Focus on Adult Health Medical-Surgical Nursing Psc Edition by Linda -Test Bank




Focus on Adult Health Medical-Surgical Nursing Psc Edition by Linda -Test Bank

Chapter 2- Health Education and Health Promotion

1. The nurse is planning to teach a 75-year-old patient about administering his medication. How can the nurse best enhance the patient’s ability to learn?
  A) Providing links to websites that contain information related to the medication
  B) Excluding family members from the session
  C) Using color-coded materials
  D) Making the information relevant to the patient’s condition



2. The nursing instructor has given an assignment to a group of nurse practitioner students. They are to break into groups of four and complete a health-promotion teaching project and present a report back to their fellow students. What project is the best example of health-promotion teaching?
  A) Demonstrating an injection technique to a patient for anticoagulant therapy
  B) Explaining the side effects of a medication to an adult patient
  C) Discussing the importance of preventing sexually transmitted infections (STIs) to a group of 12th-grade students
  D) Instructing an adolescent patient about safe food preparation



3. The nursing profession and nurses as individuals have a responsibility to promote activities that foster well-being.  What has most influenced the nurse to play this vital role?
  A) Nurses are seen as nurturing.
  B) Nurses have postsecondary education.
  C) Nurses have a desire to help others.
  D) Nurses have long-established credibility with consumers.



4. The nurse is preparing discharge teaching for a patient diagnosed with urinary retention secondary to multiple sclerosis. The nurse will teach the patient to self-catheterize at home upon discharge. What teaching method is most effective for this patient?
  A) Providing the most up-to-date information available
  B) Alleviating the patient’s guilt associated with not knowing appropriate self-care
  C) Determining the patient’s readiness to learn new information
  D) Building on previous information



5. You are the nurse planning to teach tracheostomy care to one of your patients. What is the most important variable in patient teaching that you need to utilize?
  A) Providing the most up-to-date information available
  B) Alleviating the patient’s guilt associated with not knowing appropriate self-care
  C) Determining the patient’s readiness to learn new information
  D) Building on previous information



6. A nurse has taught a patient who has asthma how to administer his daily metered-dose inhaler. How would the nurse evaluate the teaching–learning process?
  A) Using teaching aides
  B) Identifying teaching strategies
  C) Directly observing the patient using his inhaler
  D) Documenting the teaching session in the patient’s record



7. You are the oncoming nurse, and you have just taken report on your patients for the shift. One of your patients is a newly diagnosed diabetic. Which behavior shows this patient’s willingness to learn?
  A) The patient requests a visit from the diabetic educator.
  B) The patient declines a slice of pie at lunch.
  C) The patient has a family member meet with the dietician to discuss meals.
  D) The patient allows the nurse to take daily blood sugar.



8. Part of health promotion in the adolescent population is health screening. What is the goal of health screening in this population?
  A) To teach teenagers about health risks
  B) To teach coping strategies
  C) To discuss chronic health problems
  D) To detect health problems at an early age, so that they can be treated at this time



9. Despite chronic illnesses and disabilities, the elderly benefit most from what kind of activities?
  A) Those that help them eat well.
  B) Those that help them maintain independence.
  C) Those that preserve their social interactions.
  D) Those that accomplish financial stability.



10. Research has shown that patient adherence to prescribed regimens is generally low, especially when the patient will have to follow the regimen for a long period of time. What is one diagnosis in which adherence rates are low?
  A) Methicillin-resistant Staphylococcus aureus (MRSA)
  B) Sudden acute respiratory syndrome (SARS)
  C) Multiple sclerosis
  D) Beta hemolytic strep infection



11. A nurse is aware of both the importance of health education and the fact that it is an independent function of nursing practice. Under which of the following circumstances should a nurse consider providing health education?
  A) When a patient or patient’s condition has a reasonable chance of resolution
  B) During each contact that the nurse has with a health care consumer
  C) When health education is specified in a health care consumer’s plan of nursing care
  D) When the nurse possesses advanced practice credentials in health education



12. In March 2002, the Joint Commission, together with the Centers for Medicare and Medicaid Services, launched SPEAK UP, a national campaign with the ultimate goal of preventing medical errors. What means to achieving this goal does the SPEAK UP campaign propose?
  A) Encouraging patients to become informed and involved in their care
  B) Requiring nurses and other care providers to document the patient education that they provide
  C) Establishing patient education as a requirement for Medicare reimbursement
  D) Allowing patients to make informed choices about the interventions that they prefer



13. Health education is an integral component of all nurse–person interactions. However, certain individuals have a greater need for health education than others. Which one of the following individuals likely has the greatest need for health education?
  A) An IV drug user who is receiving antibiotics for the treatment of endocarditis
  B) A young adult who has suffered traumatic injuries in a motorcycle accident
  C) The parents of an infant who has been admitted for treatment of respiratory syncytial virus (RSV)
  D) An elderly woman who has just been diagnosed with congestive heart failure (|CHF)



14. A nurse is aware of the fact that nonadherence to prescribed therapy is both common and harmful. How can a nurse best promote adherence to therapeutic regimens among patients?
  A) Establish a system of rewards and punitive measures that is linked to adherence
  B) Provide examples of the harmful consequences of nonadherence to therapy
  C) Help individuals be aware of the benefits of adhering to their prescribed therapy
  D) Make adherence a requirement for treatment in early interactions with patients



15. A nurse who is caring for a patient who is newly diagnosed with HIV knows that an effective teaching–learning program requires careful and deliberate planning. What priority question should a nurse ask himself or herself before initiating health education with a patient?
  A) “What are the consequences if this person does not learn about his or her condition?”
  B) “How willing and able to learn is this person?”
  C) “Who is the best person to teach this patient?”
  D) “When is the best time to begin health education with this patient?”



16. An individual’s health status is an outcome of a complex interplay between a number of different factors. Which of the following factors is the strongest predictor of a patient’s health status?
  A) The amount of health education an individual has received
  B) The individual’s socioeconomic status
  C) The individual’s genetics
  D) The individual’s level of health literacy



17. Ms. Jimenez is a 27-year-old first-time mother who developed mastitis in the weeks following the birth of her infant. She was prescribed antibiotics and has informed the nurse that her symptoms of breast pain, redness, and swelling ceased 2 days after she began antibiotic therapy. As a result, Ms. Jimenez stopped taking her antibiotics and did not complete the ordered course. What nursing diagnoses should the nurse identify when planning health education for Ms. Jimenez? Select all that apply.
  A) Deficient knowledge
  B) Ineffective therapeutic regimen management
  C) Ineffective coping
  D) Health-seeking behaviors
  E) Impaired adjustment



18. The process of health education closely parallels the nursing process with its discrete phases of assessment, diagnosis, planning, implementation, and evaluation. What activity would the nurse perform during the planning phase of health education?
  A) Determining the patient’s current knowledge level and willingness to learn
  B) Identifying the patient’s learning needs
  C) Documenting the goals of the health education
  D) Demonstrating a necessary technique for the patient



19. A nurse on a postsurgical unit has performed health education on the correct technique for emptying a drain for a woman who will be discharged home with a drain in situ. The nurse has asked the patient to demonstrate the correct technique and will now provide feedback. Which of the following statements provides the most effective feedback for the patient?
  A) “You did a really good job of emptying your drain. You’ll do great when you get home.”
  B) “How did you feel about that?”
  C) “You should be proud of yourself; this certainly isn’t a skill that comes naturally to anyone.”
  D) “You kept the drain clean when you emptied it, and you restored the negative pressure effectively.”



20. A patient will be discharged home with a Foley catheter in situ and has been provided with a leg bag. The nurse has consequently provided education on the techniques for managing the catheter and leg bag. How should the nurse best evaluate the effectiveness of this health education?
  A) Ask the patient directly if he understands the management of the leg bag.
  B) Reiterate the correct management techniques for the patient in summary.
  C) Ask the patient to demonstrate and describe the necessary techniques.
  D) Clearly answer any questions that the patient may have about the management of the leg bag.



21. A 51-year-old woman is distraught about her new diagnosis of multiple sclerosis (MS). During a recent discussion with her nurse, the nurse mentioned the concept of wellness, which prompted the patient to state, “How can you be talking about wellness at the same time that I’ve got MS?” Which of the following principles should underlie the nurse’s response to the patient?
  A) Wellness is synonymous with health.
  B) Wellness involves maximizing function despite limitations.
  C) Wellness is defined as acceptance of one’s disabilities.
  D) Wellness is a concept that is understood better by people who have chronic illnesses than by healthy individuals.



22. A community health nurse is well aware that taking responsibility for oneself is the key to successful health promotion. Which of the following actions by the nurse’s patients best demonstrates self-responsibility and health promotion?
  A) A woman takes action to quit smoking cigarettes.
  B) A man seeks care because of an apparent cognitive decline.
  C) A man questions his pharmacist when having a prescription refilled.
  D) A woman reluctantly agrees to have her infant immunized.



23. The elderly often describe cognitive health as “staying sharp or being in the right mind.” Which of the following factors has been identified by older adults as contributing to the maintenance of cognitive health?
  A) Regular physical exercise
  B) Surrounding oneself with high-functioning peers
  C) Dietary supplements and good nutrition
  D) Health education



24. A 36-year-old man who has chewed tobacco since he was a teenager is having a discussion about this habit with his nurse practitioner. What statement would suggest that the man is in the contemplation stage of change?
  A) “I know I have to quit, and I’m sure that I will at some point.”
  B) “From what I’ve seen, chewing is a lot better for you than smoking.”
  C) “You can say what you want, but I just can’t see myself kicking the habit.”
  D) “I know it’s bad for me, and I’m going to quit at the end of the month.”



25. Specifying the immediate, intermediate, and long-term goals of learning is an integral component of the teaching-learning process. Which of the following individuals should be included in this goal-setting process? Select all that apply.
  A) An advanced practice nurse
  B) The nurse who will conduct the teaching
  C) The patient himself or herself
  D) The patient’s family members
  E) The patient’s primary care provider




Answer Key


1. D
2. C
3. D
4. C
5. C
6. C
7. A
8. D
9. B
10. C
11. B
12. A
13. D
14. C
15. B
16. D
17. A, B
18. C
19. D
20. C
21. B
22. A
23. A
24. A
25. B, C, D

Chapter 14- Patients With Coronary Vascular Disorders

1. The nurse is caring for a patient who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what?
  A) Lipids and fibrous tissue
  B) WBCs
  C) Lipoproteins
  D) High-density cholesterol



2. The nurse is caring for an adult patient who had symptoms of unstable angina during admission to the hospital. The most appropriate nursing diagnosis for the discomfort associated with angina is what?
  A) Deficient knowledge about underlying disease and methods for avoiding complications
  B) Anxiety related to fear of death
  C) Ineffective cardiopulmonary tissue perfusion secondary to coronary artery disease (CAD)
  D) Noncompliance related to failure to accept necessary lifestyle changes



3. The triage nurse in the emergency department assesses a 66-year-old male patient who has presented to the emergency department with complaints of midsternal chest pain that has lasted for the last 5 hours. The care team suspects an myocardial infarction (MI). The nurse is aware that, because of the length of time the patient has been experiencing symptoms, the following may have happened to the myocardium:
  A) May have developed an increased area of infarction
  B) Will probably not have more damage than if he came in immediately
  C) Can have restoration of the area of dead cells with proper treatment
  D) Has been damaged already, so immediate treatment is no longer necessary



4. The nurse has just admitted a 66-year-old patient for cardiac surgery. The patient tells the nurse that she is afraid of dying while undergoing the surgery. The nurse should be aware that:
  A) A further assessment of anxiety is required.
  B) A more complete physical examination is required.
  C) Preoperative fears are normal and will be alleviated with time.
  D) Teaching should be initiated immediately to alleviate the fears.



5. A patient with angina is beginning nitroglycerin.  Before administering the drug, the nurse informs the patient that, immediately after administration, the patient may experience what?
  A) Nervousness or paresthesia
  B) Throbbing headache or dizziness
  C) Drowsiness or blurred vision
  D) Tinnitus or diplopia



6. The public health nurse is participating in a health fair, and she interviews a woman with a history of hypertension who is currently smoking one pack of cigarettes per day.  She has had no manifestations of coronary artery disease (CAD) but a recent low-density lipoprotein (LDL) level of 154 mg/dL was found.  Based on her assessment, the nurse would expect that this patient would be treated in what way?
  A) Drug therapy and smoking cessation
  B) Diet and drug therapy
  C) Diet therapy only
  D) Diet therapy and smoking cessation



7. A patient with cardiovascular disease is being treated with Norvasc, a calcium channel blocking agent.  The nurse is aware that calcium channel blockers have a variety of effects.  What is one of the therapeutic effects?
  A) Decrease sinoatrial node and atrioventricular node conduction and decrease workload of the heart
  B) Prevent platelet aggregation and subsequent thrombosis
  C) Reduce myocardial oxygen consumption by blocking beta-adrenergic stimulation to the heart
  D) Reduce myocardial oxygen consumption thus decreasing ischemia and relieving pain



8. A 45-year-old adult male patient is admitted to emergency after he developed unrelieved chest pain that was present for approximately 20 minutes before he presented to the emergency department. The patient has been subsequently diagnosed with a myocardial infarction (MI). To minimize cardiac damage, what health care provider’s order will the nurse expect to see for this patient?
  A) Thrombolytics, oxygen administration, and bed rest
  B) Morphine sulfate, oxygen administration, and bed rest
  C) Oxygen administration, anticoagulants, and bed rest
  D) Bed rest, albuterol nebulizer treatments, and oxygen administration



9. The nurse is caring for a patient who is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) and who asks what complications can happen during the procedure. What statement should underlie the nurse’s response?
  A) Complications that can occur during a PTCA include dissection of the ductus arteriosa.
  B) Complications that can occur during a PTCA include hyposensitivity of the heart muscle.
  C) Complications that can occur during a PTCA include vasospasm of the coronary artery.
  D) Complications that can occur during a PTCA include closure of the pulmonary artery.



10. The nurse providing care for a patient post percutaneous transluminal coronary angioplasty (PTCA) knows to monitor the patient closely. What does the nurse know to monitor for?

Select all that apply.

  A) Abrupt closure of the coronary artery
  B) Venous insufficiency
  C) Bleeding at the insertion site
  D) Retroperitoneal bleeding
  E) Arterial occlusion



11. A 72-year-old woman with a diagnosis of angina pectoris has presented to her nurse practitioner because her chest pain on exertion has become more frequent and longer lasting in recent days. The nurse should understand that this woman’s chest pain is directly attributable to which of the following pathophysiological processes?
  A) Inflammation and physical irritation of the lumens of coronary arteries
  B) Accumulation of cellular debris in the myocardium after the rupture of atheromas
  C) Ischemia of cardiac muscle cells
  D) Accumulation of lactic acid in cardiac muscle



12. A nurse who works in a busy emergency department provides care for numerous patients who present with complaints of chest pain. Which of the following questions is most likely to help the nurse differentiate between chest pain that is attributable to angina and chest pain due to myocardial infarction (MI)?
  A) “Does resting and remaining still help your chest pain to decrease?”
  B) “Have you ever been diagnosed with high blood pressure or diabetes?”
  C) “When was the first time that you recall having chest pain?”
  D) “Does your chest pain make it difficult to move around like you normally would?”



13. An older adult patient has been admitted to a medical unit, and the nurse is conducting a comprehensive assessment of the patient in order to plan care appropriately. Which of the nurse’s following assessments directly relate to the known risk factors for cardiovascular disease?

Select all that apply.

  A) Measuring the patient’s random glucose level
  B) Assessing the patient’s oxygen saturation levels by pulse oximetry
  C) Measuring the patient’s blood pressure
  D) Auscultating the patient’s lungs
  E) Measuring the patient’s temperature orally



14. A 70-year-old man has been diagnosed with angina pectoris and subsequently prescribed nitroglycerin spray to be used sublingually when he experiences chest pain. This drug will achieve relief of the patient’s chest pain by:
  A) Blocking sympathetic stimulation of the heart and reducing oxygen demand
  B) Increasing contractility and consequent cardiac output
  C) Blocking the a-delta pain fibers in the myocardium
  D) Dilating the blood vessels and reducing preload



15. A 56-year-old man has been brought to the emergency department by emergency medical services (EMS) and has been diagnosed with a myocardial infarction (MI) based on his presentation and electrocardiogram (ECG). The patient has been identified as a candidate for percutaneous transluminal coronary angioplasty (PTCA). The nurse who is providing care for this patient should recognize that the extent of cardiac damage will primarily depend on:
  A) The patient’s previous use of antiplatelets and anticoagulants
  B) The particular risk factors that contributed to the patient’s MI
  C) The duration of oxygen deprivation to the patient’s cardiac cells
  D) The patient’s high- and low-density lipoprotein (LDL, HDL) levels prior to MI



16. A patient has returned to the nursing unit after having a percutaneous coronary intervention (PCI) in the hospital’s cardiac catheterization laboratory. The nurse who is providing care for this patient should prioritize what assessment?
  A) Assessing the patient’s capillary refill time and peripheral pulses
  B) Assessing the patient for signs and symptoms of hemorrhage
  C) Assessing the patient for signs and symptoms of acute renal failure
  D) Assessing the patient for signs and symptoms of infection



17. A 68-year-old female patient has returned to the cardiac care unit from PACU following a successful coronary artery bypass graft (CABG). The nurse who is providing care for this patient during her immediate postsurgical period must prioritize respiratory assessment because of the patient’s high risk of:
  A) Atelectasis
  B) Empyema
  C) Pulmonary embolism (PE)
  D) Pleural effusion



18. A patient has recently returned to the cardiac care unit from PACU following coronary artery bypass graft (CABG). During the nurse’s assessment of the patient, the patient acknowledges pain that he rates at 9 on a 0-to-10 pain scale. How should the nurse best respond to this assessment finding?
  A) Determine how the patient’s pain responds to increased physical activity.
  B) Explain to the patient that significant pain is expected during the immediate postoperative phase.
  C) Teach the patient nonpharmacologic interventions for pain management.
  D) Try to differentiate between incisional pain and anginal pain.



19. A patient who is recovering from a coronary artery bypass graft (CABG) is anxious about resuming normal levels of activity and mobility, citing a fear of putting undue strain on his heart, as well as being unable to safely mobilize. Consequently, the patient has expressed his intention to remain on bed rest for several days. How should the nurse respond to this patient’s concerns about activity and mobility?
  A) “There are actually a lot of benefits of moving early and often. While you’re mobilizing, we’ll keep you safe.”
  B) “Actually, your plan of care already includes several days of bed rest to make sure that your heart is fully recovered.”
  C) “It would be ideal if you could do some light mobilizing soon, but you can let us know when you would like to begin this.”
  D) “You’ll have to get permission from your cardiologist if you want to stay in bed for longer than normal.”



20. A patient in the cardiac PACU was just extubated, 5 hours after the conclusion of a coronary artery bypass graft (CABG). How can the patient’s nurse best promote adequate gas exchange for this patient?
  A) Apply continuous positive airway pressure (CPAP) as ordered.
  B) Perform deep suctioning q1h.
  C) Reposition the patient frequently.
  D) Administer nebulized bronchodilators and corticosteroids as ordered.



21. A patient who is postoperative day 2 following a coronary artery bypass graft (CABG) has been experiencing significant pain in the region of his sternal incision. What patient teaching should the nurse perform with this patient?
  A) “Try to hug a folded blanket across your chest when you move or breathe deeply.”
  B) “If possible, try to avoid coughing and breathe as shallowly as possible to relieve pressure on your incision.”
  C) “The less you can move, the less pain you’re likely to have in the area of your incision.”
  D) “Getting you up and mobilizing as soon as possible will help with this problem.”



22. A 60-year-old woman has been brought to the emergency department (ED) by ambulance after she experienced a sudden onset of dyspnea and phoned 911. The woman is obese but claims an unremarkable medical history and denies chest pain. When assessing this patient, the nurse in the ED should be aware that:
  A) Dyspnea is definitive for a respiratory, rather than cardiac, etiology.
  B) The absence of known risk factors usually rules out myocardial infarction (MI) or angina as a cause of dyspnea.
  C) Women often present with an MI much differently than do men.
  D) Acute coronary syndrome (ACS) manifests with chest pain rather than with shortness of breath.



23. A 66-year-old male patient with a high body mass index and a history of hypertension made an appointment with his primary care provider because of sudden, severe, and unprecedented fatigue over the past several days. The care provider referred the patient to the emergency department, where the patient underwent assessment for acute coronary syndrome. Assessment of the man’s cardiac biomarkers revealed normal levels of myoglobin and CK-MB but elevated levels of troponin I. What conclusion is suggested by these data?
  A) The man is having an acute myocardial infarction (MI).
  B) The man is at high risk of MI.
  C) The man had an MI in the recent past.
  D) The man had an MI several months ago.



24. A 58-year-old patient’s electrocardiogram (ECG) and presentation are suggestive of a myocardial infarction (MI), and treatment has been promptly initiated. The nurse who is part of the patient’s care team should anticipate and facilitate which of the following interventions?

Select all that apply.

  A) Providing the patient with supplementary oxygen
  B) Administering morphine by IV
  C) Administering oral warfarin (Coumadin)
  D) Administering a bolus of 0.9% NaCl
  E) Teaching the patient deep breathing and coughing techniques



25. Thrombolytic therapy is being prepared for administration to an older adult patient who has presented to the emergency department with an ST-segment elevation MI (STEMI). The nurse recognizes that the primary goal of this intervention is:
  A) To restore the flow of blood through the coronary arteries
  B) To restore function to infarcted myocardial cells
  C) To relieve the patient’s symptoms of chest pain and dyspnea
  D) To prevent the rupture of atheromas




Answer Key


1. A
2. C
3. A
4. A
5. B
6. D
7. A
8. B
9. C
10. A, C, D, E
11. C
12. A
13. A, C
14. D
15. C
16. B
17. D
18. D
19. A
20. C
21. A
22. C
23. C
24. A, B
25. A

Chapter 28- Patients With Urinary Disorders

1. The clinic nurse is teaching a young woman about preventing recurrent urinary tract infections. What information should the nurse include?
  A) Bathe daily.
  B) Avoid voiding immediately after sexual intercourse.
  C) Drink liberal amounts of fluids.
  D) Void every 6 to 8 hours.



2. The nurse is caring for an 84-year-old female patient who was brought to the emergency room by her daughter, who related that her mother has had very recent mental status changes and periods of incontinence. What condition should the nurse first suspect?
  A) Urinary retention
  B) Urinary stasis
  C) Urinary calculi
  D) Urinary tract infection (UTI)



3. A 42-year-old woman comes to the clinic complaining of intermittent urinary incontinence when she sneezes. The clinic nurse is aware that this patient is experiencing what type of incontinence?
  A) Stress incontinence
  B) Reflex incontinence
  C) Overflow incontinence
  D) Functional incontinence



4. A 52-year-old patient is scheduled to undergo ileal conduit surgery and has several appropriate questions for the nurse. What would be the most relevant nursing diagnosis for this patient?
  A) Self-care deficit related to the surgical procedure and creation of an ileal conduit
  B) Knowledge deficit about the surgical procedure and postoperative care
  C) Fear and anxiety related to the surgical procedure
  D) Risk of infection related to the surgical procedure



5. The nurse is caring for a patient who underwent percutaneous lithotripsy earlier in the day. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. What instruction should the nurse give the patient?
  A) Limit oral fluid intake for 1 to 2 weeks.
  B) Report the presence of fine, sandlike particles through the nephrostomy tube.
  C) Notify the health care provider about cloudy or foul-smelling urine.
  D) Report pink urine within 24 hours after the procedure.



6. The clinic nurse is preparing a plan of care for a patient complaining of stress incontinence. The plan of care incorporates behavioral therapy as an approach to the management of stress incontinence. What role will the nurse have in implementing the behavioral therapy approach?
  A) Provide medication teaching related to pseudoephedrine sulfate
  B) Teach the patient to perform pelvic floor muscle exercises
  C) Prepare the patient for an anterior vaginal repair procedure
  D) Provide information on the semipermanent procedure of periurethral bulking



7. A urology nurse is caring for a male patient admitted to the unit with bladder distention from prostatic hypertrophy. The health care provider orders placement of an indwelling urinary catheter. The nurse and urologist are both unsuccessful in catheterizing this patient due to the prostatic obstruction. What approach does the nurse anticipate the health care provider using to drain the patient’s bladder?
  A) Insertion of a suprapubic catheter
  B) Scheduling the patient immediately for surgery to relieve the bladder obstruction
  C) Application of warm compresses to the perineum to assist with relaxation, which will result in the patient voiding on his own
  D) Medication administration to relax the bladder muscles and attempting catheterization in 6 hours



8. The nurse has implemented a bladder retraining program with a 65-year-old woman after the removal of her indwelling urinary catheter. The nurse places the patient on a timed voiding schedule and performs an ultrasonic bladder scan after each void. The nurse notes that the patient has 50 mL of urine remaining in her bladder after voiding. What would be the nurse’s best response to this finding?
  A) Perform a straight catheterization on this patient.
  B) Avoid further interventions at this time, as this is an acceptable finding.
  C) Place an indwelling urinary catheter.
  D) Press on the patient’s bladder in an attempt to encourage complete emptying.



9. The nurse is assessing a patient admitted to the unit with kidney stones. What assessment parameters would be priorities for the nurse to address? Select all that apply.
  A) Dietary history
  B) Family history of renal stones
  C) Medication history
  D) Surgical history
  E) Vaccination history



10. A patient had an ileal conduit created and is being cared for by a postsurgical nurse. What is a complication the nurse would monitor this patient for in the immediate postoperative care period?
  A) Respiratory alkalosis
  B) Colon obstruction
  C) Ureteral obstruction
  D) Gangrene of the ilium



11. A 60-year-old woman has begun a course of oral antibiotics for the treatment of a urinary tract infection (UTI). The patient’s nurse should recognize that the causative microorganisms most likely originated from:
  A) Fecal contamination from the patient’s perineum
  B) Colonization of the patient’s urethra from bloodborne pathogens
  C) Proliferation of normal microbiotic flora
  D) Ingested microorganisms



12. A 30-year-old woman has presented for care, stating, “I’m pretty sure that I’ve got a UTI, so I think I’ll need some antibiotics.” In the presence of a UTI, the nurse would expect the woman to have which of the following signs and symptoms? Select all that apply.
  A) Pain on urination
  B) Excessively dilute urine
  C) Urinary frequency
  D) Urgency
  E) Copper-colored urine



13. A 44-year-old woman was diagnosed with an uncomplicated urinary tract infection (UTI) and completed her prescribed 3-day course of antibiotics 2 days ago. However, she states that she is experiencing the same signs and symptoms that initially prompted her to seek care. The nurse should anticipate that:
  A) The patient’s signs and symptoms will likely resolve over the next 48 to 72 hours.
  B) The patient will likely require a course of IV antibiotics.
  C) The patient may require another short course of antibiotics followed by a longer-term regimen.
  D) The patient will need to continue taking the same antibiotic for the next 4 to 6 months.



14. A gerontological nurse is aware of the high incidence and prevalence of urinary tract infections (UTIs) among older adults. Consequently, the nurse is implementing plans of care that attempt to reduce this risk. Which of the following actions present the greatest risk of UTIs for older adults?
  A) The use of antibiotics for respiratory infections
  B) The use of indwelling urinary catheters
  C) Restricting older adults’ mobility and levels of activity
  D) Restricting fluid in older adults with congestive heart failure (CHF) or renal disease



15. The nurse is planning the care of a male patient who has been admitted to the medical unit with an exacerbation of chronic pyelonephritis. Which of the following goals should the nurse prioritize in the planning of this patient’s nursing care?
  A) The patient will consume 3 to 4 L of fluid each day.
  B) The patient will void every 3 hours.
  C) The patient will express an understanding of the pathophysiology of pyelonephritis.
  D) The patient will maintain his preadmission activities of daily living (ADLs).



16. A 67-year-old woman whose medical history includes obesity, type 2 diabetes, and hypertension has admitted to her care provider that she has often been incontinent of urine over the past several months. In an effort to control her problem, she has been using absorbent pads but is motivated to find a solution to her overactive bladder. What goal should the patient and the nurse emphasize to restore the patient’s urinary continence?
  A) Making lifestyle changes that will result in weight loss
  B) Changing the woman’s diet to reduce her sodium intake
  C) Increasing the frequency of glucometer checks and improving her glycemic control
  D) Monitoring the patient’s blood pressure more closely



17. A 69-year-old man is postoperative day 2 following a transurethral prostatic resection (TUPR). The patient had his urinary catheter removed at 06:00 this morning but has not voided in the 5 hours since the removal, despite the fact that he has been drinking large amounts of fluids. What nursing assessment will most accurately determine whether the patient is retaining urine?
  A) Bladder palpation
  B) Bladder ultrasound
  C) Inspection of the patient’s pubic region
  D) An audit of the patient’s recent intake and output



18. A 62-year-old male patient was diagnosed with type 2 diabetes 5 years ago but has not implemented measures to closely monitor or control his blood sugar levels. As a result, he has begun to experience some of the sequelae of diabetes, including flaccid bladder. In cases of flaccid bladder, what pathophysiological process takes place?
  A) An incompetent sphincter results in a constant dribbling of urine.
  B) Because of a neurological lesion, the patient has no control over when the bladder empties.
  C) The patient’s bladder overfills, leading to overflow incontinence without the patient’s knowledge.
  D) Due to a lesion, the patient experiences inappropriate urges to void that are unrelated to the quantity of urine in the bladder.



19. A nurse is providing care for a patient who has had an indwelling urinary catheter in place for the past several days. To reduce this patient’s risk of developing a catheter-related infection, the nurse should:
  A) Swab the length of the tubing with chlorhexidine once per day.
  B) Ensure that the collection bag is always below the height of the patient’s bladder.
  C) Empty the collection bag whenever the contents are ³250 mL of urine.
  D) Clamp the collection tubing for 2 hours each day unless medically contraindicated.



20. A 49-year-old man has been brought to the emergency department by his wife, who states that her husband is experiencing a repeat episode of kidneys stones. When planning interventions for this patient’s immediate care, what problem is likely to be the priority?
  A) Decreased cardiac output
  B) Pain
  C) Fluid and electrolyte imbalance
  D) Decreased level of consciousness (LOC)



21. A 20-year-old male patient has been brought to the emergency department (ED) by ambulance with a gunshot wound that has resulted in urethral trauma. In light of this patient’s injuries, the ED nurse should anticipate what intervention?
  A) Insertion of a urinary catheter
  B) Cystoscopy
  C) Insertion of a suprapubic catheter
  D) Lithotripsy



22. A nurse is presenting at a community health promotion fair that is focused on disease prevention and screening. A middle-aged participant has brought up an article that she recently read about bladder cancer and has asked the nurse about prevention measures. How should the nurse respond to this woman’s inquiry?
  A) “The majority of people who develop bladder cancer have a family history of the disease, so genetics play a large part.”
  B) “If you smoke cigarettes, quitting will greatly reduce your risk of bladder cancer.”
  C) “People who tend not to drink enough fluids put themselves at an increased risk of bladder cancer.”
  D) “An unhealthy diet is the most significant risk factor for the development of bladder cancer.”



23. Cystoscopy, computed tomography, and a biopsy have culminated in a diagnosis of invasive bladder cancer for a 61-year-old female patient. Consequently, the woman is preparing to undergo a radical cystectomy. The nurse on the urological-gynecological unit of the hospital is aware that this procedure will involve the removal of:
  A) The patient’s urethra and bladder
  B) The patient’s fallopian tubes and uterus
  C) The majority of the patient’s genitourinary system
  D) The patient’s kidneys, ureters, and bladder



24. A 49-year-old male patient has just had an ileostomy created as part of the treatment plan for bladder cancer. The nurse has begun the patient’s discharge planning process and is creating an appropriate plan of care. When planning this patient’s care, what psychosocial nursing diagnosis should the nurse most likely prioritize?
  A) Dysfunctional grieving related to the presence of an ileostomy
  B) Ineffective family coping related to the presence of an ileostomy
  C) Anxiety related to the presence of an ileostomy
  D) Body image disturbance related to the presence of an ileostomy



25. In consultation with her care team, a woman with a diagnosis of cancer has had a continent urinary diversion (Indiana pouch) created. The patient is discussing the advantages and disadvantages of this procedure with her nurse. The nurse should be aware of which of the following advantages of an Indiana pouch?
  A) The patient does not have to wear an external collection bag.
  B) The procedure can be performed on an outpatient basis.
  C) The procedure allows for the spontaneous resumption of normal genitourinary function.
  D) The patient does not require medical follow-up after the procedure.




Answer Key


1. C
2. D
3. A
4. B
5. C
6. B
7. A
8. B
9. A, B, C
10. C
11. A
12. A, C, D
13. C
14. B
15. A
16. A
17. B
18. C
19. B
20. B
21. C
22. B
23. C
24. D
25. A

Chapter 42- Patients With Musculoskeletal Trauma

1. A patient has presented to the emergency room with a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. The emergency room nurse is aware that this description likely indicates which type of fracture?
  A) Compression
  B) Open
  C) Impacted
  D) Transverse



2. A patient has sustained a long bone fracture. The nurse is preparing a care plan for this patient. Which nursing action should the nurse include in the care plan to enhance fracture healing?
  A) Limit weight-bearing and exercising during the recovery.
  B) Monitor color, temperature, and pulses of the affected extremity.
  C) Avoid prolonged immobilization of the fracture fragments.
  D) Administer high doses of corticosteroids.



3. The nurse is assessing a patient’s right knee, and the assessment reveals edema, tenderness, muscle spasms, and ecchymosis. The patient states that 2 days ago he ran a half marathon and now it is painful to stand up. Based upon these symptoms, the nurse should plan care based upon the fact that the patient has likely experienced what?
  A) A first-degree strain
  B) A second-degree strain
  C) A first-degree sprain
  D) A second-degree sprain



4. The nurse is preparing a patient for discharge from the emergency room to home after the patient incurred a sprain to the left ankle. While providing discharge teaching, the nurse should instruct the patient to do what?
  A) Apply heat for the first 24 to 48 hours after injury.
  B) Maintain the ankle in a dependent position.
  C) Exercise hourly by performing rotation exercises of the ankle.
  D) Keep an elastic compression bandage on the ankle.



5. The nurse is writing a care plan for a patient admitted to the emergency department (ED) with an open fracture of the radius. The nurse will assign priority to what nursing diagnosis for this patient?
  A) Risk for infection
  B) Risk for disuse syndrome
  C) Risk for imbalanced nutrition: less than body requirements
  D) Risk for powerlessness




6. The nurse is caring for a patient who had a right extremity below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will achieve these goals?
  A) Encouraging the patient to turn from side to side and to assume a prone position
  B) Initiating range-of-motion (ROM) exercises of the hip and knee 3 months after the amputation
  C) Minimizing movement of the flexor muscles of the hip
  D) Encouraging the patient to sit in the chair for at least 8 hours of the day



7. The nurse at the pediatrician’s office is assessing a 17-year-old soccer player who presented to the clinic stating that he sustained an injury that resulted in the knee being struck medially while his foot was firmly planted on the ground. The nurse knows that the patient likely has experienced what?
  A) Lateral collateral ligament injury
  B) Medial collateral ligament injury
  C) Anterior cruciate ligament injury
  D) Posterior cruciate ligament injury



8. The patient scheduled for a Syme amputation (modified ankle disarticulation amputation) in the morning is concerned about his future ability to stand on the amputated extremity. When he asks the nurse about this, what is the nurse’s best response?
  A) “You will be able to withstand full weight-bearing on this durable extremity after it heals.”
  B) “You will have minimal weight-bearing on this extremity and will require the use of an assistive device.”
  C) “You will not be able to use this extremity and will receive teaching on use of a wheelchair.”
  D) “You will be fitted for a prosthesis, and your commitment to rehabilitation will determine your functional abilities.”



9. Radiographs were ordered for a 10-year-old boy who had his right upper arm injured. The radiographs show that the humerus appears to be fractured on one side and slightly bent on the other. What type of fracture is this an example of?
  A) Impacted
  B) Compound
  C) Compression
  D) Greenstick (incomplete)



10. Six weeks after an above-the-knee (AKA) amputation, a patient returns to the outpatient office for a routine postoperative checkup. During the nurse’s assessment, the patient reports symptoms of phantom pain. To reduce the discomfort of the phantom pain, the nurse should tell the patient to:
  A) Apply hot compresses to the area of the amputation.
  B) Avoid rehabilitation exercises until the pain subsides.
  C) Comfortably increase his level of activity.
  D) Assess for a pulse in the extremity of the amputation every 4 to 6 hours.



11. A 26-year-old man has presented to the emergency department (ED) stating that he has suffered a severe ankle sprain during a basketball game. The triage nurse is conducting a rapid assessment of the patient’s ankle and is including assessment of neurovascular status. In an assessment of neurovascular status, what parameters does the nurse examine? Select all that apply.
  A) The temperature of the patient’s foot and ankle
  B) The skin integrity of the patient’s foot and ankle
  C) The color of the patient’s foot and ankle
  D) The patient’s ability to move his toes
  E) The passive range of motion of the patient’s ankle



12. An 82-year-old woman was diagnosed with osteoporosis several years and has lost more than 5 inches in height over the past several years as a result of structural changes in her vertebrae. The nurse should recognize that this woman is experiencing the effects of:
  A) A Colles’ fracture
  B) A compression fracture
  C) A stress fracture
  D) An impacted fracture



13. An older adult man has been diagnosed with a femoral head fracture after falling outside his home, and his health care provider has chosen open reduction with internal fixation (ORIF). How should the nurse best explain this procedure to the patient?
  A) “The surgeon will give you an anesthetic and then apply a cast.”
  B) “The surgeon will place plates or rods outside your hip and keep you in traction until your bones heal.”
  C) “The surgeon will use pins and rods to keep your bones in place until they heal.”
  D) “The surgeon will use a scope inserted through punctures in your skin to remove any bone fragments.”



14. The nurse is conducting a scheduled assessment of a female patient who has been admitted to the unit following surgical repair of her fractured humerus. Which of the following assessment findings should prompt the nurse to contact the patient’s care provider?
  A) The patient’s capillary refill in her fingers is 1 to 2 seconds.
  B) The patient is able to wiggle each of her fingers and her thumb.
  C) There is a moderate amount of edema in the patient’s hand and fingers.
  D) The patient states that her hand and her fingers are numb.



15. A 77-year-old man is recovering in the hospital after a recent femoral fracture and has rung his call light. The nurse has entered the room to find the patient in distress, clutching his chest while struggling to say, “I can’t breathe.” The nurse should take prompt action based on the knowledge that this patient may be experiencing what complication of lower extremity fractures?
  A) Thromboembolism
  B) Unstable angina
  C) Acute respiratory distress syndrome (ARDS)
  D) Ischemic stroke



16. A middle-aged woman sustained an elbow fracture in a bicycle crash and has required reduction and fixation to aid healing. The nurse is aware of the need for vigilant neurovascular assessment. How should the nurse assess the function of the patient’s ulnar nerve?
  A) Ask the patient to clench and unclench her fist several times.
  B) Ask the patient to rotate her hand at the wrist.
  C) Touch the back of the patient’s hand with a pen and ask if the patient is able to feel the sensation.
  D) Ask the patient to spread her fingers as widely as possible.



17. A nurse who provides care on a reconstructive orthopedic unit has walked past the room of a patient who is receiving balanced suspension traction for the treatment of a femoral head fracture. The nurse observes a nursing assistant lifting the suspended weights to facilitate positioning a bedpan under the patient. How should the nurse best follow-up this observation?
  A) Ensure the nursing assistant knows that such transfers must be performed quickly and efficiently.
  B) Assess the patient for the ability to transfer to a commode rather than using a bedpan.
  C) Teach the nursing assistant that weights should not be removed from traction, except in an emergency.
  D) Teach the nursing assistant to apply temporary weights to compensate for positional changes.



18. Four hours after his fractured radius was fit with a cast, a 20-year-old man has returned to the cast clinic stating that his arm “hurts even more than when I broke it.” The nurse’s gentle manipulation of the patient’s fingers causes his excruciating pain. What action should the nurse take?
  A) Administer 5 mg oxycodone PO.
  B) Apply warm compresses the patient’s hand and reassess in 15 minutes.
  C) Document the patient’s complaint and implement distraction techniques.
  D) Report the patient’s symptoms to the primary care provider.



19. A 14-year-old boy has come to the cast clinic with his mother for the scheduled removal of his arm cast. In preparation for this procedure, what teaching point should the nurse provide to the boy?
  A) “Don’t be surprised if your arm looks skinnier than it normally does.”
  B) “There usually a little bit of blood under the cast, but that’s nothing to be alarmed about.”
  C) “I’ll give you some pain pills around half an hour before the removal.”
  D) “I’ll give you some medicine to relax you for the procedure, and it will ensure that you won’t remember it.”



20. An orthopedic trauma patient is receiving lower-body skeletal traction and will continue to do so for several weeks. When planning the patient’s care, what nursing diagnosis should be prioritized?
  A) Risk for impaired skin integrity
  B) Risk for ineffective protection
  C) Risk for self-care deficit, feeding
  D) Risk for bowel incontinence



21. A female patient is sufficiently stable to be transferred from the PACU to the postsurgical unit following her total hip replacement surgery early this morning. When preparing to admit this patient, the nurse on the postsurgical unit should anticipate that the patient will require what positioning?
  A) Supine with her knees slightly elevated
  B) With her legs slightly abducted
  C) In a high Fowler’s position with knees elevated
  D) With a low head-of-bed and with her knees touching each other



22. A patient is recovering in the hospital following a total hip replacement that was performed 2 days ago. In an effort to prevent the common complications associated with the surgical procedure, the nurse should implement which of the following interventions, as ordered?
  A) Passive range-of-motion (ROM) exercises with the affected leg
  B) Provision of a low-fiber, high-calorie diet
  C) Application of sequential compression devices
  D) Intermittent urinary catheterization to prevent urinary retention



23. The nurse is providing health education for a male patient who is preparing to be discharged home following a recovery from total hip replacement surgery. When reviewing the guidelines for safe mobility and positioning to prevent injury, the nurse should teach the patient to:
  A) Perform sit-ups to build core muscle strength.
  B) Resume normal sexual activity after waiting 1 week.
  C) Perform stair-climbing to build muscle strength.
  D) Avoid crossing his legs for the next several months.



24. A patient with a history of chronic foot ulcers secondary to diabetes has been admitted to the preoperative clinic in preparation for a metatarsal amputation. The patient appears stoic and avoids making eye contact with the nurse, while answering assessment questions with one-word answers. How should the nurse best respond to this patient’s demeanor?
  A) Ask the patient if he would like to have a p.r.n. benzodiazepine.
  B) Ask the patient if he is experiencing signs and symptoms of depression.
  C) Reassure the patient that many individuals with amputations lead fulfilling lives.
  D) Try to gently assess the patient’s feelings around this procedure.



25. Traumatic injuries suffered in a workplace accident have required a 30-year-old man to have a below-the-knee (BKA) amputation. At what point following surgery should the nurse begin range-of-motion (ROM) exercises with this patient?
  A) As soon as possible following surgery
  B) Once the patient has been fitted with a prosthesis
  C) After it has been determined that there are no postsurgical complications
  D) Four to six weeks after surgery




Answer Key


1. B
2. B
3. B
4. D
5. A
6. A
7. A
8. A
9. D
10. C
11. A, C, D
12. B
13. C
14. D
15. A
16. D
17. C
18. D
19. A
20. A
21. B
22. C
23. D
24. D
25. A

Chapter 56- Emergencies and Disasters

1. Which patient would the nurse prioritize as needing emergency treatment, assuming no other injuries are present except the ones outlined below?
  A) A patient with blunt chest trauma with some difficulty breathing
  B) A patient with a sore neck that was immobilized in the field on a backboard with a cervical collar
  C) A patient with a possible fractured tibia with adequate pedal pulses
  D) A patient with acute confusion due to a drug reaction



2. A patient is brought to the emergency department by ambulance with a gunshot wound to the abdomen. The nurse knows that the most common hollow organ injured in this type of injury is what?
  A) Liver
  B) Small bowel
  C) Stomach
  D) Large bowel



3. A patient has been brought to the emergency department with multiple trauma after a motor vehicle accident. After immediate threats to life have been corrected, the nurse and trauma team should:
  A) Perform a rapid physical assessment.
  B) Splint the patient’s fractures.
  C) Perform a detailed physical examination.
  D) Establish the patient’s previous medical history.



4. A 13-year-old is being admitted to the emergency department after falling from a roof. The patient has sustained blunt abdominal injuries. What is the most effective diagnostic test to assess for internal injury in the peritoneum of a patient who has a fall?
  A) Radiograph
  B) Computed tomography (CT) scan
  C) Complete blood count
  D) Barium swallow



5. A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the health care provider will implement which of the following interventions?
  A) Administration of bronchodilators
  B) Jaw thrust maneuver
  C) Endotracheal intubation
  D) Cricothyroidotomy



6. The nurse is caring for a patient who has difficulty maintaining a patent airway due to hemorrhage in the oral cavity. What would be the most appropriate nursing diagnosis for this patient?
  A) Ineffective Airway Clearance
  B) Impaired Swallowing
  C) Risk for Trauma
  D) Risk for Contamination



7. A workplace explosion has injured many workers and has left a 40-year-old male client with full-thickness burns over 65% of his body and massive internal injuries. To what category would this person be triaged?
  A) Green
  B) Yellow
  C) Red
  D) Black



8. A nurse is caring for patients exposed to a terrorist attack involving chemicals. The nurse has been advised that personal protective equipment must be worn in order to give the highest level of respiratory protection with a lesser level of skin and eye protection. What level of protection is this considered?
  A) Level A
  B) Level B
  C) Level C
  D) Level D



9. A patient exposed to anthrax by inhalation is being treated in the local hospital. What signs and symptoms would indicate that the patient is in the second stage of infection?
  A) Headache
  B) Vomiting
  C) Syncope
  D) Respiratory distress



10. A group of disaster survivors is being defused by the critical incident stress management (CISM) team. What explanation describes the purpose of defusing?
  A) To assess how the patient is coping emotionally after the disaster
  B) To educate the patient on future coping strategies in future disasters
  C) To provide individuals with education about recognizing stress reactions
  D) To assess the need for referral to mental health



11. An 82 year-old woman who lives on her own has been brought to the emergency department after being found down in her apartment for two days. The woman is showing early signs of hypovolemic shock with tachycardia, lethargy, and hypotension. At what level would this patient most likely be triaged?
  A) Level 1: Resuscitation
  B) Level 2: Emergent
  C) Level 3: Urgent
  D) Level 4: Nonurgent



12. An older adult patient has presented to the emergency department (ED) with a 12-hour history of copious bloody diarrhea. Following the appropriate assessments, what intervention should the ED nurse prioritize?
  A) Position the patient in the Trendelenburg position to maximize cerebral perfusion.
  B) Establish intravenous access to administer fluid replacement.
  C) Immobilize the patient to minimize metabolic activity.
  D) Administer oral ferrous sulfate.



13. A 15-year-old boy has been brought to the emergency department by his friends after severing his brachial artery while trying to scale a fence. In order to stop this patient’s bleeding, the nurse should:
  A) Apply a tourniquet proximal to the site of the wound.
  B) Apply direct pressure to the wound.
  C) Administer platelets.
  D) Apply a tourniquet distal to the wound.



14. A middle-aged man has come to the emergency department because his foot slipped under his lawnmower, causing trauma to all his toes and to the metatarsal region of his foot. When providing wound care in the emergency room setting, what intervention should the nurse perform?
  A) Immediately apply a sterile wound dressing.
  B) Irrigate the wound with normal saline.
  C) Apply lidocaine to the skin surfaces adjacent to the wound.
  D) Apply an ice pack to the patient’s wound.



15. A young male patient has been brought to the emergency department with a knife wound to the abdomen. When the patient’s hands are removed from the area of the wound to facilitate assessment, the patient’s intestine protrudes from the wound. How should the nurse respond to this development?
  A) Cover the protruding viscera with saline-soaked, sterile gauze.
  B) Don sterile gloves and attempt to push the organ back inside the wound.
  C) Irrigate the protruding intestine with sterile water or normal saline.
  D) Apply a pressure dressing to the wound.



16. A mountain biking accident has resulted in blunt trauma to a patient’s right upper and right lower abdominal quadrants. The emergency room nurse should recognize that this patient’s injuries create a high risk of:
  A) Orthopedic trauma
  B) Metabolic acidosis
  C) Thromboembolism
  D) Hemorrhage



17. Diagnostic peritoneal lavage (DPL) has been ordered for a patient who has suffered abdominal injuries in a farm accident. When explaining this procedure to the patient, what information should the nurse provide?
  A) “You’ll have some fluid injected into your abdomen and then it will be withdrawn to see if the same amount is returned.”
  B) “You’ll have fluid injected into your abdomen and then you’ll be monitored to see if it comes out in your urine or when you have a bowel movement.”
  C) “Fluid will be put into your abdomen and then pulled out and examined to see if blood or gastrointestinal contents are present.”
  D) “Fluid will be put into your abdomen and removed. This will be repeated several times in order to flush out your abdominal space.”



18. A trauma patient in the emergency department (ED) is showing signs of acute renal failure that the care team suspects are due to myoglobinuria. The ED nurse should recognize that these problems are most closely associated with what type of injury?
  A) Hemorrhage
  B) Severe lacerations
  C) Crush injury
  D) Blunt force trauma



19. The triage nurse’s assessment of a girl who has been brought in by her frantic parents reveals that the girl is likely in anaphylaxis. After establishing a patent airway, what action should the emergency department care team prioritize?
  A) Nebulized administration of albuterol
  B) Parenteral administration of epinephrine
  C) IV administration of hydrocortisone
  D) Sublingual administration of nitroglycerin



20. An older adult who used a propane heater to warm his apartment has been admitted to the emergency department with suspected carbon monoxide poisoning. The emergency department nurse can most accurately gauge the patient’s status by which of the following assessments?
  A) Anterior and posterior lung auscultation
  B) Assessment of oxygen saturation by pulse oximetry
  C) Analysis of carboxyhemoglobin levels
  D) Analysis of hemoglobin, hematocrit, and red blood cell levels



21. While participating in a disaster response exercise, a nurse has been reminded by the coordinators that triage in a mass casualty incident (MCI) event differs from triage in nondisaster circumstances. What principle will care providers use to guide the allocation of scarce health care resources in an MCI?
  A) Ensure that every victim receives an equitable amount of care.
  B) Do the greatest amount of good for the largest number of victims.
  C) Prioritize the care of the most critically ill victims.
  D) Focus efforts on victims with the highest risk of death.



22. In light of a recent terrorist threat involving a potent neurotoxin, the staff of a large urban hospital are participating in a preparedness exercise. The Incident Command System (ICS) has specified that staff would likely require level A protection, which would consist of:
  A) Gloves, gown, and safety shield
  B) An N-95 mask and a face shield
  C) A self-contained breathing apparatus (SCBA)
  D) A self-contained breathing apparatus (SCBA) and a chemical-resistant suit



23. In accordance with a directive from the Joint Commission, the nurse who oversees the care at a small long-term care facility has been directed to create a disaster plan. This plan should address which of the following considerations?
  A) A policy for rapid reappraisal of residents’ code status during a disaster
  B) A protocol for defining staff roles and responsibilities in a disaster
  C) A strategy for acquiring antidotes to biological weapons
  D) A plan for including residents’ family members in care during a disaster



24. A terrorist group has announced that they are responsible for the release of a nerve agent in a busy commuter rail station and victims are now being brought to the nearest hospital. Nurses at this hospital should be aware that these victims:
  A) Will have extensive skin lesions and hemorrhage from their mucous membranes
  B) Will likely have massive pulmonary and peripheral edema
  C) Will be experiencing physical erosion of their pulmonary mucosa
  D) Will likely have signs and symptoms similar to those of a cholinergic crisis



25. A terrorist group has announced that they are responsible for the release of a nerve agent in a busy commuter rail station and victims are now being brought to the nearest hospital. Nurses at this hospital should be aware that these victims:
  A) Will have extensive skin lesions and hemorrhage from their mucous membranes
  B) Will likely have massive pulmonary and peripheral edema
  C) Will be experiencing physical erosion of their pulmonary mucosa
  D) Will likely have signs and symptoms similar to those of a cholinergic crisis




Answer Key


1. A
2. B
3. A
4. B
5. C
6. A
7. D
8. B
9. D
10. C
11. B
12. B
13. B
14. B
15. A
16. D
17. C
18. C
19. B
20. C
21. B
22. D
23. B
24. D
25. D



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