
The client’s clinical manifestation of stridor suggests partial airway obstruction, a possible
peritonsillar abscess that could lead to an airway obstruction requiring rapid assessment
and potential treatment. The other clients do not have diagnoses or symptoms that indicate
any life-threatening problems.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
18. The nurse obtains the following assessment data for a client who has influenza. Which of
the following information is most important to communicate to the health care provider?
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a.
b.
c.
d.
Temperature of 38°C (100.4°)
Diffuse crackles in the lungs
Sore throat and frequent cough
Myalgia and persistent headache
ANS: B
The crackles indicate that the client may be developing pneumonia, a common
complication of influenza, which would require aggressive treatment. Myalgia, headache,
mild temperature elevation, and sore throat with cough are typical symptoms of influenza
and are treated with supportive care measures such as over-the-counter (OTC) pain
relievers and increased fluid intake.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
19. Which of the following nursing actions should the nurse perform when suctioning a
tracheostomy?
a. Insert tube 13–15 cm while suctioning.
b. Withdraw catheter in a straight time while applying intermittent suction.
c. Limit suction time to 10 seconds.
d. Oxygenate the client once all suctioning is completed.
ANS: C
Suction time should not exceed 10 seconds. The tube is inserted 13–15 cm but not while
suctioning. Suction is done intermittently while withdrawing the catheter but not in a
straight line; the catheter should be rotated when withdrawing. Oxygenating the client
after each tube insertion rather than when suctioning is completed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
20. The nurse is caring for a hospitalized older adult client who has posterior nasal packing in
place to treat a nosebleed. Which of the following assessment findings will require the
most immediate action by the nurse?
a. The oxygen saturation is 89%.
b. The nose appears red and swollen.
c. The client’s temperature is 37.8°C (100°F).
d. The client complains of level 7 (0–10 scale) pain.
ANS: A
Older clients with nasal packing are at risk of aspiration or airway obstruction. An O2
saturation of 89% should alert the nurse to assess further for these complications. The
other assessment data also indicate a need for nursing action but not as immediately as the
fall in O2 saturation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
MULTIPLE RESPONSE
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1. The nurse is preparing a teaching plan for a client with acute sinusitis. Which of the
following interventions should be included in the plan? (Select all that apply.)
a. Taking a hot shower will increase sinus drainage and decrease pain.
b. Over-the-counter (OTC) decongestants can be used as required.
c. Saline nasal spray can be made at home and used to wash out secretions.
d. Blowing the nose forcefully should be avoided to decrease nosebleed risk.
e. You will be more comfortable if you keep your head in an upright position.
ANS: A, B, C, E
The steam and heat from a shower will help thin secretions and improve drainage.
Antihistamines can be used. Clients can use either OTC sterile saline solutions or
home-prepared saline solutions to thin and remove secretions. Maintaining an upright
posture decreases sinus pressure and the resulting pain. Blowing the nose after a hot
shower or using the saline spray is recommended to expel secretions.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
2. The nurse is reviewing the charts for five clients who are scheduled for their yearly
physical examinations in October. Which of the following clients are considered a target
population for the influenza vaccination? (Select all that apply.)
a. A 72-year-old client who has diabetes
b. A 36-year-old female client who is pregnant
c. A 42-year-old client who has a 15 pack-year smoking history
d. A 30-year-old client who takes corticosteroids for rheumatoid arthritis
e. A 9-month-old client who is teething
ANS: A, B, E
The target groups for influenza vaccination include clients over 65 years of age, pregnant
women, and healthy children over 6 months of age. The 42-year-old smoker and the
30-year-old with arthritis are not targeted populations for the vaccination.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
OTHER
1. The nurse enters the room of a client who has just returned from surgery for a total
laryngectomy and radical neck dissection and notes the following problems. In which
order should the nurse address the problems?
a. The nasogastric (NG) tube is disconnected from suction and clamped off.
b. The client is in a side-lying position with the head of the bed flat.
c. The Hemovac in the neck incision contains 200 mL of bloody drainage.
d. The client is coughing blood-tinged secretions from the tracheostomy.
ANS:
B, D, C, A
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The client should first be placed in a semi-Fowler’s position to maintain the airway and
reduce incisional swelling. The blood-tinged secretions may obstruct the airway, so
suctioning is the next appropriate action. Then the Hemovac should be drained because the
200 mL of drainage will decrease the amount of suction in the Hemovac and could lead to
incisional swelling and poor healing. Finally, the NG tube should be reconnected to
suction to prevent gastric dilation, nausea, and vomiting.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 30: Nursing Management: Lower Respiratory Problems
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. Following assessment of a client with pneumonia, the nurse identifies a nursing
diagnosis of ineffective airway clearance. Which of the following information best
supports this diagnosis?
a. Weak, nonproductive cough effort
b. Large amounts of greenish sputum
c. Respiratory rate of 28 breaths/minute
d. Resting pulse oximetry (SpO2) of 85%
ANS: A
The weak, nonproductive cough indicates that the client is unable to clear the airway
effectively. The other data would be used to support diagnoses such as impaired gas
exchange and ineffective breathing pattern.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Diagnosis
2. The nurse is conducting a chest assessment on a client with pneumococcal pneumonia.
Which of the following findings should the nurse expect to assess?
a. Vesicular breath sounds
b. Increased tactile fremitus
c. Dry, nonproductive cough
d. Hyper-resonance to percussion
ANS: B
Increased tactile fremitus over the area of pulmonary consolidation is expected with
bacterial pneumonias. Dullness to percussion would be expected. Pneumococcal
pneumonia typically presents with a loose, productive cough. Adventitious breath
sounds such as crackles and wheezes are typical.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
3. The nurse is caring for a client with bacterial pneumonia who has pleurisy. Which of the
following actions should the nurse implement to promote airway clearance?
a. Assist the client to splint the chest when coughing.
b. Educate the client about the need for fluid restrictions.
c. Encourage the client to wear the nasal oxygen cannula.
d. Instruct the client on the pursed lip breathing technique.
ANS: A
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Coughing is less painful and more likely to be effective when the client splints the chest
during coughing. Fluids should be encouraged to help liquefy secretions. Nasal oxygen
will improve gas exchange, but will not improve airway clearance. Pursed lip breathing
is used to improve gas exchange in clients with COPD, but will not improve airway
clearance.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
4. The nurse is providing teaching to a client with pneumonia. Which of the following
client statements indicate a good understanding of the discharge instructions given by
the nurse?
a. “I will call the doctor if I still feel tired after a week.”
b. “I will need to use home oxygen therapy for 3 months.”
c. “I will continue to do the deep-breathing and coughing exercises at home.”
d. “I will schedule two appointments for the pneumonia and influenza vaccines.”
ANS: C
Clients should continue to cough and deep breathe after discharge for up to 6–8 weeks.
Fatigue for several weeks is expected. Home oxygen therapy is not needed with
successful treatment of pneumonia. The pneumonia and influenza vaccines can be given
at the same time.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
5. Which of the following nursing actions is most effective in preventing aspiration
pneumonia in clients who are at risk?
a. Turn and reposition immobile clients at least every 2 hours.
b. Place clients with altered consciousness in side-lying positions.
c. Monitor for respiratory symptoms in clients who are immuno-suppressed.
d. Provide for continuous subglottic aspiration in clients receiving enteral feedings.
ANS: B
The risk for aspiration is decreased when clients with a decreased level of consciousness
are placed in a side-lying or upright position. Frequent turning prevents pooling of
secretions in immobilized clients but will not decrease the risk for aspiration in clients at
risk. Monitoring of parameters such as breath sounds and oxygen saturation will help
detect pneumonia in immuno-compromised clients, but it will not decrease the risk for
aspiration. Continuous subglottic suction is recommended for intubated clients but not
for all clients receiving enteral feedings.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
6. The nurse is caring for a client with right lower-lobe pneumonia who has been treated
with intravenous (IV) antibiotics for 2 days. Which of the following assessment data
obtained by the nurse indicates that the treatment has been effective?
a. Bronchial breath sounds are heard at the right base.
b. The client coughs up small amounts of green mucus.
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c. The client’s white blood cell (WBC) count is 9 ´ 109/L.
d. Increased tactile fremitus is palpable over the right chest.
ANS: C
The normal WBC count indicates that the antibiotics have been effective. All the other
data suggest that a change in treatment is needed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
7. The health care provider writes a prescription for bacteriological testing for a client who
has a positive tuberculosis skin test. Which of the following actions should the nurse
take?
a. Repeat the tuberculin skin testing.
b. Teach about the reason for the blood tests.
c. Obtain consecutive sputum specimens from the client for 3 days.
d. Instruct the client to expectorate three specimens as soon as possible.
ANS: C
Three consecutive sputum specimens are obtained on different days for bacteriological
testing for M. tuberculosis. The client should not provide all the specimens at once.
Blood cultures are not used for tuberculosis testing. Once skin testing is positive, it is not
repeated.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
8. Which of the following information about a client who has a recent history of
tuberculosis (TB) indicates that the nurse can discontinue airborne isolation precautions?
a. Chest x-ray shows no upper lobe infiltrates.
b. TB medications have been taken for 6 months.
c. Mantoux testing shows an induration of 10 mm.
d. Three sputum smears for acid-fast bacilli are negative.
ANS: D
Negative sputum smears indicate that M. tuberculosis is not present in the sputum, and
the client cannot transmit the bacteria by the airborne route. Chest x-rays are not used to
determine whether treatment has been successful. Taking medications for 6 months is
necessary, but the multidrug-resistant forms of the disease might not be eradicated after
6 months of therapy. Repeat Mantoux testing would not be done since it will not change
even with effective treatment.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
9. The nurse is providing teaching to a client with pulmonary tuberculosis (TB) regarding
the transmission of TB. Which of the following client actions indicate that the teaching
has been effective?
a. Demonstrates correct use of a nebulizer.
b. Washes dishes and personal items after use.
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c. Covers the mouth and nose when coughing.
d. Reports daily to the public health department.
ANS: C
Covering the mouth and nose will help decrease airborne transmission of TB. The other
actions will not be effective in decreasing the spread of TB.
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX: Health Promotion and Maintenance
10. Which of the following information should the nurse include in the teaching plan for a
client who is receiving rifampin for treatment of tuberculosis?
a. “Your urine, sweat, and tears will be orange coloured.”
b. “Read a newspaper daily to check for changes in vision.”
c. “Take vitamin B6 daily to prevent peripheral nerve damage.”
d. “Call the health care provider if you notice any hearing loss.”
ANS: A
Orange-coloured body secretions are an adverse effect of rifampin. The other adverse
effects are associated with other antituberculosis medications.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
11. The nurse is teaching a client who is receiving standard multidrug therapy for
tuberculosis (TB) about possible toxic effects of the antitubercular medications. Which
of the following findings should the nurse instruct the client to report to the health care
provider?
a. Yellow-tinged skin
b. Changes in hearing
c. Orange-coloured sputum
d. Thickening of the fingernails
ANS: A
Noninfectious hepatitis is a toxic effect of isoniazid (INH), rifampin, and pyrazinamide,
and clients who develop hepatotoxicity will need to use other medications. Changes in
hearing and nail thickening are not expected with the four medications used for initial
TB drug therapy. Orange discoloration of body fluids is an expected adverse effect of
rifampin and not an indication to call the health care provider.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
12. The nurse is caring for clients with active tuberculosis (TB) who misuse alcohol and/or
are homeless. Which of the following interventions by the nurse will be most effective in
ensuring adherence with the treatment regimen?
a. Educating the client about the long-term impact of TB on health
b. Giving the client written instructions about how to take the medications
c. Teaching the client about the high risk for infecting others unless treatment is
followed
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d. Arranging for a daily noontime meal at a community centre and giving the
medication then
ANS: D
Directly observed therapy is the most effective means for ensuring compliance with the
treatment regimen, and arranging a daily meal will help to ensure that the client is
available to receive the medication. The other nursing interventions may be appropriate
for some clients, but are not likely to be as helpful with this client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
13. After 2 months of tuberculosis (TB) treatment with a standard four-drug regimen, a
client continues to have positive sputum smears for acid-fast bacilli (AFB). Which of the
following actions should the nurse take next?
a. Ask the client whether medications have been taken as directed.
b. Discuss the need to use some different medications to treat the TB.
c. Schedule the client for directly observed therapy three times weekly.
d. Educate about using a 2-drug regimen for the last 4 months of treatment.
ANS: A
The first action should be to determine whether the client has been compliant with drug
therapy because negative sputum smears would be expected if the TB bacillus is
susceptible to the medications and if the medications have been taken correctly.
Depending on whether the client has been compliant or not, different medications or
directly observed therapy may be indicated. A two-drug regimen will be used only if the
sputum smears are negative for AFB.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
14. A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph
is negative, and the nurse has no symptoms of TB. Which of the following information
should the occupational health nurse provide to the staff nurse?
a. Use and adverse effects of isoniazid (INH)
b. Standard four-drug therapy for TB
c. Need for annual repeat TB skin testing
d. Bacille Calmette–Guérin (BCG) vaccine
ANS: A
The nurse is considered to have a latent TB infection and should be treated with INH
daily for 6–9 months. The four-drug therapy would be appropriate if the nurse had active
TB. TB skin testing is not done for individuals who have already had a positive skin test.
BCG vaccine is used to prevent TB and is rarely used in Canada; it would not be helpful
for this individual, who already has a TB infection.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
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15. The nurse is caring for a client who is hospitalized with active tuberculosis (TB) and the
nurse observes a family member who is visiting the client. Which of the following
actions by the visitor should cause the nurse to intervene?
a. Washes hands before entering the client’s room
b. Hands the client a tissue from the box at the bedside
c. Puts on a surgical face mask before visiting the client
d. Brings food from a “fast-food” restaurant to the client
ANS: C
A high-efficiency particulate air (HEPA) mask, rather than a standard surgical mask,
should be used when entering the client’s room because the HEPA mask can filter out
100% of small airborne particles. Handwashing before visiting the client is not necessary,
but there is no reason for the nurse to stop the family member from doing this. Because
anorexia and weight loss are frequent problems in clients with TB, bringing food from
outside the hospital is appropriate. The family member should wash the hands after
handling a tissue that the client has used, but no precautions are necessary when giving
the client an unused tissue.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
16. Which of the following actions by the occupational health nurse at a manufacturing plant
where there is potential exposure to inhaled dust is most helpful in reducing incidence of
lung disease?
a. Teach about symptoms of lung disease.
b. Treat workers who inhale dust particles.
c. Monitor workers for shortness of breath.
d. Require the use of protective equipment.
ANS: D
Prevention of lung disease requires the use of appropriate protective equipment such as
masks. The other actions will help in recognition or early treatment of lung disease, but
will not be effective in prevention of lung damage.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
17. The nurse is developing a teaching plan for a client with a 42 pack-year history of
cigarette smoking. Which of the following information should the nurse include in the
plan of care?
a. Computed tomography (CT) screening for lung cancer
b. Options for smoking cessation
c. Reasons for annual sputum cytology testing
d. Erlotinib therapy to prevent tumour risk
ANS: B
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Because smoking is the major cause of lung cancer, the most important role for the nurse
is educating clients about the benefits of and means of smoking cessation. Early
screening of at-risk clients using sputum cytology, chest x-ray, or CT scanning has not
been effective in reducing mortality. Erlotinib may be used in clients who have lung
cancer but not to reduce risk for developing tumours.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
18. The nurse is caring for a client with stage I non–small cell lung cancer who is scheduled
for a lobectomy. The client tells the nurse, “I would rather have radiation than surgery.”
Which of the following responses by the nurse is best?
a. “Are you afraid that the surgery will be very painful?”
b. “Did you have bad experiences with previous surgeries?”
c. “Surgery is the treatment of choice for stage I lung cancer.”
d. “Tell me what you know about the various treatments available.”
ANS: D
More assessment of the client’s concerns about surgery is indicated. An open-ended
response will elicit the most information from the client. The answer beginning,
“Surgery is the treatment of choice” is accurate, but it discourages the client from
sharing concerns about surgery. The remaining two answers indicate that the nurse has
jumped to conclusions about the client’s reasons for not wanting surgery.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
19. The nurse is caring for a client who had a thoracotomy 1 hour ago and reports incisional
pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural
drainage system has 100 mL of bloody drainage and a large air leak. Which of the
following actions is best for the nurse to take next?
a. Administer the prescribed PRN morphine.
b. Assist the client to deep breathe and cough.
c. Milk the chest tube gently to remove any clots.
d. Tape the area around the insertion site of the chest tube.
ANS: A
The client is unlikely to take deep breaths or cough until the pain level is lower. A chest
tube output of 100 mL is not unusual in the first hour after thoracotomy and would not
require milking of the chest tube. An air leak is expected in the initial postoperative
period after thoracotomy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
20. A client with newly diagnosed lung cancer tells the nurse, “I think I am going to die
pretty soon.” Which of the following responses by the nurse is best?
a. “Would you like to talk to the hospital chaplain about your feelings?”
b. “Can you tell me what it is that makes you think you will die so soon?”
c. “Are you afraid that the treatment for your cancer will not be effective?”
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d. “Do you think that taking an antidepressant medication would be helpful?”
ANS: B
The nurse’s initial response should be to collect more assessment data about the client’s
statement. The answer beginning “Can you tell me what it is” is the most open-ended
question and will offer the best opportunity for obtaining more data. The answer
beginning, “Are you afraid” implies that the client thinks that the cancer will be
immediately fatal, although the client’s statement may not be related to the cancer
diagnosis. The remaining two answers offer interventions that may be helpful to the
client, but more assessment is needed to determine whether these interventions are
appropriate.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
21. The health care provider inserts a chest tube in a client with a hemo-pneumothorax.
When monitoring the client after the chest tube placement, which of the following
findings is of greatest concern?
a. A large air leak in the water-seal chamber
b. 400 mL of blood in the collection chamber
c. Complaint of pain with each deep inspiration
d. Subcutaneous emphysema at the insertion site
ANS: B
The large amount of blood may indicate that the client is in danger of developing
hypovolemic shock. Drainage greater than 100 mL is to be reported to the health care
provider. A large air leak would be expected immediately after chest tube placement for
pneumothorax. The pain should be treated but is not as urgent a concern as the
possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but
is not unusual in a client with pneumothorax.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
22. The nurse is caring for a client who has a steering wheel injury as a result of an
automobile accident. Which of the following findings should be of most concern to the
nurse during the initial assessment?
a. Paradoxical chest movement
b. The complaint of chest wall pain
c. A heart rate of 110 beats/minute
d. A large bruised area on the chest
ANS: A
Paradoxical chest movement indicates that the client may have flail chest, which can
severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain,
a slightly elevated pulse rate, and chest bruising all require further assessment or
intervention, but the priority concern is poor gas exchange.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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23. The nurse is assessing a client who has just arrived after an automobile accident and the
nurse notes that the breath sounds are absent on the right side. Which of the following
actions should the nurse anticipate?
a. Emergency pericardiocentesis
b. Stabilization of the chest wall with tape
c. Administration of an inhaled bronchodilator
d. Insertion of a chest tube with a chest drainage system
ANS: D
The client’s history and absent breath sounds suggest a right-sided pneumothorax or
hemothorax, which will require treatment with a chest tube and drainage. The other
therapies would be appropriate for an acute asthma attack, flail chest, or cardiac
tamponade, but the client’s clinical manifestations are not consistent with these
problems.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
24. The nurse is caring for a client who has a right-sided chest tube following a thoracotomy
and has continuous bubbling in the suction-control chamber of the collection device.
Which of the following actions should the nurse implement?
a. Document the presence of a large air leak
b. Obtain and attach a new collection device
c. Notify the surgeon of a possible pneumothorax
d. Take no further action with the collection device
ANS: D
Continuous bubbling is expected in the suction-control chamber and indicates that the
suction-control chamber is connected to suction. An air leak would be detected in the
water-seal chamber. There is no evidence of pneumothorax. A new collection device is
needed when the collection chamber is filled.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
25. The nurse is providing preoperative instruction for a client who is scheduled for a left
pneumonectomy for cancer of the lung. Which of the following information should the
nurse include related to postoperative care?
a. Positioning on the right side
b. Bed rest for the first 24 hours
c. Frequent use of an incentive spirometer
d. Chest tubes to water-seal chest drainage
ANS: C
Frequent deep breathing and coughing are needed after chest surgery to prevent
atelectasis. To promote gas exchange, clients after pneumonectomy are positioned on the
surgical side. Chest tubes are not usually used after pneumonectomy because the
affected side is allowed to fill with fluid. Early mobilization decreases the risk for
postoperative complications such as pneumonia and deep vein thrombosis.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
26. To determine the effectiveness of prescribed therapies for a client with cor pulmonale
and right-sided heart failure, which of the following assessments should the nurse make?
a. Lung sounds
b. Heart sounds
c. Blood pressure
d. Peripheral edema
ANS: D
Cor pulmonale is right ventricular failure caused by pulmonary hypertension, so clinical
manifestations of right ventricular failure such as peripheral edema, jugular vein
distension, and right upper-quadrant abdominal tenderness would be expected.
Abnormalities in lung sounds, blood pressure, or heart sounds are not caused by cor
pulmonale.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
27. The nurse is caring for a client with primary pulmonary hypertension (PPH) who is
receiving nifedipine. Which of the following findings indicate that the treatment is
effective?
a. BP is less than 140/90 mm Hg
b. Client reports decreased exertional dyspnea
c. Heart rate is between 60 and 100 beats/minute
d. Client’s chest x-ray indicates clear lung fields
ANS: B
Since a major symptom of PPH is exertional dyspnea, an improvement in this symptom
would indicate that the medication was effective. Nifedipine will affect BP and heart rate,
but these parameters would not be used to monitor effectiveness of therapy for a client
with PPH. The chest x-ray will show clear lung fields even if the therapy is not effective.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
28. The nurse is caring for a client with a pleural effusion who is scheduled for a
thoracentesis. Which of the following actions should the nurse implement prior to the
procedure?
a. Start a peripheral intravenous line to administer the necessary sedative drugs.
b. Position the client sitting upright on the edge of the bed and leaning forward.
c. Remove the water pitcher and remind the client not to eat or drink anything for 6
hours.
d. Instruct the client about the importance of incentive spirometer use after the
procedure.
ANS: B
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When the client is sitting up, fluid accumulates in the pleural space at the lung bases and
can more easily be located and removed. The lung will expand after the effusion is
removed; incentive spirometry is not needed to assure alveolar expansion. The client
does not usually require sedation for the procedure, and there are no restrictions on oral
intake because the client is not sedated or unconscious.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
29. The nurse has completed discharge teaching for a client who has had a lung transplant.
Which of the following client statements indicate that the teaching was effective?
a. “I will make an appointment to see the doctor every year.”
b. “I will not turn the home oxygen up higher than 2 L/minute.”
c. “I will not worry if I feel a little short of breath with exercise.”
d. “I will call the health care provider right away if I develop a fever.”
ANS: D
Low-grade fever may indicate infection or acute rejection, so the client should notify the
health care provider immediately if the temperature is elevated. Clients require frequent
follow-up visits with the transplant team; annual health care provider visits would not be
sufficient. Home oxygen use is not an expectation after lung transplant. Shortness of
breath should be reported.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
30. Which of the following prescriptions should the nurse implement first for a client who
has just been admitted with probable bacterial pneumonia and sepsis?
a. Administer Aspirin suppository.
b. Send to radiology for chest x-ray.
c. Give ciprofloxacin 400 mg IV.
d. Obtain blood cultures from two sites.
ANS: D
Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be
obtained before antibiotic administration. The chest radiograph and Aspirin
administration can be done last.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
31. The nurse is caring for a client who has just had a thoracentesis. Which of the following
information is most important to communicate to the health care provider?
a. BP is 150/90 mm Hg.
b. Oxygen saturation is 89%.
c. Pain level is 5/10 with a deep breath.
d. Respiratory rate is 24 when lying flat.
ANS: B
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Oxygen saturation would be expected to improve after a thoracentesis. A saturation of
89% indicates that a complication such as pneumothorax may be occurring. The other
assessment data also indicate a need for ongoing assessment or intervention, but the low
oxygen saturation is the priority.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
32. The nurse is caring for a client who has just been admitted with pneumococcal
pneumonia has a temperature of 38.7°C (101.7°F) with a frequent cough and symptoms
of severe pleuritic chest pain. Which of the following prescribed medications should the
nurse give first?
a. Guaifenesin
b. Acetaminophen
c. Azithromycin
d. Codeine phosphate
ANS: C
Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The
other medications also are appropriate and should be given as soon as possible, but the
priority is to start antibiotic therapy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
33. Which of the following information obtained by the nurse about a client who has human
immunodeficiency virus (HIV) and active tuberculosis (TB) disease is most important to
communicate to the health care provider?
a. The Mantoux test had an induration of only 8 mm.
b. The chest x-ray showed infiltrates in the upper lobes.
c. The client is being treated with antiretrovirals for HIV infection.
d. The client has a cough that is productive of blood-tinged mucus.
ANS: C
Drug interactions can occur between the antiretrovirals used to treat HIV infection and
the medications used to treat tuberculosis. The other data are expected in a client with
HIV and TB disease.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
34. The nurse is caring for a client with pneumonia has a fever of 38.4°C (101.1°F), a
nonproductive cough, and an oxygen saturation of 89%. The client is very weak and
needs assistance to get out of bed. Which of the following nursing diagnoses is priority?
a. Hyperthermia related to increase in metabolic rate (illness)
b. Impaired transfer ability related to insufficient muscle strength
c. Ineffective airway clearance related to retained secretions
d. Ineffective breathing pattern related to respiratory muscle fatigue
ANS: D
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All these nursing diagnoses are appropriate for the client, but the client’s oxygen
saturation indicates that all body tissues are at risk for hypoxia unless their breathing
pattern is improved.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Diagnosis
35. The nurse observes an unregulated care provider doing all the following activities when
caring for a client with a pulmonary embolism. Which of the following actions should
cause the nurse to intervene with the client’s care?
a. Lowers the head of the client’s bed to 10 degrees.
b. Splints the client’s chest during coughing.
c. Helps the client to ambulate to the bathroom.
d. Assists the client to a bedside chair for meals.
ANS: A
Positioning the client with the head of the bed lowered will decrease ventilation. The
patient should be kept on bed rest in a semi-Fowler’s position to facilitate breathing. The
other actions are appropriate for a client with a pulmonary embolism.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
36. The nurse is caring for a client with a possible pulmonary embolism who has symptoms
of chest pain and difficulty breathing. The nurse assesses a heart rate of 142, BP 100/60
mm Hg, and respirations of 42 breaths/minute. Which of the following actions should
the nurse implement first?
a. Elevate the head of the bed to 45–60 degrees.
b. Administer the ordered pain medication.
c. Notify the client’s health care provider.
d. Offer emotional support and reassurance.
ANS: A
The client has symptoms consistent with a pulmonary embolism. Elevating the head of
the bed will improve ventilation and gas exchange. The other actions can be
accomplished after the head is elevated (and oxygen is started).
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
37. After the nurse has received change-of-shift report about the following four clients,
which client should be assessed first?
a. A 77-year-old client with tuberculosis (TB) who has four antitubercular
medications due in 15 minutes
b. A 23-year-old client with cystic fibrosis who has pulmonary function testing
scheduled
c. A 46-year-old client who has a deep vein thrombosis and is complaining of sudden
onset shortness of breath.
d. A 35-year-old client who was admitted the previous day with pneumonia and has a
temperature of 37.9°C (100.2°F)
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ANS: C
Sudden onset shortness of breath in a client with a deep vein thrombosis suggests a
pulmonary embolism and requires immediate assessment and actions such as oxygen
administration. The other clients also should be assessed as soon as possible, but there is
no indication that they may need immediate action to prevent clinical deterioration.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
38. The nurse is performing tuberculosis (TB) screening in a clinic that has many clients
who have immigrated to Canada. Before doing a TB skin test on a client, which of the
following questions is most important for the nurse to ask?
a. “Is there any family history of TB?”
b. “Have you received the bacille Calmette–Guérin (BCG) vaccine for TB?”
c. “How long have you lived in the Canada?”
d. “Do you take any over-the-counter (OTC) medications?”
ANS: B
Clients who have received the BCG vaccine will have a positive Mantoux test. Another
method for screening (such as a chest x-ray) will need to be used in determining whether
the client has a TB infection. The other information also may be valuable but is not as
pertinent to the decision about doing TB skin testing.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
39. The nurse is caring for a client in the emergency department who has an open stab
wound to the right chest. Which of the following actions should the nurse implement
first?
a. Position the client so that the right chest is dependent.
b. Keep the head of the client’s bed at no more than 30 degrees elevation.
c. Tape a nonporous dressing on three sides over the chest wound.
d. Cover the sucking chest wound firmly with an occlusive dressing.
ANS: C
The dressing taped on three sides will allow air to escape when intrapleural pressure
increases during expiration, but it will prevent air from moving into the pleural space
during inspiration. Placing the client on the right side or covering the chest wound with
an occlusive dressing will allow trapped air in the pleural space and cause tension
pneumothorax. The head of the bed should be elevated to 30–45 degrees to facilitate
breathing.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
40. The nurse is caring for a client who has incisional pain, a poor cough effort, and
scattered rhonchi after a thoracotomy. Which of the following actions should the nurse
take first?
a. Assist the client to sit up at the bedside.
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b. Splint the client’s chest during coughing.
c. Medicate the client with the prescribed morphine.
d. Have the client use the prescribed incentive spirometer.
ANS: C
A major reason for atelectasis and poor airway clearance in clients after chest surgery is
incisional pain (which increases with deep breathing and coughing). The first action by
the nurse should be to medicate the client to minimize incisional pain. The other actions
are all appropriate ways to improve airway clearance but should be done after the
morphine is given.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
41. The nurse is caring for a client with primary pulmonary hypertension (PPH) who has
been taking a calcium channel blocker with no effect. Which of the following
medications should the nurse expect that the client will receive next?
a. Nifedipine
b. Diltiazem
c. Iloprost
d. Bosentan
ANS: C
Iloprost has revolutionized care for PPH. It is now the treatment of choice for select
clients unresponsive to calcium channel blockers. It is a long-acting chemically stable
prostacyclin analogue, which is administered in an aerosolized form (100–150 mcg/day).
Bosentan is an oral form of prostacyclin used to treat PPH. Nifedipine and diltiazem are
calcium channels.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
42. The nurse is caring for a client with pneumonia who has symptoms of a sharp pain
“whenever I take a deep breath.” Which of the following actions should the nurse take
next?
a. Listen to the client’s lungs.
b. Administer the PRN morphine.
c. Have the client cough forcefully.
d. Notify the client’s health care provider.
ANS: A
The client’s statement indicates that pleurisy or a pleural effusion may have developed
and the nurse will need to listen for a pleural friction rub or decreased breath sounds.
Assessment should occur before administration of pain medications. The client is
unlikely to be able to cough forcefully until pain medication has been administered. The
nurse will want to obtain more assessment data before calling the health care provider.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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OTHER
1. The nurse notes new onset confusion in an older-adult client in a long-term care facility.
The client is normally alert and oriented. In which order should the nurse take the
following actions?
a. Obtain the oxygen saturation.
b. Check the client’s pulse rate.
c. Document the change in status.
d. Notify the health care provider.
ANS:
A, B, D, C
Assessment for physiological causes of new onset confusion such as pneumonia,
infection, or perfusion problems should be the first action by the nurse. Airway and
oxygenation should be assessed first, then circulation. After assessing the client, the
nurse should notify the health care provider. Finally, documentation of the assessments
and care should be done.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 31: Nursing Management: Obstructive Pulmonary Diseases
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is caring for a client with chronic bronchitis who has a new prescription for a
combined fluticasone and salmeterol inhaler and the client asks the nurse the purpose of
using two drugs. Which of the following information is the basis for the nurse’s response?
a. One drug decreases inflammation, and the other is a bronchodilator.
b. It is a combination of long-acting and slow-acting bronchodilators.
c. The combination of two drugs works more quickly in an acute asthma attack.
d. The two drugs work together to block the effects of histamine on the bronchioles.
ANS: A
Salmeterol is a long-acting bronchodilator, and fluticasone is a corticosteroid. They work
together to prevent asthma attacks. Neither medication is an antihistamine. The two-drug
combination of salmeterol and fluticasone is not used during an acute attack because the
medications do not work rapidly.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
2. The nurse has completed client teaching about the administration of salmeterol using a
metered-dose inhaler (MDI). Which of the following actions by the client indicates good
understanding of the teaching?
a. The client attaches a spacer before using the MDI.
b. The client coughs vigorously after using the inhaler.
c. The client floats the MDI in water to see if it is empty.
d. The client activates the inhaler at the onset of expiration.
ANS: A
Spacers can improve the delivery of medication to the lower airways. The other client
actions indicate a need for further teaching.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
3. The nurse is preparing a client with possible asthma for pulmonary function testing. Which
of the following instructions should the nurse include in the teaching plan?
a. Avoid eating or drinking for several hours before the testing.
b. Use rescue medications immediately before the tests are done.
c. Take oral corticosteroids at least 2 hours before the examination.
d. Withhold bronchodilators for 6–12 hours before the examination.
ANS: D
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Bronchodilators are held before pulmonary function testing so that a baseline assessment
of airway function can be determined. Testing is repeated after bronchodilator use to
determine whether the decrease in lung function is reversible. There is no need for the
client to be NPO. Oral corticosteroids also should be held before the examination and
corticosteroids given 2 hours before the examination would be at a high level. Rescue
medications (which are bronchodilators) would not be given until after the baseline
pulmonary function was assessed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
4. Which of the following information should the nurse include when teaching the client with
asthma about the prescribed medications?
Utilize the inhaled corticosteroid when shortness of breath occurs.
Inhale slowly and deeply when using the dry-powder inhaler (DPI).
Hold your breath for 5 seconds after using the bronchodilator inhaler.
Tremors are an expected adverse effect of rapidly acting bronchodilators.
a.
b.
c.
d.
ANS: D
Tremors are a common adverse effect of short-acting b2-adrenergic (SABA) medications
and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act
rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The client should
hold the breath for 10 seconds after using inhalers.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
5. The nurse is evaluating the effectiveness of therapy for a client who has received treatment
during an asthma attack. Which of the following findings is the best indicator that the
therapy has been effective?
a. No wheezes are audible.
b. Oxygen saturation is >92%.
c. Accessory muscle use has decreased.
d. Respiratory rate is 16 breaths/minute.
ANS: B
The goal for treatment of an asthma attack is to keep the oxygen saturation >92%. The
other client data may occur when the client is too fatigued to continue with the increased
work of breathing required in an asthma attack.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
6. The nurse is assessing a client in the asthma clinic who has recorded daily peak flows that
are 85% of the baseline. Which of the following actions should the nurse plan to take?
Teach the client about the use of oral corticosteroids.
Administer a bronchodilator and recheck the peak flow.
Instruct the client to continue to use current medications.
Evaluate whether the peak flow meter is being used correctly.
a.
b.
c.
d.
ANS: C
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The client’s peak flow readings indicate good asthma control (values over 80%), and no
changes are needed. The other actions would be used for clients in the yellow or red zones
for peak flow.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
7. Which of the following actions by a client who has asthma indicates a good understanding
of the nurse’s teaching about peak flow meter use?
a. The client records an average of three peak flow readings every day.
b. The client inhales rapidly through the peak flow meter mouthpiece.
c. The client uses the albuterol metered-dose inhaler (MDI) for peak flows in the
yellow zone.
d. The client calls the health care provider when the peak flow is in the green zone.
ANS: C
Readings in the yellow zone indicate a decrease in peak flow; the client should use
short-acting b2-adrenergic (SABA) medications. The best of three peak flow readings
should be recorded. Readings in the green zone indicate good asthma control. The client
should exhale quickly and forcefully through the peak flow meter mouthpiece to obtain the
readings.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
8. The nurse is assessing a young adult client in the outpatient clinic who has a new diagnosis
of emphysema and does not have a history of smoking. Which of the following
information should the nurse anticipate teaching the client about?
a. a1-antitrypsin testing
b. Use of the nicotine patch
c. Continuous pulse oximetry
d. Effects of leukotriene modifiers
ANS: A
When emphysema occurs in young clients, especially without a smoking history, a
congenital deficiency in a1-antitrypsin should be suspected. Because the client does not
smoke, a nicotine patch would not be ordered. There is no indication that the client
requires continuous pulse oximetry. Leukotriene modifiers would be used in clients with
asthma, not with emphysema.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
9. Which of the following information about a newly admitted client with chronic obstructive
pulmonary disease (COPD) indicates that the nurse should consult with the health care
provider before administering the prescribed theophylline?
a. The client has had a recent 10-pound weight gain.
b. The client has a cough productive of green mucus.
c. The client denies any shortness of breath at present.
d. The client takes cimetidine 150 mg daily.
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ANS: D
Cimetidine interferes with the metabolism of theophylline, and concomitant administration
may lead rapidly to theophylline toxicity. The other client information would not impact
whether the theophylline should be administered or not.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
10. The nurse is caring for a client with chronic bronchitis who has a nursing diagnosis of
impaired breathing pattern related to anxiety. Which of the following nursing actions is
best to include in the plan of care?
a. Titrate oxygen to keep saturation at least 90%.
b. Discuss a high-protein, high-calorie diet with the client.
c. Suggest the use of over-the-counter sedative medications.
d. Teach the client how to effectively use pursed lip breathing.
ANS: D
Pursed lip breathing techniques assist in prolonging the expiratory phase of respiration and
decrease air trapping. There is no indication that the client requires oxygen therapy or an
improved diet. Sedative medications should be avoided because they decrease respiratory
drive.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
11. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who
has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which of the
following interventions is best to address this problem?
a. Increase the client’s intake of fruits and fruit juices.
b. Have the client exercise for 10 minutes before meals.
c. Assist the client in choosing foods with a lot of texture.
d. Offer high calorie snacks between meals and at bedtime.
ANS: D
Eating small amounts more frequently (as occurs with snacking) will increase caloric
intake by decreasing the fatigue and feelings of fullness associated with large meals.
Clients with COPD should rest before meals. Foods that have a lot of texture may take
more energy to eat and lead to decreased intake. Although fruits and juices are not
contraindicated, foods high in protein are a better choice.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
12. The nurse is interviewing a client with a new diagnosis of chronic obstructive pulmonary
disease (COPD). Which of the following information will help most in confirming a
diagnosis of chronic bronchitis?
a. The client tells the nurse about a family history of bronchitis.
b. The client’s history indicates a 40 pack-year cigarette history.
c. The client denies having any respiratory problems until the last 6 months.
d. The client complains about a productive cough every winter for 3 months.
ANS: D
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A diagnosis of chronic bronchitis is based on a history of having a productive cough for 3
months for at least 2 consecutive years. There is no familial tendency for chronic
bronchitis. Although smoking is the major risk factor for chronic bronchitis, a smoking
history does not confirm the diagnosis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
13. After the nurse has finished teaching a client about pursed lip breathing, which of the
following client actions indicate that more teaching is needed?
a. The client inhales slowly through the nose.
b. The client tenses the neck muscles while exhaling.
c. The client practises by blowing through a straw.
d. The client’s ratio of inhalation to exhalation is 1:3.
ANS: B
The client should relax the neck and shoulder muscles while doing pursed lip breathing.
The other actions by the client indicate a good understanding of pursed lip breathing.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
14. Which of the following findings by the nurse for a client with a nursing diagnosis of
impaired gas exchange will be most useful in evaluating the effectiveness of treatment?
a. Pulse oximetry reading of 91%
b. Absence of wheezes or crackles
c. Decreased use of accessory muscles
d. Respiratory rate of 22 breaths/minute
ANS: A
For the nursing diagnosis of impaired gas exchange, the best data for evaluation are
arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either
improvement or impending respiratory failure caused by fatigue.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
15. The nurse is evaluating the effectiveness of therapy for a client with cor pulmonale. Which
of the following findings should the nurse assess for in the client?
Elevated temperature
Clubbing of the fingers
Jugular vein distension
Complaints of chest pain
a.
b.
c.
d.
ANS: C
Cor pulmonale causes clinical manifestations of right ventricular failure, such as jugular
vein distension. The other clinical manifestations may occur in the client with other
complications of chronic obstructive pulmonary disease (COPD) but are not indicators of
cor pulmonale.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
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16. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who
is receiving oxygen. Which of the following actions is best for the nurse to implement to
determine the appropriate oxygen flow rate?
a. Minimize oxygen use to avoid oxygen dependency.
b. Maintain the pulse oximetry level at 90% or greater.
c. Administer oxygen according to the client’s level of dyspnea.
d. Avoid administration of oxygen at a rate of more than 2 L/minute.
ANS: B
The best way to determine the appropriate oxygen flow rate is by monitoring the client’s
oxygenation either by arterial blood gases (ABGs) or pulse oximetry; an oxygen saturation
of 90% indicates adequate blood oxygen level without the danger of suppressing the
respiratory drive. For clients with an exacerbation of COPD, an oxygen flow rate of 2
L/minute may not be adequate. Because oxygen use improves survival rate in clients with
COPD, there is not a concern about oxygen dependency. The client’s perceived dyspnea
level may be affected by other factors (such as anxiety) besides blood oxygen level.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
17. Which of the following information should the nurse include in teaching a client with
chronic obstructive pulmonary disease (COPD) who has a new prescription for home
oxygen therapy?
a. Storage of oxygen tanks will require adequate space in the home.
b. Travel opportunities will be limited because of the use of oxygen.
c. Oxygen flow should be increased if the client has more dyspnea.
d. Oxygen use can improve the client’s prognosis and quality of life.
ANS: D
Research supports the use of home oxygen to improve quality of life and prognosis. Since
increased dyspnea may be a symptom of an acute process such as pneumonia, the client
should notify the physician rather than increasing the oxygen flow rate if dyspnea becomes
worse. Oxygen can be supplied using liquid, storage tanks, or concentrators, depending on
individual client circumstances. Travel is possible by using portable oxygen concentrators.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
18. The nurse is caring for a client who is receiving 35% oxygen via a Venturi mask. To
ensure the correct amount of oxygen delivery, it is most important that the nurse
implement which of the following actions?
a. Keep the air entrainment ports clean and unobstructed.
b. Give a high enough flow rate to keep the bag from collapsing.
c. Use an appropriate adaptor to ensure adequate oxygen delivery.
d. Drain moisture condensation from the oxygen tubing every hour.
ANS: A
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The air entrainment ports regulate the oxygen percentage delivered to the client, so they
must be unobstructed. A high oxygen flow rate is needed when giving oxygen by partial
rebreather or nonrebreather masks. The use of an adaptor can improve humidification but
not oxygen delivery. Draining oxygen tubing is necessary when caring for a client
receiving mechanical ventilation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
19. Which of the following information should the nurse teach a client with COPD?
a. To exercise immediately before a meal.
b. To eat a high-calorie, low-protein diet.
c. To have 5 or 6 small meals a day.
d. Avoid foods that are cooked in a microwave.
ANS: C
Eating five to six small meals per day helps avoid feelings of bloating and early satiety.
The use of frozen foods and a microwave oven may help conserve a client’s energy in
food preparation. Exercises should be avoided for at least 1 hour before and after eating. A
high-calorie, high-protein diet is recommended.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
20. The nurse is developing a teaching plan to help increase activity tolerance at home for a
70-year-old client with severe chronic obstructive pulmonary disease (COPD). Which of
the following exercise goals should the nurse teach the client?
a. Walk until pulse rate exceeds 130.
b. Walk for a total of 20 minutes daily.
c. Exercise until shortness of breath occurs.
d. Limit exercise to activities of daily living (ADLs).
ANS: B
The goal for exercise programs for clients with COPD is to increase exercise time
gradually to a total of 20 minutes daily. Shortness of breath is normal with exercise and
not an indication that the client should stop. Limiting exercise to ADLs will not improve
the client’s exercise tolerance. A 70-year-old client should have a pulse rate of 120 or less
with exercise (80% of the maximal heart rate of 150).
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
21. The nurse is caring for a client with severe chronic obstructive pulmonary disease (COPD)
who tells the nurse, “I wish I were dead! I cannot do anything for myself anymore.” Based
on this information, which of the following nursing diagnoses is best?
a. Hopelessness related to chronic stress (expectation of death)
b. Ineffective coping related to insufficient sense of control
c. Deficient knowledge related insufficient information (education about COPD)
d. Social isolation related to insufficient personal resources (increased physical
dependence)
ANS: D
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The client’s statement about not being able to do anything for himself or herself supports
this diagnosis. Emotions frequently encountered include guilt, depression, anxiety, social
isolation, denial, and dependence. Although deficient knowledge, hopelessness, and
ineffective coping also may be appropriate diagnoses for clients with COPD, the data for
this client do not support these diagnoses.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Diagnosis
22. The nurse is admitting a client with chronic obstructive pulmonary disease (COPD) to the
hospital. Which of the following positions should the nurse place the client in to improve
gas exchange?
a. Resting in bed with the head elevated to 45–60 degrees
b. Sitting up at the bedside in a chair and leaning slightly forward
c. Resting in bed in a high Fowler’s position with the knees flexed
d. In the Trendelenburg position with several pillows behind the head
ANS: B
Clients with COPD improve the mechanics of breathing by sitting up in the “tripod”
position. Resting in bed with the head elevated would be an alternative position if the
client was confined to bed, but sitting in a chair allows better ventilation. The
Trendelenburg position or sitting upright in bed with the knees flexed would decrease the
client’s ability to ventilate well.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
23. Which of the following diagnostic tests should the nurse plan to discuss with a client who
has progressively increasing dyspnea and is being evaluated for a possible diagnosis of
chronic obstructive pulmonary disease (COPD)?
a. Eosinophil count
b. Spirometry
c. Immunoglobin E (IgE) levels
d. Radioallergosorbent test (RAST)
ANS: B
The diagnosis of COPD is confirmed by spirometry regardless of whether the client has
chronic symptoms. The other tests would be used to test for an allergic component for
asthma, but will not be used in the diagnosis of COPD.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
24. Which of the following actions should be included in the plan of care for a client with
cystic fibrosis (CF) who is admitted to the hospital with increased dyspnea?
a. Schedule a sweat chloride test.
b. Arrange for a hospice nurse visit.
c. Place the client on a low-sodium diet.
d. Perform chest physiotherapy every 4 hours.
ANS: D
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Routine scheduling of airway clearance techniques is an essential intervention for clients
with CF. A sweat chloride test is used to diagnose CF, but it does not provide any
information about the effectiveness of therapy. There is no indication that the client is
terminally ill. Clients with CF lose excessive sodium in their sweat and require high
amounts of dietary sodium.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
25. The nurse is caring for a client who is hospitalized with cystic fibrosis (CF) and is
coughing up large quantities of thick green mucus. Which of the following treatments
should the nurse include in the teaching plan?
a. Antibiotic resistance
b. Inhaled bronchodilators
c. Oral corticosteroid therapy
d. Aerosolized amoxicillin
ANS: D
The colour of the mucus and the client’s history of CF suggest Pseudomonas infection; an
antibiotic is required. Oral corticosteroids and inhaled bronchodilators will not be effective
in treating the respiratory infection; the effectiveness of bronchodilators has not been
established for CF. Pseudomonas infections are usually responsive (not resistant) to TOBI.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
26. A young adult client with cystic fibrosis (CF) tells the nurse that she is considering having
a child. Which of the following responses is best for the nurse to respond initially?
“Are you aware of the normal lifespan for clients with CF?”
“Do you need any information to help you with the decision?”
“You will need to have genetic counselling before making a decision.”
“Many women with CF do not have difficulty in conceiving children.”
a.
b.
c.
d.
ANS: B
The nurse’s initial response should be to assess the client’s knowledge level and need for
information. Although the lifespan for clients with CF is likely to be shorter than normal,
it would not be appropriate for the nurse to address this as the initial response to the
client’s comments. The other responses are accurate, but the nurse should first assess the
client’s understanding about the issues surrounding pregnancy.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
27. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who
has rhonchi throughout the lung fields and a chronic, nonproductive cough. Which of the
following nursing actions is best?
a. Change the oxygen flow rate to the highest prescribed rate.
b. Reinforce the ongoing use of pursed lip breathing techniques.
c. Educate the client to use the Flutter airway clearance device.
d. Teach the client about consistent use of inhaled corticosteroids.
ANS: C
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Airway clearance devices assist with moving mucus into larger airways where it can more
easily be expectorated. The other actions may be appropriate for some clients with COPD,
but they are not indicated for this client’s problem of thick mucous secretions.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
28. After the nurse has completed diet teaching for a client with chronic obstructive
pulmonary disease (COPD) who has a body mass index (BMI) of 20, which of the
following client statements indicate that the teaching has been effective?
a. “I will drink lots of fluids with my meals.”
b. “I will have ice cream as a snack every day.”
c. “I will exercise for 15 minutes before meals.”
d. “I will decrease my intake of meat or poultry.”
ANS: B
High-calorie foods like ice cream are an appropriate snack for clients with COPD. Fluid
intake of 3 L/day is recommended, but fluids should be taken between meals rather than
with meals to improve oral intake of solid foods. The client should avoid exercise for an
hour before meals to prevent fatigue while eating. Meat and dairy products are high in
protein and are good choices for the client with COPD.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
29. The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about
exercise. Which of the following information should the nurse include?
“Stop exercising if you start to feel short of breath.”
“Use the bronchodilator before you start to exercise.”
“Breathe in and out through the mouth while you exercise.”
“Upper body exercise should be avoided to prevent dyspnea.”
a.
b.
c.
d.
ANS: B
Use of a bronchodilator before exercise improves airflow for some clients and is
recommended. Shortness of breath is normal with exercise and not a reason to stop.
Clients should be taught to breathe in through the nose and out through the mouth (using a
pursed lip technique). Upper-body exercise can improve the mechanics of breathing in
clients with COPD.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
30. Which of the following information given by a client with asthma while the nurse is doing
the admission assessment is most indicative of a need for a change in therapy?
a. The client uses terbutaline before any aerobic exercise.
b. The client says that the asthma symptoms are worse every spring.
c. The client’s heart rate increases after using the salbutamol inhaler.
d. The client’s only medications are formoterol and salmeterol.
ANS: D
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Long-acting b2-agonists should be used only in clients who also are using an inhaled
corticosteroid for long-term control. The other information given by the client requires
further assessment by the nurse but is not unusual for a client with asthma.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
31. The nurse is conducting an admission history for a client with possible asthma who has
new-onset wheezing and shortness of breath. Which of the following information indicates
a need for a change in therapy?
a. The client has a history of pneumonia 2 years ago.
b. The client has chronic inflammatory bowel disease.
c. The client takes propranolol for hypertension.
d. The client uses acetaminophen for headaches.
ANS: C
b-blockers such as propranolol can cause bronchospasm in some clients. The other
information will be documented in the health history but does not indicate a need for a
change in therapy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
32. Which of the following topics should the nurse include in medication teaching for a client
with newly diagnosed persistent asthma?
Use of long-acting b-adrenergic medications
Adverse effects of sustained-release theophylline
Self-administration of inhaled corticosteroids
Complications associated with oxygen therapy
a.
b.
c.
d.
ANS: C
Inhaled corticosteroids are more effective in improving asthma than any other drug and are
indicated for all clients with persistent asthma. The other therapies would not typically be
first-line treatments for newly diagnosed asthma.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
33. The nurse is caring for a client with cystic fibrosis (CF) who has blood glucose levels that
are consistently 11–14 mmol/L. Which of the following nursing actions should the nurse
plan to implement?
a. Discuss the role of diet in blood glucose control.
b. Educate the client about administration of insulin.
c. Give oral hypoglycemic medications before meals.
d. Evaluate the client’s home use of pancreatic enzymes.
ANS: B
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The glucose levels indicate that the client has developed CF-related diabetes; insulin
therapy will be required. Since the etiology of diabetes in CF is inadequate insulin
production, oral hypoglycemic agents are not effective. Clients with CF need a
high-calorie diet. Inappropriate use of pancreatic enzymes would not be a cause of
hyperglycemia in a client with CF.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
34. The nurse is caring for a client with a history of asthma. Which of the following
assessments finding should the nurse communicate immediately to the health care
provider?
a. Pulse oximetry reading of 91%
b. Respiratory rate of 26 breaths/minute
c. Use of accessory muscles in breathing
d. Peak expiratory flow rate of 240 mL/minute
ANS: C
Use of accessory muscle indicates that the client is experiencing respiratory distress and
rapid intervention is needed. The other data indicate the need for ongoing monitoring and
assessment but do not suggest that immediate treatment is required.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
35. Which of the following actions should the nurse anticipate taking first when a client who
is experiencing an asthma attack develops bradycardia and a decrease in wheezing?
a. Assist with endotracheal intubation.
b. Document changes in respiratory status.
c. Encourage the client to cough and deep breathe.
d. Administer IV methylprednisolone.
ANS: A
The client’s assessment indicates impending respiratory failure, and the nurse should
prepare to assist with intubation and mechanical ventilation. IV corticosteroids require
several hours before having any effect on respiratory status. The client will not be able to
cough or deep breathe effectively. Documentation is not a priority at this time.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
36. The nurse is caring for a client in the emergency department who is experiencing an acute
asthma attack. After listening to the client’s breath sounds, which of the following actions
should the nurse take next?
a. Start an intravenous with Ringer’s Lactate.
b. Ask about inhaled corticosteroid use.
c. Determine when the dyspnea started.
d. Obtain the forced expiratory volume (FEV) flow rate.
ANS: D
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The examiner can assess the degree of severity by measuring FEV1 or PEFR, identifying
the degree of change in objective measurements, and evaluating the baseline pulse
oximetry value. The length of time the attack has persisted is not as important as
determining the client’s status at present. It is important to know about the medications the
client is using but not as important as assessing the breath sounds. Initiating IV therapy is
not a priority at this time.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
37. Which of the following findings in a client who has received omalizumab is considered an
adverse effect?
a. Pain at injection site
b. Flushing and dizziness
c. Respiratory rate 22 breaths/minute
d. Peak flow reading 75% of normal
ANS: A
Reaction at injection site is the only adverse effect of omalizumab. The other information
is not related to omalizumab therapy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
38. The nurse in the emergency department receives arterial blood gas results for four recently
admitted clients with asthma. Which of the following clients require the most rapid action
by the nurse?
a. 20-year-old with ABG results: pH 7.28, PaCO2 60 mm Hg, and PaO2 58 mm Hg
b. 32-year-old with ABG results: pH 7.50, PaCO2 30 mm Hg, and PaO2 65 mm Hg
c. 40-year-old with ABG results: pH 7.34, PaCO2 33 mm Hg, and PaO2 80 mm Hg
d. 64-year-old with ABG results: pH 7.31, PaCO2 58 mm Hg, and PaO2 64 mm Hg
ANS: A
The pH, PaCO2, and PaO2 indicate that the client has severe uncompensated respiratory
acidosis and hypoxemia. Rapid action will be required to prevent increasing hypoxemia
and correct the acidosis. The other clients also should be assessed as quickly as possible,
but do not require interventions as quickly as the 20-year-old.
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
39. The nurse is teaching a client about continuous home oxygen use and cautions the client to
take extra care to not run out of oxygen. Which of the following seasons should the nurse
instruct the client has the highest rate of oxygen evaporation?
a. Spring
b. Summer
c. Fall
d. Winter
ANS: B
During the summer, with liquid oxygen, evaporation is accelerated and may decrease
reservoir duration to less than 1 week.
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DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
40. The nurse is caring for a client with asthma who has a baseline peak flow reading of 600
mL and calls the nurse, stating that the current peak flow is 420 mL. Which of the
following actions should the nurse take first?
a. Tell the client to go to the hospital emergency department.
b. Instruct the client to use the prescribed albuterol.
c. Ask about recent exposure to any new allergens or asthma triggers.
d. Question the client about use of the prescribed inhaled corticosteroids.
ANS: B
The client’s peak flow is 70% of normal, in the yellow zone, indicating a need for
immediate use of short-acting b2-adrenergic SABA medications. Assessing for correct use
of medications or exposure to allergens also is appropriate, but would not address the
current decrease in peak flow. Because the client is currently in the yellow zone,
hospitalization is not needed.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
41. The following medications are prescribed by the health care provider for a client having an
acute asthma attack. Which medication should the nurse administer first?
Salmeterol 50 mcg per dry-powder inhaler (DPI)
Salbutamol 2.5 mg per nebulizer
Triamcinolone 2 puffs per metered-dose inhaler (MDI)
Methylprednisolone 60 mg IV
a.
b.
c.
d.
ANS: B
Salbutamol is a rapidly acting bronchodilator and is the first-line medication to reverse
airway narrowing in acute asthma attacks. It is known as an asthma rescue medication.
The other medications work more slowly.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
42. The nurse has received a change-of-shift report about the following clients with chronic
obstructive pulmonary disease (COPD). Which client should the nurse assess first?
A client with a respiratory rate of 38
A client with loud expiratory wheezes
A client with jugular vein distension and peripheral edema
A client who has a cough productive of thick, green mucus
a.
b.
c.
d.
ANS: A
A respiratory rate of 38 indicates severe respiratory distress, and the client needs
immediate assessment and intervention to prevent possible respiratory arrest. The other
clients also need assessment as soon as possible, but they do not need to be assessed as
urgently as the client with tachypnea.
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
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Chapter 32: Nursing Assessment: Hematological System
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is providing discharge teaching to a client who has had an emergency
splenectomy following an automobile accident. Which of the following events should the
nurse inform the client that they are at an increased risk of developing?
a. Infection
b. Lymphedema
c. Chronic anemia
d. Prolonged bleeding
ANS: A
The spleen plays a major role in immune function. Splenectomy increases the risk for
infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and
anemia are not increased after splenectomy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
2. The nurse is obtaining a health history from a client and notes numerous petechiae. Which
of the following assessments should the nurse anticipate?
a. Bruising on the skin
b. Pinpoint purplish-red lesions
c. Small focal red lesions
d. Brown spots on mucous membranes
ANS: B
Petechiae are small, purplish-red lesions. Ecchymosis is bruising on the skin. Small focal
red lesions are telangiectasia. Purpura are small hemorrhages on the skin or mucous
membranes resulting in a rash of purple, red, or brown spots.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
3. The nurse is reviewing laboratory data for an older-adult client. Which of the following
results should be of most concern?
White blood cell (WBC) count of 3.5 ´ 109/L
Hematocrit of 37%
Platelet count of 400 ´ 109/L
Hemoglobin of 118 g/L
a.
b.
c.
d.
ANS: A
The total WBC count is not usually affected by aging, and the low WBC here would
indicate that the client’s immune function may be compromised. The platelet count is
normal. The slight decrease in hemoglobin and hematocrit is not unusual for an older
client.
DIF:
Cognitive Level: Application
TOP: Nursing Process: Assessment
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MSC: NCLEX: Physiological Integrity
4. The health care provider performs a bone marrow aspiration from the left posterior iliac
crest on a client with pancytopenia. Which of the following actions should the nurse
implement following the procedure?
a. Elevate the head of the bed to 45 degrees.
b. Apply a sterile Band-Aid at the aspiration site.
c. Use half-inch sterile gauze to pack the wound.
d. Apply a pressure dressing on the aspiration site.
ANS: D
A pressure dressing is used to cover the aspiration site. The wound after bone marrow
biopsy is small and will not be packed with gauze. There is no indication that the head
needs to be elevated for this client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
5. The nurse is caring for a client with a chronic iron-deficiency anemia. Which of the
following assessment findings should the nurse anticipate?
Yellow-tinged sclerae
Shiny, smooth tongue
Numbness of the extremities
Gum bleeding and tenderness
a.
b.
c.
d.
ANS: B
Loss of the papillae of the tongue occurs with chronic iron deficiency. Scleral jaundice is
associated with hemolysis, gum bleeding and tenderness occur with thrombo-cytopenia or
neutropenia, and extremity numbness is associated with vitamin B12 deficiency or
pernicious anemia.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
6. A client’s complete blood count shows a hemoglobin of 200 g/L and a hematocrit of 54%.
Which of the following questions should the nurse ask to determine possible causes of this
finding?
a. “Has there been any recent weight loss?”
b. “Do you have any problems with your vision?”
c. “What is your intake of fruits and vegetables?”
d. “Have you noticed any dark or bloody stools?”
ANS: B
The hemoglobin and hematocrit results indicate polycythemia and polycythemia may
cause visual abnormalities. The other questions will be appropriate for clients who are
anemic.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
7. The nurse is caring for a client who is receiving heparin. Which of the following
laboratory tests should the nurse monitor?
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a.
b.
c.
d.
Prothrombin time (PT)
Fibrin degradation products (FDP)
International normalized ratio (INR)
Activated partial thromboplastin time (aPTT)
ANS: D
aPTT testing is used to determine whether heparin is at a therapeutic level. FDP is useful
in diagnosis of problems such as disseminated intravascular coagulation (DIC). PT and
INR are most commonly used to test for therapeutic levels of warfarin.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
8. The nurse is evaluating the red cell indices result of a client’s laboratory report. Which of
the following interpretations is correct related to a low mean corpuscular volume (MCV)?
a. Hypochromic red blood cells (RBCs)
b. Inadequate numbers of RBCs
c. Low hemoglobin in the RBCs
d. Small size of the RBCs
ANS: D
The MCV is low when the RBCs are smaller than normal. Inadequate numbers of RBCs
are an indication of anemia. Low levels of hemoglobin in the RBCs and hypochromic
RBCs result in a low mean corpuscular hemoglobin (MCH).
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
9. While examining the lymph nodes during physical assessment, the nurse would be most
concerned about which of the following findings?
a. A 2-cm nontender supraclavicular node
b. A 1-cm mobile and nontender axillary node
c. An inability to palpate any superficial lymph nodes
d. Firm inguinal nodes in a client with an infected foot
ANS: A
Enlarged and nontender nodes are most suggestive of malignancy such as lymphoma. Firm
nodes are an expected finding in an area of infection. The superficial lymph nodes are
usually not palpable in adults, but if they are palpable, they are normally 0.5–1 cm and
nontender.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
10. The nurse is caring for a client who had an intraoperative hemorrhage 12 hours ago.
Which of the following laboratory results should the nurse anticipate?
Hematocrit of 45%
Hemoglobin of 132 g/L
Decreased white blood cell (WBC) count
Elevated reticulocyte count
a.
b.
c.
d.
ANS: D
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Hemorrhage causes the release of more immature RBCs from the bone marrow into the
circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not
affected by bleeding.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
11. The nurse is caring for a client whose complete blood count (CBC) and differential
indicate that the client is neutropenic. Which of the following actions should the nurse
include in the plan of care?
a. Avoid intramuscular injections.
b. Encourage increased oral fluids.
c. Check temperature every 4 hours.
d. Increase intake of iron-rich foods.
ANS: C
Neutropenic clients are at high risk for infection and sepsis and should be monitored
frequently for signs of infection. The other actions would not address the client’s
neutropenia.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
12. The nurse is caring for a newly admitted client whose complete blood count (CBC) shows
a “shift to the left.” Which of the following assessments should the nurse monitor in the
plan of care?
a. Cool extremities
b. Pallor and weakness
c. Elevated temperature
d. Low oxygen saturation
ANS: C
The term shift to the left indicates that the number of immature polymorphonuclear
neutrophils, or bands, is elevated and is a sign of severe infection. There is no indication
that the client is at risk for hypoxemia, pallor or weakness, or cool extremities.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
13. The health care provider orders an ultrasound of the spleen for a client who has been in a
car accident. Which of the following actions should the nurse take before this procedure?
Check for any iodine allergy.
Insert a large-bore IV catheter.
Place the client on NPO status.
Assist the client to a flat position.
a.
b.
c.
d.
ANS: D
The client is placed in a flat position before splenic ultrasound. The client does not have to
be NPO or have an IV line. No iodine-containing materials are used for ultrasound.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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14. The nurse is caring for a client with pancytopenia of unknown origin who is confused and
is scheduled for the following diagnostic tests. Which of the following tests should the
nurse contact the client’s family member to obtain a signed consent form?
a. ABO blood typing
b. Bone marrow biopsy
c. Abdominal ultrasound
d. Complete blood count (CBC)
ANS: B
Bone marrow biopsy is a minor surgical procedure that requires the client or guardian to
sign a surgical consent form. The other procedures do not require a signed consent by the
client or family.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
15. The nurse is reviewing the complete blood count (CBC) for a client admitted with
abdominal pain. Which of the following information will be most important for the nurse
to communicate to the health care provider?
a. Monocytes 4%
b. Hemoglobin 116 g/L
c. Platelet count 145 ´ 109/L
d. White blood cells 13.5 ´ 109/L
ANS: D
The elevation in WBCs indicates that an abdominal infection may be the cause of the
client’s pain and that further diagnostic testing is needed. The monocytes are at a normal
level. The slight decreases in hemoglobin and platelet count also would be reported but
would not require any immediate action.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
MULTIPLE RESPONSE
1. The nurse is reviewing the laboratory results of clotting study tests for the client. Which of
the following findings should the nurse identify as abnormal? (Select all that apply.)
a. Activated clotting time 118 seconds
b. Activated partial thromboplastin time 40 seconds
c. D-dimer 200 mcg/L
d. Fibrinogen 5 g/L
e. Prothrombin time 21 seconds
ANS: B, D, E
The activated partial thromboplastin time is elevated (normal: 25–35 seconds); fibrinogen
is elevated (normal: 2–4 g/L); and, the prothrombin time is elevated (normal: 11–16
seconds). The activated clotting time is within normal limits (70–120 seconds). The
D-dimer is within normal limits (<250 mcg/L).
DIF:
Cognitive Level: Analysis
TOP: Nursing Process: Assessment
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Chapter 33: Nursing Management: Hematological Problems
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is caring for a client with anemia who is experiencing increased fatigue and
occasional palpitations at rest. Which of the following laboratory findings should the nurse
expect?
a. Normal red blood cell (RBC) indices
b. Hematocrit (Hct) of 38%
c. Hemoglobin (Hb) of 86 g/L
d. RBC count of 4.5 ´ 1012/L
ANS: C
The client’s clinical manifestations indicate moderate anemia, which is consistent with an
Hb of 60–100 g/L. The other values are all within the range of normal.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. Which of the following menu choices indicate that the client understands the nurse’s
teaching about best dietary choices for iron-deficiency anemia?
a. Omelette and whole wheat toast
b. Cantaloupe and cottage cheese
c. Strawberry and banana fruit plate
d. Cornmeal muffin and orange juice
ANS: A
Eggs and whole grain breads are high in iron. The other choices are appropriate for other
nutritional deficiencies, but are not the best choice for a client with iron-deficiency
anemia.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
3. The nurse is caring for a client who is receiving methotrexate and develops a
megaloblastic anemia. Which of the following nutrients should the nurse include in the
teaching plan?
a. Iron
b. Folic acid
c. Cobalamin (vitamin B12)
d. Ascorbic acid (vitamin C)
ANS: B
Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid
supplements is the usual treatment. The other nutrients would not correct folic acid
deficiency, although they would be used to treat other types of anemia.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
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4. The nurse is teaching a client with a new diagnosis of pernicious anemia about the
disorder. Which of the following client statements indicates that the teaching has been
effective?
a. “I need to start eating more red meat or liver.”
b. “I will stop having a glass of wine with dinner.”
c. “I will need to take a proton pump inhibitor like omeprazole.”
d. “I would rather use the nasal spray than have to get injections of vitamin B12.”
ANS: D
Since pernicious anemia prevents the absorption of vitamin B12, this client requires
injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin
deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more
foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents
absorption of the vitamin.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
5. The nurse is caring for a client who is hospitalized for treatment of severe hemolytic
anemia. Which of the following actions should the nurse implement?
Provide a diet high in vitamin K.
Place the client on protective isolation.
Alternate periods of rest and activity.
Teach the client how to avoid injury.
a.
b.
c.
d.
ANS: C
Nursing care for clients with anemia should alternate periods of rest and activity to
encourage activity without causing undue fatigue. There is no indication that the client has
a bleeding disorder, so a high vitamin K diet or teaching about how to avoid injury is not
needed. Protective isolation might be used for a client with aplastic anemia, but it is not
indicated for hemolytic anemia.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
6. The nurse has finished teaching a client about taking oral ferrous sulphate. Which of the
following client statements indicates that additional instruction is needed?
“I will call the doctor if my stools start to turn black.”
“I will take a stool softener if I feel constipated occasionally.”
“I should take the iron with orange juice about an hour before eating.”
“I should increase my fluid and fibre intake while I am taking the iron tablets.”
a.
b.
c.
d.
ANS: A
It is normal for the stools to appear black when a client is taking iron and the client should
not call the doctor about this. The other client statements are correct.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
7. The nurse is caring for a client with idiopathic aplastic anemia. Which of the following
collaborative problems should the nurse include when developing the care plan?
a. Potential complication: seizures
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b. Potential complication: infection
c. Potential complication: neurogenic shock
d. Potential complication: pulmonary edema
ANS: B
Because the client with aplastic anemia has pancytopenia, the client is at risk for infection
and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary
edema.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
8. The nurse is caring for a client with a sickle cell crisis. While caring for the client during
the crisis, which of the following actions is priority?
a. Limit the client’s intake of oral and IV fluids.
b. Evaluate the effectiveness of opioid analgesics.
c. Encourage the client to ambulate as much as tolerated.
d. Teach the client about high-protein, high-calorie foods.
ANS: B
Pain is the most common clinical manifestation of a crisis and usually requires large doses
of continuous opioids for control. Fluid intake should be increased to reduce blood
viscosity and improve perfusion. Rest is usually ordered to decrease metabolic
requirements. Clients are instructed about the need for dietary folic acid, but high-protein,
high-calorie diets are not emphasized.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
9. Which of the following statements by a client with sickle cell anemia indicates good
understanding of the nurse’s teaching about prevention of sickle cell crisis?
a. “Home oxygen therapy is frequently used to decrease sickling.”
b. “There are no effective medications that can help prevent sickling.”
c. “Routine continuous dosage narcotics are prescribed to prevent a crisis.”
d. “Risk for a crisis can be lowered by having an annual influenza vaccination.”
ANS: D
Since infection is the most common cause of a sickle cell crisis, influenza, Haemophilus
influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered.
Although continuous dose opioids and oxygen may be administered during a crisis, clients
do not receive these therapies to prevent crisis. Hydroxyurea is used for many clients to
decrease the number of sickle cell crises.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
10. The nurse is planning discharge teaching for a client who was admitted with neutropenia.
Which of the following instructions should the nurse include?
a. Limit fluids to 2–3 litres a day.
b. Include eggs and fish in the diet.
c. Avoid exposure to crowds as much as possible.
d. Drink only one or two caffeinated beverages daily.
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ANS: C
Exposure to crowds increases the client’s risk for infection and should be avoided for the
client with neutropenia. There is no restriction on caffeine use. Iron supplementation is
generally not recommended. A high-fluid intake is recommended. Eggs and seafood are to
be avoided.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
11. The nurse is admitting a client with hemolytic anemia and notes jaundice of the sclerae.
Which of the following laboratory results should the nurse assess?
Schilling test
Bilirubin level
Stool occult blood test
Gastric analysis testing
a.
b.
c.
d.
ANS: B
Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC)
hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic
anemia.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
12. The nurse is caring for a client who has been receiving a heparin infusion and warfarin for
a deep vein thrombosis (DVT) with a diagnosis of heparin-induced thrombo-cytopenia
(HIT). Which of the following actions should the nurse include in the plan of care?
a. Use low-molecular-weight heparin (LMWH) only.
b. Flush all intermittent IV lines using normal saline.
c. Administer the warfarin at the scheduled time.
d. Teach the client about the purpose of platelet transfusions.
ANS: B
All heparin is discontinued when the HIT is diagnosed. The client should be instructed to
never receive heparin or LMWH. Warfarin is usually not given until the platelet count has
returned to 150 ´ 109/L. The platelet count does not drop low enough in HIT for a platelet
transfusion, and platelet transfusions increase the risk for thrombosis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
13. The nurse is caring for a client with an acute exacerbation of polycythemia vera. Which of
the following actions should the nurse implement during treatment?
a. Place the client on bed rest.
b. Administer iron supplements.
c. Avoid use of Aspirin products.
d. Monitor fluid intake and output.
ANS: D
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Monitoring hydration status is important during an acute exacerbation because the client is
at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for
thrombosis. The client should be encouraged to ambulate to prevent deep vein thrombosis
(DVT). Iron is contraindicated in clients with polycythemia vera.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
14. Which of the following nursing interventions should be included in the care plan for a
client with immune thrombo-cytopenic purpura (ITP)?
a. Assign the client to a private room.
b. Avoid intramuscular (IM) injections.
c. Use rinses rather than a toothbrush for oral care.
d. Restrict activity to passive and active range of motion.
ANS: B
IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft
toothbrush can be used for oral care. There is no need to restrict activity or place the client
in a private room.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
15. Which of the following laboratory information should the nurse monitor to detect
heparin-induced thrombo-cytopenia (HIT) in a client who is receiving a continuous
heparin infusion?
a. Prothrombin time
b. Erythrocyte count
c. Fibrinogen degradation products
d. Activated partial thromboplastin time
ANS: D
Platelet aggregation in HIT causes neutralization of heparin so that the activated partial
thromboplastin time will be shorter and more heparin will be needed to maintain
therapeutic levels. The other data will not be affected by HIT.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
16. The nurse is admitting a client with type A hemophilia who has severe pain and swelling
in the right knee. Which of the following actions should the nurse implement initially?
a. Immobilize the knee
b. Apply heat to the joint
c. Assist the client with light weight bearing
d. Perform passive range of motion to the knee
ANS: A
The initial action should be total rest of the knee to minimize bleeding. Ice packs are used
to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are
contraindicated initially, but after the bleeding stops, ROM and physical therapy are
started.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
17. The nurse is caring for a client with von Willebrand disease who is admitted to the hospital
for minor knee surgery. Which of the following laboratory information should the nurse
assess?
a. Platelet count
b. Bleeding time
c. Thrombin time
d. Prothrombin time
ANS: B
The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time,
and thrombin time are normal in von Willebrand disease.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
18. A routine complete blood count indicates that a client may have myelodysplastic
syndrome. At this time, which of the following information should the nurse include in the
teaching plan?
a. Packed red blood cells (PRBCs) transfusion
b. Bone marrow biopsy
c. Filgrastim administration
d. Erythropoietin administration
ANS: B
Bone marrow biopsy is needed to make the diagnosis and determine the specific type of
myelodysplastic syndrome. The other treatments may be necessary if there is progression
of the myelodysplastic syndrome, but the initial action for this asymptomatic client will be
a bone marrow biopsy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
19. Which of the following actions should the nurse include in the care plan for a hospitalized
client who is neutropenic?
Avoid any IM or subcutaneous injections.
Check the oral temperature every 4 hours.
Omit all fruits or vegetables from the diet.
Place a “No Visitors” sign on the client door.
a.
b.
c.
d.
ANS: B
The earliest sign of infection in a neutropenic client is an elevation in temperature.
Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables
that are peeled or cooked are acceptable. Injections may be required for administration of
medications such as filgrastim. The number of visitors may be limited and visitors with
communicable diseases should be avoided, but a “no visitors” policy is not needed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
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20. Which of the following laboratory tests should the nurse use to determine whether the
prescribed filgrastim is effective in the treatment of a client who is receiving
chemotherapy for acute lymphocytic leukemia?
a. Platelet count
b. Reticulocyte count
c. Total lymphocyte count
d. Absolute neutrophil count
ANS: D
Filgrastim increases the neutrophil count and function in neutropenic clients. Although
total lymphocyte, platelet, and reticulocyte counts also are important to monitor in this
client, the absolute neutrophil count is used to evaluate the effects of filgrastim.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
21. The nurse is caring for a client with acute myelogenous leukemia (AML) who has
induction therapy prescribed and the client asks the nurse whether the planned
chemotherapy will be worth undergoing. Which of the following responses by the nurse is
best?
a. “If you do not want to have chemotherapy, there are other options for treatment
such as stem cell transplantation.”
b. “The decision about chemotherapy is one that you and the doctor need to make
rather than asking what I would do.”
c. “You don’t need to make a decision about treatment right now since leukemias in
adults tend to progress quite slowly.”
d. “The adverse effects of the chemotherapy are difficult, but AML frequently does
go into remission with chemotherapy.”
ANS: D
This response uses therapeutic communication by addressing the client’s question and
giving accurate information. The other responses either give inaccurate information or fail
to address the client’s question, which will discourage the client from asking the nurse for
information.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
22. The nurse is caring for a client who has a history of a transfusion-related acute lung injury
(TRALI) and is to receive a transfusion of packed red blood cells (PRBCs). Which of the
following actions should the nurse take to decrease the risk for TRALI for this client?
a. Infuse the PRBCs slowly over 4 hours.
b. Transfuse only leukocyte-reduced PRBCs.
c. Administer the scheduled oral diuretic before the transfusion.
d. Give the PRN dose of antihistamine before starting the transfusion.
ANS: B
TRALI is caused by a reaction between the donor and the client leukocytes that causes
pulmonary inflammation and capillary leaking. The other actions may help prevent
respiratory problems caused by circulatory overload or by allergic reactions, but they will
not prevent TRALI.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
23. The nurse is caring for a client with acute myelogenous leukemia (AML) who is
considering the possibility of treatment with a hematopoietic stem cell transplant (HSCT).
Which of the following actions is best for the nurse to implement to assist the client with
treatment decisions?
a. Emphasize the positive outcomes of a bone marrow transplant.
b. Discuss the need for adequate insurance to cover post-HSCT care.
c. Ask the client whether there are any questions or concerns about HSCT.
d. Explain that a cure is not possible with any other treatment except HSCT.
ANS: C
Offering the client an opportunity to ask questions or discuss concerns about HSCT will
encourage the client to voice concerns about this treatment and also will allow the nurse to
assess whether the client needs more information about the procedure. Treatment of AML
using chemotherapy is another option for the client. It is not appropriate for the nurse to
ask the client to consider insurance needs in making this decision.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
24. Which of the following nursing actions should the nurse include in the plan of care for a
client admitted with multiple myeloma?
a. Monitor fluid intake and output.
b. Administer calcium supplements.
c. Assess lymph nodes for enlargement.
d. Limit weight bearing and ambulation.
ANS: A
A high fluid intake and urine output helps prevent the complications of kidney stones
caused by hypercalcemia and renal failure caused by deposition of Bence Jones protein in
the renal tubules. Weight bearing and ambulation are encouraged to help bone retain
calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will
further increase the client’s calcium level and are not used.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
25. The nurse is caring for a client with non-Hodgkin’s lymphoma who develops a platelet
count of 38 ´ 109/L during chemotherapy. Which of the following actions should the nurse
implement based on this finding?
a. Provide oral hygiene every 2 hours.
b. Check all stools for occult blood.
c. Assess temperature every 4 hours.
d. Encourage fluids to 3 000 mL/day.
ANS: B
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Because the client is at risk for spontaneous bleeding, the nurse should check stools for
occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene
is important, but it is not necessary to provide oral care every 2 hours. The low platelet
count does not increase risk for infection, so frequent temperature monitoring is not
indicated.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
26. The nurse is caring for a client with acute myelogenous leukemia who is receiving
outpatient chemotherapy and develops an absolute neutrophil count of 0.9 ´ 109/L. Which
of the following actions by the nurse in the outpatient clinic is best?
a. Discuss the need for hospital admission to treat the neutropenia.
b. Plan to discontinue the chemotherapy until the neutropenia resolves.
c. Teach the client how to administer filgrastim injections at home.
d. Obtain a high-efficiency particulate air (HEPA) filter for the client for home use.
ANS: C
The client may be taught to self-administer filgrastim injections. Although chemotherapy
may be stopped with severe neutropenia (neutrophil count less than 0.5 ´ 109/L),
administration of filgrastim usually allows the chemotherapy to continue. Clients with
neutropenia are at higher risk for infection when exposed to other clients in the hospital.
HEPA filters are expensive and are used in the hospital, where the number of pathogens is
much higher than in the client’s home environment.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
27. Which of the following assessment data obtained by the nurse when caring for a client
with thrombo-cytopenia should be immediately communicated to the health care provider?
a. The platelet count is 52 ´ 109/L.
b. The client is difficult to arouse.
c. There are large bruises on the back.
d. There are purpura on the oral mucosa.
ANS: B
Difficulty in arousing the client may indicate a cerebral hemorrhage, which is life
threatening and requires immediate action. The other information should be documented
and reported, but would not be unusual in a client with thrombo-cytopenia.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
28. When a febrile episode occurs in a client with neutropenia, at what time should antibiotic
therapy be initiated?
Within 1 hour
After the causative agent is identified from the culture
Once the fever drops below 38°C (100.4°F)
For long-term therapy over 3 months
a.
b.
c.
d.
ANS: A
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When a febrile episode occurs in a client with neutropenia, antibiotic therapy must be
initiated immediately (within 1 hour), even before the determination by culture of a
specific causative organism. Treatment does not wait until the fever drops. Long-term
therapy over 3 months is not required at this time.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
29. The nurse is caring for a client receiving a transfusion of packed red blood cells who
develops chills, fever, headache, and anxiety 30 minutes after the transfusion is started.
After stopping the transfusion, which of the following actions is priority?
a. Draw blood for a new crossmatch
b. Send a urine specimen to the laboratory
c. Give the PRN diphenhydramine
d. Administer the PRN acetaminophen
ANS: D
The client’s clinical manifestations are consistent with a febrile, nonhemolytic transfusion
reaction. The transfusion should be stopped and antipyretics administered for the fever as
ordered. A urine specimen is needed if an acute hemolytic reaction is suspected.
Diphenhydramine is used for allergic reactions. This type of reaction does not indicate
incorrect crossmatching.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
30. Fifteen minutes after a transfusion of packed red blood cells is started, a client has
symptoms of back pain and dyspnea and a pulse rate of 124 beats/minute. Which of the
following actions should the nurse implement initially?
a. Administer oxygen therapy at a high flow rate.
b. Obtain a urine specimen to send to the laboratory.
c. Notify the health care provider about the symptoms.
d. Disconnect the transfusion and infuse normal saline.
ANS: D
The client’s symptoms indicate a possible acute hemolytic reaction caused by the
transfusion. The first action should be to disconnect the transfusion and infuse normal
saline. The other actions also are needed but are not the highest priority.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
31. Which of the following newly admitted clients should the nurse assign as a roommate for a
client who has aplastic anemia?
a. A client with severe heart failure
b. A client who has viral pneumonia
c. A client who has right leg cellulitis
d. A client with multiple abdominal drains
ANS: A
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Clients with aplastic anemia are at risk for infection because of the low white blood cell
production associated with this type of anemia, so the nurse should avoid assigning a
roommate with any possible infectious process.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
32. All of these clients are waiting to be admitted by the emergency department nurse. Which
one of the following requires the most rapid assessment and care by the nurse?
a. The client with hemochromatosis who has symptoms of abdominal pain
b. The client with thrombo-cytopenia who has blood oozing after having a tooth
extracted
c. The client with chemotherapy-induced neutropenia who has a temperature of
38.2°C (100.8°F)
d. The client with a history of sickle cell anemia who has had nausea and diarrhea for
24 hours
ANS: C
A neutropenic client with a fever is assumed to have an infection and is at risk for rapidly
developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are
needed. The other clients also require rapid assessment and care but not as urgently as the
neutropenic client.
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
33. The nurse is caring for a client with immune thrombo-cytopenic purpura (ITP) who has a
prescription for a platelet transfusion. Which of the following client information indicates
that the nurse should consult with the health care provider before administering platelets?
a. The platelet count is 42 ´ 109/L.
b. Blood pressure is 94/56 mm Hg.
c. Blood is oozing from the venipuncture site.
d. Petechiae are present on the chest and back.
ANS: A
Platelet transfusions are not usually indicated until the platelet count is below 10 ´ 109/L
unless the client is actively bleeding, so the nurse should clarify the order with the health
care provider before giving the transfusion. The other data all indicate that bleeding caused
by ITP may be occurring and indicate that the platelet transfusion is appropriate.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
34. The hemophilia clinic nurse receives a call from a client with hemophilia to discuss all of
these problems. Which of the following problems is most important to communicate to the
health care provider?
a. Skin abrasions
b. Bleeding gums
c. Multiple bruises
d. Dark tarry stools
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ANS: D
Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as
checking hemoglobin and hematocrit and administration of coagulation factors. The other
problems indicate a need for client teaching about how to avoid injury, but are not
indicators of possible serious blood loss.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
35. The nurse is caring for a client with septicemia who develops prolonged bleeding from
venipuncture sites and blood in the stools. Which of the following actions is most
important for the nurse to take?
a. Notify the client’s health care provider.
b. Avoid unnecessary venipunctures.
c. Apply sterile dressings to the sites.
d. Give prescribed proton-pump inhibitors.
ANS: A
The client’s new onset of bleeding and diagnosis of sepsis suggest that disseminated
intravascular coagulation (DIC) may have developed, which will require collaborative
actions such as diagnostic testing, blood product administration, and heparin
administration. The other actions also are appropriate, but the most important action
should be to notify the physician so that DIC treatment can be initiated rapidly.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
36. After receiving change-of-shift report for the following four clients with neutropenia,
which client should the nurse assess first?
66-year-old who has white pharyngeal lesions
35-year-old who has a fever of 38.2°C (100.8°F)
56-year-old who has frequent explosive diarrhea
23-year old who is complaining of severe fatigue
a.
b.
c.
d.
ANS: B
Any fever in a neutropenic client indicates infection and can quickly lead to sepsis and
septic shock. Rapid assessment and (if prescribed) initiation of antibiotic therapy within 1
hour are needed. The other clients also need to be assessed but do not exhibit symptoms of
potentially life-threatening problems.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
37. The nurse is caring for a client with myelodysplastic syndrome who has 20% blasts in
marrow and the health care provider has prescribed high-intensity treatment. Which of the
following treatments should the nurse prepare the client to receive?
a. Antibiotics
b. Antifungals
c. Chemotherapy
d. A blood transfusion
ANS: C
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Low-risk clients (<5% blasts in marrow) can often be treated with transfusions, antibiotics,
antifungals, EPO, and hematopoietic growth factors. High-risk clients (>5% blasts in
marrow) may be treated with single-agent chemotherapy (e.g., hydroxyurea) or intensive
chemotherapy as in AML.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
38. All of these clients call the outpatient clinic and ask to make an appointment as soon as
possible. Which of the following clients should the nurse schedule to be seen first?
a. 19-year-old with no previous health problems who has a nontender lump in the
axilla
b. 46-year-old with sickle cell anemia who says “that my eyes always look sort of
yellow”
c. 21-year-old with hemophilia who wants to learn how to self-administer factor VII
replacement
d. 50-year-old with early-stage chronic lymphocytic leukemia who has complaints of
chronic fatigue
ANS: A
The client’s age and presence of a nontender axillary lump suggest possible lymphoma,
which needs rapid diagnosis and treatment. The other clients have questions about
treatment or symptoms that are consistent with their diagnosis but do not need to be seen
urgently.
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. The nurse is caring for a client with neutropenia who is started on a cephalosporin. Which
of the following common adverse effects should the nurse observe for in the client? (Select
all that apply.)
a. Nephrotoxicity
b. Rash
c. Ototoxicity
d. Fever
e. Pruritus
ANS: B, D, E
Adverse effects common to cephalosporins include rashes, fever, and pruritus. Adverse
effects common to aminoglycosides include nephrotoxicity and ototoxicity.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
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Chapter 34: Nursing Assessment: Cardiovascular System
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is assessing a client who has just arrived in the emergency department and notes
a pulse deficit. Which of the following actions should the nurse anticipate for the client?
a. A 2-D echocardiogram
b. A cardiac catheterization
c. Hourly blood pressure checks
d. Electrocardiographic monitoring
ANS: D
Pulse deficit is a difference between simultaneously obtained apical and radial pulses and
indicates that there may be a cardiac dysrhythmia that would be detected with ECG
monitoring. Frequent BP monitoring, cardiac catheterization, and echocardiograms are
used for diagnosis of other cardiovascular disorders but would not be as helpful in
determining the immediate reason for the pulse deficit.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
2. The nurse is reviewing the 12-lead electrocardiograph (ECG) of a healthy older-adult
client who is having an annual physical examination. Which of the following findings
should be of most concern to the nurse?
a. The heart rate is 43 beats/minute.
b. The PR interval is 0.21 seconds.
c. There is a right bundle-branch block.
d. The QRS duration is 0.13 seconds.
ANS: A
The resting supine HR is not markedly affected with aging, so the decrease in HR requires
further investigation. Bundle-branch block and slight increases in PR interval or QRS
duration are common in older individuals because of increases in conduction time through
the AV node, the bundle of His, and the bundle branches.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
3. During a physical examination of a client, the nurse palpates the point of maximal impulse
(PMI) in the sixth intercostal space lateral to the left midclavicular line. Which of the
following actions should the nurse implement next?
a. Document that the PMI is in the normal anatomic location.
b. Ask the client about risk factors for coronary artery disease.
c. Auscultate both the carotid arteries for the presence of a bruit.
d. Assess the client for symptoms of left ventricular hypertrophy.
ANS: D
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The PMI should be felt at the intersection of the 5th intercostal space and the left
midclavicular line. A PMI located outside these landmarks indicates possible cardiac
enlargement, such as with left ventricular hypertrophy. Cardiac enlargement is not
necessarily associated with coronary or carotid artery disease.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
4. To auscultate for S3 or S4 gallops in the mitral area, which of the following should the
nurse implement?
a. Use the bell of the stethoscope with the client in the left lateral position.
b. Use the bell of the stethoscope with the client sitting and leaning forward.
c. Use the diaphragm of the stethoscope with the client in a reclining position.
d. Use the diaphragm of the stethoscope with the client lying flat on the left side.
ANS: A
Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the
stethoscope. Sounds associated with the mitral valve are accentuated by turning the client
to the left side, which brings the heart closer to the chest wall. The diaphragm of the
stethoscope is best to use for the higher pitched sounds such as S1 and S2.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
5. The nurse is caring for a client who is being treated for heart failure. Which of the
following laboratory results should the nurse assess to determine the effects of therapy?
a. Myoglobin
b. Homocysteine (Hcy)
c. Low-density lipoprotein (LDL)
d. B-type natriuretic peptide (BNP)
ANS: D
Increased levels of BNP are a marker for heart failure. The other laboratory results would
be used to assess for myocardial infarction (myoglobin) or risk for coronary artery disease
(Hcy and LDL).
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
6. The nurse is assessing an underweight older-adult client and observes pulsation of the
abdominal aorta in the epigastric area. Which of the following actions should the nurse
take?
a. Notify the hospital rapid response team.
b. Instruct the client to remain on bed rest.
c. Teach the client about aortic aneurysms.
d. Document the finding in the client chart.
ANS: D
Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for
thin individuals and the nurse should simply document the finding in the admission
assessment. Unless there are other abnormal findings (such as a bruit, pain, or
hyper/hypotension) associated with the pulsation, the other actions are not necessary.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
7. The nurse is caring for a client who is scheduled for a cardiac catheterization with
coronary angiography. Which of the following information should the nurse provide to the
client before the test?
a. Electrocardiographic (ECG) monitoring will be required for 24 hours after the test.
b. It will be important to lie completely still during the procedure.
c. A warm feeling may be noted when the contrast dye is injected.
d. Monitored anaesthesia care will be provided during the procedure.
ANS: C
A sensation of warmth or flushing is common when the iodine-based contrast material is
injected, which can be anxiety-producing unless it has been discussed with the client. The
client may receive a sedative drug before the procedure, but monitored anaesthesia care is
not used. ECG monitoring is used during the procedure to detect dysrhythmias, but there is
not a risk for dysrhythmias after the procedure. The client is not immobile during cardiac
catheterization and may be asked to cough or take deep breaths.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
8. The nurse is assessing a client who was admitted with heart failure and notes that the client
has jugular venous distension (JVD) when lying flat in bed. Which of the following
actions should the nurse take next?
a. Use a ruler to measure the level of the JVD.
b. Document this finding in the client’s record.
c. Observe for JVD with the head at 45 degrees.
d. Have the client perform the Valsalva manoeuvre.
ANS: C
When the client is lying flat, the jugular veins are at the level of the right atrium, so JVD is
a common (but not clinically significant) finding. JVD that persists when the client is
sitting at a 45-degree angle or greater is significant. The nurse may use a ruler to
determine the level of JVD above the heart if the JVD persists when the client is at a
45-degree angle or more. JVD is an expected finding when a client performs the Valsalva
manoeuvre because right atrial pressure increases. The nurse will document the JVD in the
record if it persists when the head is elevated.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
9. The nurse is providing teaching to a client being evaluated for rhythm disturbances with a
Holter monitor. Which of the following information should the nurse include in the
teaching plan?
a. Exercise more than usual while the monitor is in place.
b. Remove the electrodes when taking a shower or tub bath.
c. Keep a diary of daily activities while the monitor is worn.
d. Connect the recorder to a telephone transmitter once daily.
ANS: C
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The client is instructed to keep a diary describing daily activities while Holter monitoring
is being accomplished to help correlate any rhythm disturbances with client activities.
Clients are taught that they should not take a shower or bath during Holter monitoring and
that they should continue with their usual daily activities. The recorder stores the
information about the client’s rhythm until the end of the testing, when it is removed and
the data are analyzed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
10. The nurse is auscultating over the client’s abdominal aorta and hears a humming sound.
Which of the following terms should the nurse use to document this finding?
a. Thrill
b. Bruit
c. Heave
d. Murmur
ANS: B
A bruit is the sound created by turbulent blood flow in an artery. Thrills are palpable
vibrations felt when there is turbulent blood flow through the heart or in a blood vessel.
Heaves are sustained lifts over the precordium that can be observed or palpated. A murmur
is the sound caused by turbulent blood flow through the heart.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
11. The nurse is assessing the laboratory results for a client who developed chest pain 4 hours
ago and may be having a myocardial infarction. Which of the following laboratory results
is most important for the nurse to review?
a. LDL cholesterol
b. Troponins T and I
c. C-reactive protein
d. Creatine kinase-MB (CK-MB)
ANS: B
Cardiac troponins start to elevate hours (average 4–6 hours) after myocardial injury and
are specific to myocardium. Creatine kinase-MB (CK-MB) is specific to myocardial
injury and infarction, but it does not increase until 6 hours after the infarction occurs. LDL
cholesterol and C-reactive protein are useful in assessing cardiovascular risk but are not
helpful in determining whether a client is having an acute myocardial infarction.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
12. The nurse is assessing a newly admitted client and notes a thrill along the left sternal
border. To obtain more information about the cause of the thrill, which of the following
actions should the nurse take next?
a. Auscultate for any cardiac murmurs.
b. Find the point of maximal impulse.
c. Compare the apical and radial pulse rates.
d. Palpate the quality of the peripheral pulses.
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ANS: A
Both thrills and murmurs are caused by turbulent blood flow, such as occurs when blood
flows through a damaged valve. Relevant information includes the quality of the murmur,
where in the cardiac cycle the murmur is heard, and where on the thorax the murmur is
heard best. The other information also is important in the cardiac assessment but will not
provide information that is relevant to the thrill.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
13. The nurse hears a murmur between the S1 and S2 heart sounds at the client’s left 5th
intercostal space and midclavicular line. How should the nurse record this information?
“Systolic murmur heard at mitral area.”
“Diastolic murmur heard at aortic area.”
“Systolic murmur heard at Erb’s point.”
“Diastolic murmur heard at tricuspid area.”
a.
b.
c.
d.
ANS: A
The S1 signifies the onset of ventricular systole. S2 signifies the onset of diastole. A
murmur occurring between these two sounds is a systolic murmur. The mitral area is the
intersection of the left 5th intercostal space and the midclavicular line. The other responses
describe murmurs heard at different landmarks on the chest or during the diastolic phase of
the cardiac cycle.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
14. The RN is observing a student nurse who is doing a physical assessment on a client. The
RN will need to intervene immediately if the student nurse implements which of the
following interventions?
a. Places the client in the left lateral position to check for the point of maximal
impulse (PMI).
b. Presses on the skin over the tibia for 10 seconds to check for edema.
c. Palpates both carotid arteries simultaneously to compare pulse quality.
d. Documents a murmur heard along the left sternal border as an aortic murmur.
ANS: C
The carotid pulses should never be palpated at the same time to avoid vagal stimulation,
dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also
need to be corrected. However, they are not dangerous to the client.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
15. Which of the following actions should the nurse implement for a client who arrives for a
calcium-scoring CT scan?
a. Administer oral sedative medications.
b. Teach the client about the procedure.
c. Ask whether the client has eaten today.
d. Insert a large gauge intravenous catheter.
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ANS: B
The nurse will need to teach the client that the procedure is rapid and involves little risk.
The other actions are not necessary.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
16. Which of the following information obtained by the nurse who is admitting the client for
magnetic resonance imaging (MRI) will be most important to report to the health care
provider before the MRI?
a. The client has an allergy to shellfish and iodine.
b. The client has a history of coronary artery disease.
c. The client has a permanent ventricular pacemaker in place.
d. The client took all the prescribed cardiac medications today.
ANS: C
MRI is contraindicated for clients with implanted metallic devices such as pacemakers as
the magnets can alter the function of the device. The other information also will be
reported to the health care provider but does not impact whether or not the client can have
an MRI.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
17. The nurse is monitoring a client who is undergoing exercise (stress) testing on a treadmill.
Which of the following assessment findings requires the most rapid action by the nurse?
a. Client complaint of feeling tired
b. Pulse change from 80 to 96 beats/minute
c. BP increase from 134/68 to 150/80 mm Hg
d. Electrocardiographic changes indicating coronary ischemia
ANS: D
ECG changes associated with coronary ischemia (such as T-wave inversions and ST
segment depression) indicate that the myocardium is not getting adequate oxygen delivery
and that the exercise test should be terminated immediately. Increases in BP and heart rate
(HR) are normal responses to aerobic exercise. Tiredness also is normal as the intensity of
exercise increases during the stress testing.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
18. The standard policy on the cardiac unit states, “Notify the health care provider for mean
arterial pressure (MAP) less than 70 mm Hg.” Which of the following clients should the
nurse report to the health care provider?
a. Postoperative client with a BP of 116/42
b. Newly admitted client with a BP of 122/60
c. Client with left ventricular failure who has a BP of 110/70
d. Client with a myocardial infarction who has a BP of 114/50
ANS: A
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The mean arterial pressure (MAP) is calculated using the formula MAP = (diastolic
BP + 1/3 pulse pressure). The MAP for the postoperative client with a BP of 116/42 is 67.
The MAP in the other three clients is higher than 70 mm Hg.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
19. The nurse is admitting a client for a coronary arteriogram and angiogram. Which of the
following information about the client is most important for the nurse to communicate to
the health care provider?
a. The client’s pedal pulses are +1.
b. The client is allergic to iodine.
c. The client has not eaten anything today.
d. The client had an arteriogram a year ago.
ANS: B
The contrast dye used for the procedure is iodine based, so clients who have an iodine
allergy should be communicated to the health care provider. The other information also is
communicated to the health care provider but will not require a change in the usual
prearteriogram orders or medications.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
20. A transesophageal echocardiogram (TEE) is ordered for a client with possible endocarditis.
Which of the following actions included in the standard TEE orders should the nurse
accomplish first?
a. Administer O2 per mask
b. Start a large-gauge IV line
c. Place the client on NPO status
d. Give lorazepam 1 mg IV
ANS: C
The client will need to be NPO for 6 hours preceding the TEE, so the nurse should place
the client on NPO status as soon as the order is received. The other actions also will need
to be accomplished but not until just before or during the procedure.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 35: Nursing Management: Hypertension
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. Which of the following actions should the nurse in the hypertension clinic take in order to
obtain an accurate baseline blood pressure (BP) for a new client?
a. Obtain a BP reading in each arm and average the results.
b. Deflate the BP cuff at a rate of 5–10 mm Hg/second.
c. Have the client sit in a chair.
d. Assist the client to the supine position for BP measurements.
ANS: C
The client should be seated to assess the initial BP and P. The BP is obtained in both arms,
but the results of the two arms are not averaged. The client does not need to be in the
supine position. The cuff should be deflated at 2–3 mm Hg/second.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
2. The nurse obtains this information from a client with prehypertension. Which of the
following findings is most important to address with the client?
a. Low dietary fibre intake
b. No regular aerobic exercise
c. BMI of 23 kg/m2
d. Drinks wine with dinner once a week
ANS: B
The recommendations for preventing hypertension include exercising aerobically for
30–60 minutes four to seven days a week. A BMI of 23 kg/m2 is within the normal BMI
range. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fibre, but
increasing fibre alone will not prevent hypertension from developing. The client’s alcohol
intake will not increase the hypertension risk.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
3. The nurse is caring for a client with hypertension and has just administered the initial dose
of labetalol. Which of the following actions should the nurse take?
Encourage oral fluids to prevent dry mouth or dehydration.
Instruct the client to ask for help if heart palpitations occur.
Ask the client to request assistance when getting out of bed.
Teach the client that headaches may occur with this medication.
a.
b.
c.
d.
ANS: C
Labetalol decreases sympathetic nervous system activity by blocking both a- and
b-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can
cause severe orthostatic hypotension. Heart palpitations, dehydration, and headaches are
possible adverse effects of other antihypertensives.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
4. The nurse is teaching a client with stage 1 hypertension about diet modifications that
should be implemented. Which of the following diet choices indicates that the teaching has
been effective?
a. The client avoids eating nuts or nut butters.
b. The client restricts intake of dietary protein.
c. The client has only one cup of coffee in the morning.
d. The client has a glass of low-fat milk with each meal.
ANS: D
The Dietary Approaches to Stop Hypertension (DASH) recommendations for prevention
of hypertension include increasing the intake of calcium-rich foods. Caffeine restriction
and decreased protein intake are not included in the recommendations. Nuts are high in
beneficial nutrients and 4–5 servings weekly are recommended in the DASH diet.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
5. The nurse is caring for a client who has just diagnosed with hypertension and has a new
prescription for captopril. Which of the following information is important to include
when teaching the client?
a. Check BP daily before taking the medication.
b. Increase fluid intake if dryness of the mouth is a problem.
c. Include high-potassium foods such as bananas in the diet.
d. Change position slowly to help prevent dizziness and falls.
ANS: D
The angiotensin-converting enzyme (ACE) inhibitors frequently cause orthostatic
hypotension, and clients should be taught to change position slowly to allow the vascular
system time to compensate for the position change. Increasing fluid intake may counteract
the effect of the medication, and the client is taught to use gum or hard candy to relieve
dry mouth. The BP does not need to be checked at home by the client before taking the
medication. Because ACE inhibitors cause potassium retention, increased intake of
high-potassium foods is inappropriate.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
6. The nurse is caring for a client with hypertension and has a prescription for nadolol.
Which of the following assessment findings should the nurse report to the health care
provider before administering this medication?
a. Asthma
b. Peptic ulcer disease
c. Alcohol dependency
d. Myocardial infarction
ANS: A
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Nonselective b-adrenergic blockers can cause bronchospasm, putting the client with a
history of asthma at high risk. b-adrenergic blockers will have no effect on the client’s
peptic ulcer disease or alcohol dependency. b-adrenergic blocker therapy is recommended
after MI.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
7. The nurse is caring for a 52-year-old client who has no previous history of hypertension or
other health problems and has suddenly developed a BP of 188/106 mm Hg. After
reconfirming the BP, which of the following information is best for the nurse to tell the
client?
a. A BP recheck should be scheduled in a few weeks.
b. The dietary sodium and fat content should be decreased.
c. There is an immediate danger of a stroke and hospitalization will be required.
d. More diagnostic testing may be needed to determine the cause of the hypertension.
ANS: D
A sudden increase in BP in a client over age 50 or under age 20 with no previous
hypertension history or risk factors indicates that the hypertension may be secondary to
some other problem. The BP will need rapid treatment and ongoing monitoring. If the
client has no other risk factors, a stroke in the immediate future is unlikely. There is no
indication that dietary salt or fat intake has contributed to this sudden increase in BP, and
reducing intake of salt and fat alone will not be adequate to reduce this BP to an
acceptable level.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
8. Which of the following actions should the nurse include in the plan of care for a client
who is receiving sodium nitroprusside to treat a hypertensive emergency?
a. Organize nursing activities so that the client has undisturbed sleep for 6 to 8 hours
at night.
b. Assist the client up in the chair for meals to avoid complications associated with
immobility.
c. Use an automated noninvasive blood pressure machine to obtain frequent BP
measurements.
d. Place the client on NPO status to prevent aspiration caused by nausea and the
associated vomiting.
ANS: C
Frequent monitoring of BP is needed when the client is receiving rapid-acting IV
antihypertensive medications. This can be most easily accomplished with an automated BP
machine or arterial line. The client will require frequent assessments, so allowing 6 to 8
hours of undisturbed sleep is not appropriate. When clients are receiving IV vasodilators,
bed rest is maintained to prevent decreased cerebral perfusion and fainting. There is no
indication that this client is nauseated or at risk for aspiration, so an NPO status is
unnecessary.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
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9. The nurse has just finished teaching a client who is hypertensive about the newly
prescribed quinapril. Which of the following client statements indicates that more teaching
is needed?
a. “The medication may not work as well if I take any Aspirin.”
b. “My health care provider may order a blood potassium level occasionally.”
c. “I will call my health care provider if I notice that I have a frequent cough.”
d. “I won’t worry if I have a little swelling around my lips and face.”
ANS: D
Angioneurotic edema occurring with angiotensin-converting enzyme (ACE) inhibitor
therapy is an indication that the ACE inhibitor should be discontinued. The client should
be taught that if any swelling of the face or oral mucosa occurs, the health care provider
should be immediately notified because this could be life threatening. The other client
statements indicate that the client has an accurate understanding of ACE inhibitor therapy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
10. During change-of-shift report, the nurse obtains this information about a client who is
hypertensive and received the first dose of propranolol during the previous shift. Which of
the following information indicates that the client needs immediate intervention?
a. The client’s most recent BP reading is 156/94 mm Hg.
b. The client’s pulse has dropped from 64 to 58 beats/minute.
c. The client has developed wheezes throughout the lung fields.
d. The client complains that the fingers and toes feel quite cold.
ANS: C
The most urgent concern for this client is the wheezes, which indicate that bronchospasm
(a common adverse effect of the noncardioselective b-adrenergic blockers) is occurring.
The nurse should immediately obtain an oxygen saturation measurement, apply
supplemental oxygen, and notify the health care provider. The mild decrease in heart rate
and complaint of cold fingers and toes do not require any change in therapy. The BP
reading may indicate that a change in medication type or dose may be indicated; however,
this is not as urgently needed as addressing the bronchospasm.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
11. The nurse is assessing a client who is being investigated for possible white coat
hypertension. Which of the following actions should the nurse implement first?
Schedule the client for frequent BP checks in the clinic.
Instruct the client about the need to decrease stress levels.
Tell the client how to self-monitor and record BPs at home.
Teach the client about ambulatory blood pressure monitoring.
a.
b.
c.
d.
ANS: C
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Having the client self-monitor BPs at home will provide a reliable indication about
whether the client has hypertension. Frequent BP checks in the clinic are likely to be high
in a client with white coat hypertension. Ambulatory blood pressure monitoring may be
used if the data from self-monitoring is unclear. Although elevated stress levels may
contribute to hypertension, instructing the client about this is unlikely to reduce BP.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
12. Which of the following BP findings by the nurse indicate that no changes in therapy are
needed for a client with stage 1 hypertension who has a history of heart failure?
a. 108/64 mm Hg
b. 128/76 mm Hg
c. 140/90 mm Hg
d. 136/82 mm Hg
ANS: B
The goal for antihypertensive therapy for a client with hypertension and heart failure is a
BP of <130/80 mm Hg. The BP of 108/64 may indicate overtreatment of the hypertension
and an increased risk for adverse effects of drugs. The other two blood pressures indicate a
need for modifications in the client’s treatment.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
13. Which of the following information should the nurse include when teaching a client with
newly diagnosed hypertension?
a. Dietary sodium restriction will control BP for most clients.
b. Most clients are able to control BP through lifestyle changes.
c. Hypertension is usually asymptomatic until significant organ damage occurs.
d. Annual BP checks are needed to monitor treatment effectiveness.
ANS: C
Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle
changes and sodium restriction are used to help manage blood pressure, but drugs are
needed for most clients. BP should be checked by the health care provider every 3–6
months.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
14. The nurse in the emergency department received change-of-shift report on these four
clients with hypertension. Which of the following clients should the nurse assess first?
a. 52-year-old with a BP of 212/90 who has intermittent claudication
b. 43-year-old with a BP of 190/102 who is complaining of chest pain
c. 50-year-old with a BP of 210/110 who has a creatinine of 133 mcmol/L
d. 48-year-old with a BP of 200/98 whose urine shows microalbuminuria
ANS: B
The client with chest pain may be experiencing acute myocardial infarction and rapid
assessment and intervention is needed. The symptoms of the other clients also show target
organ damage, but are not indicative of acute processes.
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DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
15. The nurse is reviewing the laboratory test results for a client who has recently been
diagnosed with hypertension. Which result is most important to communicate to the health
care provider?
a. Serum creatinine of 230 mcmol/L
b. Serum potassium of 3.8 mmol/L
c. Serum hemoglobin of 147 g/L
d. Blood glucose level of 5.3 mmol/L
ANS: A
The elevated creatinine indicates renal damage caused by the hypertension. The other
laboratory results are normal.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
16. The nurse is admitting a client with a history of hypertension and is being treated with a
diuretic and an angiotensin-converting enzyme (ACE) inhibitor to the emergency
department. The client has symptoms of a severe headache and has a BP of 240/118 mm
Hg. Which of the following questions should the nurse ask first?
a. Did you take any acetaminophen today?
b. Do you have any recent stressful events in your life?
c. Have you been consistently taking your medications?
d. Have you recently taken any antihistamine medications?
ANS: C
Sudden withdrawal of antihypertensive medications can cause rebound hypertension and
hypertensive crisis. Although many over-the-counter medications can cause hypertension,
antihistamines and acetaminophen do not increase BP. Stressful events will increase BP
but not usually to the level seen in this client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
17. The nurse is caring for a client who is experiencing a hypertensive crisis and is receiving
sodium nitroprusside. Which of the following time frequencies should the nurse assess the
clients’ blood pressure and pulse during the initial administration of this medication?
a. 2–3 minutes
b. 5–10 minutes
c. 15–30 minutes
d. Hourly
ANS: A
Administered intravenously, the drugs have a rapid (within seconds to minutes) onset of
action. The client’s BP and pulse should be taken every 2–3 minutes during the initial
administration of these drugs.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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18. When a client with hypertension who has a new prescription for atenolol returns to the
health clinic after 2 weeks for a follow-up visit, the BP is unchanged from the previous
visit. Which of the following actions should the nurse take first?
a. Provide information about the use of multiple drugs to treat hypertension.
b. Teach the client about the reasons for a possible change in drug therapy.
c. Remind the client that lifestyle changes also are important in BP control.
d. Ask the client about whether the medication is actually being taken.
ANS: D
Since nonadherence with antihypertensive therapy is common, the nurse’s initial action
should be to determine whether the client is taking the atenolol as prescribed. The other
actions also may be implemented, but these would be done after assessing client
compliance with the prescribed therapy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
19. Which of the following nursing actions should the nurse take first in order to assist a client
with newly diagnosed stage 1 hypertension in making needed dietary changes?
a. Have the client record dietary intake for 3 days.
b. Give the client a detailed list of low-sodium foods.
c. Teach the client about foods that are high in sodium.
d. Help the client make an appointment with a dietitian.
ANS: A
The initial nursing action should be assessment of the client’s baseline dietary intake
through a 3-day diet history. The other actions may be appropriate, but assessment of the
client’s baseline should occur first.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
20. The charge nurse observes a new RN doing discharge teaching for a client who is
hypertensive and has a new prescription for enalapril. Which of the following actions by
the new RN should cause the charge nurse to intervene in the client’s care?
a. Check the BP with a home BP monitor every day.
b. Move slowly when moving from lying to standing.
c. Increase the dietary intake of high-potassium foods.
d. Make an appointment with the dietitian for teaching.
ANS: C
The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a
possible adverse effect. The other teaching by the new RN is appropriate for a client with
newly diagnosed hypertension who has just started therapy with enalapril.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
21. Which of the following assessment findings for a client who is receiving furosemide to
treat stage 2 hypertension is most important to report to the health care provider?
a. Blood glucose level of 10 mmol/L
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b. Blood potassium level of 3.0 mmol/L
c. Early morning BP reading of 164/96 mm Hg
d. Orthostatic systolic BP decrease of 12 mm Hg
ANS: B
Hypokalemia is a frequent adverse effect of the loop diuretics and can cause
life-threatening dysrhythmias. The health care provider should be notified of the potassium
level immediately and administration of potassium supplements initiated. The elevated
blood glucose and BP also indicate a need for collaborative interventions but will not
require action as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg is
common and will require intervention only if the client is symptomatic.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
MULTIPLE RESPONSE
1. The nurse is providing nutritional teaching to a client with hypertension. Which of the
following food groups should the nurse tell the client that they should have four to five
daily servings of? (Select all that apply.)
a. Whole grains
b. Vegetables
c. Meat, fish, and poultry
d. Fat-free dairy food
e. Fruit
ANS: B, E
Clients should be taught to have four to five daily servings of fruits and vegetables. Whole
grains should be seven to eight servings per day. Meat, fish, and poultry are limited to less
than 170 g/day. Low-fat dairy foods should be two to three servings per day.
DIF: Cognitive Level: Implementation
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
COMPLETION
1. The nurse obtains a blood pressure of 180/75 mm Hg for a client. What is the client’s
mean arterial pressure (MAP)? ____________________
ANS:
110
MAP = (DBP + 1/3 Pulse pressure)
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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Chapter 36: Nursing Management: Coronary Artery Disease and Acute Coronary
Syndrome
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is developing a health teaching plan for a 60-year-old man with the following
risk factors for coronary artery disease (CAD). Which of the following risk factors should
the nurse focus on when teaching the client?
a. Family history of coronary artery disease
b. Increased risk associated with the client’s gender
c. High incidence of cardiovascular disease in older people
d. Elevation of the client’s serum low density lipoprotein (LDL) level
ANS: D
Because family history, gender, and age are nonmodifiable risk factors, the nurse should
focus on the client’s LDL level. Decreases in LDL will help reduce the client’s risk for
developing CAD.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
2. To assist the client with coronary artery disease (CAD) in making appropriate dietary
changes, which of the following nursing interventions will be most effective?
a. Instruct the client that a diet containing no saturated fat and minimal sodium will
be necessary.
b. Emphasize the increased risk for cardiac problems unless the client makes the
dietary changes.
c. Assist the client to modify favourite high-fat recipes by using polyunsaturated oils
when possible.
d. Provide the client with a list of low-sodium, low-cholesterol foods that should be
included in the diet.
ANS: C
Lifestyle changes are more likely to be successful when consideration is given to the
client’s values and preferences. The highest percentage of calories from fat should come
from polyunsaturated fats. Although low-sodium and low-cholesterol foods are
appropriate, providing the client with a list alone is not likely to be successful in making
dietary changes. Removing saturated fat from the diet completely is not a realistic
expectation. Telling the client about the increased risk without assisting further with
strategies for dietary change is unlikely to be successful.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
3. Which of the following information collected by the nurse who is admitting a client with
chest pain suggests that the pain is caused by an acute myocardial infarction?
a. The pain increases with deep breathing.
b. The pain has persisted longer than 30 minutes.
c. The pain worsens when the client raises the arms.
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d. The pain is relieved after the client takes nitroglycerin.
ANS: B
Chest pain that lasts for 20 minutes or more is characteristic of an acute myocardial
infarction. Changes in pain that occur with raising the arms or with deep breathing are
more typical of pericarditis or musculo-skeletal pain. Stable angina is usually relieved
when the client takes nitroglycerin.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
4. Which of the following information given by a client admitted with chronic stable angina
will help the nurse confirm this diagnosis?
a. The client rates the pain at a level 3–5 (0–10 scale).
b. The client states that the pain “wakes me up at night.”
c. The client says that the frequency of the pain has increased over the last few
weeks.
d. The client states that the pain is resolved after taking one sublingual nitroglycerin
tablet.
ANS: D
Chronic stable angina is typically relieved by rest or nitroglycerin administration. The
level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or
with increased frequency is typical of unstable angina.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
5. The nurse is providing teaching to a client about use of sublingual nitroglycerin. Which of
the following client statements indicates that the teaching has been effective?
a. “I can expect indigestion as an adverse effect of nitroglycerin.”
b. “I can only take the nitroglycerin if I start to have chest pain.”
c. “I will call an ambulance if I still have pain 5 minutes after taking the
nitroglycerin.”
d. “I will help slow down the progress of the plaque formation by taking
nitroglycerin.”
ANS: C
The emergency medical services (EMS) system should be activated when chest pain or
other symptoms are not completely relieved 5 minutes after taking one nitroglycerin.
Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g.,
before intercourse). Gastric upset is not an expected adverse effect of nitroglycerin.
Nitroglycerin does not impact the underlying pathophysiology of coronary artery
atherosclerosis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
6. Which of the following statements made by a client with coronary artery disease after the
nurse has completed teaching about nutritional therapy for CAD indicates that further
teaching is needed?
a. “I will switch from whole milk to 1% or nonfat milk.”
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b. “I like fresh salmon and I will plan to eat it more often.”
c. “I will miss being able to eat peanut butter sandwiches.”
d. “I can have a cup of coffee with breakfast if I want one.”
ANS: C
Although only 30% of the daily calories should come from fats, most of the fat should
come from monosaturated fats such as are found in nuts, olive oil, and canola oil. The
client can include peanut butter sandwiches as part of their diet. The other client comments
indicate a good understanding of diet.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
7. The nurse is providing teaching to a client about the use of atenolol in preventing anginal
episodes. Which of the following client statements indicate that the teaching has been
effective?
a. “It is important not to suddenly stop taking the atenolol.”
b. “Atenolol will increase the strength of my heart muscle.”
c. “I can expect to feel short of breath when taking atenolol.”
d. “Atenolol will improve the blood flow to my coronary arteries.”
ANS: A
Clients who have been taking b-blockers can develop intense and frequent angina if the
medication is suddenly discontinued. Atenolol decreases myocardial contractility.
Shortness of breath that occurs when taking b-blockers for angina may be due to
bronchospasm and should be reported to the health care provider. Atenolol works by
decreasing myocardial oxygen demand, not by increasing blood flow to the coronary
arteries.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
8. The nurse is caring for a client who has had severe chest pain for several hours and a
diagnosis of possible acute myocardial infarction. Which of the following prescribed
laboratory tests should the nurse monitor to help determine the diagnosis?
a. Homocysteine
b. C-reactive protein
c. Cardiac-specific troponin I and troponin T
d. High-density lipoprotein (HDL) cholesterol
ANS: C
Troponin levels increase about 3–12 hours after the onset of myocardial infarction (MI).
The other laboratory data are useful in determining the client’s risk for developing
coronary artery disease (CAD) but are not helpful in determining whether an acute MI is
in progress.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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9. The nurse is caring for a client with newly diagnosed Prinzmetal’s (variant) angina and has
a prescription for amlodipine. Which of the following information is accurate about
amlodipine?
a. Reduce the “fight or flight” response
b. Decrease spasm of the coronary arteries
c. Increase the force of myocardial contraction
d. Help prevent clotting in the coronary arteries
ANS: B
Prinzmetal’s angina is caused by coronary artery spasm. Calcium channel blockers (e.g.,
amlodipine, nifedipine) are a first-line therapy for this type of angina. Platelet inhibitors,
such as Aspirin, help prevent coronary artery thrombosis, and b-blockers decrease
sympathetic stimulation of the heart. Medications or activities that increase myocardial
contractility will increase the incidence of angina by increasing oxygen demand.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
10. The nurse will suspect that the client with stable angina is experiencing an adverse effect
of the prescribed metoprolol if which of the following findings are assessed?
a. The client is restless and agitated.
b. The blood pressure is 190/110 mm Hg.
c. The client complains about feeling anxious.
d. The cardiac monitor shows a heart rate of 45.
ANS: D
Clients taking b-adrenergic blockers should be monitored for bradycardia. Because this
category of medication inhibits the sympathetic nervous system, restlessness, agitation,
hypertension, and anxiety will not be adverse effects.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
11. The nurse is caring for a client with angina who has been prescribed nadolol. Which of the
following parameters should the nurse assess to determine whether the drug is effective?
a. Decreased blood pressure and apical pulse rate
b. Fewer complaints of having cold hands and feet
c. Improvement in the quality of the peripheral pulses
d. The ability to do daily activities without chest discomfort
ANS: D
Because the medication is ordered to improve the client’s angina, effectiveness is
indicated if the client is able to accomplish daily activities without chest pain. Blood
pressure (BP) and apical pulse rate may decrease, but these data do not indicate that the
goal of decreased angina has been met. The noncardioselective b-blockers can cause
peripheral vasoconstriction, so the nurse would not expect an improvement in peripheral
pulse quality or skin temperature.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
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12. The nurse is caring for a client with a non–ST-segment-elevation myocardial infarction
(NSTEMI) who is receiving heparin. Which of the following information explains the
purpose of the heparin?
a. Platelet aggregation is enhanced by IV heparin infusion.
b. Heparin will dissolve the clot that is blocking blood flow to the heart.
c. Coronary artery plaque size and adherence are decreased with heparin.
d. Heparin will prevent the development of new clots in the coronary arteries.
ANS: D
Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery
thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or
enhance platelet aggregation.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
13. The nurse is administering IV nitroglycerin to a client with a myocardial infarction (MI).
Which of the following actions should the nurse take to evaluate the effectiveness of the
medication?
a. Check blood pressure.
b. Monitor apical pulse rate.
c. Monitor for dysrhythmias.
d. Ask about chest discomfort.
ANS: D
The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the
balance between myocardial oxygen supply and demand. The nurse also will monitor heart
rate and BP and observe for dysrhythmias, but these parameters will not indicate whether
the medication is effective.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
14. A client with ST segment elevation in several electrocardiographic (ECG) leads is
admitted to the emergency department (ED) and diagnosed as having an
ST-segment-elevation myocardial infarction (STEMI). Which of the following questions
should the nurse ask to determine whether the client is a candidate for fibrinolytic therapy?
a. “Do you take Aspirin on a daily basis?”
b. “What time did your chest pain begin?”
c. “Is there any family history of heart disease?”
d. “Can you describe the quality of your chest pain?”
ANS: B
Fibrinolytic therapy should be started within 6 hours of the onset of the myocardial
infarction (MI), so the time at which the chest pain started is a major determinant of the
appropriateness of this treatment. The other information also will be needed, but it will not
be a factor in the decision about fibrinolytic therapy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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15. Following an acute myocardial infarction, a client ambulates in the hospital hallway.
When the nurse is evaluating the client’s response, which of the following assessment data
would indicate that the exercise level should be decreased?
a. BP changes from 118/60 to 126/68 mm Hg.
b. Oxygen saturation drops from 100% to 98%.
c. Heart rate increases from 66 to 90 beats/minute.
d. Respiratory rate goes from 14 to 22 breaths/minute.
ANS: C
A change in heart rate of more than 20 beats or more indicates that the client should stop
and rest. The increases in BP and respiratory rate, and the slight decrease in oxygen
saturation, are normal responses to exercise.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
16. The nurse is administering a fibrinolytic agent to a client with an acute myocardial
infarction. Which of the following assessments should cause the nurse to stop the drug
infusion?
a. Bleeding from the gums
b. Surface bleeding from the IV site
c. A decrease in level of consciousness
d. A nonsustained episode of ventricular tachycardia
ANS: C
The change in level of consciousness indicates that the client may be experiencing
intracranial bleeding, a possible complication of fibrinolytic therapy. Bleeding of the gums
and prolonged bleeding from IV sites are expected adverse effects of the therapy. The
nurse should address these by avoiding any further injuries, but they are not an indication
to stop infusion of the fibrinolytic medication. A nonsustained episode of ventricular
tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is
effective.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
17. Three days after a myocardial infarction (MI), the client develops chest pain that increases
when taking a deep breath and is relieved by leaning forward. Which of the following
actions should the nurse take next?
a. Palpate the radial pulses bilaterally.
b. Assess the feet for peripheral edema.
c. Auscultate for a pericardial friction rub.
d. Check the cardiac monitor for dysrhythmias.
ANS: C
The client’s symptoms are consistent with the development of pericarditis, a possible
complication of MI. The other assessments listed are not consistent with the description of
the client’s symptoms.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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18. The nurse is providing teaching to a client with chronic stable angina about how to use the
prescribed short-acting and long-acting nitrates. Which of the following client statements
indicates that the teaching has been effective?
a. “I will put on the nitroglycerin patch as soon as I develop any chest pain.”
b. “I will check the pulse rate in my wrist just before I take any nitroglycerin.”
c. “I will be sure to remove the nitroglycerin patch before using any sublingual
nitroglycerin.”
d. “I will stop what I am doing and sit down before I put the nitroglycerin under my
tongue.”
ANS: D
The client should sit down before taking the nitroglycerin to decrease cardiac workload
and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather
than to treat acute pain and can be used concurrently with sublingual nitroglycerin.
Although the nurse should check blood pressure before giving nitroglycerin, clients do not
need to check the pulse rate before taking nitrates.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
19. Four days after having a myocardial infarction (MI), a client who is scheduled for
discharge asks for assistance with all the daily activities, saying, “I don’t understand how
to care for myself.” Based on this information, which of the following nursing diagnoses is
appropriate?
a. Ineffective health management related to insufficient knowledge
b. Activity intolerance related to physical deconditioning
c. Ineffective denial related to ineffective coping strategies
d. Social isolation related to insufficient personal resources
ANS: A
The client data indicate ineffective health management related to lack of knowledge of
disease process, and care after discharge. The other nursing diagnoses may be appropriate
for some clients after an MI, but the data for this client do not support denial, activity
intolerance, or social isolation.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Diagnosis
20. The nurse is caring for a client who has survived a sudden cardiac death (SCD) event and
has no evidence of an acute myocardial infarction. Which of the following information
should the nurse teach the client?
a. That sudden cardiac death events rarely reoccur
b. About the purpose of outpatient Holter monitoring
c. How to self-administer low-molecular-weight heparin
d. To limit activities after discharge to prevent future events
ANS: B
Holter monitoring is used to determine whether the client is experiencing dysrhythmias
such as ventricular tachycardia during normal daily activities. SCD is likely to recur.
Heparin will not have any effect on the incidence of SCD, and SCD can occur even when
the client is resting.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
21. The nurse is caring for a client who is 3 days post myocardial infarction and the client
states, “I just had a little chest pain. As soon as I get out of here, I’m going for my
vacation as planned.” Which of the following responses should the nurse make?
a. “Where are you planning to go for your vacation?”
b. “What do you think caused your chest pain episode?”
c. “Sometimes plans need to change after a heart attack.”
d. “Recovery from a heart attack takes at least a few weeks.”
ANS: B
When the client is experiencing denial, the nurse should assist the client in testing reality
until the client has progressed beyond this step of the emotional adjustment to MI. Asking
the client about vacation plans reinforces the client’s plan, which is not appropriate in the
immediate post-MI period. Reminding the client in denial about the MI is likely to make
the client angry and lead to distrust of the nursing staff.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
22. The nurse is evaluating the outcomes of preoperative teaching with a client scheduled for a
coronary artery bypass graft (CABG) using the internal mammary artery. Which of the
following client statements indicates that additional teaching is needed?
a. “I will have incisions in my leg where they will remove the vein.”
b. “They will circulate my blood with a machine during the surgery.”
c. “I will need to take an Aspirin a day after the surgery to keep the graft open.”
d. “They will use an artery near my heart to bypass the area that is obstructed.”
ANS: A
When the internal mammary artery is used there is no need to have a saphenous vein
removed from the leg. The other statements by the client are accurate and indicate that the
teaching has been effective.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
23. The nurse is caring for a client who has had an acute myocardial infarction and the client
asks the nurse about when sexual intercourse can be resumed. Which of the following
responses by the nurse is best?
a. “Most clients are able to enjoy intercourse without any complications.”
b. “Sexual activity uses about as much energy as climbing two flights of stairs.”
c. “The doctor will discuss sexual intercourse when your heart is strong enough.”
d. “Holding and cuddling are good ways to maintain intimacy after a heart attack.”
ANS: B
Sexual activity places about as much physical stress on the cardiovascular system as
climbing two flights of stairs. The other responses do not directly address the client’s
question, or may not be accurate for this client.
DIF:
Cognitive Level: Application
TOP: Nursing Process: Implementation
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MSC: NCLEX: Physiological Integrity
24. The nurse is caring for a client with hyperlipidemia who has a new prescription for
colestipol. Which of the following nursing actions is best when giving the medication?
a. Administer the medication at the client’s bedtime.
b. Have the client take this medication with an Aspirin.
c. Encourage the client to take the colestipol with a sip of water.
d. Give the client’s other medications 2 hours after the colestipol.
ANS: D
The bile acid sequestrants interfere with the absorption of other drugs, and giving other
medications at the same time should be avoided. Taking an Aspirin concurrently with the
colestipol may increase the incidence of gastrointestinal adverse effects such as heartburn.
An increased fluid intake is encouraged for clients taking the bile acid sequestrants to
reduce the risk for constipation. For maximum effect, colestipol should be administered
with meals.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
25. The nurse is caring for a client who was admitted the previous day to the coronary care
unit with an acute myocardial infarction. Which of the following information should the
nurse include in the teaching plan for the client?
a. Typical emotional responses to AMI
b. When client cardiac rehabilitation will begin.
c. Discharge drugs such as Aspirin and b-blockers.
d. The pathophysiology of coronary artery disease.
ANS: B
Early after an AMI, the client will want to know when resumption of usual activities can
be expected. At this time, the client’s anxiety level or denial will prevent good
understanding of complex information such as coronary artery disease (CAD)
pathophysiology. Teaching about discharge medications should be done when the time for
discharge is closer. The nurse should support the client by decreasing anxiety rather than
discussing the typical emotional response to myocardial infarction (MI).
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Planning
26. The nurse is caring for a client who has recently started taking rosuvastatin and niacin who
reports all of these symptoms to the nurse. Which of the following finding is most
important to communicate to the health care provider?
a. Generalized muscle aches and weakness
b. Skin flushing after taking the medications
c. Dizziness when changing positions quickly
d. Nausea when taking the drugs before eating
ANS: A
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Muscle aches and weakness may indicate myopathy and rhabdomyolysis, which have
caused acute renal failure and death in some clients who have taken the statin medications.
These symptoms indicate that the rosuvastatin may need to be discontinued. The other
symptoms are common adverse effects when taking niacin, and although the nurse should
follow up with the client, they do not indicate that a change in medication is needed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
27. The nurse is admitting a client to the emergency department with severe chest pain and
gives the following list of medications taken at home to the nurse. Which of the following
medications has the most immediate implications for the client’s care?
a. Sildenafil
b. Furosemide
c. Diazepam
d. Captopril
ANS: A
The nurse will need to avoid giving nitrates to the client because nitrate administration is
contraindicated in clients who are using sildenafil because of the risk of sudden death
caused by vasodilation. The other home medications also should be documented and
reported to the health care provider but do not have as immediate an impact on decisions
about the client’s treatment.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
28. The nurse is providing teaching to a client who has a prescription for transdermal
nitroglycerin drug administration via reservoir. The client asks the nurse how often each
day will the drug be administered. Which of the following information is the basis for the
nurse’s response?
a. Every 4 hours while awake
b. Every 6 hours around the clock
c. Every 12 hours
d. Once every 24 hours
ANS: D
The reservoir system delivers the drug using a rate-controlled permeable membrane. The
reservoir delivery system offers the advantage of steady plasma levels within the
therapeutic range during 24 hours; thus, only one application a day is necessary.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
29. Which of the following causes is the most common cause for sudden cardiac death?
a. Ventricular tachycardia
b. Aortic stenosis
c. Hypertrophic cardiomyopathy
d. Angina
ANS: A
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Acute ventricular dysrhythmias (e.g., ventricular tachycardia, ventricular fibrillation)
cause the majority of cases of SCD. Less commonly, SCD occurs because of a primary left
ventricular outflow obstruction (e.g., aortic stenosis, hypertrophic cardiomyopathy) or
extreme slowing of the heart (bradycardia).
DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
30. Which of the following electrocardiographic (ECG) change is most important for the nurse
to communicate to the health care provider when caring for a client with chest pain?
a. Frequent premature atrial contractions (PACs)
b. Inverted P wave
c. Sinus tachycardia
d. ST segment elevation
ANS: D
The client is likely to be experiencing an ST-segment-elevation myocardial infarction
(STEMI) and immediate therapy with percutaneous coronary intervention (PCI) or
fibrinolytic medications is indicated to minimize the amount of myocardial damage. The
other ECG changes also may suggest a need for therapy, but not as rapidly.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
31. The nurse is caring for a client with acute coronary syndrome who has returned to the
coronary care unit after having percutaneous coronary intervention and the nurse obtains
these assessment data. Which of the following data indicate the need for immediate
intervention by the nurse?
a. Pedal pulses 1+
b. Heart rate 100 beats/minute
c. Blood pressure 104/56 mm Hg
d. Chest pain level 8 on a 10-point scale
ANS: D
The client’s chest pain indicates that restenosis of the coronary artery may be occurring
and requires immediate actions, such as administration of oxygen and nitroglycerin, by the
nurse. The other information indicates a need for ongoing assessments by the nurse.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
32. The nurse is admitting a client with a myocardial infarction (MI) to the intensive care unit.
Which of the following actions should the nurse carry out first?
Obtain the blood pressure.
Attach the cardiac monitor.
Assess the peripheral pulses.
Auscultate the breath sounds.
a.
b.
c.
d.
ANS: B
Because dysrhythmias are the most common complication of MI, the first action should be
to place the client on a cardiac monitor. The other actions also are important and should be
accomplished as quickly as possible.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
33. Which of the following information about a client who has been receiving fibrinolytic
therapy for an acute myocardial infarction is most important for the nurse to communicate
to the health care provider?
a. No change in the client’s chest pain
b. A large bruise at the client’s IV insertion site
c. A decrease in ST segment elevation on the electrocardiogram (ECG)
d. An increase in cardiac enzyme levels since admission
ANS: A
Continued chest pain suggests that the fibrinolytic therapy is not effective and that other
interventions such as percutaneous coronary intervention (PCI) may be needed. Bruising is
a possible adverse effect of fibrinolytic therapy, but it is not an indication that therapy
should be discontinued. The decrease of the ST segment elevation indicates that
fibrinolysis is occurring and perfusion is returning to the injured myocardium. An increase
in cardiac enzyme levels is expected with reperfusion and is related to the washout of
enzymes into the circulation as the blocked vessel is opened.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
34. The nurse obtains the following data when caring for a client who experienced an acute
myocardial infarction 2 days previously. Which of the following information is most
important to report to the health care provider?
a. The client denies ever having a heart attack.
b. The cardiac-specific troponin level is elevated.
c. The client has occasional premature atrial contractions (PACs).
d. Crackles are auscultated bilaterally in the mid-lower lobes.
ANS: D
The crackles indicate that the client may be developing heart failure, a possible
complication of myocardial infarction (MI). The health care provider may need to order
medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the
client. Elevation in cardiac troponin level at this time is expected. PACs are not
life-threatening dysrhythmias. Denial is a common response in the immediate period after
the MI.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
35. Which of the following approaches to preventing a recurrence of sudden cardiac death is
the most common?
a. Long-term Aspirin therapy
b. Implantable cardioverter-defibrillator
c. Administration of amiodarone
d. Continuous Holter monitoring
ANS: B
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The most common approach to preventing a recurrence is the use of an implantable
cardioverter-defibrillator (ICD). Research has shown survival rates are better with an ICD
than with drug therapy alone. Drug therapy with amiodarone may be used in conjunction
with an ICD to decrease episodes of ventricular dysrhythmias. Continuous monitoring will
not prevent a recurrence. Aspirin will not prevent a recurrence of SCD.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
36. The nurse is admitting a client who has chest pain is to the emergency department and all
the following diagnostic tests are prescribed. Which of the following tests should the nurse
arrange to be completed first?
a. Electrocardiogram (ECG)
b. Computed tomography (CT) scan
c. Chest x-ray
d. Troponin level
ANS: A
The priority for the client is to determine whether an acute myocardial infarction (AMI) is
occurring so that reperfusion therapy can begin as quickly as possible. ECG changes occur
very rapidly after coronary artery occlusion. Troponin levels will increase after about 3
hours. Data from the CT scan and chest x-ray may impact the client’s care but are not
helpful in determining whether the client is experiencing a myocardial infarction (MI).
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
37. The nurse has just received a change-of-shift report about the following four clients.
Which client should the nurse assess first?
a. 38-year-old who has pericarditis and is complaining of sharp, stabbing chest pain
b. 45-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about
the planned discharge
c. 51-year-old with unstable angina who has just returned to the unit after having a
percutaneous coronary intervention (PCI)
d. 60-year-old with variant angina who is to receive a scheduled dose of nifedipine
(Adalat)
ANS: C
This client is at risk for bleeding from the arterial access site for the PCI, so the nurse
should assess the client’s blood pressure, pulse, and the access site immediately. The other
clients also should be assessed as quickly as possible, but assessment of this client has the
highest priority.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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Chapter 37: Nursing Management: Heart Failure
Lewis: Medical-Surgical Nursing in Canada, 4th Canadia Edition
MULTIPLE CHOICE
1. The nurse is caring for a client with chronic heart failure. Which of the following
conditions is a cause of chronic heart disease?
a. Dysrhythmias
b. Pulmonary embolus
c. Myocarditis
d. Congenital heart disease
ANS: D
Congenital heart disease is a cause of chronic heart failure. Dysrhythmias, pulmonary
embolus, and myocarditis are causes of acute heart failure.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. The nurse is caring for a client who is receiving IV furosemide and morphine for the
treatment of acute decompensated heart failure (ADHF) with severe orthopnea. When
evaluating the client response to the medications, which of the following is the best
indicator that the treatment has been effective?
a. Weight loss of 1 kg overnight
b. Hourly urine output greater than 60 mL
c. Reduction in client complaints of chest pain
d. Decreased dyspnea with the head of bed at 30 degrees
ANS: D
Because the client’s major clinical manifestation of ADHF is orthopnea (caused by the
presence of fluid in the alveoli), the best indicator that the medications are effective is a
decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also
may indicate that diuresis or improvement in cardiac output has occurred but are not as
specific to evaluating this client’s response.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
3. Which topic will the nurse plan to include in discharge teaching for a client with systolic
heart failure and an ejection fraction of 38%?
a. Need to participate in an aerobic exercise program several times weekly
b. Use of salt substitutes to replace table salt when cooking and at the table
c. Importance of making a yearly appointment with the primary care provider
d. Benefits and adverse effects of angiotensin-converting enzyme (ACE) inhibitors
ANS: D
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The core measure for the treatment of heart failure in clients with a low ejection fraction is
to receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise
may not be appropriate for a client with this level of heart failure, salt substitutes are not
usually recommended because of the risk of hyperkalemia, and the client will need to see
the primary care provider more frequently than annually.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
4. The nurse is conducting a health history on a client with heart failure. Which of the
following conditions in the client’s health history is a precipitating cause of heart failure?
Hyperthyroidism
Anemia
Hypovolemia
Diabetes
a.
b.
c.
d.
ANS: B
Anemia is a precipitating cause of heart failure. Also, hypovolemia and hypothyroidism
are precipitating causes. Diabetes is not a precipitating cause of heart failure.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
5. A client who has chronic heart failure tells the nurse, “I felt fine when I went to bed, but I
woke up in the middle of the night feeling like I was suffocating!” Which of the following
information should the nurse document related to this assessment?
a. Pulsus alternans
b. Two-pillow orthopnea
c. Acute bilateral pleural effusion
d. Paroxysmal nocturnal dyspnea
ANS: D
Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body
areas when the client is sleeping and is characterized by waking up suddenly with the
feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral
pulses during palpation. Orthopnea indicates that the client is unable to lie flat because of
dyspnea. Pleural effusions develop over a longer time period.
DIF: Cognitive Level: Knowledge
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
6. During a visit to a client with chronic heart failure, the home care nurse finds that the
client has ankle edema, a 2 kg weight gain, and complains of “feeling too tired to do
anything.” Based on these data, which of the following is the best nursing diagnosis for the
client?
a. Activity intolerance related to physical deconditioning
b. Disturbed body image related to alteration in self-perception
c. Impaired skin integrity related to alteration in fluid volume (peripheral edema)
d. Ineffective breathing pattern related to respiratory muscle fatigue
ANS: A
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The client’s statement supports the diagnosis of activity intolerance. There are no data to
support the other diagnoses, although the nurse will need to assess for other client
problems.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Diagnosis
7. The nurse working in the heart failure clinic will know that teaching for a client with
newly diagnosed heart failure has been effective when the client does which of the
following actions?
a. Uses an additional pillow to sleep when feeling short of breath at night.
b. Tells the home care nurse that furosemide is taken daily at bedtime.
c. Calls the clinic when the weight increases from 56 to 59 kg in 2 days.
d. Says that the nitroglycerin patch will be used for any chest pain that develops.
ANS: C
Teaching for a client with heart failure includes information about the need to weigh daily
and notify the health care provider about an increase of more than 2 kg in a 2 day period.
Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in
clients with heart failure and should be used daily, not on an “as necessary” basis.
Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The
client should call the clinic if increased orthopnea develops, rather than just compensating
by elevating the head of the bed further.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
8. The nurse is teaching the client with heart failure about a 2 g sodium diet. Which of the
following foods should the nurse explain to the client that need to be restricted?
Canned and frozen fruits
Fresh or frozen vegetables
Milk, yogourt, and other milk products.
Eggs and other high-cholesterol foods.
a.
b.
c.
d.
ANS: C
Milk and yogourt naturally contain a significant amount of sodium, and intake of these
should be limited for clients on a diet that limits sodium to 2 g daily. Other milk products,
such as processed cheeses, have very high levels of sodium and are not appropriate for a 2
g sodium diet. The other foods listed have minimal levels of sodium and can be eaten
without restriction.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
9. The nurse is caring for a client with heart failure with reduced ejection fraction. Which of
the following laboratory values should the nurse expect to assess in the client related to
ejection fraction?
a. 40%
b. 60%
c. 80%
d. 90%
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ANS: A
Normal EF is greater than 55% of the ventricular volume. Patients with HF-REF requiring
specialist intervention generally have an EF less than or equal to 40%.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
10. The nurse is caring for an older-adult client with heart failure and learns that the client
lives alone and sometimes confuses the “water pill” with the “heart pill.” When planning
for the client’s discharge the nurse will facilitate which of the following actions?
a. Transfer to a dementia care service
b. Referral to a home health care agency
c. Placement in a long-term care facility
d. Arrangements for around-the-clock care
ANS: B
The data about the client suggest that assistance in developing a system for taking
medications correctly at home is needed. A home health nurse will assess the client’s
home situation and help the client develop a method for taking the two medications as
directed. There is no evidence that the client requires services such as dementia care,
long-term care, or around-the-clock home care.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
11. Following an acute myocardial infarction, a previously healthy client develops clinical
manifestations of heart failure. The nurse anticipates discharge teaching will include
information about which of the following medications?
a. Angiotensin-converting enzyme (ACE) inhibitors
b. Digitalis preparations
c. b-adrenergic agonists
d. Calcium channel blockers
ANS: A
ACE inhibitor therapy is currently recommended to prevent the development of heart
failure in clients who have had a myocardial infarction and as a first-line therapy for
clients with chronic heart failure. Digoxin therapy for heart failure is no longer considered
a first-line measure. Calcium channel blockers are not generally used in the treatment of
heart failure. The b-adrenergic agonists such as dobutamine are administered through the
IV route and are not used as initial therapy for heart failure.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
12. The nurse is caring for a client with Class III status (NYHA) heart failure and type 2
diabetes and the client asks the nurse whether heart transplant is a possible therapy. Which
of the following responses by the nurse is best?
a. “Since you have diabetes, you would not be a candidate for a heart transplant.”
b. “The choice of a client for a heart transplant depends on many different factors.”
c. “Your heart failure has not reached the stage in which heart transplants are
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considered.”
d. “People who have heart transplants are at risk for multiple complications after
surgery.”
ANS: B
Indications for a heart transplant include end-stage heart failure, but other factors such as
coping skills, family support, and client motivation to follow the rigorous post-transplant
regimen are also considered. Clients with diabetes who have well-controlled blood glucose
levels may be candidates for heart transplant. Although heart transplants can be associated
with many complications, this response does not address the client’s question.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
13. Which of the following diagnostic tests will be most useful to the nurse in determining
whether a client admitted with acute shortness of breath has heart failure?
a. Serum creatine kinase (CK)
b. Arterial blood gases (ABGs)
c. B-type natriuretic peptide (BNP)
d. 12-lead electrocardiogram (ECG)
ANS: C
BNP is secreted when ventricular pressures increase, as with heart failure, and elevated
BNP indicates a probable or very probable diagnosis of heart failure. 12-lead ECGs, ABGs,
and CK also may be used in determining the causes or effects of heart failure but are not as
clearly diagnostic of heart failure as BNP.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
14. Which of the following actions is priority when caring for a client admitted with acute
decompensated heart failure (ADHF) who is receiving a nitrate?
Monitor blood pressure frequently.
Encourage client to ambulate in room.
Titrate nitrate rate slowly before discontinuing.
Teach client about safe home use of the medication.
a.
b.
c.
d.
ANS: A
Nitrates cause vasodilation therefore BP should be frequently monitored. Since the client
is likely to have orthostatic hypotension, the client should not be encouraged to ambulate.
Nitrate does not require titration and the priority is not to teach about safe use at home.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
15. A client with heart failure has a new order for captopril 12.5 mg PO. After administering
the first dose and teaching the client about captopril, which statement by the client
indicates that teaching has been effective?
a. “I will call for help when I need to get up to use the bathroom.”
b. “I will be sure to take the medication after eating something.”
c. “I will need to include more high-potassium foods in my diet.”
d. “I will expect to feel more short of breath for the next few days.”
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ANS: A
Captopril can cause hypotension, especially after the initial dose, so it is important that the
client not get up out of bed without assistance until the nurse has had a chance to evaluate
the effect of the first dose. The ACE inhibitors are potassium sparing, and the nurse should
not teach the client to increase sources of dietary potassium. Increased shortness of breath
is expected with initiation of b-blocker therapy for heart failure, not for ACE inhibitor
therapy. ACE inhibitors are best absorbed when taken an hour before eating.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
16. Which of the following clients is less likely to enroll in a cardiac rehabilitation program?
a. A 64-year-old male who has diabetes
b. A 51-year-old male who has a same-sex partner
c. A 52-year-old single female
d. A 39-year-old male with two children
ANS: C
Women are 36% less likely to enroll in cardiac rehabilitation programs.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
17. A client with a history of chronic heart failure is admitted to the emergency department
(ED) with severe dyspnea and a dry, hacking cough. Which of the following actions
should the nurse take first?
a. Palpate the abdomen.
b. Assess the orientation.
c. Check the capillary refill.
d. Auscultate the lung sounds.
ANS: D
This client’s severe dyspnea and cough indicate that acute decompensated heart failure
(ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be
detected and treated immediately to prevent ongoing hypoxemia and cardiac or respiratory
arrest. The other assessments will provide useful data about the client’s volume status and
also should be accomplished rapidly, but detection (and treatment) of pulmonary
complications is the priority.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
18. The home health nurse is visiting a client with chronic heart failure who has prescriptions
for a diuretic, an ACE-inhibitor, and a low-sodium diet and tells the nurse about a 2.3 kg
weight gain in the last 3 days. Which of the following actions should the nurse do first?
a. Ask the client to recall the dietary intake for the last 3 days.
b. Question the client about the use of the prescribed medications.
c. Assess the client for clinical manifestations of acute heart failure.
d. Teach the client about the importance of dietary sodium restrictions.
ANS: C
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The development of dependent edema or a sudden weight gain of more than 2 kg in 2 days
is often indicative of exacerbated HF. It is important that the client be immediately
assessed for other clinical manifestations of decompensation, such as lung crackles. A
dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and
assessment of medication compliance may be appropriate interventions but are not the first
nursing actions indicated.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
19. The nurse is caring for a client in the intensive care unit with acute decompensated heart
failure (ADHF) who has symptoms of severe dyspnea and is anxious, tachypneic, and
tachycardic. All these medications have been prescribed for the client. Which of the
following actions should the nurse implement first?
a. Give IV diazepam 2.5 mg.
b. Administer IV morphine sulphate 2 mg.
c. Increase nitroglycerin infusion by 5 mcg/min.
d. Increase dopamine infusion by 2 mcg/kg/min.
ANS: B
Morphine improves alveolar gas exchange, improves cardiac output by reducing
ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective
feeling of dyspnea. Diazepam may decrease client anxiety, but it will not improve the
cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but
it also will increase the heart rate and myocardial oxygen consumption. Nitroglycerin will
improve cardiac output and may be appropriate for this client, but it will not directly
reduce anxiety and will not act as quickly as morphine to decrease dyspnea.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
20. After receiving change-of-shift report, which of the following clients admitted with heart
failure should the nurse assess first?
a. A client who is receiving IV nitroprusside and has a blood pressure (BP) of 100/56
b. A client who is cool and clammy, with new-onset confusion and restlessness
c. A client who had dizziness after receiving the first dose of captopril
d. A client who has crackles in both posterior lung bases and is receiving oxygen
ANS: B
The client who has “wet-cold” clinical manifestations of heart failure is perfusing
inadequately and needs rapid assessment and changes in management. The other clients
also should be assessed as quickly as possible, but do not have indications of severe
decreases in tissue perfusion.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
21. Which assessment finding in a client admitted with chronic heart failure requires the most
rapid action by the nurse?
a. Oxygen saturation of 88%
b. Weight gain of 1 kg
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c. Apical pulse rate of 106 beats/minute
d. Urine output of 50 mL over 2 hours
ANS: A
In a person with HF, oxygen saturation of the blood may be reduced because the blood is
not adequately oxygenated in the lungs. Administration of oxygen, if the O2 saturation is
less than 90%, can improve tissue oxygenation. Thus, appropriate use of oxygen therapy
helps relieve dyspnea and fatigue. An increase in apical pulse rate, 1-kg weight gain, and
decreases in urine output also indicate worsening heart failure and require rapid nursing
actions, but the low oxygen saturation rate requires the most immediate nursing action.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
22. The nurse is providing health-promotion teaching related to heart health and is explaining
modifiable and nonmodifiable risk factors. Smoking is a modifiable risk factor. After a
diagnosis of cardiovascular-related illness, approximately what percentage of clients that
were smokers quit?
a. 5
b. 15
c. 25
d. 50
ANS: A
After diagnosis of a cardiovascular-related illness, fewer than 5% of Canadians quit
smoking.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
23. An outpatient who has heart failure returns to the clinic after 2 weeks of therapy with an
ACE inhibitor. Which of these assessment findings is most important for the nurse to
report to the health care provider?
a. Pulse rate of 56
b. 2+ pedal edema
c. BP of 88/42 mm Hg
d. Complaints of fatigue
ANS: C
The client’s BP indicates that the dose of the ACE inhibitor may need to be decreased
because of hypotension. Bradycardia is a frequent adverse effect of b-adrenergic blockade,
but the rate of 56 is not unusual with b-blocker therapy. b-adrenergic blockade initially
will worsen symptoms of heart failure in many clients, and clients should be taught that
some increase in symptoms, such as fatigue and edema, is expected during the initiation of
therapy with this class of drugs.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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24. The nurse is caring for a client with right-sided heart failure who asks the nurse what
caused the heart failure. Which of the following causes is the primary cause of right-sided
heart failure?
a. Cor pulmonale
b. Chronic pulmonary hypertension
c. Left-sided heart failure
d. Acute decompensated heart failure
ANS: C
The primary cause of right-sided failure is left-sided failure. In this situation, left-sided
failure results in pulmonary congestion and increased pressure in the blood vessels of the
lungs (pulmonary hypertension).
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
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Chapter 38: Nursing Management: Dysrhythmias
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is interpreting an ECG strip to determine whether there is a delay in impulse
conduction through the atria. Which of the following components of an ECG strip should
the nurse measure?
a. P wave
b. P–R interval
c. Q–T interval
d. QRS complex
ANS: A
The P wave represents the depolarization of the atria. The P–R interval represents
depolarization of the atria, atrioventricular (AV) node, bundle of His, bundle branches,
and the Purkinje fibres. The QRS represents ventricular depolarization. The Q–T interval
represents depolarization and repolarization of the entire conduction system.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. The nurse needs to estimate quickly the heart rate for a client with a regular heart rhythm.
Which of the following methods is best to use?
a. Print a 1-minute electrocardiogram (ECG) strip and count the number of QRS
complexes.
b. Count the number of large squares in the R–R interval and divide by 300.
c. Use the 3-second markers to count the number of QRS complexes in 6 seconds and
multiply by 10.
d. Calculate the number of small squares between one QRS complex and the next and
divide into 1 500.
ANS: C
This is the quickest way to determine the ventricular rate for a client with a regular rhythm.
All the other methods are accurate, but take longer.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
3. A client has a junctional escape rhythm on the monitor. The nurse will expect the client to
have a heart rate of how many beats/minute?
20–30
40–60
70–80
90–100
a.
b.
c.
d.
ANS: B
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If the sinoatrial (SA) node fails to discharge, the atrioventricular (AV) node will
automatically discharge at the normal rate of 40–60. The slower rates are typical of the
bundle of His and the Purkinje system and may be seen with failure of both the SA and
AV nodes to discharge. The normal SA node rate is 60–100 beats/minute.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
4. The nurse obtains a monitor strip on a client who has had a myocardial infarction and
makes the following analysis: P wave not apparent, ventricular rate 162, R–R interval
regular, P–R interval not measurable, and QRS complex wide and distorted, QRS duration
0.18 second. Which of the following cardiac rhythms should the nurse interpret from these
findings?
a. Atrial fibrillation
b. Sinus tachycardia
c. Ventricular fibrillation
d. Ventricular tachycardia
ANS: D
The absence of P waves, wide QRS, rate >150, and the regularity of the rhythm indicate
ventricular tachycardia. Atrial fibrillation is grossly irregular, has a narrow QRS
configuration, and has fibrillatory atrial activity. Sinus tachycardia has P waves.
Ventricular fibrillation is irregular and does not have a consistent QRS duration.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
5. The nurse notes that a client’s cardiac monitor shows that every other beat is earlier than
expected, has no P wave, and has a QRS complex with a wide and bizarre shape. How
should the nurse document the rhythm?
a. Ventricular couplets
b. Ventricular bigeminy
c. Ventricular R-on-T phenomenon
d. Ventricular multifocal contractions
ANS: B
Ventricular bigeminy describes a rhythm in which every other QRS complex is wide and
bizarre looking. Pairs of wide QRS complexes are described as couplets. There is no
indication that the premature ventricular contractions (PVCs) are multifocal or that the
R-on-T phenomenon is occurring.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
6. The nurse is caring for a client who has a normal cardiac rhythm and a heart rate of 72
beats/minute, except that the P–R interval is 0.24 seconds. Which of the following actions
should the nurse implement?
a. Notify the client’s health care provider immediately.
b. Administer atropine per agency bradycardia protocol.
c. Prepare the client for temporary pacemaker insertion.
d. Document the finding and continue to monitor the client.
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ANS: D
First-degree atrioventricular (AV) block is asymptomatic and requires ongoing monitoring
because it may progress to more serious forms of heart block. The rate is normal, so there
is no indication that atropine is needed. Immediate notification of the health care provider
about an asymptomatic rhythm is not necessary.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
7. The nurse is caring for a client who was admitted with a myocardial infarction and
experiences a 50-second episode of ventricular tachycardia, then converts to sinus rhythm
with a heart rate of 98 beats/minute. Which of the following actions should the nurse take
next?
a. Notify the health care provider.
b. Perform synchronized cardioversion.
c. Administer the PRN IV lidocaine.
d. Document the rhythm and monitor the client.
ANS: C
The burst of sustained ventricular tachycardia indicates that the client has significant
ventricular irritability, and antidysrhythmic medication administration is needed to prevent
further episodes and accelerate repolarization. The nurse should notify the health care
provider after the medications are administered. Defibrillation is not indicated given that
the client is currently in a sinus rhythm. Documentation and continued monitoring are not
adequate responses to this situation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
8. The nurse administers IV atropine to a client with symptomatic type 1, second-degree
atrioventricular (AV) block. Which of the following findings indicate that the medication
has been effective?
a. Increase in the client’s heart rate
b. Decrease in premature contractions
c. Increase in peripheral pulse volume
d. Decrease in ventricular ectopic beats
ANS: A
Atropine will increase the heart rate and conduction through the AV node. Because the
medication increases electrical conduction, not cardiac contractility, the quality of the
peripheral pulses is not used to evaluate the drug effectiveness. The client does not have
ventricular ectopy or premature contractions.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
9. The nurse is caring for a client with dilated cardiomyopathy who has an atrial fibrillation
that has been unresponsive to drug therapy for several days. Which of the following
actions should the nurse anticipate?
a. Electrical cardioversion
b. IV adenosine
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c. Anticoagulant therapy with warfarin
d. Insertion of an implantable cardioverter-defibrillator
ANS: C
Atrial fibrillation therapy that has persisted for more than 48 hours requires anticoagulant
treatment for 3 weeks before attempting cardioversion; this is done to prevent
embolization of clots from the atria. Adenosine is not used to treat atrial fibrillation.
Cardioversion may be done after several weeks of Coumadin therapy. ICDs are used for
clients with recurrent ventricular fibrillation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
10. Which of the following information will the nurse include when teaching a client who is
scheduled to have a permanent pacemaker inserted for treatment of chronic atrial
fibrillation with slow ventricular response?
a. The pacemaker prevents or minimizes ventricular irritability.
b. The pacemaker paces the atria at rates up to 500 impulses/minute.
c. The pacemaker discharges if ventricular fibrillation and cardiac arrest occur.
d. The pacemaker stimulates a heartbeat if the client’s heart rate drops too low.
ANS: D
The permanent pacemaker will discharge when the ventricular rate drops below the set
rate. The pacemaker will not decrease ventricular irritability or discharge if the client
develops ventricular fibrillation. Since the client has a slow ventricular rate, overdrive
pacing will not be used.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
11. The nurse is providing instruction to a client on the management of a new implantable
cardioverter-defibrillator (ICD). Which of the following client statements indicate that the
teaching has been effective?
a. “It will be 6 weeks before I can take a bath or return to my usual activities.”
b. “I will notify the airlines when I make a reservation that I have a pacemaker.”
c. “I won’t lift the arm on the pacemaker side up very high until I see the doctor.”
d. “I must avoid cooking with a microwave oven or being near a microwave in use.”
ANS: C
The client is instructed to avoid lifting the arm on the pacemaker side above the shoulder
to avoid displacing the pacemaker leads. The client should notify airport security about the
presence of a pacemaker before going through the metal detector, but there is no need to
notify the airlines when making a reservation. Microwave oven use does not affect the
pacemaker. The insertion procedure involves minor surgery that will have a short recovery
period.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
12. Which of the following actions by a new nurse who is caring for a client who has just had
an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more
education about care of clients with ICDs?
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a. The nurse assists the client to do active range-of-motion exercises for all
extremities.
b. The nurse assists the client to fill out the application for obtaining a Medic Alert
ID and bracelet.
c. The nurse gives atenolol to the client without consulting first with the health care
provider.
d. The nurse teaches the client that sexual activity usually can be resumed once the
surgical incision is healed.
ANS: A
The client should avoid moving the arm on the ICD insertion site until healing has
occurred in order to prevent displacement of the ICD leads. The other actions by the new
nurse are appropriate for this client.
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
13. Which of the following actions should the nurse take when preparing for cardioversion of
a client with supraventricular tachycardia who is alert and has a blood pressure of 110/66
mm Hg?
a. Turn the synchronizer switch to the “off” position.
b. Perform cardiopulmonary resuscitation (CPR) until the paddles are in correct
position.
c. Set the defibrillator/cardioverter energy to 300 J.
d. Administer a sedative before cardioversion is implemented.
ANS: D
When a client has a nonemergency cardioversion, sedation is used just before the
procedure. The synchronizer switch is turned on for cardioversion. The initial level of
joules for cardioversion is low (e.g., 50). CPR is not indicated for this client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
14. The nurse is caring for a young adult client who had a mandatory electrocardiogram (ECG)
before participating on a college swim team and is found to have sinus bradycardia, rate 52.
BP is 114/54 mm Hg, and the student denies any health problems. Which of the following
actions by the nurse is best?
a. Allow the student to participate on the swim team.
b. Refer the student to a cardiologist for further assessment.
c. Obtain more detailed information about the student’s health history.
d. Tell the student to stop swimming immediately if any dyspnea occurs.
ANS: A
In an aerobically trained individual, sinus bradycardia is normal. The student’s normal BP
and negative health history indicate that there is no need for a cardiology referral or for
more detailed information about the health history. Dyspnea during an aerobic activity
such as swimming is normal.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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15. When analyzing the waveforms of a client’s electrocardiogram (ECG), the nurse will need
to investigate further upon assessing which of the following findings?
a. T wave of 0.16 second
b. P–R interval of 0.18 second
c. Q–T interval of 0.34 second
d. QRS interval of 0.14 second
ANS: D
Because the normal QRS interval is 0.04–0.10 seconds, the client’s QRS interval of 0.14
seconds indicates that the conduction through the ventricular conduction system is
prolonged. The P–R interval, Q–T interval, and T-wave interval are within the normal
range.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
16. The nurse is caring for a client who has a ST segment change that indicates an acute
inferior wall myocardial infarction. Which of the following leads is best for monitoring the
client?
a. I
b. II
c. V6
d. MCL1
ANS: B
Lead II reflects the inferior area of the heart that is experiencing the ST segment changes
and will best reflect any electrocardiographic changes that indicate further damage to the
myocardium. The other leads do not reflect the inferior part of the myocardial wall and
will not provide data about further ischemic changes.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
17. Which of the following laboratory results for a client whose cardiac monitor shows
multifocal premature ventricular contractions (PVCs) is most important for the nurse to
communicate to the health care provider?
a. Blood glucose 12.8 mmol/L
b. Serum chloride 90 mmol/L
c. Serum sodium 133 mmol/L
d. Serum potassium 2.8 mmol/L
ANS: D
Electrolyte imbalances increase the risk for ventricular dysrhythmias such as PVCs,
ventricular tachycardia, and ventricular fibrillation; the health care provider will need to
prescribe a potassium infusion to correct this hypokalemia. Although the other laboratory
values also are abnormal, they are not likely to be the etiology of the client’s PVCs and do
not require immediate correction.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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18. The nurse is caring for a client whose cardiac monitor has a pattern of undulations of
varying contours and amplitude with no measurable ECG pattern. The client is
unconscious and pulseless. Which of the following actions should the nurse take first?
a. Defibrillate at 200 J.
b. Give O2 per bag-valve-mask.
c. Give epinephrine (Adrenalin) IV.
d. Prepare for endotracheal intubation.
ANS: A
The client’s rhythm and assessment indicate ventricular fibrillation and cardiac arrest; the
initial action should be to defibrillate. If a defibrillator is not immediately available or is
unsuccessful in converting the client to a better rhythm, the other actions may be
appropriate.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
19. The nurse is caring for a client whose cardiac monitor shows sinus rhythm, rate 60–70.
The P–R interval is 0.18 seconds at 1:00 A.M., 0.20 seconds at 2:30 P.M., and 0.23
seconds at 4:00 P.M. Which of the following actions should the nurse take at this time?
a. Prepare for possible temporary pacemaker insertion.
b. Administer atropine sulphate 1 mg IV per agency protocol.
c. Document the client’s rhythm and assess the client’s response to the rhythm.
d. Call the health care provider before giving the prescribed metoprolol.
ANS: D
The client has progressive first-degree atrioventricular (AV) block, and the b-blocker
should be held until discussing the medication with the health care provider.
Documentation and assessment are appropriate but not fully adequate responses. The
client with first-degree AV block usually is asymptomatic, and a pacemaker is not
indicated. Atropine is sometimes used for symptomatic bradycardia, but there is no
indication that this client is symptomatic.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
20. The nurse is caring for a client who develops sinus bradycardia at a rate of 32 beats/minute,
has a BP of 80/36 mm Hg, and symptoms of feeling faint. Which of the following actions
should the nurse take?
a. Continue to monitor the rhythm and BP.
b. Apply the transcutaneous pacemaker (TCP).
c. Have the client perform the Valsalva manoeuvre.
d. Give the scheduled dose of diltiazem.
ANS: B
The client is experiencing symptomatic bradycardia, and treatment with TCP is
appropriate. Continued monitoring of the rhythm and BP is an inadequate response.
Calcium channel blockers will further decrease the heart rate, and the diltiazem should be
held. The Valsalva manoeuvre will further decrease the rate.
DIF:
Cognitive Level: Application
TOP: Nursing Process: Implementation
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MSC: NCLEX: Physiological Integrity
21. A young adult client arrives at the student health centre at the end of the quarter
complaining that, “My heart is skipping beats.” An electrocardiogram (ECG) shows
occasional premature ventricular contractions (PVCs). What of the following actions
should the nurse take first?
a. Have the client transported to the hospital emergency department (ED).
b. Administer O2 at 2–3 L/minute using nasal prongs.
c. Ask the client about any history of coronary artery disease.
d. Question the client about current stress level and coffee use.
ANS: D
In a client with a normal heart, occasional PVCs are a benign finding. The timing of the
PVCs suggests stress or caffeine as possible etiologic factors. It is unlikely that the client
has coronary artery disease, and this should not be the first question the nurse asks. The
client is hemodynamically stable, so there is no indication that the client needs to be seen
in the ED or that oxygen needs to be administered.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
22. The nurse has received change-of-shift report about the following clients on the telemetry
unit. Which of the following clients should the nurse see first?
a. A client with atrial fibrillation, rate 88, who has a new order for warfarin
b. A client with type 1 second-degree atrioventricular (AV) block, rate 60, who is
dizzy when ambulating
c. A client who is in a sinus rhythm, rate 98, after having electrical cardioversion 2
hours ago
d. A client whose implantable cardioverter-defibrillator (ICD) fired three times today
who has a dose of amiodaronedue
ANS: D
The frequent firing of the ICD indicates that the client’s ventricles are very irritable, and
the priority is to assess the client and administer the amiodarone. The other clients may be
seen after the amiodarone is administered.
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
23. The nurse is caring for a client who is on the telemetry unit and develops atrial flutter, rate
150, with associated dyspnea and diaphoresis. Which of the following actions that are
included in the hospital dysrhythmia protocol should the nurse take first?
a. Obtain a 12-lead electrocardiogram (ECG).
b. Give O2 via nasal cannula at 3–4 L/minute.
c. Take the client’s blood pressure and respiratory rate.
d. Notify the health care provider of the change in rhythm.
ANS: B
Since this client has dyspnea in association with the new rhythm, the nurse’s initial actions
should be to ensure a patent airway and oxygen administration. The other actions also are
important and should be implemented rapidly.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
24. The nurse is caring for a client whose cardiac monitor shows sinus tachycardia, rate 102,
and is apneic with no pulses are palpable by the nurse. Which of the following actions
should the nurse do first?
a. Start CPR.
b. Defibrillate.
c. Administer atropine per hospital protocol.
d. Give 100% oxygen per nonrebreather mask.
ANS: A
The client’s clinical manifestations indicate pulseless electrical activity and the nurse
should immediately start CPR. The other actions would not be of benefit to this client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
25. The nurse is caring for a client who has been experiencing dizziness and shortness of
breath for several days. During cardiac monitoring in the emergency department (ED), the
nurse obtains the following electrocardiographic tracing.
Which of the following cardiac rhythms should the nurse identify?
a. Sinus rhythm with premature ventricular contractions (PVCs)
b. Junctional escape rhythm
c. Third-degree atrioventricular (AV) block
d. Sinus rhythm with premature atrial contractions (PACs)
ANS: C
The inconsistency between the atrial and ventricular rates and the variable P–R interval
indicate that the rhythm is third-degree AV block. Sinus rhythm with PACs or PVCs will
have a normal rate and consistent P–R intervals with occasional PACs or PVCs. A
junctional escape rhythm will not have P waves.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
OBJ: Special Questions: Alternate Item Format
MSC: NCLEX: Physiological Integrity
26. The nurse is caring for a client in the emergency department who has symptoms of a
“racing” heart and nervousness. The nurse places the client on a cardiac monitor and
obtains the following electrocardiographic tracing.
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Which of the following actions should the nurse take next?
a. Get ready to perform electrical cardioversion.
b. Have the client perform the Valsalva manoeuvre.
c. Obtain the client’s blood pressure and oxygen saturation.
d. Prepare to give b-blocker medication to slow the heart rate.
ANS: C
The client has sinus tachycardia, which may have multiple etiologies such as pain,
dehydration, anxiety, and myocardial ischemia; further assessment is needed before
determining the treatment. Vagal stimulation or b-blockade may be used after further
assessment of the client. Electrical cardioversion is used for some tachydysrhythmias, but
would not be used for sinus tachycardia.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
COMPLETION
1. The nurse is analyzing an electrocardiographic rhythm strip of a client with a regular
cardiac rhythm and finds there are 25 small blocks from one R wave to the next. The nurse
calculates the client’s heart rate as ____________________ beats per minute.
ANS:
60
There are 1 500 small blocks in a minute, and the nurse will divide 1 500 by 25.
DIF: Cognitive Level: Knowledge
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
OTHER
1. The nurse is caring for a client who requires defibrillation. In which order will the nurse
accomplish the following steps?
a. Turn the defibrillator on.
b. Deliver the electrical charge.
c. Select the appropriate energy level.
d. Place the paddles on the client’s chest.
e. Check the location of other personnel and call out “all clear.”
ANS:
A, C, D, E, B
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This order will result in rapid defibrillation without endangering hospital personnel.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 39: Nursing Management: Inflammatory and Structural Heart Disorders
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is obtaining a health history from a client with a prosthetic mitral valve who has
symptoms of infective endocarditis (IE). Which of the following questions by the nurse is
best?
a. “Have you been to the dentist lately?”
b. “Do you have a history of a heart attack?”
c. “Is there a family history of endocarditis?”
d. “Have you had any recent immunizations?”
ANS: A
Dental procedures place the client with a prosthetic mitral valve at risk for infective
endocarditis (IE). Myocardial infarction (MI), immunizations, and a family history of
endocarditis are not risk factors for IE.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. The nurse is assessing a client with infective endocarditis (IE). Which of the following
findings should the nurse expect to assess?
A new regurgitant murmur
A pruritic rash on the trunk
Involuntary muscle movement
Substernal chest pain and pressure
a.
b.
c.
d.
ANS: A
New regurgitant murmurs occur in IE because vegetation on the valves prevents valve
closure. Substernal chest discomfort, rashes, and involuntary muscle movement are
clinical manifestations of other cardiac disorders such as angina and rheumatic fever.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
3. The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular
insufficiency for the client with infective endocarditis (IE). Which of the following
findings support this diagnosis?
a. Fever, chills, and diaphoresis
b. Urine output less than 30 mL/hour
c. Petechiae of the buccal mucosa and conjunctiva
d. Increase in pulse rate of 15 beats/minute with activity
ANS: B
Decreased renal perfusion caused by inadequate cardiac output will lead to poor urine
output. Petechiae, fever, chills, and diaphoresis are symptoms of IE but are not caused by
decreased cardiac output. An increase in pulse rate of 15 beats/minute is normal with
exercise.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Diagnosis
4. The nurse is planning care for a client hospitalized with a streptococcal infective
endocarditis (IE). Which of the following interventions should the nurse include?
a. Monitor laboratories for streptococcal antibodies.
b. Arrange for insertion of a long-term IV catheter.
c. Encourage the client to get regular aerobic exercise.
d. Teach the importance of completing all oral antibiotics.
ANS: B
Treatment for IE involves 4–6 weeks of IV antibiotic therapy in order to eradicate the
bacteria, which will require a long-term IV catheter such as a peripherally inserted central
catheter (PICC) line. Rest periods and limiting physical activity to a moderate level are
recommended during the treatment for IE. Oral antibiotics are not effective in eradicating
the infective bacteria that cause IE. Blood cultures, rather than antibody levels, are used to
monitor the effectiveness of antibiotic therapy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
5. The nurse is admitting a client with possible acute pericarditis. Which of the following
diagnostic assessments should the nurse plan to teach the client about?
a. Electrolyte levels
b. Echocardiography
c. Daily blood cultures
d. Cardiac catheterization
ANS: B
Echocardiograms are useful in detecting the presence of the pericardial effusions
associated with pericarditis. Blood cultures are not indicated unless the client has evidence
of sepsis. Cardiac catheterization is not a diagnostic procedure for pericarditis. Electrolyte
levels are not helpful in making a diagnosis of pericarditis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
6. Which of the following techniques should the nurse use to assess the client with
pericarditis for the presence of a pericardial friction rub?
a. Auscultate with the stethoscope diaphragm at the lower left sternal border.
b. Listen for a rumbling, low-pitched, systolic sound over the left anterior chest.
c. Feel the precordial area with the palm of the hand to detect vibration with cardiac
contraction.
d. Ask the client to stop breathing during auscultation to distinguish the sound from a
pleural friction rub.
ANS: A
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Pericardial friction rubs are heard best with the diaphragm at the lower left sternal border.
Because dyspnea is one clinical manifestation of pericarditis, the nurse should time the
friction rub with the pulse rather than ask the client to stop breathing during auscultation.
Friction rubs are not typically low pitched or rumbling and are not confined to systole.
Rubs are not assessed by palpation.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
7. Cardiac tamponade is suspected in a client who has acute pericarditis. Which of the
following actions should the nurse implement to assess for the presence of pulsus
paradoxus?
a. Check the electrocardiogram (ECG) for variations in rate in relation to inspiration
and expiration.
b. Note when Korotkoff sounds are audible during both inspiration and expiration.
c. Auscultate for a pericardial friction rub that increases in volume during inspiration.
d. Subtract the diastolic blood pressure (DBP) from the systolic blood pressure
(SBP).
ANS: B
Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when
Korotkoff sounds can be heard during only expiration and when they can be heard
throughout the respiratory cycle. The other methods described would not be useful in
determining the presence of pulsus paradoxus.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
8. The nurse has identified a nursing diagnosis of acute pain related to inflammatory process
for a client with acute pericarditis. Which of the following actions is best for the nurse to
implement?
a. Force fluids to 3 000 mL/day to decrease fever and inflammation.
b. Teach about deep, slow respirations to control the pain.
c. Remind the client to ask for the opioid pain medication every 4 hours.
d. Position the client in Fowler’s position, leaning forward on the overbed table.
ANS: D
Sitting upright and leaning forward frequently will decrease the pain associated with
pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep
respirations tends to increase pericardial pain. Opioids are not very effective at controlling
pain caused by acute inflammatory conditions and are usually ordered PRN. The client
would receive scheduled doses of a nonsteroidal anti-inflammatory drug (NSAID).
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
9. The nurse is conducting an admission health history with a client with possible rheumatic
fever. Which of the following questions is most pertinent to ask?
a. “Have you had a recent sore throat?”
b. “Are you using any illegal IV drugs?”
c. “Do you have any family history of congenital heart disease?”
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d. “Can you recall having any chest injuries in the last few weeks?”
ANS: A
Rheumatic fever occurs as a result of an abnormal immune response to a streptococcal
infection. Although illicit intravenous (IV) drug use should be discussed with the client
before discharge, it is not a risk factor for rheumatic fever and would not be as pertinent
when admitting the client. Family history is not a risk factor for rheumatic fever. Chest
injury would cause musculo-skeletal chest pain rather than rheumatic fever.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
10. The nurse is caring for a client with rheumatic fever who has subcutaneous nodules,
erythema marginatum, and polyarthritis. Which of the following nursing diagnoses best
reflects these findings?
a. Activity intolerance related to physical deconditioning (arthralgia)
b. Risk for infection as evidenced by immunosupression
c. Chronic pain related to injury agent (permanent joint fixation)
d. Risk for impaired skin integrity evidenced by pressure over bony prominence
ANS: A
The client’s joint pain will lead to difficulty with activity. The skin lesions seen in
rheumatic fever are not open or pruritic and thus do not pose a high risk for infection.
Although acute joint pain will be a problem for this client, joint inflammation is a
temporary clinical manifestation of rheumatic fever and is not associated with permanent
joint changes.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Diagnosis
11. The nurse establishes the nursing diagnosis of ineffective health maintenance related to
lack of knowledge concerning long-term management of rheumatic fever when a client
who is recovering from rheumatic fever says which of the following statements?
a. “I will need to have monthly antibiotic injections for 10 years or longer.”
b. “I will need to take Aspirin or ibuprofen to relieve my joint pain.”
c. “I will call the doctor if I develop excessive fatigue or difficulty breathing.”
d. “I will be immune to further episodes of rheumatic fever after this infection.”
ANS: D
Clients with a history of rheumatic fever are more susceptible to a second episode. The
other client statements are correct and would not support the nursing diagnosis of
ineffective health maintenance.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Diagnosis
12. Which of the following actions should the community health nurse include when planning
ways to decrease the incidence of rheumatic fever?
Immunize susceptible groups in the community with streptococcal vaccine.
Teach community members to seek treatment for streptococcal pharyngitis.
Educate about the importance of monitoring temperature when infections occur.
Provide prophylactic antibiotics to people with a family history of rheumatic fever.
a.
b.
c.
d.
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ANS: B
The incidence of rheumatic fever is decreased by treatment of streptococcal infections
with antibiotics. Family history is not a risk factor for rheumatic fever. There is no
immunization that is effective in decreasing the incidence of rheumatic fever. Education
about monitoring temperature will not decrease the incidence of rheumatic fever.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
13. The nurse is assessing a client with mitral valve stenosis and hypoxemia. Which of the
following findings should the nurse expect to assess?
a. Diastolic murmur
b. Peripheral edema
c. Right upper quadrant tenderness
d. Complaints of shortness of breath
ANS: D
The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs,
resulting in hypoxemia and dyspnea. The other findings also may be associated with mitral
valve disease, but are not indicators of possible hypoxemia.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
14. The nurse is caring for a client who is scheduled for percutaneous transluminal balloon
valvuloplasty to treat mitral stenosis. When explaining the advantage of valvuloplasty
instead of valve replacement to the client, which of the following information should the
nurse include?
a. Biological replacement valves require the use of immuno-suppressive drugs.
b. Mechanical mitral valves require replacement approximately every 5 years.
c. Lifelong anticoagulant therapy is needed after mechanical valve replacement.
d. Ongoing cardiac care by a health care provider is unnecessary after valvuloplasty.
ANS: C
Long-term anticoagulation therapy is needed after mechanical valve replacement, and this
would restrict decisions about career and childbearing in this client. Mechanical valves are
durable and last longer than 5 years. All valve repair procedures are palliative, not curative,
and require lifelong health care. Biological valves do not activate the immune system, and
immuno-suppressive therapy is not needed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
15. The nurse is providing discharge teaching for a client with mitral valve prolapse (MVP)
without valvular regurgitation. Which of the following client statements indicate that
teaching has been effective?
a. Plan to take antibiotics before any dental appointments
b. Limit physical activity to avoid stressing the heart valves.
c. Take one Aspirin a day to prevent embolization from the valve.
d. Avoid use of over-the-counter (OTC) medications that contain stimulant drugs.
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ANS: D
Use of stimulant medications should be avoided by clients with MVP since these may
exacerbate symptoms. Daily Aspirin and restricted physical activity are not needed by
clients with mild MVP. Antibiotic prophylaxis is needed for clients with MVP with
regurgitation but will not be necessary for this client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
16. The nurse is caring for a client with aortic stenosis and establishes a nursing diagnosis of
acute pain related to decreased coronary blood flow. Which of the following interventions
is best?
a. Promote rest to decrease myocardial oxygen demand.
b. Educate the client about the need for anticoagulant therapy.
c. Teach the client to use sublingual nitroglycerin for chest pain.
d. Elevate the head of the bed 60 degrees to decrease venous return.
ANS: A
Rest is recommended to balance myocardial oxygen supply and demand and to decrease
chest pain. The client with aortic stenosis requires higher preload to maintain cardiac
output, so nitroglycerin and measures to decrease venous return are contraindicated.
Anticoagulation is not recommended unless the client has atrial fibrillation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
17. The nurse is conducting postoperative teaching with a client who had a mitral valve
replacement with a mechanical valve. Which of the following information should the
nurse include in the teaching plan?
a. Use of daily Aspirin for anticoagulation
b. Correct method for taking the radial pulse
c. Need for frequent laboratory blood testing
d. Possibility of valve replacement in 7–10 years
ANS: C
Anticoagulation therapy with warfarin is needed for a client with mechanical valves to
prevent clotting on the valve; this will require frequent international normalized ratio
(INR) testing. Daily Aspirin use will not be effective in reducing risk for clots on the valve.
Mechanical valves are durable and would last longer than 7–10 years. Monitoring of the
radial pulse is not necessary after valve replacement.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
18. The nurse is caring for a client who has had recent cardiac surgery and develops
pericarditis, with symptoms of chest pain at a level 6 (0–10 scale) with deep breathing.
Which of the following prescribed PRN medications should the nurse administer?
a. Fentanyl 2 mg IV
b. Morphine sulphate 6 mg IV
c. Ibuprofen 800 mg PO
d. Acetaminophen 650 mg PO
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ANS: C
The pain associated with pericarditis is caused by inflammation, so nonsteroidal
anti-inflammatory drugs (NSAIDs) like ibuprofen are most effective. Opioid analgesics
are usually not used for the pain associated with pericarditis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
19. The nurse is caring for a client with infective endocarditis of the tricuspid valve. Which of
the following findings should the nurse plan to monitor for the presence of endocarditis in
the client?
a. Dyspnea
b. Flank pain
c. Hemiparesis
d. Splenomegaly
ANS: A
Embolization from the tricuspid valve would cause symptoms of pulmonary embolus.
Flank pain, hemiparesis, and splenomegaly would be associated with embolization from
the left-sided valves.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
20. The nurse is caring for a client with acute dyspnea and is diagnosed with dilated
cardiomyopathy. Which of the following information should the nurse include when
teaching the client about management of this disorder?
a. Elevating the legs above the heart will help relieve angina.
b. No more than two alcoholic drinks daily are recommended.
c. Careful adherence to diet and medication regimen will prevent heart failure.
d. Notify the health care provider about any symptoms of heart failure.
ANS: D
The client should be instructed to notify the health care provider about any worsening of
heart failure symptoms. Because dilated cardiomyopathy does not respond well to therapy,
even clients with good adherence to therapy may have recurrent episodes of heart failure.
The client is instructed to avoid alcoholic beverages. Elevation of the legs above the heart
will worsen symptoms (although this approach is appropriate for a client with hypertrophic
cardiomyopathy).
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
21. The nurse is taking a health history from a 24-year-old client with hypertrophic
cardiomyopathy (HC). Which of the following information obtained by the nurse is most
relevant?
a. The client reports using cocaine once at age 16.
b. The client has a history of a recent upper respiratory infection.
c. The client’s 29-year-old brother had a sudden cardiac arrest.
d. The client has a family history of coronary artery disease.
ANS: C
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About half of all cases of HC have a genetic basis, and it is the most common cause of
sudden cardiac death in otherwise healthy young people; the information about the client’s
brother will be helpful in planning care (such as an automatic implantable
cardioverter-defibrillator [AICD]) for the client and in counselling other family members.
The client should be counselled against use of stimulant drugs, but the one-time use
indicates that the client is not at current risk for cocaine use. Viral infections and CAD are
risk factors for dilated cardiomyopathy, but not for HC.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
22. The nurse is conducting discharge teaching about the need for prophylactic antibiotics
when having dental procedures. This teaching would be provided to a client with which of
the following diagnoses?
a. Acute myocardial infarction
b. Exacerbation of heart failure
c. Mechanical mitral valve replacement
d. Rheumatic fever after a streptococcal infection.
ANS: C
Current guidelines recommend the use of prophylactic antibiotics before dental procedures
for clients with prosthetic valves to prevent infective endocarditis (IE). The other clients
are not at risk for IE.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
23. Which of the following prescriptions written by the health care provider for a client
admitted with infective endocarditis (IE) and a fever should the nurse implement first?
a. Order blood cultures drawn from two sites.
b. Give acetaminophen (Tylenol) PRN for fever.
c. Administer ceftriaxone 1 g IV.
d. Obtain a transesophageal echocardiogram.
ANS: A
Treatment of the IE with antibiotics should be started as quickly as possible, but it is
essential to obtain blood cultures before initiating antibiotic therapy to obtain accurate
sensitivity results. The echocardiogram and Tylenol administration also should be
implemented rapidly, but the blood cultures (and then administration of the antibiotic)
have the highest priority.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
24. Which of the following findings in a client with infective endocarditis (IE) is most
important for the nurse to communicate to the health care provider?
Generalized muscle aching
Sudden onset left flank pain
Janeway’s lesions on the palms
Temperature 38.1° C
a.
b.
c.
d.
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ANS: B
Sudden onset of flank pain indicates possible embolization to the kidney and may require
diagnostic testing such as a renal arteriogram and interventions to improve renal perfusion.
The other findings are typically found in IE but do not require any new interventions.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
25. Which of the following assessment data obtained by the nurse when assessing a client with
acute pericarditis should be reported immediately to the health care provider?
a. Pulsus paradoxus 8 mm Hg
b. Blood pressure (BP) of 166/96
c. Jugular vein distension (JVD) to the level of the jaw
d. Level 6 (0–10 scale) chest pain with deep inspiration
ANS: C
The JVD indicates that the client may have developed cardiac tamponade and may need
rapid intervention to maintain adequate cardiac output. Hypertension would not be
associated with complications of pericarditis, and the BP is not high enough to indicate
that there is any immediate need to call the health care provider. A pulsus paradoxus of 8
mm Hg is normal. Level 6/10 chest pain should be treated but is not unusual with
pericarditis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
26. Which of the following assessment information obtained by the nurse for a client with
aortic stenosis is most important to report to the health care provider?
a. The client complains of chest pain associated with ambulation.
b. A loud systolic murmur is audible along the right sternal border.
c. A thrill is palpable at the 2nd intercostal space, right sternal border.
d. The point of maximum impulse (PMI) is at the left midclavicular line.
ANS: A
Chest pain occurring with aortic stenosis is caused by cardiac ischemia, and reporting this
information would be a priority. A systolic murmur and thrill are expected in a client with
aortic stenosis. A PMI at the left midclavicular line is normal.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
27. The nurse is caring for a client who had an acute myocardial infarction (MI) 3 days prior
and has symptoms of stabbing chest pain that increases with deep breathing. Which of the
following actions should the nurse take first?
a. Auscultate the heart sounds.
b. Check the client’s oral temperature.
c. Notify the client’s health care provider.
d. Give the ordered acetaminophen.
ANS: A
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The client’s clinical manifestations and history are consistent with pericarditis, and the
first action by the nurse should be to listen for a pericardial friction rub. Checking the
temperature, giving acetaminophen, and notifying the health care provider also are
appropriate actions but would not be done before listening for a rub.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
28. The nurse is assessing a client who has mitral valve regurgitation. Which of the following
findings should be communicated to the health care provider immediately?
a. 4+ peripheral edema in both legs
b. Crackles audible to the lung apices
c. A palpable thrill felt over the left anterior chest
d. A loud systolic murmur all across the precordium
ANS: B
Crackles that are audible throughout the lungs indicate that the client is experiencing
severe left ventricular failure with pulmonary congestion and needs immediate
interventions such as diuretics. A systolic murmur and palpable thrill would be expected in
a client with mitral regurgitation. Although 4+ peripheral edema indicates a need for a
change in therapy, it does not need to be addressed urgently.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
OBJ: Special Questions: Prioritization
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Chapter 40: Nursing Management: Vascular Disorders
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is discussing risk factor modification for a client who has a 4-cm abdominal
aortic aneurysm. The nurse should focus client teaching on which of the following risk
factors?
a. Male gender
b. Marfan syndrome
c. Abdominal trauma history
d. Uncontrolled hypertension
ANS: D
All of the factors contribute to the client’s risk, but only the hypertension can potentially
be modified to decrease the client’s risk for further expansion of the aneurysm.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
2. The nurse is obtaining a health history from a client who has a 5-cm thoracic aortic
aneurysm that was discovered during a routine chest x-ray. Which of the following
symptoms should the nurse expect to assess in the client?
a. Back or lumbar pain
b. Difficulty swallowing
c. Abdominal tenderness
d. Changes in bowel habits
ANS: B
Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the
esophagus. The other symptoms will be important to assess for in clients with abdominal
aortic aneurysms.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
3. Several hours after an open surgical repair of an abdominal aortic aneurysm, the client
develops a urinary output of 20 mL/hour for 2 hours. Which of the following prescriptions
should the nurse anticipate?
a. An additional antibiotic
b. White blood cell (WBC) count
c. Decrease in IV infusion rate
d. Blood urea nitrogen (BUN) level
ANS: D
The decreased urine output suggests decreased renal perfusion, and monitoring of renal
function is needed. There is no indication that infection is a concern, so antibiotic therapy
and a WBC count are not needed. The IV rate may be increased because hypovolemia may
be contributing to the client’s decreased urinary output.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
4. A client in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD).
Which of the following medication categories should the nurse plan to include when
providing client teaching about PAD management?
a. Statins
b. Vitamins
c. Thrombolytics
d. Anticoagulants
ANS: A
Current research indicates that statin use by clients with PAD improves multiple outcomes.
There is no research that supports the use of the other medication categories in PAD.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
5. The nurse is caring for a client with chronic atrial fibrillation who develops sudden severe
pain, pulselessness, pallor, and coolness in the left leg. Which of the following actions
should the nurse implement first?
a. Elevate the left leg on a pillow.
b. Apply an elastic wrap to the leg.
c. Assist the client in gently exercising the leg.
d. Notify the health care provider.
ANS: D
The client’s history and clinical manifestations are consistent with acute arterial occlusion.
Clinical manifestations of acute arterial ischemia include the “six Ps”: pain, pallor,
paralysis, pulselessness, paresthesia, and poikilothermia (adaptation of the limb to the
environmental temperature, most often cool). Without immediate intervention, ischemia
may progress quickly to tissue necrosis and gangrene within a few hours. If the nurse
detects these signs, the nurse should immediately notify the health care provider. Elevating
the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise
will increase oxygen demand for the tissues of the leg.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
6. A client at the clinic says, “I have always taken an evening walk, but lately my leg cramps
and hurts after just a few minutes of walking. The pain goes away after I stop walking,
though.” Which of the following actions should the nurse implement?
a. Attempt to palpate the dorsalis pedis and posterior tibial pulses.
b. Check for the presence of tortuous veins bilaterally on the legs.
c. Ask about any skin colour changes that occur in response to cold.
d. Assess for unilateral swelling, redness, and tenderness of either leg.
ANS: A
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The nurse should assess for other clinical manifestations of peripheral arterial disease in a
client who describes intermittent claudication. Changes in skin colour that occur in
response to cold are consistent with Raynaud’s phenomenon. Tortuous veins on the legs
suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness point to
venous thrombo-embolism (VTE).
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
7. The nurse is assessing a client who has chronic peripheral artery disease (PAD) of the legs
and an ulcer on the left great toe. Which of the following findings should the nurse expect?
A positive Homans’ sign
Swollen, dry, scaly ankles
Prolonged capillary refill in all the toes
A large amount of drainage from the ulcer
a.
b.
c.
d.
ANS: C
Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the
periphery. The other listed clinical manifestations are consistent with chronic venous
disease.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
8. The nurse is providing teaching to a client with critical limb ischemia. Which of the
following client statements indicate further teaching is required?
a. “I will have to buy some loose clothing that does not bind across my legs or
waist.”
b. “I will use a heating pad on my feet at night to increase the circulation and warmth
in my feet.”
c. “I will walk to the point of pain, rest, and walk again until I develop pain for a half
hour daily.”
d. “I will change my position every hour and avoid long periods of sitting with my
legs down.”
ANS: B
Because the client has impaired circulation and sensation to the feet, the use of a heating
pad could lead to burns. The other client statements are correct and indicate that teaching
has been successful.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
9. The nurse is providing teaching to a client with newly diagnosed Raynaud’s phenomenon
about how to manage the condition. Which of the following behaviours by the client
indicates that the teaching has been effective?
a. The client avoids the use of Aspirin and nonsteroidal anti-inflammatory drugs
(NSAIDs).
b. The client exercises indoors during the winter months.
c. The client places the hands in hot water when they turn pale.
d. The client takes pseudoephedrine for cold symptoms.
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ANS: B
Clients should avoid temperature extremes by exercising indoors when it is cold. To avoid
burn injuries, the client should use warm, rather than hot, water to warm the hands.
Pseudoephedrine is a vasoconstrictor and should be avoided. There is no reason to avoid
taking Aspirin and NSAIDs with Raynaud’s phenomenon.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
10. The nurse notes bruising and discoloration of the right leg of a client that has just arrived
in the recovery unit from having vein ligation surgery. Which of the following
interventions is priority?
a. Place the client in the Trendelenburg position.
b. Contact the health care provider.
c. Elevate the bed at the knee and put pillows under the feet.
d. Elevate the legs 15 degrees to limit edema.
ANS: D
After vein ligation surgery, the legs should be elevated 15 degrees to limit edema. Placing
the client in the Trendelenburg position will lower the head below heart level, which is not
indicated for this client. Placing pillows under the calf or elevating the bed at the knee may
cause blood stasis at the calf level. Bruising and discoloration are expected after vein
ligation surgery so there is no need to contact the health care provider at this time.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
11. The health care provider prescribes an infusion of argatroban and daily partial
thromboplastin time (PTT) testing for a client with venous thrombo-embolism (VTE).
Which of the following actions should the nurse include in the plan of care?
a. Avoid giving any IM medications to prevent localized bleeding.
b. Discontinue the infusion for PTT values greater than 50 seconds.
c. Monitor posterior tibial and dorsalis pedis pulses with the Doppler.
d. Have vitamin K available in case reversal of the argatroban is needed.
ANS: A
IM injections are avoided in clients receiving anticoagulation. A PTT of 50 seconds is
within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not
affected by VTE.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
12. A client with a venous thrombo-embolism (VTE) is started on enoxaparin and warfarin.
The client asks the nurse why two medications are necessary. Which of the following
responses by the nurse is accurate?
a. “Administration of two anticoagulants reduces the risk for recurrent venous
thrombosis.”
b. “Enoxaparin will start to dissolve the clot, and warfarin will prevent any more
clots from occurring.”
c. “The enoxaparin will work immediately, but the warfarin takes several days to
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have an effect on coagulation.”
d. “Because of the potential for a pulmonary embolism, it is important for you to
have more than one anticoagulant.”
ANS: C
Low-molecular-weight heparin (LMWH) is used because of the immediate effect on
coagulation and discontinued once the international normalized ratio (INR) value
indicates that the warfarin has reached a therapeutic level. LMWH has no thrombolytic
properties. The use of two anticoagulants is not related to the risk for pulmonary embolism,
and two are not necessary to reduce the risk for another VTE.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
13. The nurse has initiated discharge teaching for a client who is to be maintained on warfarin
following hospitalization for venous thrombo-embolism (VTE). Which of the following
client statements indicates that additional teaching is required?
a. “I should reduce the amount of green, leafy vegetables that I eat.”
b. “I should wear a Medic Alert bracelet stating that I take warfarin.”
c. “I will need to have blood tests routinely to monitor the effects of the warfarin.”
d. “I will check with my health care provider before I begin or stop any medication.”
ANS: A
Clients taking warfarin are taught to follow a consistent diet with regard to foods that are
high in vitamin K, such as green, leafy vegetables. The other client statements are
accurate.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
14. The nurse is caring for a client who had a sclerotherapy for treatment of superficial
varicose veins and is a service-counter worker. Which of the following information should
the nurse include when providing discharge teaching to the client?
a. Sitting at the work counter, rather than standing, is recommended.
b. Compression stockings should be applied before getting out of bed.
c. Exercises such as walking or jogging cause recurrence of varicosities.
d. Taking one Aspirin daily will help prevent clotting around venous valves.
ANS: B
Compression stockings are applied with the legs elevated to reduce pressure in the lower
legs. Walking is recommended to prevent recurrent varicosities. Sitting and standing are
both risk factors for varicose veins and venous insufficiency. An Aspirin a day is not
adequate to prevent venous thrombosis and would not be recommended to the client who
had just had sclerotherapy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
15. The nurse is providing teaching to a client with chronic venous insufficiency who has a
venous ulcer on the right lower leg. Which of the following topics should the nurse include
in the teaching plan?
a. Adequate carbohydrate intake
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b. Prophylactic antibiotic therapy
c. Application of compression to the leg
d. Methods of keeping the wound area dry
ANS: C
Compression of the leg is essential to healing of venous ulcers in clients with chronic
venous insufficiency. High dietary intake of protein, rather than carbohydrates, is needed.
Prophylactic antibiotics are not routinely used for venous ulcers. Moist environment
dressings are used to hasten wound healing.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
16. A client is admitted to the hospital with a diagnosis of chronic venous insufficiency.
Which of the following client statements is most consistent with this diagnosis?
a. “I can’t get my shoes on at the end of the day.”
b. “I can never seem to get my feet warm enough.”
c. “I wake up during the night because my legs hurt.”
d. “I have burning leg pains after I walk three blocks.”
ANS: A
Because the edema associated with venous insufficiency increases when the client has
been standing, shoes will feel tighter at the end of the day. The other client statements are
characteristic of peripheral artery disease (PAD).
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
17. Which of the following nursing actions should be included in the plan of care for a client
who has had endovascular repair of an abdominal aortic aneurysm?
a. Record hourly chest tube drainage.
b. Monitor fluid intake and urine output.
c. Check the abdominal wound for redness or swelling.
d. Teach the reason for a prolonged rehabilitation process.
ANS: B
Because renal artery occlusion can occur after endovascular repair, the nurse should
monitor parameters of renal function such as intake and output. Chest tubes will not be
needed for endovascular surgery, the recovery period will be short, and there will not be
an abdominal wound.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
18. Which of the following actions by a nurse who is administering fondaparinux to a client
with venous thrombo-embolism (VTE) indicates that more education about the medication
is needed?
a. The nurse avoids rubbing the injection site after giving the medication.
b. The nurse injects the medication into the abdominal subcutaneous tissue.
c. The nurse fails to assess the partial thromboplastin time (PTT) before
administration of the medication.
d. The nurse ejects the air bubble in the syringe before administering the medication.
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ANS: D
The air bubble is not ejected before giving fondaparinux. The other actions by the nurse
are appropriate.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
19. A client tells the health care provider about experiencing cold, numb fingers when running
during the winter and is diagnosed with Raynaud’s phenomenon. Based upon this
diagnosis, the client should be investigated for which of the following conditions?
a. Hypertension
b. Hyperlipidemia
c. Autoimmune disorders
d. Coronary artery disease
ANS: C
Secondary Raynaud’s phenomenon may occur in conjunction with autoimmune diseases
such as rheumatoid arthritis, and clients should be screened for autoimmune disorders.
Raynaud’s phenomenon is not associated with hyperlipidemia, hypertension, or coronary
artery disease.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
20. While working in the outpatient clinic, the nurse notes that the medical record states that a
client has intermittent claudication. Which of the following client statements is consistent
with this information?
a. “When I stand too long, my feet start to swell up.”
b. “Sometimes I get tired when I climb a lot of stairs.”
c. “My fingers hurt when I go outside in cold weather.”
d. “My legs cramp whenever I walk more than a block.”
ANS: D
Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent
claudication. Finger pain associated with cold weather is typical of Raynaud’s
phenomenon. Fatigue that occurs sometimes with exercise is not typical of intermittent
claudication, which is reproducible. Swelling associated with prolonged standing is typical
of venous disease.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
21. The nurse is developing a teaching plan for a client newly diagnosed with peripheral
artery disease (PAD). Which of the following information should the nurse include?
a. “Exercise only if you do not experience any pain.”
b. “It is very important that you stop smoking cigarettes.”
c. “Try to keep your legs elevated whenever you are sitting.”
d. “Put on support hose early in the day before swelling occurs.”
ANS: B
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Smoking cessation is essential for slowing the progression of PAD to critical limb
ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs
will decrease if the legs are elevated. Clients with PAD are taught to exercise to the point
of feeling pain, rest, and then resume walking. Support hose are not used for clients with
PAD.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
22. The nurse is admitting a client to the emergency department with a history of an
abdominal aortic aneurysm with severe back pain and absent pedal pulses. Which of the
following actions should the nurse take first?
a. Obtain the blood pressure.
b. Ask the client about tobacco use.
c. Draw blood for ordered laboratory testing.
d. Assess for the presence of an abdominal bruit.
ANS: A
Since the client appears to be experiencing aortic dissection, the nurse’s first action should
be to determine the hemodynamic status by assessing blood pressure. The other actions
also may be done, but they will not provide information that will determine what
interventions are needed immediately for this client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
23. Which of the following clients admitted to the emergency department should the nurse
assess first?
62-year-old who has gangrenous ulcers on both feet
50-year-old who is complaining of “tearing” chest pain
45-year-old who is taking anticoagulants and has bloody stools
36-year-old who has right calf tenderness, redness, and swelling
a.
b.
c.
d.
ANS: B
The client’s presentation is consistent with aortic dissection, which will require rapid
intervention. The other clients do not need urgent interventions.
DIF: Cognitive Level: Analysis
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
24. Immediately after repair of an abdominal aortic aneurysm, a client has absent popliteal,
posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which of the
following actions should the nurse take first?
a. Wrap both the legs in warm blankets.
b. Notify the surgeon and anaesthesiologist.
c. Document that the pulses are absent and recheck in 30 minutes.
d. Review the preoperative assessment form for data about the pulses.
ANS: D
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Many clients with aortic aneurysms also have peripheral arterial disease, so the nurse
should check the preoperative assessment to determine whether pulses were present before
surgery before notifying the health care providers about the absent pulses. Because the
client’s symptoms may indicate graft occlusion or multiple emboli and a possible need to
return to surgery, it is not appropriate to wait 30 minutes before taking action. Warm
blankets will not improve the circulation to the client’s legs.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
25. The nurse is caring for a client on the first postoperative day after an abdominal aortic
aneurysm repair. Which of the following assessment findings is most important to
communicate to the health care provider?
a. Absence of flatus
b. Loose, bloody stools
c. Hypotonic bowel sounds
d. Abdominal pain with palpation
ANS: B
Loose, bloody stools at this time may indicate intestinal ischemia or infarction and should
be reported immediately because the client may need an emergency bowel resection. The
other findings are normal on the first postoperative day after abdominal surgery.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
26. A client asks the nurse if there are any natural products that would decrease anticoagulant
effects. The nurse tells the client that which of the following natural products causes a
decrease in anticoagulant effects?
a. Horse chestnut
b. Licorice root
c. Turmeric
d. Green tea
ANS: D
Green tea is a natural product that would decrease anticoagulant effects. Horse chestnut,
licorice root, and turmeric are natural products that would increase anticoagulant effects.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
27. The nurse is caring for a client with peripheral artery disease who is Aspirin intolerant.
Which of the following medications should the nurse anticipate the health care provider
prescribing for the client related to this intolerance?
a. Pentoxifylline
b. Clopidogrel
c. Ramipril
d. Warfarin
ANS: B
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For clients who are Aspirin intolerant clopidogrel (75 mg/day) is indicated. Pentoxifylline
is used to treat intermittent claudication. Ramipril is an ACE inhibitor. Warfarin is an
anticoagulant and is not recommended for the prevention of coronary artery disease in
clients with PAD.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
28. The nurse is planning expected outcomes for a client with thromboangiitis obliterans
(Buerger’s disease). Which of the following outcomes has the highest priority for this
client?
a. Cessation of smoking
b. Control of serum lipid levels
c. Maintenance of appropriate weight
d. Demonstration of meticulous foot care
ANS: A
Absolute cessation of nicotine use is needed to reduce the risk for amputation in clients
with Buerger’s disease. Other therapies have limited success in treatment of this disease.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
29. The nurse is caring for a client with a right calf venous thrombo-embolism. Which of the
following information requires immediate action by the nurse?
Complaint of left calf pain
New onset shortness of breath
Red skin colour of left lower leg
Temperature of 38°C (100.4°F)
a.
b.
c.
d.
ANS: B
New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such
as oxygen administration and notification of the health care provider. The other findings
are typical of VTE.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
30. Which of the following responses by a client that is on anticoagulant therapy indicates the
need for further teaching?
a. “I can still have a glass of wine with my dinner”
b. “For pain relief I will take ibuprofen”
c. “I take my pills at two o’clock every day”
d. “I will use an electric razor for shaving”
ANS: B
Clients on anticoagulant therapy should avoid all NSAIDs; therefore ibuprofen should not
be taken for pain relief. It is acceptable to have an alcohol intake of a glass of wine daily.
It is important that medications be taken at the same time every day. Clients are taught to
avoid the use of a straight razor.
DIF:
Cognitive Level: Application
TOP: Nursing Process: Implementation
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MSC: NCLEX: Physiological Integrity
COMPLETION
1. The nurse is assessing a client with possible peripheral artery disease (PAD) and obtains a
brachial BP of 140/80 and an ankle pressure of 110/70. The nurse calculates the client’s
ankle–brachial index (ABI) as ____________________.
ANS:
0.78 or 0.79
The ABI is calculated by dividing the ankle systolic BP by the brachial systolic BP.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 41: Nursing Assessment: Gastro-intestinal System
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is performing a nutritional assessment on a client. Which of the following
information obtained by the nurse is of most concern?
a. Decreased appetite
b. Difficulty chewing food
c. Unintentional weight loss
d. Complaints of indigestion
ANS: C
Unintentional weight loss is not a normal finding in any age client and may indicate a
problem such as cancer or depression. Poor appetite, difficulty in chewing, and complaints
of indigestion are common in older clients. These will need to be addressed, but are not of
as much concern as the weight loss.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. The nurse is to promote bowel evacuation in a client with chronic complaints of
constipation? Which of the following times should the nurse suggest that the client should
attempt defecation?
a. In the mid-afternoon
b. After eating breakfast
c. Right after getting up in the morning
d. Immediately before the first daily meal
ANS: B
These reflexes are most active after the first daily meal. Arising in the morning, the
anticipation of eating, and physical exercise do not stimulate these reflexes.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
3. The nurse is caring for a client who has a history of a total gastrectomy. Which of the
following clinical manifestations should the nurse monitor in the client?
a. Constipation
b. Dehydration
c. Elevated total cholesterol
d. Cobalamin deficiency
ANS: D
The client with a total gastrectomy does not secrete intrinsic factor, which is needed for
cobalamin (vitamin B12) absorption. Because the stomach absorbs only small amounts of
water and nutrients, the client is not at higher risk for dehydration, elevated cholesterol, or
constipation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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4. The nurse is caring for a client who has an obstruction of the common bile duct. Which of
the following findings should the nurse monitor in this client?
a. Melena
b. Steatorrhea
c. Decreased serum cholesterol levels
d. Increased serum indirect bilirubin levels
ANS: B
A common bile duct obstruction will reduce the absorption of fat in the small intestine,
leading to fatty stools. Gastrointestinal (GI) bleeding is not caused by common bile duct
obstruction. Serum cholesterol levels are increased with biliary obstruction. Direct
bilirubin level is increased with biliary obstruction.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
5. During change-of-shift report, the nurse receives the following information about a client
who is scheduled for a colonoscopy. Which information should be communicated to the
health care provider before sending the client for the procedure?
a. The client has a permanent pacemaker to prevent bradycardia.
b. The client is worried about discomfort during the examination.
c. The client has had an allergic reaction to shellfish and iodine in the past.
d. The client refused to drink the ordered polyethylene glycol.
ANS: D
If the client has had inadequate bowel preparation, the colon cannot be visualized and the
procedure should be rescheduled. Because contrast solution is not used during
colonoscopy, the iodine allergy is not pertinent. A pacemaker is a contraindication to
magnetic resonance imaging (MRI), but not to colonoscopy. The nurse should instruct the
client about the sedation used during the examination to decrease the client’s anxiety about
discomfort.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
6. The nurse is obtaining a history from a client who is admitted with jaundice. Which of the
following statements is most indicative of a need for client teaching?
a. “I used cough syrup several times a day last week.”
b. “I take a baby Aspirin every day to prevent strokes.”
c. “I need to take an antacid for indigestion several times a week”
d. “I use acetaminophen every 4 hours for chronic pain.”
ANS: D
Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the
client’s jaundice. The other client statements require further assessment by the nurse, but
do not indicate a need for client education.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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7. The nurse is preparing to assess a client’s liver. When palpating the liver, which of the
following techniques should the nurse implement?
a. Place one hand on the client’s back and press upward and inward with the other
hand below the client’s right costal margin.
b. Place one hand on top of the other and use the upper fingers to apply pressure and
the bottom fingers to feel for the liver edge.
c. Press slowly and firmly over the right costal margin with one hand and withdraw
the fingers quickly after the liver edge is felt.
d. Place one hand under the client’s lower ribs and press the left lower rib cage
forward, palpating below the costal margin with the other hand.
ANS: A
The liver is normally not palpable below the costal margin, the nurse needs to push inward
below the right costal margin while lifting the client’s back slightly with the left hand. The
other methods will not allow palpation of the liver.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
8. The nurse is listening to a client’s abdomen. Which of the following findings indicate a
need for a focused abdominal assessment?
a. Loud gurgles
b. High-pitched gurgles
c. Absent bowel sounds
d. Frequent clicking sounds
ANS: C
Absent bowel sounds are abnormal and require further assessment by the nurse. The other
sounds may be heard normally.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
9. The nurse is caring for a client following a needle biopsy of the liver at the bedside. Which
of the following actions should the nurse implement?
a. Put pressure on the biopsy site using a sandbag.
b. Elevate the head of the bed to facilitate breathing.
c. Place the client on the right side with the bed flat.
d. Check the client’s postbiopsy coagulation studies.
ANS: C
After a biopsy, the client lies on the right side for a minimum of two hours with the bed
flat to splint the biopsy site. Coagulation studies are checked before the biopsy. A sandbag
does not exert adequate pressure to splint the site.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
10. Which of the following information obtained by the nurse when admitting a client who is
scheduled for an ultrasound of the gallbladder indicates that the ultrasound may need to be
rescheduled?
a. The client has a permanent gastrostomy tube.
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b. The client took a laxative the previous evening.
c. The client ate a low-fat bagel an hour previously.
d. The client had a high-fat meal the previous evening.
ANS: C
Food intake can cause the gallbladder to contract and result in a suboptimal study. The
client should be NPO for 8–12 hours before the test. A high-fat meal the previous evening,
laxative use, or a gastrostomy tube will not affect the results of the study.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
11. The nurse is assessing an alert and independent older-adult client in the clinic for
malnutrition risk. Which of the following questions is best as the initial assessment
question?
a. “How do you get to the grocery store to buy your food?”
b. “Do you have any difficulty in preparing or eating food?”
c. “Can you tell me the foods that you have eaten over the past 24 hours?”
d. “Are you taking any medications that alter your taste or tolerance of foods?”
ANS: C
This question is the most open-ended and will provide the best overall information about
the client’s daily intake and risk for poor nutrition. The other questions may be asked,
depending on the client’s response to the first question.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
12. Which of the following information collected by the nurse when caring for a client who
has just arrived in the recovery area after an esophagogastroduodenoscopy (EGD) is most
important to communicate to the health care provider?
a. The client is very sleepy.
b. The oral temperature is 38.7°C (101.7°F).
c. The apical pulse is 104 beats/minute.
d. The client complains of a sore throat.
ANS: B
A temperature elevation may indicate that a perforation has occurred. The other
assessment data are normal immediately after the procedure.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
13. Which of the following assessment findings in a client who is being admitted to the
hospital is most important to report to the health care provider?
Tympany on percussion of the abdomen
Liver edge 3 cm below the costal margin
Bowel sounds of 20/minute in each quadrant
Aortic pulsations visible in the epigastric area
a.
b.
c.
d.
ANS: B
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Normally the lower border of the liver is not palpable below the ribs, so this finding
suggests hepatomegaly. The other findings are within normal range for the physical
assessment.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
14. Which of the following actions by a nursing student when caring for a client who has just
returned to the nursing unit after an esophagogastroduodenoscopy (EGD) requires that the
RN intervene?
a. Offering the client a glass of water
b. Positioning the client on the right side
c. Checking the vital signs every 30 minutes
d. Swabbing the client’s mouth with cold water
ANS: A
Immediately after EGD, the client will have a decreased gag reflex and is at risk for
aspiration. The client should be NPO for 2–4 hours. Assessment for return of the gag
reflex should be done prior to administering any fluids by mouth. The other actions by the
student are appropriate.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
15. The health care provider sees a client at 10 A.M. and writes a prescription for endoscopic
retrograde cholangiopancreatography (ERCP) as soon as possible. Which of the following
actions that are included in the agency protocol for ERCP should the nurse take first?
a. Place the client on NPO status.
b. Administer sedative medications.
c. Ensure the consent form is signed.
d. Explain the procedure to the client.
ANS: A
The client will need to be NPO for 8 hours before the ERCP is done, so the nurse’s initial
action should be to place the client on NPO status. The other actions can be done after the
client is NPO.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
MULTIPLE RESPONSE
1. The nurse is caring for a client who has just had a colonoscopy. Which of the following
symptoms should alert the nurse that a perforation has occurred? (Select all that apply.)
a. Malaise
b. Abdominal distension
c. Hypertension
d. Bradycardia
e. Tenesmus
ANS: A, B, E
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Following a colonoscopy the nurse should observe the client for rectal bleeding and signs
of perforation (e.g., malaise, abdominal distension, tenesmus).
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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Chapter 42: Nursing Management: Nutritional Problems
Lewis: Medical-Surgical Nursing In Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is assessing a client who is a vegan. Which of the following findings may
indicate the need for cobalamin supplementation?
a. Anemia
b. Ecchymoses
c. Dry, scaly skin
d. Gingival swelling
ANS: A
Cobalamin (vitamin B12) cannot be obtained from foods of plant origin, so the client will
be most at risk for signs of cobalamin deficiency, megaloblastic anemia, and the
neurological signs of cobalamin deficiency. The other symptoms listed are associated with
other nutritional deficiencies but would not be associated with a vegan diet.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. The nurse is admitting a client with a body mass index (BMI) of 17 kg/m2 and a low
albumin level. Which of the following assessment findings should the nurse expect to
find?
a. Restlessness
b. Hypertension
c. Pitting edema
d. Food allergies
ANS: C
Edema occurs when serum albumin levels and plasma oncotic pressure decrease. The
blood pressure and level of consciousness are not directly affected by malnutrition. Food
allergies are not an indicator of nutritional status.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
3. The nurse is teaching a client about a high calorie, high protein diet. Which of the
following menu choices indicates that the teaching has been effective?
Baked fish with applesauce
Beef noodle soup and canned corn
Fresh vegetables with yogourt topping
Fried chicken with potatoes and gravy
a.
b.
c.
d.
ANS: D
Foods that are high in calories include fried foods and those covered with sauces. High
protein foods include meat and dairy products. The other choices are lower in calories and
protein.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
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4. The nurse is caring for a client with a body mass index (BMI) of 31 kg/m2, a normal
C-reactive protein level, and low transferrin and albumin levels. The nurse will plan client
teaching to increase the client’s intake of foods that are high in which of the following?
a. Iron
b. Protein
c. Calories
d. Carbohydrate
ANS: B
The client’s C-reactive protein and transferrin levels indicate low protein stores. The BMI
is in the obese range, so increasing caloric intake is not indicated. The data do not indicate
a need for increased carbohydrate or iron intake.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
5. The nurse has just started a client on continuous tube feedings of a full-strength
commercial formula at 100 mL/hour using a closed system method and has had six
diarrhea stools the first day. Which of the following actions should the nurse plan to take?
a. Slow the infusion rate of the tube feeding.
b. Check gastric residual volumes more frequently.
c. Change the enteral feeding system and formula every 8 hours.
d. Discontinue administration of water through the feeding tube.
ANS: A
Loose stools indicate poor absorption of nutrients and indicate a need to slow the feeding
rate or decrease the concentration of the feeding. Water should be given when clients
receive enteral feedings to prevent dehydration. When a closed enteral feeding system is
used, the tubing and formula are changed every 24 hours. High residual volumes do not
contribute to diarrhea.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
6. The nurse is caring for a client who is receiving tube feedings through a percutaneous
endoscopic gastrostomy (PEG). Which of the following actions should the nurse include in
the plan of care?
a. Keep the client positioned on the left side.
b. Obtain a daily x-ray to verify tube placement.
c. Check the gastric residual volume every 4–6 hours.
d. Avoid giving bolus tube feedings through the PEG tube.
ANS: C
The gastric residual volume is assessed every 4–6 hours to decrease the risk for aspiration.
The client does not need to be positioned on the left side. An x-ray is obtained
immediately after placement of the PEG tube to check position, but daily x-rays are not
needed. Bolus feedings can be administered through a PEG tube.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
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7. The nurse is caring for a client who is malnourished and is receiving parenteral nutrition
(PN) containing amino acids and dextrose for the past 24 hours. The nurse observes that
about 50 mL remain in the PN container. Which of the following actions is best for the
nurse to take?
a. Ask the health care provider to clarify the written PN order.
b. Add a new container of PN using the current tubing and filter.
c. Hang a new container of PN and change the IV tubing and filter.
d. Infuse the remaining 50 mL and then hang a new container of PN.
ANS: B
All PN solutions are changed at 24 hours. PN solutions containing dextrose and amino
acids require a change in tubing and filter every 72 hours rather than daily. Infusion of the
additional 50 mL will increase client risk for infection. Changing the IV tubing and filter
more frequently than required will unnecessarily increase costs. The nurse (not the health
care provider) is responsible for knowing the indicated times for tubing and filter changes.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
8. After 6 hours of parenteral nutrition (PN) infusion, the nurse checks a client’s capillary
blood glucose level and finds it to be 6.7 mmol/L. Which of the following actions should
the nurse take?
a. Obtain a venous blood glucose specimen.
b. Slow the infusion rate of the PN infusion.
c. Recheck the capillary blood glucose in 4 hours.
d. Notify the health care provider of the glucose level.
ANS: C
Mild hyperglycemia is expected during the first few days after PN is started and requires
ongoing monitoring. Because the glucose elevation is small and expected, notification of
the health care provider is not necessary. There is no need to obtain a venous specimen for
comparison. Slowing the rate of the infusion is beyond the nurse’s scope of practice and
will decrease the client’s nutritional intake.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
9. The nurse is caring for a client with protein calorie malnutrition who has had abdominal
surgery and is receiving parenteral nutrition (PN). Which of the following findings is the
best indicator that the client is receiving adequate nutrition?
a. Blood glucose is 6.1 mmol/L.
b. Serum albumin level is 35 g/L.
c. Fluid intake and output are balanced.
d. Surgical incision is healing normally.
ANS: D
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Because poor wound healing is a possible complication of malnutrition for this client,
normal healing of the incision is an indicator of the effectiveness of the PN in providing
adequate nutrition. Blood glucose is monitored to prevent the complications of
hyperglycemia and hypoglycemia, but it does not indicate that the client’s nutrition is
adequate. The intake and output will be monitored but do not indicate that the PN is
effective. The albumin level is in the low-normal range but does not reflect adequate
caloric intake, which is also important for the client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
10. The nurse is caring for a client who has a wound infection after major surgery and has
only been taking in about 50% to 75% of the ordered meals. The client states, “Nothing on
the menu really appeals to me.” Which of the following actions by the nurse will be most
effective in improving the client’s oral intake?
a. Make a referral to the dietitian.
b. Order at least six small meals daily.
c. Teach the client about high-calorie, high-protein foods.
d. Have family members bring in favourite foods from home.
ANS: D
The client’s statement that the hospital foods are unappealing indicates that favourite
home-cooked foods might improve intake. The other interventions also may help improve
the client’s intake, but the most effective action will be to offer the client more appealing
foods.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
11. Which of the following actions should the nurse implement when using a soft, silicone
nasogastric tube for enteral feedings?
Avoid giving medications through the feeding tube.
Flush the tubing after checking for residual volumes.
Administer continuous feedings using an infusion pump.
Replace the tube every 3–5 days to avoid mucosal damage.
a.
b.
c.
d.
ANS: B
The soft silicone feeding tubes are small in diameter and can easily become clogged unless
they are flushed after the nurse checks the residual volume. Either intermittent or
continuous feedings can be given. The tubes are less likely to cause mucosal damage than
the stiffer polyvinyl chloride tubes used for nasogastric suction and do not need to be
replaced at certain intervals. Medications can be given through these tubes, but flushing
after medication administration is important to avoid clogging.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
12. The nurse is caring for a client who is receiving continuous enteral nutrition through a
small-bore silicone feeding tube, has a computed tomography (CT) scan ordered, and will
have to be placed in a flat position for the scan. Which of the following actions by the
nurse is best?
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a.
b.
c.
d.
Shut the feeding off 30–60 minutes before the scan.
Ask the health care provider to reschedule the CT scan.
Connect the feeding tube to continuous suction during the scan.
Send the client to CT scan with oral suction in case of aspiration.
ANS: A
The tube feeding should be shut off 30–60 minutes before any procedure requiring the
client to lie flat. Because the CT scan is ordered for diagnosis of client problems,
rescheduling is not usually an option. Prevention, rather than treatment, of aspiration is
needed. Small-bore feeding tubes are soft and collapse easily with aspiration or suction,
making nasogastric suction of gastric contents unreliable.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
13. The nurse is admitting a client for electrolyte disorders of unknown etiology. Which of the
following findings is most important to report to the health care provider?
a. The client’s knuckles are macerated.
b. The client uses laxatives on a daily basis.
c. The client has a history of weight fluctuations.
d. The client’s serum potassium level is 2.9 mmol/L.
ANS: D
The low serum potassium level may cause life-threatening cardiac dysrhythmias and
potassium supplementation is needed rapidly. The other information also will be reported
because it suggests that bulimia may be the etiology of the client’s electrolyte disturbances,
but it does not suggest imminent life-threatening complications.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
14. The student nurse is caring for a client who is receiving intermittent tube feedings. Which
of the following actions by the student nurse should cause the RN to intervene in the
clients’ care?
a. Positions the head of the bed 30 degrees
b. Flushes the tube before and after the feeding
c. Checks residual volume every hour
d. Maintains the elevated bed position one hour after the feeding.
ANS: C
The residual volume should be checked every 4 hours not every hour. Elevate the head of
bed to a minimum of 30 degrees, but preferably 45 degrees to prevent aspiration. With
intermittent delivery is used, the head should remain elevated for 30–60 minutes after
feeding. The tube is to be flushed before and after the feeding.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
15. The nurse is preparing to teach an 82-year-old Indigenous client who lives with an adult
daughter about ways to improve nutrition. Which of the following actions should the nurse
take first?
a. Ask the daughter about the client’s food preferences.
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b. Determine who shops for groceries and prepares the meals.
c. Question the client about how many meals per day are eaten.
d. Assure the client that culturally appropriate foods will be included.
ANS: B
The family member who shops for groceries and cooks will be in control of the client’s
diet, so the nurse will need to ensure that this family member is involved in any teaching
or discussion about the client’s nutritional needs. The other information also will be
assessed and used but will not be useful in meeting the client’s nutritional needs unless
nutritionally appropriate foods are purchased and prepared.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
16. How many grams of protein will the nurse recommend to meet the minimum daily
requirement for a client who weighs 66 kg?
a. 36
b. 53
c. 75
d. 98
ANS: B
The recommended daily protein intake is 0.8–1 g/kg of body weight, which for this client
is 66 kg ´ 0.8 g = 52.8 or 53 g/day.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
17. The nurse receives change-of-shift report about the following four clients. Which of the
following clients should the nurse assess first?
a. A client who has malnutrition associated with 4+ generalized pitting edema
b. A client whose parenteral nutrition has 10 mL of solution left in the infusion bag
c. A client whose gastrostomy tube is plugged after crushed medications were given
through the tube
d. A client who is receiving continuous enteral feedings and has new-onset crackles
throughout the lungs
ANS: D
The client data suggest aspiration has occurred and rapid assessment and intervention are
needed. The other clients also should be assessed as quickly as possible, but the data about
them do not suggest any immediately life-threatening complications.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
18. Which of the following actions should the nurse take first in order to improve calorie and
protein intake for a client who eats only about 50% of each meal because of “feeling too
tired to eat much”?
a. Teach the client about the importance of good nutrition.
b. Serve multiple small feedings of high-calorie, high-protein foods.
c. Obtain an order for enteral feedings of liquid nutritional supplements.
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d. Consult with the health care provider about providing parenteral nutrition (PN).
ANS: B
Eating small amounts of food frequently throughout the day is less fatiguing and will
improve the client’s ability to take in more nutrients. Teaching the client may be
appropriate, but will not address the client’s inability to eat more because of fatigue. Tube
feedings or PN may be needed if the client is unable to take in enough nutrients orally, but
increasing the oral intake should be attempted first.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
19. The nurse is caring for a client and notes that the peripheral parenteral nutrition (PN) bag
has only 20 mL left and a new PN bag has not yet arrived from the pharmacy. Which of
the following interventions is priority?
a. Monitor the client’s capillary blood glucose until a new PN bag is hung.
b. Flush the peripheral line with saline and wait until the new PN bag is available.
c. Infuse 5% dextrose in water until the new PN bag is delivered from the pharmacy.
d. Decrease the rate of the current PN infusion to 10 mL/hour until the new bag
arrives.
ANS: C
To prevent hypoglycemia, the nurse should infuse a 5% dextrose solution until the next
PN bag can be started. Decreasing the rate of the ordered PN infusion is beyond the
nurse’s scope of practice. Flushing the line and then waiting for the next bag may lead to
hypoglycemia. Monitoring the capillary blood glucose is appropriate but is not the priority.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
20. The nurse is caring for a client with anorexia nervosa who is 163 cm tall and weighs 41 kg.
Laboratory tests reveal hypokalemia and iron-deficiency anemia. Which of the following
nursing diagnoses has the highest priority for the client?
a. Risk for activity intolerance as evidenced by physical deconditioning
b. Risk for electrolyte imbalance as evidenced by insufficient fluid volume
c. Ineffective health maintenance related to ineffective coping strategies (obsession
with body image)
d. Imbalanced nutrition: less than body requirements related to insufficient dietary
intake
ANS: B
The client’s hypokalemia may lead to life-threatening cardiac dysrhythmias. The other
diagnoses also are appropriate for this client but are not associated with immediate risk for
fatal complications.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Diagnosis
21. The nurse is caring for a client who is to have a bolus tube feeding. Which of the
following actions should the nurse implement?
a. Deliver the feeding via a syringe over 15 minutes.
b. Increase the rate of the tube feeding to deliver the bolus over 5 minutes.
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c. Withhold water by mouth for 30 minutes prior to the bolus feeding.
d. Question the order as tube feedings are not to be delivered as a bolus.
ANS: A
Bolus feedings are typically delivered by gravity via a syringe over approximately 15
minutes when the feeding tube is placed in the stomach. The tube feeding rate would not
be increased as the bolus should be delivered by gravity via a syringe. It is important to
remember that the client still needs water (1 mL/cal formula received), and this may be
administered at any time that the client can tolerate it.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
MULTIPLE RESPONSE
1. During a busy day, the nurse admits all of the following clients to the medical-surgical unit.
Which clients are most important to refer to the dietitian for a complete nutritional
assessment? (Select all that apply.)
a. A 24-year-old who has a history of weight gains and losses
b. A 53-year-old who complains of intermittent nausea for the past 2 days
c. A 66-year-old who is admitted for debridement of an infected surgical wound
d. A 45-year-old admitted with chest pain and possible myocardial infarction (MI)
e. A 32-year-old with rheumatoid arthritis who takes prednisone daily
ANS: A, C, E
Weight fluctuations, use of corticosteroids, and draining or infected wounds all suggest
that the client may be at risk for malnutrition. Clients with chest pain or MI are not usually
poorly nourished. Although vomiting that lasts 5 days places a client at risk, nausea that
has persisted for 2 days does not always indicate poor nutritional status or risk for health
problems caused by poor nutrition.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
OTHER
1. The nurse is caring for a comatose client who is receiving continuous enteral nutrition
through a soft nasogastric tube and notes the presence of new crackles in the client’s lungs.
In which order will the nurse take the following actions?
a. Turn off the tube feeding.
b. Document assessment findings.
c. Check the tube feeding residual volume.
d. Notify the client’s health care provider.
ANS:
A, C, D, B
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The assessment data indicate that aspiration may have occurred, and the nurse’s first
action should be to turn off the tube feeding to avoid further aspiration. The next action
should be to check the residual volume because it provides data about possible causes of
aspiration. The health care provider should be notified and informed of all the assessment
data the nurse has just obtained. Lastly, the nurse documents the assessment findings.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 43: Nursing Management: Obesity
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is developing a weight loss plan for a young adult client who is morbidly obese.
Which of the following statements by the nurse is most likely to help the client in losing
weight on the planned 1 000-calorie diet?
a. “It will be necessary to change lifestyle habits permanently to maintain weight
loss.”
b. “You will decrease your risk for future health problems such as diabetes by losing
weight now.”
c. “Most of the weight that you lose during the first weeks of dieting is water weight
rather than fat.”
d. “You are likely to start to notice changes in how you feel with just a few weeks of
diet and exercise.”
ANS: D
Motivation is a key factor in successful weight loss and a short-term outcome provides a
higher motivation. A young adult client is unlikely to be motivated by future health
problems. Telling a client that the initial weight loss in water will be discouraging,
although this may be correct. Changing lifestyle habits is necessary, but this process
occurs over time and discussing this is not likely to motivate the client.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
2. The nurse has completed teaching a client about the recommended amounts of foods from
different food groups. Which of the following menu selections indicates that the initial
instructions about health eating have been understood?
a. 90 mL of pork roast, a cup of corn, tomatoes, and 125 mL rice
b. A chicken breast and a cup of tossed salad with nonfat dressing
c. A 180 mL can of tuna mixed with nonfat mayonnaise and chopped celery
d. 90 mL of roast beef, 60 mL of low-fat cheese, and a half-cup of carrot sticks
ANS: A
This selection is most consistent with What is a Healthy Plate? The other choices are all
missing at least one food group.
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX: Health Promotion and Maintenance
3. The nurse is collaborating with an obese client who is enrolled in a behaviour modification
program. Which of the following nursing actions is best?
a. Having the client write down the caloric intake of each meal
b. Asking the client about situations that tend to increase appetite
c. Encouraging the client to eat small amounts throughout the day rather than having
scheduled meals
d. Suggesting that the client have a reward, such as a piece of sugarless candy, after
achieving a weight-loss goal
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ANS: B
Behaviour modification programs focus on how and when the person eats and
de-emphasize aspects such as calorie counting. Nonfood rewards are recommended for
achievement of weight-loss goals. Clients are often taught to restrict eating to designated
meals when using behaviour modification.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
4. Which of the following client behaviours indicate that an overweight client has understood
the nurse’s teaching about the best exercise plan for weight loss?
a. Walking for 40 minutes 6 or 7 days/week
b. Lifting weights with friends three times/week
c. Playing soccer for an hour on the weekend
d. Running for 10–15 minutes three times/week
ANS: A
Exercise should be done daily for at least 15–30 minutes. Exercising in highly aerobic
activities for short bursts or only once a week is not helpful and may be dangerous in an
individual who has not been exercising. Running may be appropriate, but a client should
start with an exercise that is less stressful and can be done for a longer period. Weight
lifting is not as helpful as aerobic exercise in weight loss.
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX: Health Promotion and Maintenance
5. The nurse is providing nutritional teaching to a client who is to start on a very-low-calorie
diet. Which of the following calorie amounts should the nurse tell the client that daily
calories are not to exceed?
a. 500
b. 800
c. 1 100
d. 1 400
ANS: B
A very-low-calorie diet does not exceed 800 calories/day. A low-calorie diet is between
800 and 1 200 calories/day.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
6. Which of the following surgeries places the client at greatest risk of developing dumping
syndrome postoperatively?
a. Vertical banded gastroplasty
b. Adjustable gastric banding
c. Vertical sleeve gastrectomy
d. Lap-Band
ANS: A
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A possible complication of vertical banded gastroplasty is dumping syndrome. Dumping
syndrome is not a possible complication in adjustable gastric banding, vertical sleeve
gastrectomy, or Lap-Band.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
7. A few months after bariatric surgery, an older-adult client tells the nurse, “My skin is
hanging in folds. I think I need cosmetic surgery.” Which of the following responses by
the nurse is best?
a. “Perhaps you would like to talk to a counsellor about your body image.”
b. “The important thing is that your weight loss is improving your health.”
c. “The skin folds will gradually disappear once most of the weight is lost.”
d. “Cosmetic surgery is certainly a possibility once your weight has stabilized.”
ANS: D
Reconstructive surgery may be used to eliminate excess skin folds after at least a year has
passed since the surgery. Skin folds may not disappear over time, especially in older
clients. The response, “The important thing is that your weight loss is improving your
health.” ignores the client’s concerns about appearance and implies that the nurse knows
what is important. Whereas it may be helpful for the client to talk to a counsellor, it is
more likely to be helpful to know that cosmetic surgery is available.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
8. The nurse is caring for a client who returns to the surgical nursing unit following a vertical
banded gastroplasty with a nasogastric tube to low, intermittent suction and a
patient-controlled analgesia (PCA) machine for pain control. Which of the following
nursing actions should be included in the postoperative plan of care?
a. Irrigate the nasogastric (NG) tube frequently with normal saline.
b. Offer sips of sweetened liquids at frequent intervals.
c. Remind the client that PCA use may slow the return of bowel function.
d. Support the surgical incision during client coughing and turning in bed.
ANS: D
The incision should be protected from strain to decrease the risk for wound dehiscence.
The client should be encouraged to use the PCA since pain control will improve cough
effort and client mobility. NG irrigation may damage the suture line or overfill the
stomach pouch. Sugar-free clear liquids are offered during the immediate postoperative
time to decrease the risk for dumping syndrome.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
9. Which of the following information should the nurse plan to include in discharge teaching
for a client after gastric bypass surgery?
a. Avoid drinking fluids with meals.
b. Choose high-fat foods for at least 30% of intake.
c. Choose foods that are high in fibre to promote bowel function.
d. Development of flabby skin can be prevented by daily exercise.
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ANS: A
Intake of fluids with meals tends to cause dumping syndrome and diarrhea. Food choices
should be low in fat and fibre. Exercise does not prevent the development of flabby skin.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
10. Which of the following assessments should the nurse do to help determine if an obese
client seen in the clinic has metabolic syndrome?
a. Take the client’s apical pulse.
b. Check the client’s blood pressure.
c. Ask the client about dietary intake.
d. Dipstick the client’s urine for protein.
ANS: B
Elevated blood pressure is one of the characteristics of metabolic syndrome. The other
information also may be obtained by the nurse, but it will not assist with the diagnosis of
metabolic syndrome.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
11. Which of the following topics is of most importance for the nurse to include when
teaching a client about testing for possible metabolic syndrome?
a. Blood glucose test
b. Cardiac enzyme tests
c. Postural blood pressures
d. Resting electrocardiogram
ANS: A
A fasting blood glucose test from 4–6 mmol/L is one of the diagnostic criteria for
metabolic syndrome. The other tests are not used to diagnose metabolic syndrome,
although they may be used to check for cardiovascular complications of the disorder.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
12. What of the following specific information should the nurse include in client teaching for
an overweight client who is starting a weight loss plan?
a. Weigh yourself at the same time every morning.
b. Start dieting with a 600- to 800-calorie diet for rapid weight loss.
c. Low carbohydrate diets lead to rapid weight loss but are difficult to maintain.
d. Weighing all foods on a scale is necessary to choose appropriate portion sizes.
ANS: C
The restrictive nature of fad diets makes the weight loss achieved by the client more
difficult to maintain. Portion size can be estimated in other ways besides weighing.
Severely calorie-restricted diets are not necessary for clients in the overweight category of
obesity and need to be closely supervised. Clients should weigh weekly rather than daily.
DIF:
Cognitive Level: Application
TOP: Nursing Process: Implementation
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MSC: NCLEX: Physiological Integrity
13. Which of the following clients in the clinic should the nurse plan to teach about risks
associated with obesity?
Client who has a BMI of 18 kg/m2
Client with a waist circumference 86 cm
Client who has a body mass index (BMI) of 24 kg/m2
Client whose waist measures 75 cm and hips measure 85 cm
a.
b.
c.
d.
ANS: D
The waist-to-hip ratio for this client is 0.88, which exceeds the recommended level of
<0.80. A BMI of 24 kg/m2 is normal. Health risks associated with obesity increase in
women with a waist circumference larger than 89 cm and men with a waist circumference
larger than 102 cm. A client with a BMI of 18 kg/m2 is considered underweight.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
14. The nurse is caring for a client who has undergone bariatric surgery and has just arrived on
the unit from the recovery room. Which of the following actions should the nurse
implement to promote tidal flow and reduce abdominal pressure?
a. Perform passive range-of-motion exercises.
b. Elevate the head of the bed 45 degrees.
c. Inform the client that ambulation will occur in one hour.
d. Administer heparin, as ordered.
ANS: B
Maintain the head of the client at a 35- to 40-degree angle to reduce abdominal pressure
and increase tidal flow. Passive range-of-motion exercises may be completed but will not
affect abdominal pressure. Ambulation postoperatively is not expected in the first couple
of hours. Heparin may be ordered but that will not promote tidal flow or reduce abdominal
pressure.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
15. A client who has been successfully losing 0.5 kg weekly for several months is weighed at
the clinic and has not lost any weight for the last month. Which of the following actions
should the nurse do first?
a. Review the diet and exercise guidelines with the client.
b. Instruct the client to weigh weekly and record the weights.
c. Ask the client whether there have been any changes in exercise or diet patterns.
d. Discuss the possibility that the client has reached a temporary weight loss plateau.
ANS: C
The initial nursing action should be assessment of any reason for the change in weight loss.
The other actions may be needed, but further assessment is required before any
interventions are planned or implemented.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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16. The nurse obtains these assessment data for a client who has been taking orlistat for
several months as part of a weight loss program. Which of the following findings is most
important to report to the health care provider?
a. The client frequently has liquid stools.
b. The client is pale and has many bruises.
c. The client is experiencing a plateau in weight loss.
d. The client complains of abdominal bloating after meals.
ANS: B
Because orlistat blocks the absorption of fat-soluble vitamins, the client may not be
receiving an adequate amount of vitamin K, resulting in a decrease in clotting factors.
Abdominal bloating and liquid stools are common adverse effects of orlistat and indicate
that the nurse should remind the client that fat in the diet may increase these adverse
effects. Weight loss plateaus are normal during weight reduction.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
17. The nurse is developing a weight reduction plan for an obese client who wants to lose
weight. Which of the following questions should the nurse ask first?
a. “Which food types do you like best?”
b. “How long have you been overweight?”
c. “What kind of physical activities do you enjoy?”
d. “What factors do you think led to your obesity?”
ANS: D
The nurse should obtain information about the client’s perceptions of the reasons for the
obesity to develop a plan individualized to the client. The other information also will be
obtained from the client, but the client is more likely to make changes when the client’s
beliefs are considered in planning.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
18. On the first postoperative day the nurse is caring for a client who has had a Roux-en-Y
gastric bypass procedure. Which of the following assessment findings should be reported
immediately to the surgeon?
a. Use of patient-controlled analgesia (PCA) several times an hour for pain
b. Irritation and skin breakdown in skin folds
c. Bilateral crackles audible at both lung bases
d. Emesis of bile-coloured fluid past the nasogastric (NG) tube
ANS: D
Vomiting with an NG tube in place indicates that the NG tube needs to be repositioned by
the surgeon to avoid putting stress on the gastric sutures. The nurse should implement
actions to decrease skin irritation and have the client cough and deep breathe, but these do
not indicate a need for rapid notification of the surgeon. Frequent PCA use after bariatric
surgery is expected.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
OBJ: Special Questions: Prioritization
MSC: NCLEX: Physiological Integrity
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19. The nurse is planning preoperative teaching for a client undergoing a Roux-en-Y gastric
bypass as treatment for morbid obesity. Which of the following interventions is priority?
a. Demonstrating passive range-of-motion exercises to the legs.
b. Discussing the necessary postoperative modifications in lifestyle
c. Teaching the client proper coughing and deep-breathing techniques
d. Educating the client about the postoperative presence of a nasogastric (NG) tube
ANS: C
Coughing and deep breathing can prevent major postoperative complications such as
carbon monoxide retention and hypoxemia. Information about passive range of motion,
the NG tube, and postoperative modifications in lifestyle also will be discussed, but
avoidance of respiratory complications is the priority goal after surgery.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
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Chapter 44: Nursing Management: Upper Gastro-intestinal Problems
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is caring for a client with deep partial-thickness burns who is anxious about the
upcoming dressing change, is in severe pain, and is nauseated. Which of the following
actions will be most useful in decreasing the client’s nausea?
a. The client NPO for 2 hours before and after dressing changes.
b. Avoid performing dressing changes close to the client’s mealtimes.
c. Administer the prescribed morphine sulphate before dressing changes.
d. Give the ordered prochlorperazine before dressing changes.
ANS: C
The client’s nausea is associated with stress and severe pain; therefore the best treatment
will be to provide adequate pain medication before dressing changes. The nurse should
avoid doing painful procedures close to mealtimes, but nausea or vomiting that occurs at
other times also should be addressed. Keeping the client NPO does not address the reason
for the nausea and vomiting and will have an adverse effect on the client’s nutrition.
Administration of antiemetics is not the best choice for a client with nausea caused by
pain.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
2. The nurse is caring for a client who has been NPO during treatment for nausea and
vomiting caused by gastric irritation and is to start oral intake. Which of the following
menu choices should the nurse offer to the client?
a. A glass of orange juice
b. A dish of lemon gelatin
c. A cup of coffee with cream
d. A bowl of hot chicken broth
ANS: B
Clear liquids are usually the first foods started after a client has been nauseated. Acidic
foods such as orange juice, very hot foods, and coffee are poorly tolerated when clients
have been nauseated.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
3. The nurse is caring for a client who is receiving chemotherapy and develops a Candida
albicans oral infection. Which of the following actions should the nurse anticipate?
Hydrogen peroxide rinses
The use of antiviral agents
Referral to a dentist for professional tooth cleaning
Administration of nystatin oral tablets
a.
b.
c.
d.
ANS: D
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Candida albicans is treated with an antifungal such as nystatin. Oral saltwater rinses may
be used but will not cure the infection. Antiviral agents are used for viral infections such
as herpes simplex. Referral to a dentist is indicated for gingivitis but not for Candida
infection.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
4. The nurse is assessing the mouth of a client who uses smokeless tobacco for signs of oral
cancer. Which of the following findings is of most concern?
a. Bleeding during tooth brushing
b. Painful blisters at the border of the lips
c. Red, velvety patches on the buccal mucosa
d. White, curdlike plaques on the posterior tongue
ANS: C
A red, velvety patch suggests erythroplasia, which has a high incidence (90%) of
progression to malignant cancer. The other lesions are suggestive of acute processes
(gingivitis, oral candidiasis, and herpes simplex).
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
5. To decrease the risk for cancers of the tongue and buccal mucosa, which of the following
information should the nurse include when teaching a client who is seen for an annual
physical examination in the outpatient clinic?
a. Avoid use of cigarettes and smokeless tobacco.
b. Use sunscreen when outside even on cloudy days.
c. Complete antibiotics used to treat throat infections.
d. Use antivirals to treat herpes simplex virus (HSV) infections.
ANS: A
Tobacco use greatly increases the risk for oral cancer. Acute throat infections do not
increase risk for oral cancer, although chronic irritation of the oral mucosa does increase
risk. Sun exposure does not increase the risk for cancers of the buccal mucosa. Human
papillomavirus (HPV) infection is associated with increased risk, but HSV infection is not
a risk factor for oral cancer.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
6. The nurse is assessing a client with gastro-esophageal reflux disease (GERD) who is
experiencing increasing discomfort. Which of the following client statements indicate that
additional client education about GERD is needed?
a. “I take antacids between meals and at bedtime each night.”
b. “I sleep with the head of the bed elevated on 10-cm blocks.”
c. “I quit smoking several years ago, but I still chew a lot of gum.”
d. “I eat small meals throughout the day and have a bedtime snack.”
ANS: D
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GERD is exacerbated by eating late at night, and the nurse should plan to teach the client
to avoid eating at bedtime. The other client actions are appropriate to control symptoms of
GERD.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
7. The nurse is admitting a client with a stroke who is unconscious and unresponsive to
stimuli and learns from the client’s family that the client has a history of gastro-esophageal
reflux disease (GERD). Which of the following assessment parameters should the nurse
plan to assess frequently?
a. Apical pulse
b. Bowel sounds
c. Breath sounds
d. Abdominal girth
ANS: C
Because GERD may cause aspiration, the unconscious client is at risk for developing
aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be
affected by the client’s stroke or GERD and do not require more frequent monitoring than
the routine.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
8. The nurse is caring for a client with recurring heartburn who receives a new prescription
for esomeprazole. Which of the following information should the nurse include when
teaching the client about this medication?
a. It neutralizes stomach acid and provides relief of symptoms in a few minutes.
b. It reduces the reflux of gastric acid by increasing the rate of gastric emptying.
c. It coats and protects the lining of the stomach and esophagus from gastric acid.
d. It treats gastro-esophageal reflux disease by decreasing stomach acid production.
ANS: D
It is a proton pump inhibitor that decreases the rate of gastric acid secretion. Promotility
drugs such as metoclopramide increase the rate of gastric emptying. Cryoprotective
medications such as sucralfate protect the stomach. Antacids neutralize stomach acid and
work rapidly.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
9. The nurse is teaching a client with gastro-esophageal reflux disease (GERD) about
recommended dietary modifications. Which of the following diet choices for a snack 2
hours before bedtime indicates that the teaching has been effective?
a. Chocolate pudding
b. Glass of low-fat milk
c. Peanut butter sandwich
d. Cherry gelatin and fruit
ANS: D
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Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES)
pressure. Foods like chocolate are avoided because they lower LES pressure. Milk
products increase gastric acid secretion. High-fat foods such as peanut butter decrease both
gastric emptying and LES pressure.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
10. The nurse is assessing a client who recently has been experiencing frequent heartburn in
the clinic. Which of the following information should the nurse include in the teaching
plan?
a. Barium swallow
b. Radionuclide tests
c. Endoscopy procedures
d. Proton pump inhibitors
ANS: D
Because diagnostic testing for heartburn that is probably caused by gastro-esophageal
reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are
frequently used for a short period as the first step in the diagnosis of GERD. The other
tests may be used but are not usually the first step in diagnosis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
11. The nurse is caring for an older-adult client who has diagnosed with esophageal cancer
and the client tells the nurse, “I know that my chances are not very good, but I do not feel
ready to die yet.” Which of the following responses by the nurse is best?
a. “You may have quite a few years still left to live.”
b. “Thinking about dying will only make you feel worse.”
c. “Having this new diagnosis must be very hard for you.”
d. “It is important that you be realistic about your prognosis.”
ANS: C
This response is open-ended and will encourage the client to further discuss feelings of
anxiety or sadness about the diagnosis. Clients with esophageal cancer have only a low
survival rate, so the response “You may have quite a few years still left to live” is
misleading. The response beginning, “Thinking about dying” indicates that the nurse is not
open to discussing the client’s fears of dying. And the response beginning, “It is important
that you be realistic,” discourages the client from feeling hopeful, which is important to
clients with any life-threatening diagnosis.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
12. Which of the following information should the nurse include when teaching a client with
newly diagnosed gastro-esophageal reflux disease (GERD)?
a. “Peppermint tea may be helpful in reducing your symptoms.”
b. “You should avoid eating between meals to reduce acid secretion.”
c. “Vigorous physical activities may increase the incidence of reflux.”
d. “It will be helpful to keep the head of your bed elevated on blocks.”
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ANS: D
Elevating the head of the bed will reduce the incidence of reflux while the client is
sleeping. Peppermint will lower LES pressure and increase the chance for reflux. Small,
frequent meals are recommended to avoid abdominal distension. There is no need to make
changes in physical activities because of GERD.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
13. The nurse is caring for a client who has just arrived on the postoperative unit after having
a laparoscopic esophagectomy for treatment of esophageal cancer. Which of the following
nursing actions should be included in the postoperative plan of care?
a. Elevate the head of the bed to at least 30 degrees.
b. Reposition the nasogastric (NG) tube if drainage stops or decreases.
c. Notify the doctor immediately about bloody NG drainage.
d. Start oral fluids when the client has active bowel sounds.
ANS: A
Elevation of the head of the bed decreases the risk for reflux and aspiration of gastric
secretions. The client should be in the Fowler’s or semi-Fowler’s position. The NG tube
should not be repositioned without consulting with the health care provider. Bloody NG
drainage is expected for the first 8–12 hours. A swallowing study is needed before oral
fluids are started.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
14. Which of the following information should the nurse plan to teach to a client with newly
diagnosed achalasia?
a. A liquid or blenderized diet will be necessary.
b. Drinking fluids with meals should be avoided.
c. Endoscopic procedures may be used for treatment.
d. Lying down and resting after meals is recommended.
ANS: C
Endoscopic and laparoscopic procedures are the most effective therapy for improving
symptoms caused by achalasia. Clients are advised to drink fluid with meals. Keeping the
head elevated after eating will improve esophageal emptying. A semisoft diet is
recommended to improve esophageal emptying.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
15. The nurse is caring for a client who is nauseated, vomiting up blood-streaked fluid and has
acute gastritis. Which of the following assessments should the nurse ask the client about to
determine possible risk factors for gastritis?
a. The amount of fat in the diet
b. History of recent weight gain or loss
c. Any family history of gastric problems
d. Use of nonsteroidal anti-inflammatory drugs (NSAIDs)
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ANS: D
Use of an NSAID is associated with damage to the gastric mucosa, which can result in
acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk
factors for acute gastritis.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
16. Cobalamin injections have been prescribed for a client with chronic atrophic gastritis.
Which of the following client statements indicate that the teaching regarding the injections
has been effective?
a. “The cobalamin injections will prevent me from becoming anemic.”
b. “These injections will increase the hydrochloric acid in my stomach.”
c. “These injections will decrease my risk for developing stomach cancer.”
d. “The cobalamin injections need to be taken until my inflamed stomach heals.”
ANS: A
Cobalamin supplementation prevents the development of pernicious anemia. The
incidence of stomach cancer is higher in clients with chronic gastritis, but cobalamin does
not reduce the risk for stomach cancer. Chronic gastritis may cause achlorhydria, but
cobalamin does not correct this. The loss of intrinsic factor secretion with chronic gastritis
is permanent, and the client will need lifelong supplementation with cobalamin.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
17. The nurse is caring for a client with peptic ulcer disease associated with the presence of
Helicobacter pylori and is being treated with triple drug therapy. Which of the following
medications should the nurse include in the client teaching?
a. Sucralfate, nystatin and bismuth
b. Amoxicillin, clarithromycin and omeprazole
c. Famotidine, magnesium hydroxide, and pantoprazole
d. Metoclopramide, bethanechol, and promethazine
ANS: B
The drugs used in triple drug therapy include a proton pump inhibitor such as omeprazole
and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not
included in the protocol for H. pylori infection.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
18. The nurse is admitting a client to the emergency department who has had several episodes
of bloody diarrhea. Which of the following actions should the nurse anticipate taking?
a. Obtain a stool specimen for culture.
b. Administer antidiarrheal medications.
c. Teach about adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs).
d. Provide education about antibiotic therapy.
ANS: A
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Clients with bloody diarrhea should have a stool culture for E. coli O157:H7. NSAIDs
may cause occult blood in the stools, but not diarrhea. Antidiarrheal medications usually
are avoided for possible infectious diarrhea to avoid prolonging the infection. Antibiotic
therapy in the treatment of infectious diarrhea is controversial because it may precipitate
kidney complications.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
19. The nurse is caring for a client with vomiting of “coffee-ground” emesis. Which of the
following procedures should the nurse anticipate for the client?
a. Endoscopy
b. Angiography
c. Gastric analysis testing
d. Barium contrast studies
ANS: A
Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI)
bleeding. Angiography is used only when endoscopy cannot be done because it is more
invasive and has more possible complications. Gastric analysis testing may help with
determining the cause of gastric irritation, but it is not used for acute GI bleeding. Barium
studies are helpful in determining the presence of gastric lesions, but not whether the
lesions are actively bleeding.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
20. The nurse is admitting a client with Escherichia coli O157:H7 food poisoning who has
bloody diarrhea and dehydration. Which of the following prescriptions should the nurse
question?
a. Infuse lactated Ringer’s solution at 250 mL/hour.
b. Monitor blood urea nitrogen and creatinine daily.
c. High protein, high fat diet.
d. Provide a clear liquid diet and progress diet as tolerated.
ANS: C
The client would not have an intake of solid food at this time. Clear fluids would be
ordered. The other orders are appropriate.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
21. The health care provider prescribes intravenous (IV) ranitidine for a client with
gastrointestinal (GI) bleeding caused by peptic ulcer disease. When teaching the client
about the effect of the medication, which of the following information should the nurse
include?
a. “Ranitidine decreases secretion of gastric acid.”
b. “Ranitidine neutralizes the acid in the stomach.”
c. “Ranitidine constricts the blood vessels in the stomach and decreases bleeding.”
d. “Ranitidine covers the ulcer with a protective material that promotes healing.”
ANS: A
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Ranitidine is a histamine-2 (H2) receptor blocker, which decreases the secretion of gastric
acid. The response beginning, “Ranitidine constricts the blood vessels” describes the effect
of vasopressin. The response beginning “Ranitidine neutralizes the acid” describes the
effect of antacids. And the response beginning “Ranitidine covers the ulcer” describes the
action of sucralfate.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
22. The family member of a client who has suffered massive abdominal trauma in an
automobile accident asks the nurse why the client is receiving famotidine. Which of the
following information should the nurse provide to the family about the medication for this
client?
a. It prevents aspiration of gastric contents.
b. It inhibits the development of stress ulcers.
c. It lowers the chance for H. pylori infection.
d. It decreases the risk for nausea and vomiting.
ANS: B
Famotidine is administered to prevent the development of physiological stress ulcers,
which are associated with a major physiological insult such as massive trauma. Famotidine
does not decrease nausea or vomiting, prevent aspiration, or prevent H. pylori infection.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
23. The nurse is caring for a client with a bleeding duodenal ulcer who has a nasogastric (NG)
tube in place and a prescription for 30 mL of aluminum hydroxide/magnesium hydroxide
to be instilled through the tube every hour. Which of the following assessments should the
nurse do to evaluate the effectiveness of this treatment?
a. Periodically aspirate and test gastric pH.
b. Monitor arterial blood gas values on a daily basis.
c. Check each stool for the presence of occult blood.
d. Measure the amount of residual stomach contents hourly.
ANS: A
The purpose for antacids is to increase gastric pH. Checking gastric pH is the most direct
way of evaluating the effectiveness of the medication. Arterial blood gases may change
slightly, but this does not directly reflect the effect of antacids on gastric pH. Because the
client has upper gastrointestinal (GI) bleeding, occult blood in the stools will appear even
after the acute bleeding has stopped. The amount of residual stomach contents is not a
reflection of resolution of bleeding or of gastric pH.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
24. The nurse is caring for a client with a peptic ulcer and a nasogastric (NG) tube who
develops sudden, severe upper abdominal pain, diaphoresis, and a very firm abdomen.
Which of the following actions should the nurse take next?
a. Irrigate the NG tube.
b. Obtain the vital signs.
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c. Listen for bowel sounds.
d. Give the ordered antacid.
ANS: B
The client’s symptoms suggest acute perforation, and the nurse should assess for signs of
hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would
be contraindicated because any material in the stomach will increase the spillage into the
peritoneal cavity. The nurse should assess the bowel sounds, but this is not the first action
that should be taken.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
25. Twelve hours after undergoing a gastroduodenostomy (Billroth I), a client has symptoms
of increasing abdominal pain. The client has absent bowel sounds and 200 mL of bright
red nasogastric (NG) drainage in the last hour. Which of the following actions should the
nurse take next?
a. Notify the surgeon.
b. Irrigate the NG tube.
c. Administer the prescribed morphine.
d. Continue to monitor the NG drainage.
ANS: A
Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate
possible postoperative hemorrhage, and immediate actions such as blood transfusion
and/or return to surgery are needed. Because the NG is draining, there is no indication that
irrigation is needed. The client may need morphine, but this is not the highest priority
action. Continuing to monitor the NG drainage is not an adequate response.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
26. The nurse is providing discharge teaching for a client following a gastroduodenostomy for
treatment of a peptic ulcer. Which of the following client statements indicate that the
teaching has been effective?
a. “Persistent heartburn is expected after surgery.”
b. “I will try to drink liquids along with my meals.”
c. “Vitamin supplements may be needed to prevent problems with anemia.”
d. “I will need to choose foods that are low in fat and high in carbohydrate.”
ANS: C
Cobalamin deficiency may occur after partial gastrectomy, and the client may need to
receive cobalamin via injections or nasal spray. Foods that have moderate fat and low
carbohydrate should be chosen to prevent dumping syndrome. Ingestion of liquids with
meals is avoided to prevent dumping syndrome. Although peptic ulcer disease may recur,
persistent heartburn is not expected after surgery and the client should call the health care
provider if this occurs.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
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27. A client recovering from a gastrojejunostomy (Billroth II) for treatment of a duodenal
ulcer develops dizziness, weakness, and palpitations about 20 minutes after eating. Which
of the following information should the nurse teach to the client to avoid recurrence of
these symptoms?
a. Lie down for about 30 minutes after eating.
b. Choose foods that are high in carbohydrates.
c. Increase the amount of fluid intake with meals.
d. Drink sugared fluids or eat candy after each meal.
ANS: A
The client is experiencing symptoms of dumping syndrome, which may be reduced by
lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will
increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct
the hypoglycemia that is associated with dumping syndrome but will not prevent dumping
syndrome.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
28. A client who requires daily use of a nonsteroidal anti-inflammatory drug (NSAID) for
management of severe rheumatoid arthritis has recently developed melena. Which of the
following information should the nurse include in the teaching plan?
a. Substitution of acetaminophen for the NSAID
b. Use of enteric-coated NSAIDs to reduce gastric irritation
c. Reasons for using corticosteroids to treat the rheumatoid arthritis
d. The benefits of misoprostol in protecting the gastrointestinal (GI) mucosa
ANS: D
Misoprostol, a prostaglandin analogue, reduces acid secretion and incidence of upper GI
bleeding associated with NSAID use. Enteric coating of NSAIDs does not reduce the risk
for GI bleeding. Corticosteroids increase the risk for ulcer development and will not be
substituted for NSAIDs for this client. Acetaminophen will not be effective in treating the
client’s rheumatoid arthritis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
29. The health care provider prescribes antacids and sucralfate for treatment of a client’s
peptic ulcer. Which of the following information should the nurse include in the client’s
teaching plan?
a. Antacids 30 minutes before the sucralfate
b. Sucralfate at bedtime and antacids before meals
c. Antacids after eating and sucralfate 30 minutes before eating
d. Sucralfate and antacids together 30 minutes before each meal
ANS: C
Sucralfate is most effective when the pH is low and should not be given with or soon after
antacid. Antacids are most effective when taken after eating. Administration of sucralfate
30 minutes before eating and antacids just after eating will ensure that both drugs can be
most effective. The other regimens will decrease the effectiveness of the medications.
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DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
30. Which of the following information is best for the nurse to include when teaching a client
with peptic ulcer disease (PUD) about dietary management of the disease?
a. “Avoid foods that cause pain after you eat them.”
b. “High-protein foods are least likely to cause pain.”
c. “You will need to remain on a bland diet indefinitely.”
d. “You should avoid eating many raw fruits and vegetables.”
ANS: A
The best information is that each individual should choose foods that are not associated
with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa,
but chewing well seems to decrease this and some clients may tolerate these well.
High-protein foods not only help to neutralize acid but they also stimulate hydrochloric
(HCl) acid secretion and may increase discomfort for some clients. Bland diets may be
recommended during an acute exacerbation of PUD, but there is little scientific evidence
to support their use.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
31. The nurse is caring for a client with stomach cancer who had a recent 9.1 kg unintended
weight loss. Which of the following nursing actions should be included in the plan of care?
a. Refer the client for hospice services.
b. Infuse IV fluids through a central line.
c. Teach the client about antiemetic therapy.
d. Offer supplemental feedings between meals.
ANS: D
The client data indicate a poor nutritional state and improvement in nutrition will be
helpful in improving response to therapies such as surgery, chemotherapy, or radiation.
Nausea and vomiting are not common clinical manifestations of stomach cancer. There is
no indication that the client requires hospice or IV fluid infusions.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
32. The nurse is counselling a client with a family history of stomach cancer about risk factors.
Which of the following is a risk factor for the development of stomach cancer?
a. Type A blood
b. Chronic abdominal distension
c. Long-term use of H2 blocking medications
d. Exposure to emotionally or physically stressful situations
ANS: A
Clients with Type A blood have an increased the risk for stomach cancer. Use of H2
blockers, stressful situations, and abdominal distension is not associated with an increased
incidence of stomach cancer.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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33. Which of the following assessment findings in a client who had a total gastrectomy 12
hours previously is most important to report to the health care provider?
a. Absent bowel sounds
b. Scant nasogastric (NG) tube drainage
c. Complaints of incisional pain
d. Temperature 38.9°C (102°F)
ANS: D
An elevation in temperature may indicate leakage at the anastomosis, which may require
return to surgery or keeping the client NPO. The other findings are expected in the
immediate postoperative period for clients who have this surgery.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
34. Which of the following information about a client who has just been admitted to the
hospital with nausea and vomiting requires the most rapid intervention by the nurse?
The client has taken only sips of water.
The client is lethargic and difficult to arouse.
The client’s chart indicates a recent resection of the small intestine.
The client has been vomiting several times a day for the last 4 days.
a.
b.
c.
d.
ANS: B
A lethargic client is at risk for aspiration, and the nurse will need to position the client to
decrease aspiration risk. The other information also is important to collect, but it does not
require as quick action as the risk for aspiration.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
35. The nurse is caring for a client with acute gastrointestinal (GI) bleeding who is receiving
normal saline IV at a rate of 500 mL/hour. Which of the following findings obtained by
the nurse is most important to communicate immediately to the health care provider?
a. The client’s blood pressure (BP) has increased to 142/94 mm Hg.
b. The nasogastric (NG) suction is returning coffee-ground material.
c. The client’s lungs have crackles audible to the midline.
d. The bowel sounds are very hyperactive in all four quadrants.
ANS: C
The client’s lung sounds indicate that pulmonary edema may be developing as a result of
the rapid infusion of IV fluid and that the fluid infusion rate should be slowed. The return
of coffee-ground material in an NG tube is expected for a client with upper GI bleeding.
The BP is slightly elevated but would not be an indication to contact the health care
provider immediately. Hyperactive bowel sounds are common when a client has GI
bleeding.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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36. The health care provider prescribes the following therapies for a client who has been
admitted with dehydration and hypotension after 3 days of nausea and vomiting. Which
order should the nurse implement first?
a. Infuse normal saline at 250 mL/hour.
b. Administer IV ondansetron.
c. Provide oral care with moistened swabs.
d. Insert a nasogastric (NG) tube.
ANS: A
Because the client has severe dehydration, rehydration with IV fluids is the priority. The
other orders should be accomplished as quickly as possible after the IV fluids are initiated.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
37. After receiving change-of-shift report, which of the following clients should the nurse
assess first?
a. A client who was admitted yesterday with gastrointestinal (GI) bleeding and has
melena
b. A client who is crying after receiving a diagnosis of esophageal cancer
c. A client with esophageal varices who has a blood pressure of 96/54 mm Hg
d. A client with nausea who has a dose of metoclopramide (Reglan) scheduled
ANS: C
The client’s history and blood pressure indicate possible hemodynamic instability caused
by GI bleeding. The data about the other clients do not indicate acutely life-threatening
complications.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
38. Which of the following findings in a client with a hiatal hernia who returned from a
laparoscopic Nissen fundoplication 4 hours ago is most important for the nurse to address
immediately?
a. The client is experiencing intermittent waves of nausea.
b. The client has absent breath sounds throughout the left lung.
c. The client has decreased bowel sounds in all four quadrants.
d. The client complains of 6/10 (0–10 scale) abdominal pain.
ANS: B
Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid
diagnosis and treatment. The abdominal pain and nausea also should be addressed but they
are not as high priority as the client’s respiratory status. The client’s decreased bowel
sounds are expected after surgery and require ongoing monitoring but no other action.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
39. The nurse is admitting a client who is vomiting bright red blood to the emergency
department. Which of the following assessments should the nurse perform first?
a. Checking the level of consciousness
b. Measuring the quantity of any emesis
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c. Auscultating the chest for breath sounds
d. Taking the blood pressure (BP) and pulse
ANS: D
The nurse is concerned about blood loss and possible hypovolemic shock in a client with
acute gastrointestinal (GI) bleeding; BP and pulse are the best indicators of these
complications. The other information also is important to obtain, but BP and pulse rate are
the best indicators for hypoperfusion.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
40. All of the following prescriptions are received for a client who has vomited 1 500 mL of
bright red blood. Which order will the nurse implement first?
a. Insert a nasogastric (NG) tube and connect to suction.
b. Administer intravenous (IV) famotidine 40 mg.
c. Draw blood for typing and crossmatching.
d. Infuse 1 000 mL of lactated Ringer’s solution.
ANS: D
Because the client has vomited a large amount of blood, correction of hypovolemia and
prevention of hypovolemic shock are the priorities. The other actions also are important to
implement quickly but are not the highest priorities.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
MULTIPLE RESPONSE
1. Which of the following symptoms should the nurse anticipate in a client with a duodenal
ulcer? (Select all that apply.)
Decreased gastric secretion
Nausea and vomiting
Pain about 1 hour after a meal
Middle of the night pain
relief from pain with administration of an antacid
a.
b.
c.
d.
e.
ANS: B, D, E
A client with a duodenal ulcer may have nausea and vomiting, pain in the middle of the
night, and relief from pain with an administration of an antacid.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
2. Which of the following findings should the nurse anticipate in a client with an upper GI
bleed? (Select all that apply.)
a. Increased urinary output
b. Black, tarry stool
c. Constipation
d. Diaphoresis
e. Epigastric pain
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ANS: B, D, E
A client with an upper GI bleed may have a black tarry stool, diaphoresis, and epigastric
pain. The client would have complaints of diarrhea, not constipation. The client would
have a decreased urinary output, not an increased one.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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Chapter 45: Nursing Management: Lower Gastro-intestinal Problems
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is caring for a client who has watery, incontinent diarrhea and has diagnosed
with Clostridium difficile. Which of the following actions should the nurse include in the
plan of care?
a. Order a diet with no dairy products for the client.
b. Place the client in a private room with contact isolation.
c. Teach the client about why antibiotics are not being used.
d. Educate the client about proper food handling and storage.
ANS: B
Because C. difficile is highly contagious, the client should be placed in a private room and
contact precautions should be used. There is no need to restrict dairy products for this type
of diarrhea. Metronidazole is frequently used to treat C. difficile. Improper food handling
and storage do not cause C. difficile.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
2. A client tells the nurse, “I have problems with constipation now that I am older, so I use a
suppository every morning.” Which of the following actions should the nurse take first?
a. Encourage the client to increase oral fluid intake.
b. Inform the client that a daily bowel movement is unnecessary.
c. Assess the client about individual risk factors for constipation.
d. Suggest that the client increase dietary intake of high-fibre foods.
ANS: C
The nurse’s initial action should be further assessment of the client for risk factors for
constipation and for usual bowel pattern. The other actions may be appropriate but will be
based on the assessment.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
3. The nurse is teaching a client who has chronic constipation about the use of psyllium.
Which of the following information should the nurse include?
Absorption of fat-soluble vitamins may be reduced by fibre-containing laxatives.
Dietary sources of fibre should be eliminated to prevent excessive gas formation.
Use of this type of laxative to prevent constipation does not cause adverse effects.
Large amounts of fluid should be taken to prevent impaction or bowel obstruction.
a.
b.
c.
d.
ANS: D
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A high fluid intake is needed when clients are using bulk-forming laxatives to avoid
worsening constipation. Although bulk-forming laxatives are generally safe, the nurse
should emphasize the possibility of constipation or obstipation if inadequate fluid intake
occurs. Although increased gas formation is likely to occur with increased dietary fibre,
the client should gradually increase dietary fibre and eventually may not need the psyllium.
Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by
bulk-forming laxatives.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
4. The nurse is obtaining a history for a female client who is being evaluated for acute lower
abdominal pain and vomiting. Which of the following questions is most useful in
determining the cause of the client’s symptoms?
a. “Is it possible that you are pregnant?”
b. “Can you tell me more about the pain?”
c. “What type of foods do you usually eat?”
d. “What is your usual elimination pattern?”
ANS: B
A complete description of the pain provides clues about the cause of the problem. The
usual diet and elimination patterns are less helpful in determining the reason for the
client’s symptoms. Although the nurse should ask whether the client is pregnant to
determine whether the client might have an ectopic pregnancy and before any radiology
studies are done, this information is not the most useful in determining the cause of the
pain.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
5. The nurse is caring for a client who had an exploratory laparotomy with a resection of a
short segment of small bowel two days previously. The client has gas pains and abdominal
distension. Which of the following nursing actions is best to take at this time?
a. Give a return-flow enema.
b. Assist the client to ambulate.
c. Administer the ordered IV morphine sulphate.
d. Insert the ordered promethazine suppository.
ANS: B
Ambulation will improve peristalsis and help the client eliminate flatus and reduce gas
pain. Morphine will further reduce peristalsis. A return-flow enema may decrease the
client’s symptoms, but ambulation is less invasive and should be tried first. Promethazine
is used as an antiemetic rather than to decrease gas pains or distension.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
6. The nurse is caring for a client who has blunt abdominal trauma after an automobile
accident and severe pain. A peritoneal lavage returns brown drainage with fecal material.
Which of the following actions should the nurse plan to take next?
a. Auscultate the bowel sounds.
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b. Prepare the client for surgery.
c. Check the client’s oral temperature.
d. Obtain information about the accident.
ANS: B
Return of brown drainage and fecal material suggests perforation of the bowel and the
need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and
obtaining information about the accident are appropriate actions, but the priority is to
prepare to send the client for emergency surgery.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
7. The nurse is admitting a client for evaluation of right lower quadrant abdominal pain with
nausea and vomiting and an O2 saturation of 90%. Which of the following actions should
the nurse take?
a. Check for rebound tenderness.
b. Assist the client to cough and deep breathe.
c. Administer oxygen via nasal cannula.
d. Encourage the client to take sips of clear liquids.
ANS: C
The client’s clinical manifestations are consistent with appendicitis but the main priority is
to administer oxygen as the O2 saturation is only 90%. The client should be NPO in case
immediate surgery is needed. Checking for rebound tenderness frequently is unnecessary
and uncomfortable for the client. The client will need to know how to cough and deep
breathe postoperatively, but coughing will increase pain at this time.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
8. Which of the following nursing actions should be included in the plan of care for a male
client with bowel irregularity and a new diagnosis of irritable bowel syndrome (IBS)?
a. Encourage the client to express feelings and ask questions about IBS.
b. Suggest that the client increase the intake of milk and other dairy products.
c. Educate the client about the use of Tegaserod to reduce symptoms.
d. Teach the client to avoid using nonsteroidal anti-inflammatory drugs (NSAIDs).
ANS: A
Because psychological and emotional factors can affect the symptoms for IBS,
encouraging the client to discuss emotions and ask questions is an important intervention.
Tegaserod (Zelnorm) has been recently used to treat women with IBS whose primary
bowel symptom is constipation however this question is asking about a male client.
Although yogourt may be beneficial, milk is avoided because lactose intolerance can
contribute to symptoms in some clients. NSAIDs can be used by clients with IBS.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
9. The nurse is caring for a client with an acute exacerbation of ulcerative colitis having
14–16 bloody stools a day and crampy abdominal pain associated with the diarrhea. Which
of the following actions should the nurse take?
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a.
b.
c.
d.
Place the client on NPO status.
Administer IV metoclopramide.
Teach the client about total colectomy surgery.
Administer cobalamin injections.
ANS: A
An initial therapy for an acute exacerbation of inflammatory bowel disease (IBD) is to rest
the bowel by making the client NPO. Cobalamin (vitamin B12) is absorbed in the ileum,
which is not affected by ulcerative colitis. Although total colectomy is needed for some
clients, there is no indication that this client is a candidate. Metoclopramide increases
peristalsis and will worsen symptoms.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
10. The nurse is admitting a client with an exacerbation of inflammatory bowel disease (IBD).
Which of the following nursing actions should the nurse include in the plan of care?
Restrict oral fluid intake.
Monitor stools for blood.
Increase dietary fibre intake.
Ambulate four times daily.
a.
b.
c.
d.
ANS: B
Since anemia or hemorrhage may occur with IBD, stools should be assessed for the
presence of blood. The other actions would not be appropriate for the client with IBD.
Because dietary fibre may increase gastrointestinal (GI) motility and exacerbate the
diarrhea, severe fatigue is common with IBD exacerbations, and dehydration may occur.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
11. The nurse is teaching a client with ulcerative colitis about sulphasalazine. Which of the
following client statements indicates that the teaching has been effective?
a. “I will need to take this medication for at least one year.”
b. “I will need to avoid contact with people who are sick.”
c. “The medication will need to be tapered if I need surgery.”
d. “The medication will prevent infections that cause the diarrhea.”
ANS: A
Sulphasalazine usually has a maintenance dose that the client takes for one year. It is not
used to treat infections. Sulphasalazine does not reduce immune function. Unlike
corticosteroids, tapering of sulphasalazine is not needed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
12. The nurse is caring for a client with an exacerbation of ulcerative colitis who is having
15–20 stools daily and has external hemorrhoids. Which of the following client behaviours
indicate that teaching regarding maintenance of skin integrity has been effective?
a. The client uses incontinence briefs to contain loose stools.
b. The client asks for antidiarrheal medication after each stool.
c. The client uses witch hazel compresses to decrease anal discomfort.
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d. The client cleans the perianal area with soap and water after each stool.
ANS: C
Witch hazel compresses are suggested to reduce anal irritation and discomfort.
Incontinence briefs may trap diarrhea and increase the incidence of skin breakdown.
Antidiarrheal medications are not given 15–20 times a day. The perianal area should be
washed with plain water after each stool.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
13. The nurse is providing client teaching about recommended dietary choices for a client with
an acute exacerbation of inflammatory bowel disease (IBD). Which of the following diet
choices by the client indicates a need for more teaching?
a. Scrambled eggs
b. White toast and jam
c. Oatmeal with cream
d. Pancakes with syrup
ANS: C
During acute exacerbations of IBD, the client should be on a low-residue diet and avoid
high-fibre foods such as whole grains. High-fat foods also may cause diarrhea in some
clients. The other choices are low residue and would be appropriate for this client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
14. The nurse is caring for a client who has had a total proctocolectomy and permanent
ileostomy who tells the nurse, “I cannot bear to even look at the stoma. I do not think I can
manage all these changes.” Which of the following actions is best?
a. Develop a detailed written plan for ostomy care for the client.
b. Ask the client more about the concerns with stoma management.
c. Reassure the client that care for the ileostomy will become easier.
d. Postpone any client teaching until the client adjusts to the ileostomy.
ANS: B
Encouraging the client to share concerns assists in helping the client adjust to the body
changes. Acknowledgement of the client’s feelings and concerns is important rather than
offering false reassurance. Because the client indicates that the feelings about the ostomy
are the reason for the difficulty with the many changes, development of a detailed ostomy
care plan will not improve the client’s ability to manage the ostomy. Although detailed
ostomy teaching may be postponed, the nurse should offer teaching about some aspects of
living with an ostomy.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Implementation
15. The nurse is caring for a client who has a new diagnosis of Crohn’s disease after having
frequent diarrhea and a weight loss of 4.5 kg over 2 months. Which of the following topics
should the nurse plan to include in the teaching plan?
a. Medication use
b. Fluid restriction
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c. Enteral nutrition
d. Activity restrictions
ANS: A
Medications are used to induce and maintain remission in clients with inflammatory bowel
disease (IBD). Decreased activity level is indicated only if the client has severe fatigue
and weakness. Fluids are needed to prevent dehydration. There is no advantage to enteral
feedings.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
16. The nurse is caring for a client with Crohn’s disease who develops a fever and symptoms
of a urinary tract infection (UTI) with tan, fecal-smelling urine. Which of the following
information should the nurse teach the client?
a. To clean the perianal area carefully after any stools
b. About fistula formation between the bowel and bladder
c. To empty the bladder before and after sexual intercourse
d. About the effects of corticosteroid use on immune function
ANS: B
Fistulas between the bowel and bladder occur in Crohn’s disease and can lead to UTI.
There is no information indicating that the client’s risk for UTI is caused by poor cleaning
or not voiding before and after intercourse. Steroid use may increase the risk for infection,
but the characteristics of the client’s urine indicate that a fistula has occurred.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
17. The nurse is caring for a client who has a large bowel obstruction that occurred as a result
of diverticulosis. Which of the following symptoms should the nurse monitor for when
assessing the client?
a. Referred back pain
b. Metabolic alkalosis
c. Projectile vomiting
d. Abdominal distension
ANS: D
Abdominal distension is seen in lower intestinal obstruction. Metabolic alkalosis is
common in high intestinal obstruction because of the loss of HCl acid from vomiting.
Referred back pain is not a common clinical manifestation of intestinal obstruction.
Bile-coloured vomit is associated with higher intestinal obstruction.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
18. The nurse is preparing a 50-year-old client for an annual physical examination. Which of
the following diagnostic tests should the nurse teach to the client?
a. Endoscopy
b. Fecal occult blood test
c. Computerized tomography screening
d. Carcinoembryonic antigen (CEA) testing
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ANS: B
At age 50, individuals with an average risk for colorectal cancer (CRC) should begin
screening for CRC, including a fecal occult blood test (FOBT). Colonoscopy is the gold
standard for CRC screening. The other diagnostic tests are not recommended as part of a
routine annual physical examination at age 50.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
19. The nurse is conducting preoperative preparation for a client scheduled for an
abdominal-perineal resection. Which of the following actions should the nurse implement?
a. Give IV antibiotics starting 24 hours before surgery to reduce the number of bowel
bacteria.
b. Teach the client that activities such as sitting at the bedside will be started the first
postoperative day.
c. Instruct the client that another surgery in 8–12 weeks will be used to create an
ileal-anal reservoir.
d. Administer polyethylene glycol lavage solution (GoLYTELY) to ensure that the
bowel is empty before the surgery.
ANS: D
A bowel-cleansing agent is used to empty the bowel before surgery to reduce the risk for
infection. Oral antibiotics (rather than IV antibiotics) are given to reduce colonic and rectal
bacteria. Sitting is contraindicated after an abdominal-perineal resection. A permanent
colostomy is created with this surgery.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
20. Before undergoing a colon resection for cancer of the colon, a client has an elevated
carcinoembryonic antigen (CEA) test. Which of the following explanations should the
nurse provide to the client about this test?
a. It confirms the diagnosis of colon cancer.
b. It monitors the tumour status after surgery.
c. It identifies the extent of cancer spread or metastasis.
d. It determines the need for postoperative chemotherapy.
ANS: B
CEA is used to monitor for cancer recurrence after surgery. CEA levels do not help
determine whether there is metastasis of the cancer. Confirmation of the diagnosis is made
on the basis of biopsy. Chemotherapy use is based on factors other than CEA.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
21. Which of the following nursing actions is most important to include in the plan of care for
a client who had an abdominal-perineal resection the previous day?
a. Teach about a low-residue diet.
b. Monitor output from the stoma.
c. Assess the perineal drainage and incision.
d. Encourage acceptance of the colostomy stoma.
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ANS: C
Because the perineal wound is at high risk for infection, the initial care is focused on
assessment and care of this wound. Teaching about diet is best done closer to discharge
from the hospital. There will be very little drainage into the colostomy until peristalsis
returns. The client will be encouraged to assist with the colostomy, but this is not the
highest priority in the immediate postoperative period.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
22. During the initial postoperative assessment of a client’s stoma formed from a transverse
colostomy, the nurse finds it to be deep pink with moderate edema and a small amount of
bleeding. Which of the following actions should the nurse take based upon these findings?
a. Document the stoma assessment.
b. Monitor the stoma every 30 minutes.
c. Notify the surgeon about the stoma appearance.
d. Place an ice pack on the stoma to reduce swelling.
ANS: A
The stoma appearance indicates good circulation to the stoma. There is no indication that
surgical intervention is needed or that frequent stoma monitoring is required. Swelling of
the stoma is normal for 2–3 weeks after surgery, and an ice pack is not needed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
23. The nurse is caring for a client who has ulcerative colitis and a proctocolectomy and
ileostomy. Which of the following information should the nurse include in client teaching?
a. Restrict fluid intake to prevent constant liquid drainage from the stoma.
b. Use care when eating high-fibre foods to avoid obstruction of the ileum.
c. Irrigate the ileostomy daily to avoid having to wear a drainage appliance.
d. Change the pouch every day to prevent leakage of contents onto the skin.
ANS: B
High-fibre foods are introduced gradually and should be well chewed to avoid obstruction
of the ileostomy. Clients with ileostomies lose the absorption of water in the colon and
need to take in increased amounts of fluid. The pouch should be drained frequently but is
changed every 5–7 days. The drainage from an ileostomy is liquid and continuous, so
control by irrigation is not possible.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
24. The nurse is providing discharge teaching for a client with a new colostomy. Which of the
following client actions indicates that the teaching has been effective?
a. Empties the colostomy bag once it is 2/3 full.
b. Drinks at least 1 000 mL of fluid a day.
c. Contacts the health care provider if there is pain or erythema in the peristomal
area.
d. Takes acetaminophen when a temperature of 38.3°C (100.9°F) occurs.
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ANS: C
The health care provider should be contacted if there is pain or erythema in the peristomal
area. If the client has a temperature, the health care provider should be contacted. The
colostomy should be emptied before it becomes 1/3 full. The client should drink at least
1 500–2 000 mL per day to avoid dehydration.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
25. The nurse is providing teaching to a client with a new ileostomy. Which of the following
daily drainage amounts should the nurse inform the client is expected after the bowel
adjusts to the ileostomy?
a. 400 mL
b. 600 mL
c. 800 mL
d. 1 000 mL
ANS: C
After the proximal small bowel adapts to reabsorb more fluid, the average amount of
ileostomy drainage is about 800 mL daily.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
26. Which of the following actions should the nurse implement when initiating the initial plan
of care for a client admitted with acute diverticulitis?
a. Give stool softeners.
b. Administer IV fluids.
c. Order a diet high in fibre and fluids.
d. Prepare the client for colonoscopy.
ANS: B
A client with acute diverticulitis will be NPO and given parenteral fluids. A diet high in
fibre and fluids will be implemented before discharge. Bulk-forming laxatives, rather than
stool softeners, are usually given, and these will be implemented later in the
hospitalization. The client with acute diverticulitis will not have a colonoscopy because of
the risk for perforation and peritonitis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
27. The nurse is providing discharge teaching for a client who has had a herniorrhaphy to
repair an incarcerated inguinal hernia. Which of the following information should be
included in the teaching?
a. Encourage the client to cough.
b. Provide sitz baths several times daily.
c. Avoid use of acetaminophen for pain.
d. Apply a scrotal support and encourage deep breathing.
ANS: D
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A scrotal support is used to reduce discomfort and deep breathing, but coughing is not
encouraged. Coughing will increase pressure on the incision. Sitz baths will not relieve
pain and would not be of use after this surgery. Acetaminophen can be used for
postoperative pain.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
28. After the nurse has completed teaching a client with newly diagnosed celiac disease,
which of the following breakfast choices by the client indicates good understanding of the
information?
a. Corn tortilla with eggs
b. Bagel with cream cheese
c. Oatmeal with non-fat milk
d. Whole wheat toast with butter
ANS: A
Avoidance of gluten-containing foods is the only treatment for celiac disease. Corn does
not contain gluten, while oatmeal and wheat do.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
29. Which of the following instructions should the nurse include in discharge teaching for a
client who has had a hemorrhoidectomy at an outpatient surgical centre?
Maintain a low-residue diet until the surgical area is healed.
Use ice packs on the perianal area to relieve pain and swelling.
Take prescribed pain medications before a bowel movement is expected.
Delay having a bowel movement for several days until healing has occurred.
a.
b.
c.
d.
ANS: C
Bowel movements may be very painful, and clients may avoid defecation unless pain
medication is taken before the bowel movement. Delay of bowel movements is likely to
lead to constipation. A high-residue diet will increase stool bulk and prevent constipation.
Sitz baths are used to relieve pain and keep the surgical area clean.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
30. A client calls the clinic and tells the nurse about a new onset of severe and frequent,
diarrhea. Which of the following actions should the nurse anticipate for this client?
Collect a stool specimen.
Prepare for colonoscopy.
Schedule a barium enema.
Have blood cultures drawn.
a.
b.
c.
d.
ANS: A
Acute diarrhea is usually caused by an infectious process and stool specimens are obtained
for culture and examined for parasites or white blood cells. There is no indication that the
client needs a colonoscopy, blood cultures, or a barium enema.
DIF:
Cognitive Level: Application
TOP: Nursing Process: Planning
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MSC: NCLEX: Physiological Integrity
31. The nurse is caring for a client with Crohn’s disease who has megaloblastic anemia.
Which of the following medications should the nurse anticipate teaching the client about
taking on an ongoing basis?
a. Oral ferrous sulphate tablets
b. Regular blood transfusions
c. Iron dextran (Imferon) infusion
d. Cobalamin (B12) nasal spray or injections
ANS: D
Crohn’s disease frequently affects the ileum, where absorption of cobalamin occurs, and it
must be administered regularly by nasal spray or IM to correct the anemia. Iron deficiency
does not cause megaloblastic anemia. The client may need occasional transfusions but not
regularly scheduled transfusions.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
32. The nurse is performing an admission assessment for a client with abdominal pain and
palpates the left lower quadrant and the client indicates right lower quadrant pain. Which
of the following descriptors should the nurse use to document this finding?
a. Rebound pain
b. Cullen sign
c. Rovsing sign
d. McBurney point
ANS: C
Rovsing sign occurs when palpation of the left lower quadrant causes pain in the right
lower quadrant. McBurney point, rebound pain, and Cullen sign are used to describe other
aspects of the abdominal assessment.
DIF: Cognitive Level: Knowledge
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
33. The nurse is caring for a critically ill client who develops incontinence of watery stools.
What of the following actions is best for the nurse to take to prevent complications
associated with ongoing incontinence?
a. Insert a rectal tube.
b. Use incontinence briefs.
c. Apply a perianal pouch.
d. Assist the client to a bedside commode at frequent intervals.
ANS: C
Perianal pouching is an alternative in the management of fecal incontinence. Rectal tubes
are avoided because of possible damage to the anal sphincter and ulceration of the rectal
mucosa. Incontinence briefs may be helpful but, unless they are changed frequently, are
likely to increase the risk for skin breakdown. A critically ill client will not be able to use
the commode.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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34. The nurse is interviewing a client with abdominal pain and possible irritable bowel
syndrome. Which of the following questions is most important for the nurse to ask?
a. “Have you been passing a lot of gas?”
b. “What foods affect your bowel patterns?”
c. “Do you have any abdominal distension?”
d. “How long have you had abdominal pain?”
ANS: D
One criterion for the diagnosis of irritable bowel syndrome (IBS) is the presence of
abdominal discomfort or pain for at least 3 months. Abdominal distension, flatulence, and
food intolerance also are associated with IBS, but are not diagnostic criteria.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
35. Which of the following prescribed interventions should the nurse implement first when
caring for a client who has just diagnosed with peritonitis caused by a ruptured
diverticulum?
a. Administer morphine sulphate 4 mg IV.
b. Infuse metronidazole 500 mg IV.
c. Send the client for a computerized tomography scan.
d. Insert a nasogastric (NG) tube and connect it to intermittent low suction.
ANS: B
Since peritonitis can be fatal if treatment is delayed, the initial action should be to start
antibiotic therapy (after any ordered cultures are obtained). The other actions can be done
after antibiotic therapy is initiated.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
36. Which of the following actions should the nurse take first when a client calls the clinic
complaining of diarrhea of 24 hours’ duration?
a. Ask the client to describe the character of the stools and any associated symptoms.
b. Inform the client that laboratory testing of blood and stool specimens will be
necessary.
c. Suggest that the client drink clear liquid fluids with electrolytes, such as Gatorade
or Pedialyte.
d. Advise the client to use over-the-counter loperamide to slow gastrointestinal (GI)
motility.
ANS: A
The initial response by the nurse should be further assessment of the client. The other
responses may be appropriate, depending on what is learned in the assessment.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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37. A client is admitted to the emergency department with severe abdominal pain with
rebound tenderness. The vital signs include temperature 38.3°C (100.9°F), pulse 130,
respirations 34, and blood pressure (BP) 84/50. Which of the following interventions
should the nurse implement first?
a. Administer IV ketorolac 5 mg.
b. Draw blood for a complete blood count (CBC).
c. Obtain a computed tomography (CT) scan of the abdomen.
d. Infuse 1 000 mL of lactated Ringer’s solution over 30 minutes.
ANS: D
The priority for this client is to treat the client’s hypovolemic shock with fluid infusion.
The other actions should be implemented after starting the fluid infusion.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
38. The nurse is caring for a client following an exploratory laparotomy and bowel resection
who has a nasogastric tube to suction and symptoms of nausea and stomach distension.
Which of the following actions should the nurse take first?
a. Auscultate for hypotonic bowel sounds.
b. Notify the client’s health care provider.
c. Reposition the tube and check for placement.
d. Remove the tube and replace it with a new one.
ANS: C
Repositioning the tube will frequently facilitate drainage. Because this is a common
occurrence, it is not appropriate to notify the health care provider. Information about the
presence or absence of bowel tones will not be helpful in improving drainage. Removing
the tube and replacing it are unnecessarily traumatic to the client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
39. A client is brought to the emergency department with a knife impaled in the abdomen
following a domestic fight. During the initial assessment of the client, which of the
following actions should the nurse implement?
a. Assess the BP and pulse.
b. Remove the knife to assess the wound.
c. Determine the presence of Rovsing sign.
d. Insert a urinary catheter and assess for hematuria.
ANS: A
The initial assessment is focused on determining whether the client has hypovolemic
shock. The knife should not be removed until the client is in surgery, where bleeding can
be controlled. Rovsing sign is assessed in the client with suspected appendicitis. A client
with a knife in place will be taken to surgery and assessed for bladder trauma there.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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40. A client with ulcerative colitis who is taking azathioprine calls the nurse in the outpatient
clinic about all of these symptoms. Which of the following symptoms is most important to
communicate to the health care provider?
a. Nausea
b. Joint pain
c. Frequent headaches
d. Elevated temperature
ANS: D
Since azathioprine suppresses immune function, rapid treatment of infection is essential.
The other client complaints are common adverse effects of the medication, but do not
indicate any potentially life-threatening complications.
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
41. The nurse is interviewing a 40-year-old client and obtains information about the following
client problems. Which of the following information is most important to communicate to
the health care provider?
a. The client had an appendectomy at age 17.
b. The client smokes a pack/day of cigarettes.
c. The client has a history of frequent constipation.
d. The client has recently noticed blood in the stools.
ANS: D
Blood in the stools is a possible clinical manifestation of colorectal cancer and requires
further testing by the health care provider. The other client information also will be
communicated to the health care provider, but does not indicate an urgent need for further
testing or intervention.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
42. When assessing the colour of a new stoma in the postoperative period, which of the
following findings should cause the nurse to suspect anemia?
a. Light red to rose
b. Pale pink
c. Blanching, dark red to purple
d. Dark red
ANS: B
A pale pink stoma indicates anemia. A light red rose or dark red brick colour indicates a
viable stoma mucosa. A blanching dark red to purple stoma may indicate inadequate blood
supply to the stoma, low flow state, excessive tension on the bowel mesentery at the time
of construction, or venous congestion; usually occurs in the first 72 hour after surgery.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
43. The nurse is caring for a client who has been taking antibiotics for several days and
develops watery diarrhea. Which of the following actions should the nurse take first?
a. Notify the health care provider.
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b. Obtain a stool specimen for analysis.
c. Provide education about handwashing.
d. Place the client on contact precautions.
ANS: D
The client’s history and new onset diarrhea suggest a C. difficile infection, which requires
implementation of contact precautions to prevent spread of the infection to other clients.
The other actions also are appropriate but can be accomplished after contact precautions
are implemented.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
44. After receiving change-of-shift report, which of the following clients should the nurse
assess first?
a. A client whose new ileostomy has drained 800 mL over the previous 8 hours
b. A client with familial adenomatous polyposis who has occult blood in the stool
c. A client with ulcerative colitis who has had six liquid stools in the previous 4 hours
d. A client who has abdominal distension and an apical heart rate of 136 beats/minute
ANS: D
The client’s abdominal distension and tachycardia suggest hypovolemic shock caused by
problems such as peritonitis or intestinal obstruction, which will require rapid intervention.
The other clients also should be assessed as quickly as possible, but the data do not
indicate any life-threatening complications associated with their diagnoses.
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
45. A client with a gunshot wound to the abdomen undergoes surgery, and a colostomy is
formed as illustrated. Which of the following information should the nurse include in
client teaching?
a.
b.
c.
d.
This type of colostomy is usually temporary.
Soft, formed stool can be expected as drainage.
Stool will be expelled from both ostomy stomas.
Irrigations can regulate drainage from the stomas.
ANS: A
A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the
proximal stoma only. The stool from the transverse colon will be liquid and regulation
through irrigations will not be possible.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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MULTIPLE RESPONSE
1. The nurse is assessing a client with colorectal cancer. Which of the following symptoms
should the nurse expect to assess? (Select all that apply.)
a. Weight gain
b. Early satiety
c. Right shoulder pain
d. Rectal bleeding
e. Decreased flatus
ANS: B, D
The symptoms of colorectal cancer include early satiety and rectal bleeding, including
other signs and symptoms. The client would experience weight loss, not gain. Right
shoulder pain is not a symptom of colorectal cancer but abdominal and low back pain are
often seen. Clients with colorectal cancer have increased flatus, not decrease flatus.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 46: Nursing Management: Liver, Pancreas, and Biliary Tract Problems
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. A client contracts hepatitis from contaminated food. During the acute (icteric) phase of the
client’s illness, which of the following serological findings should the nurse expect?
a. Antibody to hepatitis D virus (anti-HDV)
b. Hepatitis B surface antigen (HBsAg)
c. Anti-hepatitis A virus immunoglobulin G (anti-HAV IgG)
d. Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)
ANS: D
Hepatitis A is transmitted through the oral–fecal route, and antibody to HAV IgM appears
during the acute phase of hepatitis A. The client would not have antigen for hepatitis B or
antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong
immunity.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. Which of the following findings in a blood specimen indicates that the administration of
hepatitis B vaccine to a client has been effective?
a. HBsAg
b. Anti-HBs
c. Anti-HBc IgG
d. Anti-HBc IgM
ANS: B
The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to
the vaccine. The other laboratory values indicate current infection with HBV.
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX: Health Promotion and Maintenance
3. A client in the outpatient clinic is diagnosed with acute hepatitis C virus (HCV) infection.
Which of the following actions by the nurse is best?
Schedule the client for HCV genotype testing.
Administer immune globulin and the HCV vaccine.
Instruct the client on ribavirin treatment.
Teach that the infection will resolve in a few months.
a.
b.
c.
d.
ANS: A
Genotyping of HCV has an important role in managing treatment and is done before drug
therapy is initiated. Since most clients with acute HCV infection convert to the chronic
state, the nurse should not teach the client that the HCV will resolve in a few months.
Immune globulin or vaccine is not available for HCV. Ribavirin is used for chronic HCV
infection.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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4. The nurse is caring for a client who is diagnosed with acute hepatitis B. Which of the
following information should the nurse include in the teaching plan?
a. Ways to increase exercise and activity level
b. Self-administration of a-interferon
c. Adverse effects of nucleoside and nucleotide analogs
d. Measures that will be helpful in improving appetite
ANS: D
Maintaining adequate nutritional intake is important for regeneration of hepatocytes.
Interferon and antivirals may be used for chronic hepatitis B, but they are not prescribed
for acute hepatitis B infection. Rest is recommended.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
5. The nurse is caring for a client with chronic hepatitis C who is prescribed combination
therapy of a-interferon and ribavirin. Which of the following findings should the nurse
monitor for the presence of hepatitis C in the client?
a. Leukopenia
b. Hypokalemia
c. Polycythemia
d. Hypoglycemia
ANS: A
Therapy with ribavirin and a-interferon may cause leukopenia. The other problems are not
associated with this drug therapy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
6. Which of the following clients should alert the nurse that screening for hepatitis C should
be done?
a. The client eats frequent meals in fast-food restaurants.
b. The client recently travelled to an undeveloped country.
c. The client had a blood transfusion after surgery in 1998.
d. The client reports a one-time use of IV drugs 20 years ago.
ANS: D
Any client with a history of IV drug use should be tested for hepatitis C. Blood
transfusions given after 1992, when an antibody test for hepatitis C became available, do
not pose a risk for hepatitis C. Hepatitis C is not spread by the oral–fecal route and
therefore is not caused by contaminated food or by travelling in underdeveloped countries.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
7. The nurse is caring for a client who is admitted with an abrupt onset of jaundice, nausea,
and abnormal liver function studies. Serological testing is negative for viral causes of
hepatitis. Which of the following questions by the nurse is best?
a. “Is there any history of IV drug use?”
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b. “Are you taking corticosteroids for any reason?”
c. “Do you use any over-the-counter (OTC) drugs?”
d. “Have you recently travelled to a foreign country?”
ANS: C
The client’s symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms
suggest toxic hepatitis, which can be caused by commonly used OTC drugs such as
acetaminophen. Travel to a foreign country and a history of IV drug use are risk factors for
viral hepatitis. Corticosteroid use does not cause the symptoms listed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
8. The nurse is caring for a client with cirrhosis who has 4+ pitting edema of the feet and legs.
Which of the following assessments is priority for the nurse to monitor?
a. Hemoglobin
b. Temperature
c. Activity level
d. Albumin
ANS: D
The low oncotic pressure caused by hypoalbuminemia is a major pathophysiological factor
in the development of edema. The other parameters also should be monitored, but they are
not directly associated with the client’s current symptoms.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
9. The nurse is preparing a teaching plan for a young adult client who is diagnosed with early
alcoholic cirrhosis. Which of the following topics is most important to include in client
teaching?
a. Need to abstain from alcohol
b. Use of vitamin B supplements
c. Maintenance of a nutritious diet
d. Treatment with lactulose
ANS: A
The disease progression can be stopped or reversed by alcohol abstinence. The other
interventions may be used when cirrhosis becomes more severe to decrease symptoms or
complications, but the priority for this client is to stop the progression of the disease.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
10. The nurse is caring for a client with cirrhosis who has scheduled doses of spironolactone
and furosemide and has a serum potassium level of 3.2 mmol/L. Which of the following
actions should the nurse take?
a. Give both drugs as scheduled.
b. Administer the spironolactone.
c. Administer the furosemide and withhold the spironolactone.
d. Withhold both drugs until talking with the health care provider.
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ANS: B
Spironolactone is a potassium-sparing diuretic and will help to increase the client’s
potassium level. The nurse does not need to talk with the doctor before giving the
spironolactone, although the health care provider should be notified about the low
potassium value. The furosemide will further decrease the client’s potassium level and
should be held until the nurse talks with the health care provider.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
11. Which of the following actions should the nurse implement to evaluate the effectiveness of
treatment for a client who has hepatic encephalopathy?
Request that the client stand on one foot.
Ask the client to extend both arms to the front.
Instruct the client to perform the Valsalva manoeuvre.
Have the client walk a few steps with the eyes closed.
a.
b.
c.
d.
ANS: B
Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic
encephalopathy. The other tests also might be done as part of the neurological assessment
but would not be diagnostic for hepatic encephalopathy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
12. The nurse is caring for a client who has advanced cirrhosis and is receiving lactulose.
Which of the following findings by the nurse indicates that the medication is effective?
a. The client is alert and oriented.
b. The client denies nausea or anorexia.
c. The client’s bilirubin level decreases.
d. The client has at least one stool daily.
ANS: A
The purpose for lactulose in the client with cirrhosis is to lower ammonia levels and
prevent encephalopathy. Although lactulose may be used to treat constipation, that is not
the purpose for this client. Lactulose will not decrease nausea and vomiting or lower
bilirubin levels.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
13. Which of the following nursing actions should be included in the plan of care for a client
who is being treated for bleeding esophageal varices with balloon tamponade?
a. Monitor the client for shortness of breath.
b. Encourage the client to cough every 4 hours.
c. Deflate the gastric balloon every 8–12 hours.
d. Verify the position of the balloon every 6 hours.
ANS: A
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A common complication of balloon tamponade is occlusion of the airway by the balloon
so it is important to monitor the client’s respiratory status. In addition, if the gastric
balloon ruptures, the esophageal balloon may slip upward and occlude the airway.
Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon
position is verified after insertion and does not require further verification. The esophageal
balloon is deflated every 8–12 hours to avoid necrosis, but if the gastric balloon is deflated,
the esophageal balloon may occlude the airway.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
14. The nurse is caring for a client with severe cirrhosis who has an episode of bleeding
esophageal varices. Which of the following laboratory tests should the nurse monitor to
detect possible complications of the bleeding episode?
a. Bilirubin
b. Ammonia
c. Potassium
d. Prothrombin time
ANS: B
The blood in the gastrointestinal (GI) tract will be absorbed as protein and may result in an
increase in ammonia level because the liver cannot metabolize protein well. The
prothrombin time, bilirubin, and potassium levels also should be monitored, but these will
not be affected by the bleeding episode.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
15. Which of the following nursing actions should be included in the plan of care for a client
with cirrhosis who has ascites and 4+ edema of the feet and legs?
a. Weekly weight of client
b. Reposition the client every 4 hours
c. Restrict sodium intake.
d. Perform passive range-of-motion QID.
ANS: C
To maintain skin integrity, restrict sodium intake as ordered to prevent additional fluid
retention. The client should be weighed daily, not weekly. Repositioning the client every 4
hours will not be adequate to maintain skin integrity; clients should be repositioned at least
every two hours. Passive range of motion will not take pressure off areas like the sacrum
that are vulnerable to breakdown.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
16. The nurse is caring for a client who has had a transjugular intrahepatic portosystemic
shunt (TIPS) placement. Which of the following findings indicate that the procedure has
been effective?
a. Lower indirect bilirubin level
b. Increase in serum albumin level
c. Decrease in episodes of variceal bleeding
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d. Improvement in alertness and orientation
ANS: C
TIPS is used to lower pressure in the portal venous system and decrease the risk of
bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not
affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
17. The health care provider plans a paracentesis for a client with ascites caused by liver
cancer. Which of the following actions should the nurse implement to prepare the client
for the procedure?
a. Place the client on NPO status.
b. Assist the client to lie flat in bed.
c. Ask the client to empty the bladder.
d. Position the client on the right side.
ANS: C
The client should empty the bladder to decrease the risk of bladder perforation during the
procedure. The client would be positioned in Fowler’s position and would not be able to
lie flat without compromising breathing. Since no sedation is required for paracentesis, the
client does not need to be NPO.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
18. The nurse is assessing a client who had a liver transplant a week previously and obtains
the following data. Which of the following findings is most important to communicate to
the health care provider?
a. Dry lips and oral mucosa
b. Crackles at both lung bases
c. Temperature 38.2°C (100.8°F)
d. No bowel movement for 4 days
ANS: C
Infection risk is high in the first few months after liver transplant and fever is frequently
the only sign of infection. The other client data indicate the need for further assessment or
nursing actions, but do not indicate a need for urgent action.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
19. Which of the following laboratory test results is most important for the nurse to monitor
when evaluating the effects of therapy for a client who has acute pancreatitis?
Calcium
Bilirubin
Amylase
Potassium
a.
b.
c.
d.
ANS: C
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Amylase is elevated in acute pancreatitis. Although changes in the other values may occur,
they would not be as useful in evaluating whether the prescribed therapies have been
effective.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
20. Which of the following assessment findings in a client with acute pancreatitis should the
nurse report most quickly to the health care provider?
Nausea and vomiting
Hypotonic bowel sounds
Abdominal tenderness and guarding
Muscle twitching and finger numbness
a.
b.
c.
d.
ANS: D
Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany
unless calcium gluconate is administered. Numbness or tingling around the lips and in the
fingers is an early indicator of hypocalcemia. Although the other findings also should be
reported to the health care provider, they do not indicate complications that require rapid
action.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
21. The nurse is obtaining a health history from a client with acute pancreatitis. Which of the
following information should the nurse specifically assess when conducting a health
history?
a. Alcohol use
b. Diabetes mellitus
c. High-protein diet
d. Cigarette smoking
ANS: A
Alcohol use is one of the most common risk factors for pancreatitis in Canada. In Canada,
the most common cause is gallbladder disease (gallstones) followed by alcoholism.
Cigarette smoking, diabetes, and high-protein diets are not risk factors.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
22. The nurse is educating a client with chronic pancreatitis about the prescribed pancrelipase?
At which of the following times should the nurse teach the client to take the medication?
a. Bedtime
b. With every meal
c. Upon arising in the morning
d. As soon as abdominal pain starts
ANS: B
Pancreatic enzymes are used to help with digestion of nutrients and should be taken with
every meal or snacks.
DIF:
Cognitive Level: Application
TOP: Nursing Process: Implementation
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MSC: NCLEX: Physiological Integrity
23. The nurse is providing discharge instructions to a client following a laparoscopic
cholecystectomy. Which of the following client statements indicate that the teaching has
been effective?
a. “I can remove the bandages on my incisions tomorrow and take a shower.”
b. “I can expect some yellow-green drainage from the incision for a few days.”
c. “I should plan to limit my activities and not return to work for 4–6 weeks.”
d. “I will always need to maintain a low-fat diet since I no longer have a gallbladder.”
ANS: A
After a laparoscopic cholecystectomy, the client will have Band-Aids in place over the
incisions. Clients are discharged the same (or next) day and have few restrictions on
activities of daily living. Drainage from the incisions would be abnormal, and the client
should be instructed to call the health care provider if this occurs. A low-fat diet may be
recommended for a few weeks after surgery but will not be a lifelong requirement.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
24. Which of the following data obtained by the nurse during the assessment of a client with
cirrhosis is of most concern?
a. The client’s hands flap back and forth when the arms are extended.
b. The client has ascites and a 2-kg weight gain from the previous day.
c. The client’s skin has multiple spider-shaped blood vessels on the abdomen.
d. The client complains of right upper-quadrant pain with abdominal palpation.
ANS: A
The asterixis indicates that the client has hepatic encephalopathy, and hepatic coma may
occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for
the client with cirrhosis and do not require a change in treatment. The ascites and weight
gain do indicate the need for treatment but not as urgently as the changes in neurological
status.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
25. The nurse is caring for a client with cirrhosis and esophageal varices who has a new
prescription for propranolol. Which of the following assessment findings is the best
indicator that the medication has been effective?
a. The apical pulse rate is 68 beats/minute.
b. Stools test negative for occult blood.
c. The client denies complaints of chest pain.
d. Blood pressure is less than 140/90 mm Hg.
ANS: B
Since the purpose of b-blocker therapy for clients with esophageal varices is to decrease
the risk for bleeding from esophageal varices, the best indicator of the effectiveness for
propranolol is the lack of blood in the stools. Although propranolol is used to treat
hypertension, angina, and tachycardia, the purpose for use in this client is to decrease the
risk for bleeding from esophageal varices.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
26. The nurse is admitting a client with acute bleeding from esophageal varices who asks the
nurse the purpose for the ordered pantoprazole. Which of the following responses by the
nurse is best?
a. The medication will reduce the risk for aspiration.
b. The medication will decrease nausea and anorexia.
c. The medication will inhibit the development of gastric ulcers.
d. The medication will prevent irritation to the esophageal varices.
ANS: D
Pantoprazole is a proton pump inhibitor. Supportive measures during an acute variceal
bleed include administration of fresh-frozen plasma and packed red blood cells, vitamin K,
and proton pump inhibitors. Although ranitidine does decrease the risk for peptic ulcers,
reduce nausea, and help prevent aspiration pneumonia, these are not the primary purpose
for H2 receptor blockade in this client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
27. The nurse is taking the BP of a client with severe acute pancreatitis and notices carpal
spasm of the client’s hand. Which of the following actions should the nurse take next?
a. Ask the client about any arm pain.
b. Retake the client blood pressure.
c. Check the calcium level on the chart.
d. Notify the health care provider immediately.
ANS: C
The client with acute pancreatitis is at risk for hypocalcemia, and the assessment data
indicate a positive Trousseau’s sign. The health care provider should be notified after the
nurse checks the client’s calcium level. There is no indication that the client needs to have
the BP rechecked or that there is any arm pain.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
28. The nurse is caring for a client with acute pancreatitis who has a nasogastric (NG) tube to
suction and is NPO. Which of the following information obtained by the nurse indicates
that these therapies have been effective?
a. Bowel sounds are present.
b. Grey Turner sign resolves.
c. Electrolyte levels are normal.
d. Abdominal pain is decreased.
ANS: D
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NG suction and NPO status will decrease the release of pancreatic enzymes into the
pancreas and decrease pain. Although bowel sounds may be hypotonic with acute
pancreatitis, the presence of bowel sounds does not indicate that treatment with NG
suction and NPO status have been effective. Electrolyte levels will be abnormal with NG
suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will
eventually resolve, it would not be appropriate to wait for this to occur to determine
whether treatment was effective.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
29. The nurse is caring for a client with acute pancreatitis. Which of the following findings is
of most concern?
Absent bowel sounds
Abdominal tenderness
Left upper quadrant pain
Palpable abdominal mass
a.
b.
c.
d.
ANS: D
A palpable abdominal mass in the epigastric area may indicate the presence of a pancreatic
pseudocyst, which will require rapid surgical drainage to prevent sepsis. Absent bowel
sounds, abdominal tenderness, and left upper quadrant pain are common in acute
pancreatitis and do not require rapid action to prevent further complications.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
30. Which of the following actions should be included in the plan of care for a client who has
recently been diagnosed with asymptomatic non-alcoholic fatty liver disease (NAFLD)?
Teach symptoms of variceal bleeding.
Discuss the need to increase caloric intake.
Review the client’s current medication list.
Draw blood for hepatitis serology testing.
a.
b.
c.
d.
ANS: C
Some medications can increase the risk for NAFLD and these should be eliminated.
NAFLD is not associated with hepatitis, weight loss is usually indicated, and variceal
bleeding would not be a concern in a client with asymptomatic NAFLD.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
31. The nurse is caring for a client with chronic hepatitis C infection who has these
medications prescribed. Which of the following medications require further discussion
with the health care provider prior to administration?
a. Ribavirin 600 mg PO bid
b. Pegylated a-interferon SUBCUT daily
c. Diphenhydramine 25 mg PO every 4 hours PRN itching
d. Dimenhydrinate 50 mg PO every 6 hours PRN nausea
ANS: B
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Pegylated a-interferon is administered once weekly not daily. The other medications are
appropriate for a client with chronic hepatitis C infection.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
32. During change-of-shift report, the nurse learns about the following four clients. Which
client requires the most rapid assessment?
a. 50-year-old with chronic pancreatitis who has gnawing abdominal pain
b. 48-year-old who has compensated cirrhosis and is complaining of anorexia
c. 45-year-old with cirrhosis and severe ascites who has an oral temperature of
38.8°C (101.8°F)
d. 56-year-old who is recovering from a laparoscopic cholecystectomy and has severe
shoulder pain
ANS: C
This client’s history and fever suggest spontaneous bacterial peritonitis, which would
require rapid assessment and interventions such as antibiotic therapy. The clinical
manifestations for the other client are consistent with their diagnoses and do not indicate
complications are occurring.
DIF: Cognitive Level: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
33. The nurse is admitting a client who is homeless and has viral hepatitis with symptoms of
severe anorexia and fatigue. Which of the following client goals should have the highest
priority when the nurse is developing the plan of care?
a. Increase activity level.
b. Maintain adequate nutrition.
c. Establish a stable home environment.
d. Identify the source of exposure to hepatitis.
ANS: B
The highest priority outcome is to maintain nutrition because adequate nutrition is needed
for hepatocyte regeneration. Finding a home for the client and identifying the source of the
infection would be appropriate activities, but they do not have as high a priority as
ensuring adequate nutrition. Although the client’s activity level will be gradually increased,
rest is indicated during the acute phase of hepatitis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
34. The nurse is admitting a client to the emergency department with pancreatitis who has
been vomiting blood. Which of the following actions should the nurse take first?
a. Insert a large-gauge IV catheter.
b. Draw blood for coagulation studies.
c. Check BP, heart rate, and respirations.
d. Place the client in the supine position.
ANS: C
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The nurse’s first action should be to determine the client’s hemodynamic status by
assessing vital signs. Drawing blood for coagulation studies and inserting an IV catheter
also are appropriate. However, the vital signs may indicate the need for more urgent
actions. Since aspiration is a concern for this client, the nurse will need to assess the
client’s vital signs and neurological status before placing the client in the supine position.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
35. The nurse is planning care for a client with acute severe pancreatitis. Which of the
following client outcomes is priority?
a. Expressing satisfaction with pain control
b. Developing no ongoing pancreatic problems
c. Maintaining normal respiratory function
d. Having adequate fluid and electrolyte balance
ANS: C
Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of
adequate respiratory function is the priority goal. The other outcomes also would be
appropriate for the client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
36. Which of the following nursing actions is a priority when the nurse is caring for a client
with pancreatic cancer?
Offer high-calorie, high-protein dietary choices.
Offer psychological support for anxiety or depression.
Educate about the need to avoid scratching pruritic areas.
Administer prescribed opioids to relieve pain as needed.
a.
b.
c.
d.
ANS: D
Effective pain management will be necessary in order for the client to improve nutrition,
be receptive to education, or manage anxiety or depression.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
37. The nurse is admitting a client with acute cholecystitis. Which of the following findings is
most important for the nurse to report to the health care provider?
The client’s urine is bright yellow.
The client’s stools are clay coloured.
The client complains of chronic heartburn.
The client has an increase in pain after eating.
a.
b.
c.
d.
ANS: B
The clay-coloured stools indicate biliary obstruction, which requires rapid intervention to
resolve. The other data are not unusual for a client with this diagnosis, although the nurse
also would report the other assessment information to the health care provider.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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38. The nurse is caring for a client following an incisional cholecystectomy for cholelithiasis.
Which of the following actions is priority for the nurse to implement?
a. Client education about low-fat food choices
b. Perform leg exercises hourly while awake.
c. Ambulate the evening of the operative day.
d. Turn, cough, and deep breathe every 2 hours.
ANS: D
Postoperative nursing care for incisional cholecystectomy is the same as general
postoperative nursing care. Postoperative nursing care after a cholecystectomy focuses on
prevention of respiratory complications because the surgical incision is high in the
abdomen and impairs coughing and deep breathing. The other nursing actions also are
important to implement but are not as high a priority as ensuring adequate ventilation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
39. Which of the following diagnoses is often a misdiagnosis for older-adult clients with liver
disease?
a. Fulminate hepatic failure
b. Cirrhosis
c. Dementia
d. Epstein-Barr virus
ANS: C
In older adults with liver disease, hepatic encephalopathy may be misdiagnosed as
dementia.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
MULTIPLE RESPONSE
1. After an unimmunized individual is exposed to hepatitis B through a needle-stick injury,
which of the following actions should the nurse plan to take? (Select all that apply.)
a. Administer hepatitis B vaccine.
b. Test for antibodies to hepatitis B.
c. Teach about a-interferon therapy.
d. Give hepatitis B immune globulin.
e. Educate about oral antiviral therapy.
ANS: A, B, D
The recommendations for hepatitis B exposure include both vaccination and immune
globulin administration. In addition, baseline testing for hepatitis B antibodies will be
needed. Interferon and oral antivirals are not used for hepatitis B prophylaxis.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
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Chapter 47: Nursing Assessment: Urinary System
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is reviewing a client’s chart and notes that the client has dysuria. To assess
whether there is any improvement, which of the following questions should the nurse
ask?
a. “Do you have any blood in your urine?”
b. “Do you have to urinate very frequently?”
c. “Do you have any pain when you urinate?”
d. “Do you have to get up at night to urinate?”
ANS: C
Dysuria is painful urination. The alternate responses are used to assess other urinary tract
symptoms: hematuria, nocturia, and frequency.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. A client’s urine dipstick indicates a small amount of protein in the urine. Which of the
following actions should the nurse take next?
a. Check which medications the client is currently taking.
b. Obtain a clean-catch urine specimen for culture and sensitivity testing.
c. Ask the client about any family history of chronic renal failure.
d. Send a urine specimen to the laboratory to test for ketones and glucose.
ANS: A
Normally the urinalysis will show zero to trace amounts of protein, but some
medications may give false-positive readings. The other actions by the nurse may be
appropriate, but checking for medications that may affect the dipstick accuracy should
be done first.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
3. A creatinine clearance test is ordered for a hospitalized client with possible renal
insufficiency. Which of the following equipment will the nurse need to obtain?
a. Sterile specimen cup
b. Large container for urine
c. Foley catheter and drainage bag
d. Towelettes for perineal cleaning
ANS: B
Since creatinine clearance testing involves a 24-hour urine specimen, the nurse should
obtain a large container for the urine collection. Catheterization, cleaning of the
perineum with antiseptic towelettes, and a sterile specimen cup are not needed for this
test.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
4. The nurse is preparing to conduct an annual health and physical examination on a client
who is employed as a hairdresser and has a 10 pack-year history of cigarette smoking.
Which of the following conditions should the nurse plan to teach the client about the
increased risk for based upon the client history?
a. Renal failure
b. Kidney stones
c. Pyelonephritis
d. Bladder cancer
ANS: D
Exposure to the chemicals involved with working as a hairdresser and in smoking both
increase the risk of bladder cancer, and the nurse should assess whether the client
understands this risk. The client is not at increased risk for renal failure, pyelonephritis,
or kidney stones.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
5. During assessment of a client with decreased renal function, which of the following
medications taken by the client at home is of most concern to the nurse?
a. Ibuprofen
b. Warfarin
c. Folic acid
d. Penicillin
ANS: A
The nonsteroidal anti-inflammatory durgs (NSAIDs) are nephrotoxic and should be
avoided in clients with impaired renal function. The nurse also should ask about reasons
the client is taking the other medications, but the medication of most concern is the
ibuprofen.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
6. The nurse is admitting an older-adult client with benign prostatic hyperplasia. Which of
the following actions should be included in the nursing plan of care?
a. Limit fluid intake to no more than 1 500 mL/day.
b. Leave a light on in the bathroom during the night.
c. Pad the client’s bed to accommodate overflow incontinence.
d. Ask the client to use a urinal so that all urine can be measured.
ANS: B
The client’s age and diagnosis indicate a likelihood of nocturia, so leaving the light on in
the bathroom is appropriate. Fluids should be encouraged because dehydration is more
common in older clients. The information in the question does not indicate that
measurement of the client’s output is necessary or that the client has overflow
incontinence.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
7. The nurse is assessing a client’s urinary system and is unable to palpate either kidney.
Which of the following actions should the nurse take next?
a. Obtain a urine specimen to check for hematuria.
b. Document the information on the assessment form.
c. Ask the client about any history of recent sore throat.
d. Ask the health care provider about scheduling a renal ultrasound.
ANS: B
The kidneys are protected by the abdominal organs, ribs, and muscles of the back and
may not be palpable under normal circumstances, so no action except to document the
assessment information is needed. Asking about a recent sore throat, checking for
hematuria, or obtaining a renal ultrasound may be appropriate when assessing for renal
problems for some clients, but there is nothing in the question stem to indicate that they
are appropriate for this client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
8. Which of the following techniques should the nurse use to assess the flank area of a
client with pyelonephritis for tenderness?
a. Push gently into the two lowest intercostal spaces.
b. Palpate along both sides of the lumbar vertebral column.
c. Position one hand flat at the costovertebral angle (CVA) and strike it with the
other fist.
d. Use two fingers to percuss the area between the iliac crest and ribs along the
midaxillary line.
ANS: C
Checking for flank pain is best performed by percussion of the CVA and asking about
pain. The other techniques would not assess for flank pain.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
9. The nurse is reviewing the result of a client’s creatinine clearance test which is 60
mL/minute. Which of the following values is the client’s glomerular filtration rate (GFR)
in mL/minute?
a. 30
b. 60
c. 120
d. 240
ANS: B
The creatinine clearance approximates the GFR. The other responses are not accurate.
DIF:
Cognitive Level: Comprehension
TOP: Nursing Process: Assessment
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MSC: NCLEX: Physiological Integrity
10. For which of the following purposes does the nurse use auscultation during assessment
of the urinary system?
a. Check for ureteral peristalsis.
b. Assess for bladder distension.
c. Identify renal artery or aortic bruits.
d. Determine the position of the kidneys.
ANS: C
The presence of a bruit may indicate problems such as renal artery tortuosity or
abdominal aortic aneurysm. Auscultation would not be helpful in assessing for the other
listed urinary tract information.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
11. The nurse is preparing a client for an intravenous pyelogram (IVP) and obtains the nurse
the following information. Which information has the most immediate implications for
the client’s care?
a. The client describes allergies to shellfish and penicillin.
b. The client has not had anything to eat or drink for 8 hours.
c. The client complains of costovertebral angle (CVA) tenderness.
d. The client used a bisacodyl tablet the previous night.
ANS: A
Iodine-based contrast dye is used during IVP and for many computed tomography (CT)
scans. The nurse will need to notify the health care provider before the procedures so
that the client can receive medications such as antihistamines or corticosteroids before
the procedures are started. The other information also is important to note and document
but does not have immediate implications for the client’s care during the procedures.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
12. The nurse is teaching a client scheduled for a cystoscopy about the procedure. Which of
the following statements should the nurse include in the teaching plan?
a. “Your health care provider will insert a lighted tube into the bladder, and little
catheters will be inserted through the tube into your kidney.”
b. “Your health care provider will place a catheter into an artery in your groin and
inject a dye that will visualize the blood supply to the kidneys.”
c. “Your health care provider will inject a radioactive solution into a vein in your arm
and the distribution of the isotope in your kidneys and bladder will be checked.”
d. “Your health care provider will insert a lighted tube into the bladder through your
urethra, inspect the bladder, and instill a dye that will outline your bladder on
x-ray.”
ANS: D
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With a cystoscopy, a cystoscope is inserted into the bladder for direct visualization, and
then contrast solution is injected through the scope so that x-rays can be taken. The
response beginning, “Your health care provider will place a catheter” describes a renal
arteriogram procedure. The response beginning, “Your health care provider will inject a
radioactive solution” describes a nuclear scan. The response beginning, “Your health
care provider will insert a lighted tube into the bladder, and little catheters will be
inserted” describes a retrograde pyelogram.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
13. The nurse is preparing a client for a cystoscopy. Which of the following postprocedural
information should the nurse include in the teaching plan?
a. NPO for 8 hours to prevent nausea and vomiting
b. Strict bed rest for about 4–6 hours
c. Request prescribed opioids as necessary for pain.
d. May experience blood-tinged urine and urinary frequency.
ANS: D
Pink-tinged urine and urinary frequency are expected after cystoscopy. Burning on
urination is common, but pain that requires opioids for relief is not expected. A good
fluid intake is encouraged after this procedure. Bed rest is not required following
cystoscopy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
14. The nurse is caring for a client with an elevated blood urea nitrogen (BUN) and serum
creatinine who is scheduled for a renal arteriogram. Which of the following bowel
preparation prescriptions should the nurse question?
a. Fleet enema
b. Tap-water enema
c. Bisacodyl tablets
d. Castor oil
ANS: A
High-phosphate enemas, such as Fleet enemas, should be avoided in clients with
elevated BUN and creatinine because phosphate cannot be excreted by clients with renal
failure. The other medications for bowel evacuation are more appropriate.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
15. The health care provider orders a clean-catch urine specimen for culture and sensitivity
testing for a client with a suspected urinary tract infection (UTI). Which of the following
actions should the nurse implement to obtain the specimen?
a. Teach the client to clean the urethral area, void a small amount into the toilet, and
then void into a sterile specimen cup.
b. Have the client empty the bladder completely, and then obtain the next urine
specimen that the client is able to void.
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c. Insert a short, small “mini” catheter attached to a collecting container into the
urethra and bladder to obtain the specimen.
d. Clean the area around the meatus with a povidone-iodine swab, and then have the
client void into a sterile container.
ANS: A
Teach the client to clean the urethral area, void a small amount into the toilet, and then
void into a sterile specimen cup best describes the technique for obtaining a clean-catch
specimen. The answer beginning, “insert a short, small, ‘mini’ catheter attached to a
collecting container” describes a technique that would result in a sterile specimen, but a
health care provider’s order for a catheterized specimen would be required. Using
povidone-iodine before obtaining the specimen is not necessary and might result in
suppressing the growth of some bacteria. And the technique described in the answer
beginning “have the client empty the bladder completely” would not result in a sterile
specimen.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
16. The nurse is preparing a client with a decreased glomerular filtration rate for an
intravenous pyelogram (IVP). Which of the following actions should be included in the
plan of care?
a. Monitor the urine output after the procedure.
b. Assist with monitored anesthesia care (MAC).
c. Give oral contrast solution before the procedure.
d. Insert a large size urinary catheter before the IVP.
ANS: A
Clients with impaired renal function are at risk for decreased renal function after IVP
because the contrast medium used is nephrotoxic, so the nurse should monitor the
client’s urine output. MAC sedation and retention catheterization are not required for the
procedure. The contrast medium is given intravenously, not orally.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
17. The nurse is caring for a client with diabetic nephropathy who is scheduled for a right
renal biopsy. Immediately after the biopsy, which of the following actions is essential?
a. Monitor the blood urea nitrogen (BUN) and creatinine to assess renal function.
b. Check blood glucose to assess for hyperglycemia or hypoglycemia.
c. Insert a straight catheter to check for gross or microscopic hematuria.
d. Apply a pressure dressing and keep the client prone for 30–60 minutes.
ANS: D
After the procedure, a pressure dressing is applied, and the client is kept prone for 30–60
minutes. Usually bed rest is prescribed for 24 hours. The blood glucose and
BUN/creatinine will not be affected by the biopsy. Although monitoring for hematuria is
needed, there is no need for catheterization.
DIF:
Cognitive Level: Application
TOP: Nursing Process: Implementation
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MSC: NCLEX: Physiological Integrity
18. A client with a possible urinary tract infection (UTI) gives the nurse in the clinic a urine
specimen that is a red-orange colour. Which of the following actions should the nurse
take first?
a. Notify the client’s health care provider.
b. Ask the client about use of any medications.
c. Question the client about any UTI risk factors.
d. Teach about the correct procedure for midstream urine collection.
ANS: B
A red-orange colour in the urine is normal with some over-the-counter (OTC)
medications such as phenazopyridine (Pyridium). The colour would not be expected
with urinary tract infection, is not a sign that poor technique was used in obtaining the
specimen, and does not need to be communicated to the health care provider until further
assessment is done.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
19. Which of the following actions should the nurse plan to take first when admitting a client
who has a history of neurogenic bladder as a result of a spinal cord injury?
a. Ask about the usual urinary pattern and any measures used for bladder control.
b. Assist the client to the toilet at scheduled times to help ensure bladder emptying.
c. Check the client for urinary incontinence every 2 hours to maintain skin integrity.
d. Use intermittent catheterization on a regular schedule to avoid the risk of infection.
ANS: A
Before planning any interventions, the nurse should complete the assessment and
determine the client’s normal bladder pattern and the usual measures used by the client
at home. All the other responses may be appropriate, but until the assessment is
complete, an individualized plan for the client cannot be developed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
20. The nurse is reviewing the results of a client’s urinalysis. Which of the following
information indicates that the nurse should notify the health care provider?
a. pH 6.2
b. Trace protein
c. WBC: 20–26/hpf
d. Specific gravity: 1.021
ANS: C
The increased number of white blood cells (WBCs) indicates the presence of urinary
tract infection or inflammation. Normal WBC result in a urinalysis report is 0–5/hpf. The
other findings are normal.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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21. A client who had a cystoscopy the previous day calls the urology clinic and gives the
nurse all the following information. Which of the following client statements should be
reported immediately to the health care provider?
a. “My urine still looks pink.”
b. “My IV site is still bruised.”
c. “I have a temperature of 38.3°C (100.9°F).”
d. “I did not sleep well last night.”
ANS: C
The client’s elevated temperature may indicate a bladder infection, a possible
complication of cystoscopy. The health care provider should be notified so that antibiotic
therapy can be started. Pink-tinged urine is expected after a cystoscopy. The insomnia
and bruising should be discussed further with the client but do not indicate a need to
notify the health care provider.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
22. The nurse is caring for a client following an intravenous pyelogram (IVP) and obtains all
of the following assessment data. Which of the following findings require immediate
action by the nurse?
a. The heart rate is 58 beats/minute.
b. The respiratory rate is 38 breaths/minute.
c. The client complains of a dry mouth.
d. The urine output is 400 mL in the first 2 hours.
ANS: B
The increased respiratory rate indicates that the client may be experiencing an allergic
reaction (anaphylactic reaction) to the contrast medium used during the procedure. The
nurse should immediately assess the client’s oxygen saturation and breath sounds. The
other data are not unusual findings following an IVP.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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Chapter 48: Nursing Management: Renal and Urologic Problems
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. A client returns to the clinic with recurrent dysuria after being treated with
trimethoprim-sulfamethoxazole for 3 days. Which of the following actions should the
nurse plan to take?
a. Remind the client about the need to drink 1 000 mL of fluids daily.
b. Obtain a midstream urine specimen for culture and sensitivity testing.
c. Teach the client to take the prescribed trimethoprim-sulfamethoxazole for at least 3
more days.
d. Suggest that the client use acetaminophen to treat the symptoms.
ANS: B
Since uncomplicated urinary tract infections (UTIs) are usually successfully treated with 3
days of antibiotic therapy, this client will need a urine culture and sensitivity to determine
appropriate antibiotic therapy. Acetaminophen would not be as effective as other
over-the-counter (OTC) medications such as phenazopyridine in treating dysuria. The
fluid intake should be increased to at least 1 800 mL/day. Since the UTI has persisted after
treatment with trimethoprim-sulfamethoxazole, the client is likely to need a different
antibiotic.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
2. The nurse is providing client teaching to a client with cystitis regarding prevention of
future urinary tract infections (UTIs). Which of the following client statements indicate
that teaching has been effective?
a. “I can use vaginal sprays to reduce bacteria.”
b. “I will drink a quart of water or other fluids every day.”
c. “I will wash with soap and water before sexual intercourse.”
d. “I will empty my bladder every 2–4 hours during the day.”
ANS: D
Voiding every 2–4 hours is recommended to prevent UTIs. Use of vaginal sprays is
discouraged. The bladder should be emptied before and after intercourse, but cleaning with
soap and water is not necessary. A quart of fluids is insufficient to provide adequate urine
output to decrease risk for UTI.
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX: Health Promotion and Maintenance
3. The nurse is caring for a client who has had a segmental cystectomy. Which of the
following information should the nurse include in the postoperative teaching for the client?
a. Limit fluid intake for at least 7 days.
b. Urine should be amber and not contain blood clots.
c. In about one week urine will have rust-coloured flecks.
d. Avoid sitz baths for a week after surgery.
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ANS: C
Approximately 7–10 days following tumour resection or ablation, the patient may observe
dark red or rust-coloured flecks in the urine. These are anticipated and represent scabs
from the healing tumour resection sites. Other postoperative instructions for a segmental
cystectomy includes to drink a large volume of fluid each day for the first week following
the procedure and to avoid intake of alcoholic beverages. Urine is anticipated to be pink
during the first several days after the procedure, but it should not be bright red or contain
blood clots. The patient can be encouraged to take a 15–20-minute sitz bath two to three
times a day to promote muscle relaxation and to reduce the risk of urinary retention.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
4. The nurse is caring for a client with benign prostatic hyperplasia who has chills, fever, and
is vomiting. Which of the following findings by the nurse is most helpful in determining
whether the client has an upper urinary tract infection (UTI)?
a. Suprapubic pain
b. Bladder distention
c. Foul-smelling urine
d. Costovertebral tenderness
ANS: D
Costovertebral tenderness is characteristic of pyelonephritis. The other symptoms are
characteristic of lower UTI and are likely to be present if the client also has an upper UTI.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
5. The nurse is teaching a client with interstitial cystitis about management of the condition.
Which of the following client statements indicate that further instruction is required?
“I will have to stop having coffee and orange juice for breakfast.”
“I should start taking a high potency multiple vitamin every morning.”
“I will buy some calcium glycerophosphate (Prelief) at the pharmacy.”
“I should call the doctor about increased bladder pain or odorous urine.”
a.
b.
c.
d.
ANS: B
High-potency multiple vitamins may irritate the bladder and increase symptoms. The other
client statements indicate good understanding of the teaching.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
6. The nurse is admitting a client with acute glomerulonephritis. Which of the following
assessments is most important for the nurse to include?
Recent sore throat and fever
History of high blood pressure
Frequency of bladder infections
Family history of kidney stones
a.
b.
c.
d.
ANS: A
Acute glomerulonephritis frequently occurs after a streptococcal infection such as strep
throat. It is not caused by hypertension, urinary tract infection (UTI), or kidney stones.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
7. Which of the following findings by the nurse for a client admitted with glomerulonephritis
indicates that treatment has been effective?
The client denies pain with voiding.
The urine dipstick is negative for nitrites.
Peripheral and periorbital edema is resolved.
The antistreptolysin-O (ASO) titre is decreased.
a.
b.
c.
d.
ANS: C
Since edema is a common clinical manifestation of glomerulonephritis, resolution of the
edema indicates that the prescribed therapies have been effective. Antibodies to
streptococcus will persist after a streptococcal infection. Nitrites will be negative and the
client will not experience dysuria since the client does not have a urinary tract infection.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
8. The nurse is caring for a client with nephrotic syndrome who develops flank pain. Which
of the following medication classifications should the nurse anticipate including in the
client teaching plan?
a. Antibiotics
b. Anticoagulants
c. Corticosteroids
d. Antihypertensives
ANS: B
Flank pain in a client with nephrosis suggests a renal vein thrombosis, and anticoagulation
is needed. Antibiotics are used to treat a client with flank pain caused by pyelonephritis.
Antihypertensives are used if the client has high blood pressure. Corticosteroids may be
used to treat nephrotic syndrome but will not resolve a thrombosis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
9. The nurse is admitting a client with new onset nephrotic syndrome. Which of the
following findings should the nurse expect to assess related to this illness?
Poor skin turgor
High urine ketones
Recent weight gain
Low blood pressure
a.
b.
c.
d.
ANS: C
The client with a nephrotic syndrome will have weight gain associated with edema.
Hypertension is a clinical manifestation of nephrotic syndrome. Skin turgor is normal
because of the edema. Urine protein is high.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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10. The nurse is caring for a client whose renal calculus is analyzed as being very high in uric
acid. To prevent recurrence of stones, which of the following foods should the nurse teach
the client to avoid eating?
a. Milk and dairy products
b. Legumes and dried fruits
c. Organ meats and sardines
d. Spinach, chocolate, and tea
ANS: C
Organ meats and fish such as sardines increase purine levels and uric acid. Spinach,
chocolate, and tomatoes should be avoided in clients who have oxalate stones. Milk, dairy
products, legumes, and dried fruits may increase the incidence of calcium-containing
stones.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
11. Which of the following actions should the nurse teach to a client to help prevent the
recurrence of renal calculi?
a. Use a filter to strain all urine.
b. Avoid dietary sources of calcium.
c. Drink diuretic fluids such as coffee.
d. Have 2 000–3 000 mL of fluid a day.
ANS: D
A fluid intake of 2 000–2 200 mL daily is recommended to help flush out minerals before
stones can form. Avoidance of calcium is not usually recommended for clients with renal
calculi. Coffee tends to increase stone recurrence. There is no need for a client to strain all
urine routinely after a stone has passed, and this will not prevent stones.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
12. The nurse is planning teaching for a client with benign nephrosclerosis. Which of the
following information should the nurse include in the teaching plan?
a. Monitor and record blood pressure daily.
b. Obtain and document daily weights.
c. Measure daily intake and output amounts.
d. Prevent bleeding caused by anticoagulants.
ANS: A
Hypertension is the major symptom of nephrosclerosis. Measurements of intake and
output and daily weights are not necessary unless the client develops renal insufficiency.
Anticoagulants are not used to treat nephrosclerosis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
13. The nurse is caring for a young adult female client who is diagnosed with polycystic
kidney disease. Which of the following information should the nurse include in teaching at
this time?
a. Importance of genetic counselling
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b. Complications of renal transplantation
c. Methods for treating chronic and severe pain
d. Differences between hemodialysis and peritoneal dialysis
ANS: A
Because a young female client may be considering having children, the nurse should
include information about genetic counselling when teaching the client. The well-managed
client will not need to choose between hemodialysis and peritoneal dialysis or know about
the effects of transplantation for many years. There is no indication that the client has
chronic pain.
DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
14. The nurse is assessing a male client with symptoms of a feeling of incomplete bladder
emptying and a split, spraying urine stream. Which of the following conditions should the
nurse question the client about when taking a health history?
a. Bladder infection
b. Recent kidney trauma
c. Gonococcal urethritis
d. Benign prostatic hyperplasia
ANS: C
The client’s clinical manifestations are consistent with urethral strictures, a possible
complication of gonococcal urethritis. These symptoms are not consistent with benign
prostatic hyperplasia, kidney trauma, or bladder infection.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
15. The nurse is obtaining the health history for a client who smokes two packs of cigarettes
daily. Which of the following conditions should the nurse include in the teaching plan that
the client is at an increased risk for developing?
a. Kidney stones
b. Bladder cancer
c. Bladder infection
d. Interstitial cystitis
ANS: B
Cigarette smoking is a risk factor for bladder cancer. The client’s risk for developing
interstitial cystitis, urinary tract infection (UTI), or kidney stones will not be reduced by
quitting smoking.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
16. The nurse is admitting an older-adult client with dehydration who is confused and
incontinent of urine. Which of the following nursing actions is best to include in the plan
of care?
a. Apply absorbent incontinent pads.
b. Restrict fluids after the evening meal.
c. Insert an in-dwelling catheter until the symptoms have resolved.
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d. Assist the client to the bathroom every 2 hours during the day.
ANS: D
In older or confused clients, incontinence may be avoided by using scheduled toileting
times. In-dwelling catheters increase the risk for urinary tract infection (UTI). Incontinent
pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a client
with dehydration.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
17. A female client asks the nurse for a perineal pad, stating that laughing or coughing causes
leakage of urine. Which of the following interventions is best to include in the care plan?
Assist the client to the bathroom q3hr.
Place a commode at the client’s bedside.
Demonstrate how to perform the Credé manoeuvre.
Teach the client how to perform Kegel exercises.
a.
b.
c.
d.
ANS: D
Exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The
Credé manoeuvre is used to help empty the bladder for clients with overflow incontinence.
Placing the commode close to the bedside and assisting the client to the bathroom are
helpful for functional incontinence.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Health Promotion and Maintenance
18. The nurse is caring for a client following rectal surgery who voids about 50 mL of urine
every 30–60 minutes. Which of the following nursing actions is best?
a. Use a bladder scan device to check the postvoiding residual.
b. Monitor the client’s intake and output over the next few hours.
c. Have the client take small amounts of fluid frequently throughout the day.
d. Reassure the client that this is normal after rectal surgery because of anesthesia.
ANS: A
A bladder scan device can be used to check for residual urine after the client voids.
Because the client’s history and clinical manifestations are consistent with overflow
incontinence, it is not appropriate to have the client drink small amounts. Although
overflow incontinence is not unusual after surgery, the nurse should intervene to correct
the physiological problem, not just reassure the client. The client may develop reflux into
the renal pelvis as well as discomfort from a full bladder if the nurse waits to address the
problem for several hours.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
19. The nurse is caring for a client who has a history of functional urinary incontinence.
Which of the following nursing actions should be included in the plan of care?
a. Place a bedside commode near the client’s bed.
b. Demonstrate the use of the Credé manoeuvre to the client.
c. Use an ultrasound scanner to check postvoiding residuals.
d. Teach the use of Kegel exercises to strengthen the pelvic floor.
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ANS: A
Modifications in the environment make it easier to avoid functional incontinence.
Checking for residual urine and performing the Credé manoeuvre are interventions for
overflow incontinence. Kegel exercises are useful for stress incontinence.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
20. The home health nurse is teaching a client with a neurogenic bladder how to use
intermittent catheterization for bladder emptying. Which of the following client statements
indicates that the teaching has been effective?
a. “I will use a sterile catheter and gloves for each time I self-catheterize.”
b. “I will clean the catheter carefully before and after each catheterization.”
c. “I will need to buy seven new catheters weekly and use a new one every day.”
d. “I will need to take prophylactic antibiotics to prevent any urinary tract infections.”
ANS: B
Clients who are at home can use a clean technique for intermittent self-catheterization and
change the catheter every 7 days. There is no need to use a new catheter every day, to use
sterile catheters, or to take prophylactic antibiotics.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
21. The nurse is caring for a client who has had an ureterolithotomy with a left ureteral
catheter and a urethral catheter in place. Which of the following actions should the nurse
include in the plan of care?
a. Provide education about home care for both catheters.
b. Apply continuous steady tension to the ureteral catheter.
c. Clamp the ureteral catheter unless output from the urethral catheter stops.
d. Call the health care provider if the ureteral catheter output drops suddenly.
ANS: D
The health care provider should be notified if the ureteral catheter output decreases since
obstruction of this catheter may result in an increase in pressure in the renal pelvis.
Tension on the ureteral catheter should be avoided in order to prevent catheter
displacement. To avoid pressure in the renal pelvis, the catheter is not clamped. Since the
client is not usually discharged with a ureteral catheter in place, client teaching about both
catheters is not needed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
22. The nurse is caring for a client who has bladder cancer and had a cystectomy with creation
of an Indiana pouch. Which of the following topics should the nurse include in client
teaching?
a. Application of ostomy appliances
b. Catheterization technique and schedule
c. Analgesic use before emptying the pouch
d. Use of barrier products for skin protection
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ANS: B
The Indiana pouch enables the client to self-catheterize every 4–6 hours. There is no need
for an ostomy device or barrier products. Catheterization of the pouch is not painful.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
23. The nurse is caring for a client who is two days postoperative with an ileal conduit, and the
client will not look at the stoma or participate in care, and insists that no one but the
ostomy nurse specialist care for the stoma. Which of the following nursing diagnoses best
reflects the data that the nurse has obtained?
a. Anxiety related to threat to current status (effects of procedure on lifestyle)
b. Disturbed body image related to alteration in self-perception
c. Ineffective coping related to insufficient sense of control
d. Ineffective denial related to ineffective coping strategies (denial of altered body
function)
ANS: B
The client’s unwillingness to look at the stoma or participate in care indicates that
disturbed body image is the best diagnosis. No data suggest that the impact on lifestyle is a
concern for the client, or that ineffective coping is a result of an insufficient sense of
control. The client’s insistence that only the ostomy nurse care for the stoma indicates that
denial is not present.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Diagnosis
24. A client who has had a transurethral resection with fulguration for bladder cancer 3 days
previously calls the nurse at the urology clinic. Which of the following information given
by the client is most important to report to the health care provider?
a. The client is using opioids for pain.
b. The client has noticed clots in the urine.
c. The client is very anxious about the cancer.
d. The client is taking a 15-minute sitz bath twice a day.
ANS: B
Clots in the urine are not expected and require further follow-up. Sitz baths two to three
times a day, use of opioids for pain, and anxiety are typical after this procedure.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
25. The nurse is preparing a client with bladder cancer for intravesical chemotherapy. Which
of the following information should the nurse teach the client about in preparation for the
treatment?
a. Premedicating to prevent nausea
b. Where to obtain wigs and scarves
c. The importance of oral care during treatment
d. The need to empty the bladder before treatment
ANS: D
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Intravesical chemotherapy is the instillation of the agent directly into the bladder; therefore
the client needs to have an empty bladder before the instillation of the chemotherapy.
Systemic adverse effects are not experienced with intravesical chemotherapy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
26. Which of the following nursing actions is most helpful in decreasing the risk for
hospital-acquired infection (HAI) of the urinary tract in clients admitted to the hospital?
Avoid unnecessary catheterizations.
Encourage adequate oral fluid intake.
Test urine with a dipstick daily for nitrites.
Provide thorough perineal hygiene to clients.
a.
b.
c.
d.
ANS: A
Since catheterization bypasses many of the protective mechanisms that prevent urinary
tract infection (UTI), avoidance of catheterization is the most effective means of reducing
HAI. The other actions will also be helpful, but are not as useful as decreasing urinary
catheter use.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
27. The nurse is assessing a client who has a lower urinary tract infection (UTI). Which of the
following symptoms should the nurse ask about initially?
a. Nausea
b. Flank pain
c. Poor urine output
d. Pain with urination
ANS: D
Pain with urination is a common symptom of a lower UTI. Urine output does not decrease,
but frequency may be experienced. Flank pain and nausea are associated with an upper
UTI.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
28. Which assessment finding for a client who has just been admitted with acute
pyelonephritis is most important for the nurse to report to the health care provider?
a. Foul-smelling urine
b. Complaint of flank pain
c. Blood pressure 88/45 mm Hg
d. Temperature 37.8°C (100°F)
ANS: C
The low blood pressure indicates that urosepsis and septic shock may be occurring and
should be immediately reported. The other findings are typical of pyelonephritis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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29. The nurse is caring for a client who is diagnosed with nephrotic syndrome and has 3+
ankle and leg edema with ascites. Which of the following nursing diagnoses is a priority
for the client?
a. Excess fluid volume related to low serum protein levels
b. Activity intolerance related to increased weight and fatigue
c. Disturbed body image related to peripheral edema and ascites
d. Altered nutrition: less than required related to protein restriction
ANS: A
The client has massive edema, so the priority problem at this time is the excess fluid
volume. The other nursing diagnoses also are appropriate, but the focus of nursing care
should be resolution of the edema and ascites.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Diagnosis
30. The nurse is caring for a client with benign prostatic hyperplasia (BPH) and a markedly
distended bladder who is agitated and confused. Which of the following interventions
prescribed by the health care provider should the nurse implement first?
a. Insert a urinary retention catheter.
b. Schedule an intravenous pyelogram.
c. Administer lorazepam 0.5 mg PO.
d. Draw blood for blood urea nitrogen (BUN) and creatinine testing.
ANS: A
The client’s history and clinical manifestations are consistent with acute urinary retention,
and the priority action is to relieve the retention by catheterization. The BUN and
creatinine measurements can be obtained after the catheter is inserted. The client’s
agitation may resolve once the bladder distention is corrected, and sedative drugs should
be used cautiously in older clients. The IVP is an appropriate test, but does not need to be
done urgently.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
31. The nurse is caring for a client with renal calculi, gross hematuria, and severe colicky left
flank pain. Which of the following actions is priority at this time?
a. Encourage oral fluid intake.
b. Administer prescribed analgesics.
c. Monitor temperature every 4 hours.
d. Give antiemetics as needed for nausea.
ANS: B
Although all of the nursing actions may be used for clients with renal lithiasis, the client’s
presentation indicates that management of pain is the highest priority action. If the client
has urinary obstruction, increasing oral fluids may increase the symptoms. There is no
evidence of infection or nausea.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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32. The nurse is providing teaching to a client with impaired urinary elimination related to an
UTI who weighs 70 kg. Which of the following daily fluid intake amounts should the
nurse include in the teaching plan?
a. 650 mL
b. 1 250 mL
c. 1 850 mL
d. 2 450 mL
ANS: C
The recommended daily liquid intake for the ambulatory adult is approximately 33 mL/kg
of body weight per day. Thus, a 70-kg person would require 2 310 mL each day. Because
the person will obtain approximately 20% of this fluid from food, this leaves 1 848 mL
obtained by drinking, or nearly eight 236-mL glasses of fluid.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
33. The nurse is caring for a client who has had left-sided extracorporeal shock wave
lithotripsy. Which of the following findings is most important to report to the health care
provider?
a. Blood in urine
b. Left flank pain
c. Left flank bruising
d. Drop in urine output
ANS: D
Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is
important to report a drop in urine output. Left flank pain, bruising, and hematuria are
common after lithotripsy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
34. The nurse is caring for a client following an open loop resection and fulguration of the
bladder who is unable to void. Which of the following actions should the nurse implement
first?
a. Insert a straight catheter and drain the bladder.
b. Assist the client to take a 15-minute sitz bath.
c. Encourage the client to drink several glasses of water.
d. Teach the client how to do isometric perineal exercises.
ANS: B
Sitz baths will relax the perineal muscles and promote voiding. Although the client should
be encouraged to drink fluids and Kegel exercises are helpful in the prevention of
incontinence, these activities would not be helpful for a client experiencing retention.
Catheter insertion increases the risk for urinary tract infection (UTI) and should be
avoided when possible.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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35. The nurse observes an unregulated care provider (UCP) taking the following actions when
caring for a client with a retention catheter. Which of the following actions require the
nurse to intervene with client care?
a. Taping the catheter to the skin on the client’s upper inner thigh
b. Cleaning around the client’s urinary meatus with soap and water
c. Using an alcohol-based hand cleaner before performing catheter care
d. Disconnecting the catheter from the drainage tube to obtain a specimen
ANS: D
The catheter should not be disconnected from the drainage tube because this increases the
risk for urinary tract infection (UTI). The other actions are appropriate and do not require
any intervention.
DIF: Cognitive Level: Application
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
36. The nurse is caring for a client who had a nephrectomy after having massive trauma to the
kidney. Which of the following assessment findings obtained postoperatively is most
important to communicate to the surgeon?
a. Blood pressure is 102/58.
b. Incisional pain level is 8/10.
c. Urine output is 20 mL/hour for 2 hours.
d. Crackles are heard at both lung bases.
ANS: C
Because the urine output should be at least 0.5 mL/kg/hour, a 40 mL output for 2 hours
indicates that the client may have decreased renal perfusion because of bleeding,
inadequate fluid intake, or obstruction at the suture site. The blood pressure requires
ongoing monitoring but does not indicate inadequate perfusion at this time. The client
should cough and deep breathe, but the crackles do not indicate a need for an immediate
change in therapy. The incisional pain should be addressed, but this is not as potentially
life-threatening as decreased renal perfusion. In addition, the nurse can medicate the client
for pain.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
37. Which of the following findings for a client who has had a cystectomy with an ileal
conduit the previous day is most important for the nurse to communicate to the health care
provider?
a. Cloudy appearing urine
b. Hypotonic bowel sounds
c. Heart rate 102 beats/minute
d. Continuous drainage from stoma
ANS: C
Tachycardia may indicate infection, hemorrhage, or postoperative atelectasis and shock,
which are all serious complications of this surgery. The urine from an ileal conduit
normally contains mucus and is cloudy. Hypotonic bowel sounds are expected after bowel
surgery. Continuous drainage of urine from the stoma is normal.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
38. Which of the following information noted by the nurse when caring for a client with a
bladder infection is most important to report to the health care provider?
a. Dysuria
b. Hematuria
c. Left-sided flank pain
d. Temperature 37.8°C (100°F)
ANS: C
Flank pain indicates that the client may have developed pyelonephritis as a complication
of the bladder infection. The other clinical manifestations are consistent with a lower
urinary tract infection (UTI).
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
MULTIPLE RESPONSE
1. The nurse is teaching a client about avoiding the recurrence of a urinary tract infection.
Which of the following information should be included in the teaching plan? (Select all
that apply.)
a. Teach the client to wipe from back to front after voiding.
b. Suggest the use of a diaphragm during intercourse.
c. Advice the client to urinate every 2–4 hours during the day.
d. Advise the client to report cloudy urine.
e. Educate about the effects of a bubble bath.
ANS: C, D, E
The nurse would teach about voiding q2hr to q4hr during the day, avoiding bubble baths
and advising the client to report cloudy urine, as well as pain, frequency, and urgency. The
client is to be taught to wipe from back to front. Diaphragm use should be discouraged
temporarily, rather than suggested as an option.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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Chapter 49: Nursing Management: Acute Kidney Injury and Chronic Kidney
Disease
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is caring for a client who has had an insertion of an arteriovenous graft (AVG)
in the right forearm and has symptoms of pain and coldness of the right fingers. Which of
the following actions should the nurse take?
a. Elevate the client’s arm above the level of the heart.
b. Report the client’s symptoms to the health care provider.
c. Remind the client about the need to take a daily low-dose Aspirin tablet.
d. Educate the client about the normal vascular response after AVG insertion.
ANS: B
The client’s complaints suggest the development of distal ischemia (steal syndrome) and
may require revision of the AVG. Elevation of the arm above the heart will decrease
perfusion. Pain and coolness are not normal after AVG insertion. Aspirin therapy is not
used to maintain grafts.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
2. The nurse is caring for a client with acute kidney injury (AKI) who has an arterial blood
pH of 7.30. Which of the following assessment findings should the nurse anticipate?
Vasodilation
Poor skin turgor
Bounding pulses
Rapid respirations
a.
b.
c.
d.
ANS: D
Clients with metabolic acidosis caused by AKI may have Kussmaul’s respirations as the
lungs try to regulate carbon dioxide. Bounding pulses and vasodilation are not associated
with metabolic acidosis. Because the client is likely to have fluid retention, poor skin
turgor would not be a finding in AKI.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
3. The nurse is caring for a client with severe heart failure who develops elevated blood urea
nitrogen (BUN) and creatinine levels. The nurse will plan care to meet which of the
following goals of treatment?
a. Replace fluid volume
b. Prevent hypertension
c. Maintain cardiac output
d. Dilute nephrotoxic substances
ANS: C
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The primary goal of treatment for acute kidney injury (AKI) is to eliminate the cause and
provide supportive care while the kidneys recover. Because this client’s heart failure is
causing AKI, the care will be directed toward treatment of the heart failure. For renal
failure caused by hypertension, hypovolemia, or nephrotoxins, the other responses would
be correct.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
4. The nurse is caring for a client with acute glomerulonephritis, acute kidney injury (AKI),
and hyperkalemia who is prescribed calcium gluconate IV. Which of the following
parameters should the nurse assess to evaluate the effectiveness of the medication?
a. Urine output
b. Calcium level
c. Cardiac rhythm
d. Neurological status
ANS: C
The calcium gluconate helps prevent dysrhythmias that might be caused by the
hyperkalemia. The nurse will monitor the other data as well, but these will not be helpful
in determining the effectiveness of the calcium gluconate.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
5. The nurse is caring for a client with stage 2 chronic kidney disease (CKD) who is
scheduled for an intravenous pyelogram (IVP). Which of the following prescriptions for
the client should the nurse question?
a. NPO for 6 hours before IVP procedure
b. Normal saline 500 mL IV before procedure
c. Ibuprofen 400 mg PO PRN for pain
d. Dulcolax suppository 4 hours before IVP procedure
ANS: C
The contrast dye used in IVPs is potentially nephrotoxic, and concurrent use of other
nephrotoxic medications such as the NSAIDs should be avoided. The suppository and
NPO status are necessary to ensure adequate visualization during the IVP. IV fluids are
used to ensure adequate hydration, which helps reduce the risk for contrast-induced renal
failure.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
6. The nurse is teaching a client with stage 5 chronic kidney disease (CKD) about
management of CKD. Which of the following client statements indicate that the teaching
was effective?
a. “I need to try to get more protein from dairy products.”
b. “I will try to increase my intake of fruits and vegetables.”
c. “I will measure my urinary output each day to help calculate the amount I can
drink.”
d. “I need to take the erythropoietin to boost my immune system and help prevent
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infection.”
ANS: C
The client with end-stage renal disease is taught to measure urine output as a means of
determining an appropriate oral fluid intake. Erythropoietin is given to increase the red
blood cell count and will not offer any benefit for immune function. Dairy products are
restricted because of the high phosphate level. Many fruits and vegetables are high in
potassium and should be restricted in the client with CKD.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
7. The nurse is caring for a client with chronic kidney disease (CKD) who is prescribed
calcium carbonate. Which of the following parameters should the nurse assess in order to
determine the effectiveness of the treatment?
a. Blood pressure
b. Phosphate level
c. Neurological status
d. Creatinine clearance
ANS: B
Calcium carbonate is prescribed to bind phosphorus and prevent mineral and bone disease
in clients with CKD. The other data will not be helpful in evaluating the effectiveness of
calcium carbonate.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
8. Which of the following assessments should the nurse complete before administering
sodium polystyrene sulphonate to a client with hyperkalemia?
a. Blood urea nitrogen (BUN) and creatinine
b. Blood glucose level
c. Client’s bowel sounds
d. Level of consciousness (LOC)
ANS: C
Sodium polystyrene sulphonate should not be given to a client who does not have normal
bowel function because bowel necrosis can occur. The BUN and creatinine, blood glucose,
and LOC would not affect the nurse’s decision to give the medication.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
9. The nurse is teaching a client who is receiving hemodialysis about appropriate dietary
choices. Which of the following menu choices by the client indicates that the teaching has
been effective?
a. Scrambled eggs, English muffin, and apple juice
b. Oatmeal with cream, half a banana, and herbal tea
c. Split-pea soup, whole-wheat toast, and nonfat milk
d. Cheese sandwich, tomato soup, and cranberry juice
ANS: A
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Scrambled eggs would provide high-quality protein, and apple juice is low in potassium.
Cheese is high in salt and phosphate, and tomato soup would be high in potassium.
Split-pea soup is high in potassium, and dairy products are high in phosphate. Bananas are
high in potassium, and the cream would be high in phosphate.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
10. The nurse is preparing to administer calcium carbonate to a client with chronic kidney
disease (CKD). Which of the following laboratory results should the nurse check prior to
administration?
a. Creatinine
b. Potassium
c. Total cholesterol
d. Serum phosphate
ANS: D
If serum phosphate is elevated, the calcium and phosphate can cause soft tissue
calcification. The calcium carbonate should not be given until the phosphate level is
lowered. Total cholesterol, creatinine, and potassium values do not affect whether calcium
carbonate should be administered.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
11. Which of the following information is most useful to the nurse in evaluating improvement
in kidney function for a client who is hospitalized with acute kidney injury (AKI)?
a. Blood urea nitrogen (BUN) level
b. Urine output
c. Creatinine level
d. Calculated glomerular filtration rate (GFR)
ANS: D
GFR is the preferred method for evaluating kidney function. BUN levels can fluctuate
based on factors such as fluid volume status. Urine output can be normal or high in clients
with AKI and does not accurately reflect kidney function. Creatinine alone is not an
accurate reflection of renal function.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
12. The nurse is caring for a client who requires vascular access for hemodialysis and asks the
nurse what the differences are between an arteriovenous (AV) fistula and a graft. Which of
the following information should the nurse explain is an advantage of the fistula?
a. Is much less likely to clot
b. Increases client mobility
c. Accommodates larger needles.
d. Can be used sooner after surgery.
ANS: A
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AV fistulas are much less likely to clot than grafts although it takes longer for them to
mature to the point where they can be used for dialysis. The choice of an AV fistula or a
graft does not have an impact on needle size or client mobility.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
13. The nurse is caring for a client with a left arm arteriovenous fistula. Which of the
following actions should the nurse include in the plan of care to maintain the patency of
the fistula?
a. Check the fistula site for a bruit and thrill.
b. Assess the rate and quality of the left radial pulse.
c. Compare blood pressures in the left and right arms.
d. Irrigate the fistula site with saline every 8–12 hours.
ANS: A
The presence of a thrill and bruit indicates adequate blood flow through the fistula. Pulse
rate and quality are not good indicators of fistula patency. Blood pressures should never be
obtained on the arm with a fistula. Irrigation of the fistula might damage the fistula, and
typically only dialysis staff would access the fistula.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
14. The nurse is caring for a client who has had progressive chronic kidney disease (CKD) for
several years and is starting hemodialysis. Which of the following information about diet
should the nurse include in client teaching?
a. Increased calories are needed because glucose is lost during hemodialysis.
b. Unlimited fluids are allowed since retained fluid is removed during dialysis.
c. More protein will be allowed because of the removal of urea and creatinine by
dialysis.
d. Dietary sodium and potassium are unrestricted because these levels are normalized
by dialysis.
ANS: C
Once the client is started on dialysis and nitrogenous wastes are removed, there is less
protein lost; therefore more protein in the diet is encouraged. Fluids are still restricted to
avoid excessive weight gain and complications such as shortness of breath. Glucose is not
lost during hemodialysis. Sodium and potassium intake continues to be restricted to avoid
the complications associated with high levels of these electrolytes.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
15. Which of the following actions by a client who is using peritoneal dialysis (PD) indicates
that the nurse should provide more teaching about PD?
The client slows the inflow rate when experiencing pain.
The client leaves the catheter exit site without a dressing.
The client plans 30–60 minutes for a dialysate exchange.
The client cleans the catheter while taking a bath every day.
a.
b.
c.
d.
ANS: D
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Clients are taught to avoid insertion site infection and should be encouraged to take
showers rather than baths to avoid infections at the catheter insertion side. The other client
actions indicate good understanding of peritoneal dialysis.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
16. The nurse is taking a history for a client who is a possible candidate for a kidney transplant.
Which of the following information indicates that the client is not an appropriate candidate
for transplantation?
a. The client has metastatic lung cancer.
b. The client has poorly controlled type 1 diabetes.
c. The client has a history of chronic hepatitis C infection.
d. The client is infected with the human immunodeficiency virus.
ANS: A
Disseminated malignancies are a contraindication to transplantation. The conditions of the
other clients are not contraindications for kidney transplant.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
17. The nurse is caring for a client who had kidney transplantation several years ago. Which of
the following findings may indicate that the client is experiencing adverse effects to the
prescribed corticosteroid?
a. Joint pain
b. Tachycardia
c. Postural hypotension
d. Increase in creatinine level
ANS: A
Aseptic necrosis of the weight-bearing joints can occur when clients take corticosteroids
over a prolonged period. Increased creatinine level, orthostatic dizziness, and tachycardia
are not caused by corticosteroid use.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
18. The nurse is assessing a client who had a kidney transplant 8 years ago and is receiving the
immunosuppressants tacrolimus, cyclosporin, and prednisone. Which of the following
findings is of most concern to the nurse?
a. The blood glucose is 7.9 mmol/L.
b. The client’s blood pressure is 150/92.
c. There is a nontender lump in the axilla.
d. The client has a round, moonlike face.
ANS: C
A nontender lump suggests a malignancy such as a lymphoma, which could occur as a
result of chronic immuno-suppressive therapy. The elevated glucose, moon face, and
hypertension are possible adverse effects of the prednisone and should be addressed, but
they are not as great a concern as the possibility of a malignancy.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
19. The nurse is interviewing a client with chronic kidney disease (CKD) who brings all home
medications to the clinic to be reviewed by the nurse. Which of the following medications
being used by the client indicates that client teaching is required?
a. Multivitamin with iron
b. Milk of magnesia 30 mL
c. Calcium acetate
d. Acetaminophen 650 mg
ANS: B
Magnesium is excreted by the kidneys, and clients with CKD should not use
over-the-counter products containing magnesium. The other medications are appropriate
for a client with CKD.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
20. The nurse is caring for a client with hypertension and stage 2 chronic kidney disease
(CKD) who is prescribed ramapril. Which of the following laboratory tests should the
nurse assess before administration of the medication?
a. Glucose
b. Potassium
c. Creatinine
d. Phosphate
ANS: B
Angiotensin-converting enzyme (ACE) inhibitors are frequently used in clients with CKD
because they delay the progression of the CKD, but they cause potassium retention.
Therefore, careful monitoring of potassium levels is needed in clients who are at risk for
hyperkalemia. The other laboratory values would also be monitored in clients with CKD
but would not affect whether the captopril was given or not.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
21. The nurse is caring for a client with diabetes who has been admitted with pneumonia and
is prescribed gentamicin 60 mg IV. Which of the following parameters should the nurse
monitor to evaluate the client for adverse effects of the medication?
a. Urine osmolality
b. Serum potassium
c. Blood glucose level
d. Blood urea nitrogen (BUN) and creatinine
ANS: D
When a client at risk for chronic kidney disease (CKD) receives a nephrotoxic medication,
it is important to monitor renal function with BUN and creatinine levels. The other
laboratory values would not be useful in determining the effect of the gentamicin.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
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22. The nurse is caring for a client with end-stage renal disease (ESRD). Which of the
following findings indicate that the nurse should consult with the health care provider
before giving the prescribed erythropoiesis-stimulating agent (ESA)?
a. Creatinine 99 mcmol/L
b. Oxygen saturation 89%
c. Hemoglobin level 130 g/L
d. Blood pressure 98/56 mm Hg
ANS: C
High hemoglobin levels are associated with a higher rate of thromboembolic events and
increased risk of death from serious cardiovascular events (heart attack, heart failure,
stroke) when ESA is administered to a target hemoglobin of 110 g/L with a range of
100–120 g/L). Hemoglobin levels higher than 120 g/L indicate a need for a decrease in
erythropoiesis-stimulating agent dose. The other information will also be reported to the
health care provider but will not affect whether the medication is administered.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
23. The nurse is caring for a client with acute kidney injury (AKI) who requires hemodialysis
and a temporary vascular access is obtained by placing a catheter in the left femoral vein.
Which of the following interventions should be included in the plan of care?
a. Place the client on bed rest.
b. Start continuous pulse oximetry.
c. Discontinue the retention catheter.
d. Restrict the client’s oral protein intake.
ANS: A
The client with a femoral vein catheter must be on bed rest to prevent trauma to the vein.
Protein intake is likely to be increased when the client is receiving dialysis. The retention
catheter is likely to remain in place because accurate measurement of output will be
needed. There is no indication that the client needs continuous pulse oximetry.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
24. The nurse is caring for a client who has been admitted with a severe crushing injury after
an industrial accident. Which of the following laboratory results is most important to
report to the health care provider?
a. Serum creatinine level 190 mcmol/L
b. Serum potassium level 6.5 mmol/L
c. White blood cell count 11.5 ´ 109/L
d. Blood urea nitrogen (BUN) 18 mmol/L
ANS: B
The hyperkalemia associated with crushing injuries may cause cardiac arrest and should be
treated immediately. The nurse will also report the other laboratory values, but
abnormalities in these are not immediately life-threatening.
DIF:
Cognitive Level: Application
TOP: Nursing Process: Assessment
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MSC: NCLEX: Physiological Integrity
25. The nurse is caring for a client with a history of benign prostatic hyperplasia (BPH) with
acute urinary retention and an elevated blood urea nitrogen (BUN) and creatinine. Which
of the following prescribed therapies should the nurse implement first?
a. Obtain renal ultrasound.
b. Insert retention catheter.
c. Infuse normal saline at 50 mL/hour.
d. Draw blood for complete blood count.
ANS: B
The client’s elevation in BUN is most likely associated with hydronephrosis caused by the
acute urinary retention, so the insertion of a retention catheter is the first action to prevent
ongoing postrenal failure for this client. The other actions also are appropriate but should
be implemented after the retention catheter.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
26. The nurse is caring for a client who was admitted 10 days previously with acute kidney
injury (AKI) caused by dehydration. Which of the following findings is most important for
the nurse to report to the health care provider?
a. The blood urea nitrogen (BUN) level is 23.1 mmol/L.
b. The creatinine level is 186 mcmol/L.
c. Urine output over an 8-hour period is 2 500 mL.
d. The glomerular filtration rate is <30 mL/minute/1.73m2.
ANS: C
The high urine output indicates a need to increase fluid intake to prevent hypovolemia.
The other information is typical of AKI and will not require a change in therapy.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
27. After noting lengthening QRS intervals in a client with acute kidney injury (AKI), which
of the following actions should the nurse take first?
Document the QRS interval.
Notify the client’s health care provider.
Look at the client’s current blood urea nitrogen (BUN) and creatinine levels.
Check the client’s most recent blood potassium level.
a.
b.
c.
d.
ANS: D
The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the
most recent potassium and then notify the client’s health care provider. The BUN and
creatinine will be elevated in a client with AKI, but they would not directly affect the
electrocardiogram (ECG). Documentation of the QRS interval also is appropriate, but
interventions to decrease the potassium level are needed to prevent life-threatening
bradycardia.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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28. The nurse is caring for a client with acute kidney injury who is dehydrated with symptoms
of oliguria, anemia, and hyperkalemia. Which of the following prescribed actions should
the nurse take first?
a. Insert a urinary retention catheter.
b. Place the client on a cardiac monitor.
c. Administer an erythropoiesis-stimulating agent (ESA).
d. Give sodium polystyrene sulfonate.
ANS: B
Since hyperkalemia can cause fatal cardiac dysrhythmias, the initial action should be to
monitor the cardiac rhythm. ESA’s will take time to correct the hyperkalemia and anemia.
The catheter allows monitoring of the urine output, but does not correct the cause of the
renal failure.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
29. The nurse is caring for a client who is receiving hemodialysis and has symptoms of nausea,
vomiting, and a headache. Which of the following actions is priority?
a. Infuse a hypotonic solution
b. Increase the rate of the dialysis
c. Administer an antiemetic medication
d. Stop the dialysis solution
ANS: D
The client’s symptoms suggest disequilibrium syndrome, which is a rare complication of
modern HD and develops as a result of very rapid changes in the composition of the
extracellular fluid. Urea, sodium, and other solutes are removed more rapidly from the
blood than from the cerebro-spinal fluid and the brain. This creates a high osmotic
gradient in the brain resulting in the shift of fluid into the brain, causing cerebral edema.
Manifestations include nausea, vomiting, confusion, restlessness, headaches, twitching and
jerking, and seizures. Treatment consists of slowing or stopping dialysis and infusing
hypertonic saline solution, albumin, or mannitol to draw fluid from the brain cells back
into the systemic circulation.
DIF: Cognitive Level: Application
TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
30. The RN observes a nursing student carrying out all of these actions while caring for a
client with stage 2 chronic kidney disease. Which of the following actions require the RN
to intervene?
a. The student administers erythropoietin subcutaneously.
b. The student assists the client to ambulate in the hallway.
c. The student gives the iron supplement and phosphate binder with lunch.
d. The student carries a tray containing low-protein foods into the client’s room.
ANS: C
Oral phosphate binders should not be given at the same time as iron because they prevent
the iron from being absorbed. The phosphate binder should be given with a meal and the
iron given at a different time. The other actions by the RN student are appropriate for a
client with renal insufficiency.
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DIF: Cognitive Level: Application
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
31. The nurse is assessing a client who is receiving peritoneal dialysis with 2 L inflows.
Which of the following information should be reported immediately to the health care
provider?
a. The client has an outflow volume of 1 800 mL.
b. The client’s peritoneal effluent appears cloudy.
c. The client has abdominal pain during the inflow phase.
d. The client complains of feeling bloated after the inflow.
ANS: B
Cloudy appearing peritoneal effluent is a sign of peritonitis and should be reported
immediately so that treatment with antibiotics can be started. The other problems can be
addressed through nursing interventions such as slowing the inflow and repositioning the
client.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
32. Two hours after a kidney transplant, the nurse obtains all of the following data when
assessing the client. Which information is most important to communicate to the health
care provider?
a. The urine output is 900–1 100 mL/hour.
b. The blood urea nitrogen (BUN) and creatinine levels are elevated.
c. The client’s central venous pressure (CVP) is decreased.
d. The client has level 8 (on a 10-point scale) incisional pain.
ANS: C
The decrease in CVP suggests hypovolemia, which must be rapidly corrected to prevent
renal hypoperfusion and acute tubular necrosis. The other information is not unusual in a
client after a transplant.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
33. The nurse is caring for a client in the oliguric phase of acute renal failure who has a
24-hour fluid output of 150 mL emesis and 250 mL urine. Which of the following amounts
in mL should the nurse plan a fluid replacement for the following day?
a. 400
b. 800
c. 1 000
d. 1 400
ANS: C
Usually fluid replacement should be based on the client’s measured output plus 600
mL/day for insensible losses.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
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34. The nurse is caring for a client receiving hemodialysis who has symptoms of nausea and
dizziness. Which of the following actions should the nurse take first?
a. Slow down the rate of dialysis.
b. Obtain blood to check the blood urea nitrogen (BUN) level.
c. Check the client’s blood pressure.
d. Give prescribed PRN antiemetic drugs.
ANS: C
The client’s complaints of nausea and dizziness suggest hypotension, so the initial action
should be to check the BP. The other actions may also be appropriate, based on the blood
pressure obtained.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
35. Which of the following parameters is most important for the nurse to consider when
titrating the IV fluid infusion rate immediately after a client has had kidney
transplantation?
a. Heart rate
b. Blood urea nitrogen (BUN) level
c. Urine output
d. Creatinine clearance
ANS: C
Fluid volume is replaced based on urine output after transplant because the urine output
can be as high as a litre an hour. The other data will be monitored but are not the most
important determinants of fluid infusion rate.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
36. The nurse is caring for a client who has leg cramps during hemodialysis. Which of the
following actions should the nurse implement first?
Reposition the client
Massage the client’s legs
Give acetaminophen
Infuse a bolus of normal saline
a.
b.
c.
d.
ANS: D
Muscle cramps during dialysis are caused by rapid removal of sodium and water.
Treatment includes infusion of normal saline. The other actions do not address the reason
for the cramps.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
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Chapter 50: Nursing Assessment: Endocrine System
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is evaluating the laboratory results for a client who has increased secretion of
the anterior pituitary hormones. Which of the following findings should the nurse
anticipate when reviewing the laboratory findings?
a. Decreased serum thyroxine levels
b. Elevated serum aldosterone levels
c. An increase in urinary free cortisol
d. Low urinary excretion of catecholamines
ANS: C
Increased secretion of adrenocorticotropic hormone (ACTH) by the anterior pituitary
gland will lead to an increase in serum and urinary cortisol levels. An increase, rather than
a decrease, in thyroxine level would be expected with increased secretion of
thyroid-stimulating hormone (TSH) by the anterior pituitary. Aldosterone and
catecholamine levels are not controlled by the anterior pituitary.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. The nurse is obtaining the health history from a client. Which of the following statements
by the client indicates further assessment of thyroid function may be necessary?
a. “I notice my breasts are tender lately.”
b. “I am so thirsty that I drink all day long.”
c. “I get up several times at night to urinate.”
d. “I feel a lump in my throat when I swallow.”
ANS: D
Difficulty in swallowing can occur with a goitre. Nocturia is associated with diseases such
as diabetes mellitus, diabetes insipidus, or chronic kidney disease. Breast tenderness would
occur with excessive gonadal hormone levels. Thirst is a sign of disease such as diabetes.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
3. The nurse is caring for a client who is preparing for a growth hormone stimulation test.
Which of the following adverse effects should the nurse monitor for during the test?
a. Bradycardia
b. Hypotension
c. Hyperglycemia
d. Tachypnea
ANS: B
During a growth hormone stimulation test, the nurse should continually assess for
hypoglycemia and hypotension. There is no indication to monitor for bradycardia or
tachypnea.
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DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
4. The nurse is interviewing a client who has a possible thyroid disorder. Which of the
following questions will provide the most useful information?
a. “What methods do you use to help cope with stress?”
b. “Have you experienced any blurring or double vision?”
c. “Do you have to get up at night to empty your bladder?”
d. “Have you had any recent unplanned weight gain or loss?”
ANS: D
Because thyroid function affects metabolic rate, changes in weight may indicate hyper- or
hypofunction of the thyroid gland. Nocturia, visual difficulty, and changes in stress level
are associated with other endocrine disorders.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
5. The nurse is caring for a client in the outpatient clinic who has a prescription for blood
cortisol testing. Which of the following instructions should the nurse provide for the
client?
a. “Avoid adding any salt to your foods for 24 hours before the test.”
b. “You will need to lie down for 30 minutes before the blood is drawn.”
c. “Come to the laboratory to have the blood drawn early in the morning.”
d. “Do not have anything to eat or drink before the blood test is obtained.”
ANS: C
Cortisol levels are usually drawn in the morning, when levels are highest. The other
instructions would be given to clients who were having other endocrine testing.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
6. A client has a total serum calcium level of 3.3 mmol/L. Which of the following laboratory
results should the nurse assess next?
a. Calcitonin
b. Catecholamine
c. Thyroid hormone
d. Parathyroid hormone
ANS: D
Parathyroid hormone is the major controller for blood calcium levels. Although calcitonin
secretion is a counter-mechanism to parathyroid hormone, it does not play a major role in
calcium balance. Catecholamine and thyroid hormone levels do not affect serum calcium
level.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
7. During a physical examination, the nurse finds that a client’s thyroid gland cannot be
palpated. Which of the following is the best action for the nurse to take?
a. Palpate the client’s neck more deeply
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b. Document that the thyroid was nonpalpable
c. Notify the health care provider immediately
d. Teach the client about thyroid hormone testing
ANS: B
The thyroid is frequently nonpalpable. The nurse should simply document the finding.
There is no need to notify the health care provider immediately about a normal finding.
There is no indication for TSH testing unless there is evidence of thyroid dysfunction.
Deep palpation of the neck is not appropriate.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
8. The nurse is caring for a client who has clinical manifestations of hypothyroidism. Which
of the following laboratory tests is most accurate to evaluate thyroid function?
Thyroxine (T4) level
Triiodothyronine (T3) level
Thyroid-stimulating hormone (TSH) level
Thyrotropin-releasing hormone (TRH) level
a.
b.
c.
d.
ANS: C
The most sensitive and accurate laboratory test is measurement of TSH; thus it is often
recommended as a first diagnostic test for evaluation of thyroid function. A low TSH level
indicates that the client’s hypothyroidism is caused by decreased anterior pituitary
secretion of TSH. Low T3 and T4 levels are not diagnostic of the primary cause of the
hypothyroidism. TRH levels indicate the function of the hypothalamus.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
9. A client who has diabetes mellitus asks the nurse what the glycosylated hemoglobin
(HbA1C) test measures. Which of the following explanations should be the basis of the
nurse’s response?
a. Glucose levels 2 hours after a meal
b. Circulating, non-fasting glucose levels
c. Glucose control over the past 3 months
d. Hypoglycemic episodes in the past 90 days
ANS: C
Glycosylated hemoglobin testing measures glucose control over the last 3 months. Glucose
testing after a meal or random testing may reveal impaired glucose tolerance and indicate
prediabetes, but it is not done on clients who already have a diagnosis of diabetes. There is
no test to evaluate for hypoglycemic episodes in the past.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
10. The nurse is caring for a client who is taking spironolactone. Which of the following
parameters should the nurse monitor?
a. Decreased urinary output
b. Evidence of fluid overload.
c. Increased serum sodium levels.
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d. Elevated serum potassium levels.
ANS: D
Spironolactone is a diuretic and it blocks aldosterone. Recalling that aldosterone increases
the excretion of potassium, a medication that blocks aldosterone will tend to cause
hyperkalemia. Aldosterone also promotes the reabsorption of sodium and water in the
renal tubules, so spironolactone will tend to cause increased urine output, a decreased or
normal serum sodium level, and signs of dehydration.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Evaluation
11. The nurse is teaching a client how to prepare for an oral glucose tolerance test (OGTT).
Which of the following client response indicates that the teaching has been effective?
a. Fast 12 hours before the procedure
b. Clear fluid diet 12 hours prior to the test
c. Drink only full fluids 6 hours before the test
d. No fluid or food restrictions prior to the test
ANS: D
Fasting for 12 hours before the procedure demonstrates that teaching has been effective.
The client is to be NPO 12 hours prior to the test. A clear fluid diet 12 hours pretest is not
indicated. A full fluid diet 6 hours pretest is not indicated.
DIF: Cognitive Level: Application
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Assessment
12. A client is scheduled for a growth hormone stimulation test. Which of the following items
should the nurse obtain in preparation for the test?
a. Basin of ice
b. Cardiac monitor
c. Vial of glargine insulin
d. Intravenous dextrose solution
ANS: D
Hypoglycemia is induced during the growth hormone stimulation test, and the nurse
should be prepared to administer glucose IV immediately or have a sweet snack available
for the client immediately following the test. Regular insulin is used to induce
hypoglycemia (glargine is never given intravenously). The client does not require cardiac
monitoring during the test. Although blood samples for some tests must be kept on ice,
this is not true for the growth hormone stimulation test.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
13. The regulation of oxytocin during childbirth is an example of which of the following
mechanisms?
Physiological rhythm
Secondary input
Loop regulation
Positive feedback
a.
b.
c.
d.
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ANS: D
An example of the regulation of oxytocin during childbirth is an example of positive
feedback. The positive feedback mechanism increases the target organ action beyond
normal. The release of oxytocin is stimulated by pressure receptors in the vagina. As the
fetus enters the vagina during childbirth, the pressure receptors sense increased pressure
and signal the brain to release more oxytocin.
DIF: Cognitive Level: Comprehension
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
14. The nurse is caring for a client who is scheduled for a 24-hour urine collection for
17-ketosteroids. Which of the following actions should the nurse implement?
Keep the specimen on ice
Insert a retention catheter
Have the client void and save that specimen to start the collection
Encourage the client to drink 2–3 L of fluid during the 24 hours
a.
b.
c.
d.
ANS: A
The specimen must be kept on ice or refrigerated until the collection is finished. Voided or
catheterized specimens are acceptable for the test. The initial voided specimen is discarded.
There is no fluid intake requirement for the 24-hour collection.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
15. When reviewing the laboratory results for a client’s total calcium level, which of the
following information should the nurse consider?
a. The blood glucose is elevated.
b. The phosphate level is normal.
c. The serum albumin level is low.
d. The magnesium level is normal.
ANS: C
Part of the total calcium is bound to albumin, so hypoalbuminemia can lead to
misinterpretation of calcium levels. Ionized calcium unaffected by albumin levels. The
other laboratory values will not affect total calcium interpretation.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
16. The nurse is caring for a client who was admitted with tetany. Which of the following
laboratory values should the nurse monitor?
a. Total protein
b. Blood glucose
c. Ionized calcium
d. Serum phosphate
ANS: C
Tetany is associated with hypocalcemia. The other values would not be useful for this
client in relation to tetany.
DIF:
Cognitive Level: Application
TOP: Nursing Process: Assessment
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MSC: NCLEX: Physiological Integrity
17. Which of the following information about a client who is scheduled for an oral glucose
tolerance test should be reported to the health care provider before starting the test?
Occasional orthostatic dizziness.
A 5-kg weight gain in the last month.
Intake of 1 L of water an hour previously.
Oral corticosteroid use for rheumatoid arthritis.
a.
b.
c.
d.
ANS: D
Corticosteroids can affect blood glucose results. The other information will be provided to
the provider but will not affect the test results.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
18. The student nurse is caring for a client with goitre and possible hyperthyroidism. Which of
the following actions by the student nurse should cause the nursing instructor to intervene?
Palpates the neck to check thyroid size.
Checks the blood pressure on both arms.
Administers nonmedicated eye drops to the client’s eyes.
Lowers the thermostat to decrease the temperature in the room.
a.
b.
c.
d.
ANS: A
Palpation can cause the release of thyroid hormones in a client with an enlarged thyroid
and should be avoided. The other actions by the new RN are appropriate when caring for a
client with an enlarged thyroid.
DIF: Cognitive Level: Application
TOP: Nursing Process: Evaluation
MSC: NCLEX: Safe and Effective Care Environment
19. The nurse is caring for a client who is undergoing a water deprivation test. Which of the
following findings is most important for the nurse to communicate to the health care
provider?
a. Intense thirst
b. 2.3 kg weight loss
c. Orthostatic hypotension
d. No change in urine osmolality
ANS: B
A drop in the weight of more than 2 kg indicates severe dehydration, and the test should be
discontinued. The other assessment data are not unusual with this test.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
20. A client with a possible pituitary adenoma is scheduled for a computed tomography (CT)
scan with contrast media. Which of the following client information is most important for
the nurse to communicate to the health care provider before the test?
a. Bilateral poor peripheral vision
b. Allergies to iodine and shellfish
c. Recent weight loss of 8.5 kg
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d. History of ongoing headaches
ANS: B
Since the usual contrast media is iodine-based, the health care provider will need to know
about the allergy before the CT scan. The other findings are common with any mass in the
brain such as a pituitary adenoma.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
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Chapter 51: Nursing Management: Endocrine Problems
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. The nurse is assessing a client with suspected acromegaly at the clinic. To assist in making
the diagnosis, which question should the nurse ask?
a. “Have you had a recent head injury?”
b. “Do you have to wear larger shoes now?”
c. “Are you experiencing tremors or anxiety?”
d. “Is there any family history of acromegaly?”
ANS: B
Acromegaly causes an enlargement of the hands and feet. Head injury and family history
are not risk factors for acromegaly. Tremors and anxiety are not clinical manifestations of
acromegaly.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Assessment
2. The nurse is providing preoperative teaching for a client scheduled for a hypophysectomy
for treatment of a pituitary adenoma. Which of the following instructions should the nurse
include in client teaching?
a. Cough and deep breathe every 2 hours postoperatively
b. Bed rest for the first 24 hours after the surgery
c. Be positioned flat with sandbags at the head postoperatively
d. Have a NG tube after the surgery
ANS: D
The client should be taught that they will have a NG tube after surgery. It is not necessary
to remain on bed rest after this surgery. Coughing is discouraged because it may cause
leakage of cerebro-spinal fluid (CSF) from the suture line. The head of the bed should be
elevated 30 degrees to reduce pressure on the sella turcica and decrease the risk for
headaches.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Implementation
3. The nurse is caring for a client who has had a transsphenoidal resection of a pituitary
tumour. Which of the following nursing actions should be included in the postoperative
plan of care?
a. Monitor urine output every hour.
b. Palpate extremities for dependent edema.
c. Check hematocrit hourly for first 12 hours.
d. Obtain continuous pulse oximetry for 24 hours.
ANS: A
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After pituitary surgery, the client is at risk for diabetes insipidus caused by cerebral edema
and monitoring of urine output and urine specific gravity is essential. Hemorrhage is not a
common problem. There is no need to check the hematocrit hourly. The client is at risk for
dehydration, not volume overload. The client is not at high risk for problems with
oxygenation, and continuous pulse oximetry is not needed.
DIF: Cognitive Level: Application
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
4. A client is suspected of having a pituitary tumour causing panhypopituitarism. During
assessment of the client, which of the following findings should the nurse anticipate?
a. High blood pressure
b. Elevated blood glucose
c. Tachycardia and cardiac palpitations
d. Changes in secondary sex character