Test Bank For Introduction To Medical Surgical Nursing 6th Edition By Linton

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Introduction to Medical-Surgical Nursing, 6th Edition

Chapter 01: The Health Care System

Linton: Introduction to Medical-Surgical Nursing, 6th Edition

 

MULTIPLE CHOICE

 

  1. An 89-year-old man, who was recently discharged from a rehabilitation hospital because of an inability to concentrate and frequent memory lapses, cannot be left alone while his family works. What options should the discharge planning team suggest that will satisfy safety concerns and give the greatest quality of life to the patient?
a. Placement in a day care center from 8 AM to 5 PM daily
b. Placement in a long-term psychiatric facility
c. Placement in a high-security nursing home
d. Admission to a general hospital for evaluation

 

 

ANS:  A

Day care centers provide supervision, safety, nutritious meals, and socialization while the caregiving family works.

 

DIF:    Cognitive Level: Application          REF:   p. 7                OBJ:   5

TOP:   Day Care Centers                           KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Reduction of Risk

 

  1. A 66-year-old hospitalized patient is anxious about how the physician will be paid now that he is on Medicare Parts A and B, instead of his previous privately funded insurance plan. Who should the nurse explain is the payor to the physician on this plan?
a. Previous privately funded insurance plan
b. Medicare Part A
c. Medicare Part B
d. Patient or patient’s family

 

 

ANS:  C

Part A pays skilled care facilities. Part B pays for physician’s services. The previously held insurance is no longer available because of the patient’s age. The family or patient is not responsible because Part B is in effect.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 11              OBJ:   4

TOP:   Health Care Funding                       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. What health care plan is the best referral for an unemployed 42-year-old patient with renal failure who has lost his job-related private insurance?
a. Medicare
b. Medicaid
c. Public health facility
d. Community-based outpatient clinic

 

 

ANS:  B

Medicaid is available to needy low-income persons younger than 65 years of age who have a permanent disability. Medicare is for persons 65 years and older. Public health services are involved with prevention more often than with chronic care.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 11              OBJ:   4

TOP:   Health Care Funding                       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. A patient with terminal lung cancer with extensive metastasis is requesting a hospice transfer. What criteria are included as requirements for this transfer?
a. The patient requests and agrees to the guidelines of hospice care without requiring a physician’s order.
b. The physician confirms that the patient has 6 months or less of life remaining and has provided a written order for hospice care.
c. Proof confirms that the family can no longer care for the patient at home.
d. The patient’s specific diagnosis is included on a list of accepted diseases that qualifies the patient for hospice care.

 

 

ANS:  B

The four criteria for transfer to hospice care are (1) diagnosis of any terminal illness, (2) prognosis of less than 6 months of life, (3) informed consent of patient, and (4) written physician’s order.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 7                OBJ:   5

TOP:   Hospice Care                                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A patient admitted yesterday with a diagnosis-related group (DRG) diagnosis of abdominal pain of an unknown cause is being discharged this afternoon because all diagnostic test results have been negative. What does this scenario exemplify?
a. Effective laboratory response
b. Medicare guidelines limiting hospital stay
c. Cost containment related to a DRG diagnosis
d. Patient who should not have been admitted in the first place

 

 

ANS:  C

Cost containment is a means by which the cost of hospitalization time is reduced when the need for acute hospital care is no longer necessary.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 11-12         OBJ:   6

TOP:   Cost Containment per DRGs          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A nurse is discussing discharge to a transitional subacute facility with a 72-year-old patient diagnosed with diabetes and bilateral leg amputation. What should the nurse inform the patient regarding the stay in the new facility?
a. It will be limited to 25 days.
b. It will be limited to 50 days.
c. It will be limited to 75 days.
d. It is totally unlimited.

 

 

ANS:  D

Medicare limitations are waived for patients who have undergone amputations.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 8                OBJ:   4

TOP:   Stay in a Skilled Care Facility         KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. A patient is applying for Medicaid. What does the receipt of benefits require?
a. Following a supervised health maintenance plan
b. Enrolling in the Medicare-Preferred Drug Plan
c. Qualifying for the food stamp program
d. Having an annual income of less than $10,000

 

 

ANS:  B

The Medicare-Preferred Drug Plan is a condition of Medicaid eligibility. Nonenrollment may cause the loss of all health care benefits.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 11              OBJ:   4

TOP:   Medicare-Preferred Drug Plan        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Coordinated Care

 

  1. Which is true concerning proprietary agencies?
a. They are organized to be nonprofit operations.
b. They are organized to make a profit on their operation.
c. Any profit they make is immediately used to purchase better equipment and services.
d. They must participate in Medicare.

 

 

ANS:  B

These agencies are usually owned by large corporations and established for the purpose of making a profit. Although most such agencies do participate in Medicare, it is not required.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 6                OBJ:   6

TOP:   Proprietary Agencies                                 KEY:              Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which patient should the nurse recognize as eligible for a referral to Medicaid?
a. Military automobile mechanic with severe asthma
b. Pregnant unmarried young woman employed at a discount retail store for 3 years
c. College student on scholarship who works part-time at the college library and who needs medication for arthritis
d. Unemployed young mother on welfare who needs diabetic medication for one of her children

 

 

ANS:  D

Medicaid covers medication and health care services for welfare recipients for child health and long-term care.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 11              OBJ:   4

TOP:   Medicaid Services Eligibility          KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Coordinated Care

 

  1. Why was the Balanced Budget Act of 1997 the cause of closures of many proprietary home health care agencies?
a. It specified that all care be given by registered nurses (RNs).
b. It listed specific diagnoses that could qualify a patient for home health care.
c. It limited the amount of money that could be spent on a patient.
d. It increased the criteria for patient eligibility for home care.

 

 

ANS:  C

The Balanced Budget Act of 1997 placed a limit on the amount of money that could be spent on a patient’s home health care regardless of diagnosis or needs.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 6                OBJ:   6

TOP:   Balanced Budget Act of 1997        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Who is considered the forerunner of modern public health nursing in the United States?
a. Vincent DePaul
b. William Rathbone
c. Florence Nightingale
d. Lillian Wald

 

 

ANS:  D

Lillian Wald is recognized as the forerunner of modern public health nursing.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 4                OBJ:   1

TOP:   Leaders and Founders of Public Health Nursing             KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What is true about voluntary health care agencies?
a. They are supported by tax dollars.
b. They are governed by boards made up of community members.
c. They receive no fee for services.
d. They use volunteers as health care providers.

 

 

ANS:  B

Voluntary agencies are governed by boards made up of community members and are supported by a variety of sources. They are not supported by tax dollars.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 5                OBJ:   5

TOP:   Voluntary Agencies                        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Health Promotion and Maintenance: Coordinated Care

 

  1. A client who is hospitalized for treatment after a stroke asks the nurse how long Medicare can be expected to cover his treatment. What is the nurse’s most informative response?
a. “Your Part B will cover your hospital care as long as is necessary.”
b. “Your health care provider will determine how long your Medicare coverage will be in effect.”
c. “You are allowed 50 days of inpatient care annually.”
d. “You can receive skilled care for up to 100 days.”

 

 

ANS:  D

Persons hospitalized for skilled nursing care receive 100 days of Medicare coverage.

 

DIF:    Cognitive Level: Application          REF:   p. 11              OBJ:   4

TOP:   Skilled Care Limitation                   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Coordinated Care

 

  1. What statement exemplifies that health care benefits are supported by both federal and state funding?
a. Cost-containment prospective funding
b. Department of Health and Human Services (DHHS) Social Security benefits for dentures
c. Centers for Disease Control and Prevention (CDC) surveillance of persons at risk for acquired immunodeficiency syndrome (AIDS)
d. Medicaid provision for skilled care in the home

 

 

ANS:  D

Federal and state cooperation are involved in home skilled care issues.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 11              OBJ:   4

TOP:   Coordinating Medicaid/Medicare Benefits

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Coordinated Care

 

  1. A nurse is assessing a 65-year-old patient scheduled for outpatient cataract removal surgery in 10 days. What should the nurse stress this patient will need?
a. Adequate insurance
b. Adequate postoperative care at home
c. Specialized glasses
d. Preservation and protection of vision

 

 

ANS:  B

Outpatient surgical patients are at great risk for postoperative complications in the absence of professional monitoring. This risk emphasizes the need for preoperative teaching and the provision of postoperative support in the home.

 

DIF:    Cognitive Level: Application          REF:   p. 4                OBJ:   6

TOP:   Postoperative Care for Outpatients KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Coordinated Care

 

  1. With what type of professionals are skilled nursing facilities mandated to staff facilities?
a. Licensed health professionals around the clock
b. RN in charge on each shift
c. RNs to supervise the patient care given by aides
d. Only RNs to provide complex care

 

 

ANS:  A

A skilled facility must have licensed health care professionals around the clock. Licensed practical nurses (LPNs) may supervise nursing assistants (NAs), who are the major caregivers. LPNs can provide wound care and ostomy care and monitor intravenous therapies.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 9                OBJ:   5

TOP:   Skilled Nursing Facilities Staffing Requirements

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. What is the purpose of a long-term care facility?
a. Rehabilitation of patients to their former level of functioning
b. Restoration of patients to their optimal level of independence
c. To offer care to patients who do not need hospitalization but cannot care for themselves
d. Exclusive care for patients with dementia

 

 

ANS:  C

Long-term care facilities care for patients who do not need to be hospitalized but who cannot care for themselves. Although many patients with dementia are residents in a long-term care facility, the purpose of such facilities is not to provide their care exclusively.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 9                OBJ:   5

TOP:   Long-Term Care Facilities              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. A resident in a long-term care facility has difficulty swallowing and frequently chokes on food and liquids. The nurse identifies an increased risk of aspiration. To whom should the nurse initiate a referral for a swallowing evaluation?
a. Physician who specializes in throat disorders
b. Dietitian
c. Nutritionist
d. Speech therapist

 

 

ANS:  D

Speech therapists are qualified to evaluate swallowing disorders.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 6                OBJ:   5

TOP:   Swallowing Difficulties                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Coordinated Care

 

  1. What did the 2003 report from the Institute of Medicine (IOM), “Health Professions Education: A Bridge to Quality,” outline?
a. Specific software technology to increase efficiency in health care
b. Evaluation tool to evaluate the quality of health care
c. Recommendations for curriculum changes in professional health care schools
d. Five core competencies for health care professionals

 

 

ANS:  D

The 2003 IOM report “Health Professions Education: A Bridge to Quality” stressed the need for health professionals to be proficient in five areas: (1) providing patient-centered care, (2) working as a member of a team, (3) using evidence-based medicine, (4) focusing on quality improvement, and (5) using information technology.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 12              OBJ:   8

TOP:   IOM Report    KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. What is the difference between a health maintenance organization (HMO) and a fee-for-service plan? (Select all that apply.)
a. An HMO requires a set fee from each client.
b. An HMO allows clients to select their own health care providers.
c. An HMO permits admission to any inpatient facility.
d. An HMO offers limited referral options.
e. An HMO provides both inpatient and outpatient care.

 

 

ANS:  A, E

HMOs require a set fee from each client to use health care providers specified or hired by each HMO. Inpatient and outpatient care are provided in specified facilities. HMOs have a large group of specialists to whom it refers clients. Fee-for-service plans are more expensive, but they allow clients to choose the health care provider and facility.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 5 | p. 7 | p. 10

OBJ:   4                    TOP:   Comparison of HMO to Fee-for-Service

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Coordinated Care

 

  1. What should a nurse assure the parents of a newborn with a congenital heart defect that will ease and support the home care for their child? (Select all that apply.)
a. Availability of smaller and more compact equipment
b. Specialized DRGs for home care of children
c. Medicaid-funded home care services
d. Home care services funded by private insurance
e. Grants and stipends from various drug manufacturers

 

 

ANS:  A, B, C, D

Medicaid funds home care for children, specialized DRGs, and home-sized equipment make home care for children more easily accomplished.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 11-12         OBJ:   4

TOP:   Home Health Care for Children      KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Coordinated Care

 

  1. A nurse outlines the benefits of using a home health aide to a homebound patient. With what should the home health aide assist this patient? (Select all that apply.)
a. Bathing
b. Doing laundry
c. Shopping for groceries
d. Administering medications
e. Ambulating

 

 

ANS:  A, E

Home health aides may assist with bathing, ambulation, skin care, and minor homemaking chores. They are not qualified to administer medications. Tasks of laundry, heavy house cleaning, and grocery shopping are inappropriate for home health aides and are more appropriately assigned to a homemaker serviceperson.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 6                OBJ:   5

TOP:   Home Health Aid Utilization          KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Coordinated Care

 

  1. A patient inquires about eligibility for home health care. What should the nurse explain is the criteria for skilled home health care? (Select all that apply.)
a. Annual income less than $20,000
b. Need for physical or speech therapy
c. Nonavailability of transportation
d. Must be homebound
e. Need for wound dressing changes

 

 

ANS:  B, D, E

Eligibility for skilled care from a home health care aide includes the need for nursing care for IV therapies, respirators, wound dressing changes, and physical or speech therapy. No requirement relative to low income or the lack of transportation exists, but the patient must be homebound.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 5-6             OBJ:   5

TOP:   Home Health Care                          KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. What is the mission of the Public Health Service (PHS)? (Select all that apply.)
a. Ensure safety of foods and cosmetics.
b. Provide access to health care services for low-income individuals.
c. Conduct medical research.
d. Support substance abuse prevention and treatment.
e. Monitor and prevent disease outbreaks.
f. Provide insurance coverage for low-income individuals.

 

 

ANS:  A, B, C, D, E

The PHS focus is on all levels of ensuring community health, both in providing treatment and supporting prevention. The PHS also supports medical research.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 2                OBJ:   3

TOP:   Public Health Service                                KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. What is true regarding the Medicare Prescription Drug Plan? (Select all that apply.)
a. It is included in Medicare Part A.
b. There is a $250 deductible.
c. Approximately 25% of prescription drug expenses are covered.
d. Only prescriptions written by a medical physician are covered.
e. It reimburses 95% of out-of-pocket expenses over $3600.

 

 

ANS:  B, E

Medicare Prescription Plan (Medicare Part D) requires a separate enrollment, pays 50% of drug expenses after the $250 deductible is satisfied, honors all prescriptions written by licensed medical personnel who have prescriptive power, and covers 95% of out-of-pocket expenses up to $3600.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 10-11         OBJ:   4

TOP:   Medicare Prescription Plan             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. Why do physicians prefer to use e-prescription systems? (Select all that apply.)
a. Drug requests are processed more efficiently.
b. Drug duplications are prevented.
c. Less expensive drugs are used.
d. Contraindications for a drug are identified.
e. Both the generic and trade names are labeled.

 

 

ANS:  A, B, D

E-prescription systems that expedite the request also generate drug information related to contraindications and side effects and can identify duplication of drugs.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 12              OBJ:   8

TOP:   Topic: E-prescriptions                    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk

 

  1. What services are considered to be under the administration of the U.S. Department of Health and Human Services (HHS)? (Select all that apply.)
a. Public Health Service (PHS)
b. Administration for Children and Families
c. Administration on Aging
d. American Medical Association
e. Centers for Medicare and Medicaid

 

 

ANS:  A, B, C, E

The Public Health Service (PHS), Administration for Children and Families, Administration on Aging, and Centers for Medicare and Medicaid all share the administration of the Department of Health and Human Services (HHS).

 

DIF:    Cognitive Level: Knowledge          REF:   p. 2                OBJ:   5

TOP:   DHHS            KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

COMPLETION

 

  1. The nurse clarifies that the insurance plan that pays the physician in advance each month for each enrolled patient, whether or not the patient is treated by the physician, is a strategy known as _____.

 

ANS:

capitation

Capitation is the system of payment that collects monthly “fees” from enrollees and pays the physician whether the patient has been treated or not. It is rather like a salary that assures the attention of a physician in the event of an illness.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 10              OBJ:   4

TOP:   Capitation      KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment

Chapter 03: Legal and Ethical Considerations

Linton: Introduction to Medical-Surgical Nursing, 6th Edition

 

MULTIPLE CHOICE

 

  1. A good friend of a licensed practical/vocational nurse (LPN/LVN) confides that she is in a serious romantic relationship with a man the LPN/LVN had as a patient when he was diagnosed with the human immunodeficiency virus (HIV). The policies of the Health Insurance Portability and Accountability Act (HIPAA) prevent the nurse from warning her friend. What is this situation considered?
a. Moral dilemma
b. Moral uncertainty
c. Moral distress
d. Moral outrage

 

 

ANS:  C

Moral distress occurs when a nurse feels powerless because moral beliefs cannot be honored because of institutional or other barriers.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 32              OBJ:   1

TOP:   Moral Distress                                           KEY:              Nursing Process Step: N/A

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. A nurse reminds a resident in a long-term care facility that he has autonomy in many aspects of his institutionalization. What is an example of autonomy?
a. Selection of medication times
b. Availability of his own small electrical appliances
c. Smoking in the privacy of his own room
d. Application of advance directives

 

 

ANS:  D

The application of advance directives is an autonomous decision. Agency protocols relative to medication times, access to private electrical devices, and smoking are rarely waived; these policies are not in the control of the resident.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 32              OBJ:   2

TOP:   Autonomy      KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. How might an LPN/LVN exhibit beneficence?
a. Remove defective equipment from the patient’s room.
b. Willingly work extra shifts during a staff shortage.
c. Adhere to agency policy.
d. Join the National Association for Practical Nurse Education and Service (NAPNES) and attend educational seminars.

 

 

ANS:  A

Beneficence means promoting good and reducing harm. Removing defective equipment demonstrates that the LPN/LVN is reducing possible harm to the patient. Working extra shifts, adhering to policy, and joining NAPNES are personal values, not beneficence.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 32              OBJ:   2

TOP:   Beneficence   KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. An LPN/LVN is educating a group of nursing students regarding values demonstrated in their nursing practice. Where will the LPN/LVN indicate the base of these values is derived?
a. Nursing school education
b. Family influence
c. Peer relationships
d. Agency policies

 

 

ANS:  B

The family shapes values that are demonstrated in later life. These values may be enhanced or challenged by life experiences, but the base is forged in the family.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 32              OBJ:   3

TOP:   Values            KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. One obstetric nurse remarks, “I don’t see how these young single women can keep on having babies without being married. Everyone knows a child needs a father.” What is this nurse exhibiting?
a. Ethnocentrism
b. Moral uncertainty
c. Values clarification
d. Professional concern

 

 

ANS:  A

Ethnocentricity is the belief that one’s own culture and values are superior to those of another. Such statements are based on values clarification and, perhaps, on moral outrage.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 33              OBJ:   5

TOP:   Ethnocentrism/Values Clarification                                           KEY:   Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A nursing student asks the instructor to define the philosophic stand of utilitarianism. What example should the instructor provide?
a. An army officer sacrifices six paratroopers to save 100 prisoners of war.
b. A priest burns down his church because it was defiled by Satanists.
c. A mother jumps off a cliff with her baby to avoid being captured by Indians.
d. A soldier murders captured enemies to prevent their divulging military secrets.

 

 

ANS:  A

The sacrifice of six to save 100 is an example of the greater good. The other options are based on the philosophy of deontology.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 33              OBJ:   6

TOP:   Utilitarianism                                  KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. An LPN/LVN explains to a patient that the hospital has an institutional ethics committee. What is the main function of this committee?
a. Preside over policy implementation.
b. Revoke the license of someone who violates the law.
c. Solve personnel disputes.
d. Ensure that hiring adheres to ethnic equality.

 

 

ANS:  A

The main job of the institutional ethics committee is to preside over the implementation of agency policy.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 34              OBJ:   8

TOP:   Institutional Ethics Committee        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. An LPN/LVN charts that “the patient is drunk and acting in a crazy manner.” The team leader cautions the LPN/LVN that this documentation is not appropriate. What charges of commission of the intentional tort is this an example of?
a. Assault
b. Wrongful publication
c. Defamation of character
d. Invasion of privacy

 

 

ANS:  C

Charting or saying unsupported defamatory statements can lead to tort litigation.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 38              OBJ:   2

TOP:   Torts              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. When an LPN/LVN assists an older woman to stand after a fall in a shopping mall parking lot, the woman twists and sprains her ankle. What protects the LPN/LVN from litigation or an unintentional tort?
a. Hospital malpractice insurance
b. Good faith agreement
c. Good Samaritan law
d. Personal professional insurance

 

 

ANS:  C

The Good Samaritan law protects individuals who assist at an accident scene if they act in good faith. Professional insurance is not in effect because the actions were not performed while the LPN/LVN was on duty.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 39              OBJ:   2

TOP:   Torts              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. An LPN/LVN trimmed the toenails of a patient with diabetes too short, which results in a toe amputation from infections. What is the LPN/LVN guilty of?
a. Unintentional tort
b. Intentional tort
c. Negligence
d. Malpractice

 

 

ANS:  D

Malpractice occurs when an unintentional tort causes an injury to a patient.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 39              OBJ:   2

TOP:   Malpractice    KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. What must an LPN/LVN acquiring a signature on a surgical informed consent document ensure?
a. The patient is not sedated.
b. The physician is present.
c. The family member is a witness.
d. The signature is in ink.

 

 

ANS:  A

Before surgery, the consent form must be signed before any preoperative sedation is administered. A sedated person cannot give a valid consent.

 

DIF:    Cognitive Level: Application          REF:   p. 40              OBJ:   9

TOP:   Informed Consent                          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. A physician has written an order for Synthroid, 137 mg. The LPN/LVN is aware that the drug is measured in micrograms. What action should the nurse implement?
a. Transcribe the order as if it were written in micrograms.
b. Notify the nursing supervisor.
c. Transcribe the order as written.
d. Call the prescribing physician.

 

 

ANS:  D

The LPN/LVN may call the physician to clarify the order but may not alter the written order in any way. The order for the correct dose will be written as a new order.

 

DIF:    Cognitive Level: Application          REF:   p. 40              OBJ:   12

TOP:   Doctor’s Orders                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. A physician has written an order for morphine sulfate, 100 mg. The LPN/LVN inquires if he meant to write 10 mg. The physician confirms that he meant 100 mg. What action should the LPN/LVN implement?
a. Call a member of the hospital administration.
b. Refuse to transcribe the order.
c. Call the pharmacist.
d. Notify the nursing supervisor.

 

 

ANS:  D

In the event of a physician’s refusal to clarify a questionable order, the LPN/LVN should notify the nursing supervisor to intervene.

 

DIF:    Cognitive Level: Application          REF:   p. 40              OBJ:   12

TOP:   Doctor’s Orders                              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

MULTIPLE RESPONSE

 

  1. On what are health care ethics based? (Select all that apply.)
a. Autonomy
b. Fidelity
c. Professionalism
d. Justice
e. Nonmaleficence

 

 

ANS:  A, B, D, E

Health care ethics are based on autonomy, fidelity, beneficence, justice, and nonmaleficence

 

DIF:    Cognitive Level: Knowledge          REF:   p. 32              OBJ:   2

TOP:   Health Care Ethics                          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Coordinated Care

 

  1. How does values clarification support nursing practice? (Select all that apply.)
a. Guides decision making
b. Gives insight to patients
c. Enhances peer relationships
d. Helps understand him or herself
e. Gains the confidence of supervisors

 

 

ANS:  A, B, D

Values clarification gives a person a foundation for moral decisions and insight into self and others.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 33              OBJ:   4

TOP:   Values Clarification                        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. An LPN/LVN arrives on duty at 0700 and is faced with the ethical dilemma of inadequate staffing for the day shift. How should the LPN/LVN invoke a “safe harbor”? (Select all that apply.)
a. Immediately file a written protest with administration.
b. Leave duty.
c. Refuse the assignment.
d. Call hospital administration.
e. Suggest that the nursing assistants (NAs) file a written protest.

 

 

ANS:  A, E

Filing a written protest relative to short staffing provides the “safe harbor” for the LPN/LVN and protects his or her license. Nonacceptance of the assignment or leaving duty is considered abandonment. Suggesting that the NA file a similar protest is an effective action.

 

DIF:    Cognitive Level: Application          REF:   p. 40              OBJ:   N/A

TOP:   Inadequate Staffing                        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

COMPLETION

 

  1. The values that direct human behavior and are concerned with defining right from wrong are known as _____.

 

ANS:

ethics

An individual’s ability to define right from wrong is based on a value system called ethics.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 31              OBJ:   1

TOP:   Ethics             KEY:  Nursing Process Step: N/A

MSC:  NCLEX: Psychosocial Integrity

 

OTHER

 

  1. Prioritize the steps in solving an ethical dilemma. (Separate the letters with a comma and space: A, B, C, D.)
  2. Evaluate the outcome.
  3. Plan an approach.
  4. Visualize the consequences.
  5. Take action.
  6. Identify the problem.

 

ANS:

E, B, C, D, A

To solve an ethical dilemma, one must clearly identify the problem, plan an approach, visualize the consequences, take action, and evaluate the outcome.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 34              OBJ:   7

TOP:   Solving an Ethical Dilemma           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

Chapter 11: The Older Patient

Linton: Introduction to Medical-Surgical Nursing, 6th Edition

 

MULTIPLE CHOICE

 

  1. How is the term old age or aged best defined?
a. Person’s state of mind
b. Person older than 65 years of age
c. Process of growing older
d. Person of advanced age

 

 

ANS:  D

Aged or old age is defined as advanced in years.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 137            OBJ:   2

TOP:   Definitions of Old Age                   KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. How is aging recognized by gerontologists as a developmental process?
a. Measured in chronologic years
b. Directly related to heredity
c. Related to behavioral characteristics
d. Begins at the time of birth

 

 

ANS:  D

Geriatrics is the science of old age and the application of knowledge related to the biologic, biomedical, behavioral, and social aspects of aging.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 137            OBJ:   2

TOP:   Definitions of Old Age                   KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What understanding is a prerequisite for a nurse working with the geriatric patient?
a. Specialized knowledge is needed.
b. Geriatric patients are physically impaired.
c. Most geriatric patients will develop dementia.
d. Geriatric patients need to be closely supervised.

 

 

ANS:  A

Knowledge, understanding, and caring are prerequisites for working effectively with older adults. Although specialized formal education programs at the graduate level are available for gerontologic nurses, many nurses gain specials skills through on-the-job experiences.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 138            OBJ:   1

TOP:   Roles of the Gerontologic Nurse    KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A 78-year-old resident of a long-term care facility insists on wearing high heels and miniskirts to the dining room for meals and will not leave her room without first applying glamorous makeup. What should the gerontologic nurse assess as the reason for this behavior?
a. Insecurity about her appearance
b. Trying to cope with the changes of aging
c. Denial concerning her advancing age
d. Her fashion consciousness

 

 

ANS:  C

Some older people confront aging, but others deny it by acting in a younger manner.

 

DIF:    Cognitive Level: Analysis               REF:   p. 138-139     OBJ:   2

TOP:   Ageism: Myths and Stereotypes      KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. What does Butler, a well-known gerontologist, relay regarding ageism?
a. It dehumanizes older individuals.
b. It is based on the biologic theory of aging.
c. It is based on natural and purposeful occurrences.
d. It continues to change as the population ages.

 

 

ANS:  A

Ageism is the stereotyping of and discrimination against people because of their age.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 138-139     OBJ:   2

TOP:   Ageism: Myths and Stereotypes      KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What are the effects of aging on the nervous system?
a. Accelerated loss of neurons in the brain
b. Gradually declining loss of intellectual capability
c. Decreased conduction speed of neurons
d. Loss of long-term memory

 

 

ANS:  C

Age-related effects on body systems are integral parts of the basis of nursing care for older adults. The aging nervous system is characterized by decreased conduction speed of neurons.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 140-141     OBJ:   3

TOP:   Physiologic Change                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse is caring for older adult patients with mild cognitive impairment (MCI). What are these patients more likely to develop?
a. Dementia, non-Alzheimer type
b. Alzheimer dementia
c. Parkinson disease
d. Psychotic disorders

 

 

ANS:  B

Approximately 40% of people with MCI develop Alzheimer dementia within 3 years.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 140            OBJ:   3

TOP:   Physiologic Change                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. What is the most appropriate nursing action when planning activities to improve short-term memory for an older adult patient experiencing memory deficits?
a. Maintain the same daily schedule.
b. Rehearse memory training.
c. Provide a varied and stimulating daily schedule.
d. Conduct deep-breathing exercises.

 

 

ANS:  B

Using mnemonics and memory rehearsal may improve memory performance in some older individuals.

 

DIF:    Cognitive Level: Application          REF:   p. 140-141     OBJ:   3

TOP:   Physiologic Change                        KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What is the best example of normal memory change or lapse of memory?
a. Relying on another person to remember names or important events
b. Occasional forgetfulness or inability to recall names or facts
c. Difficulty in recalling recent events
d. Difficulty in recalling past events

 

 

ANS:  B

Memory lapses such as forgetting a name or misplacing an item are common, normal memory changes.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 140            OBJ:   3

TOP:   Physiologic Change                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity: Psychosocial Adaptation

 

  1. Which facts are generally accepted for most older adults?
a. Intellectual capabilities are impaired.
b. Functional brain activities decrease.
c. Functional intellectual capability is maintained.
d. Creativity and judgment are severely impaired.

 

 

ANS:  C

Functional ability may not be significantly affected because reserve cells are able to compensate.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 140            OBJ:   3

TOP:   Physiologic Change                        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What factor increases the risk of respiratory infection for older adults?
a. Decreased ciliary action
b. Decreased physical activity
c. Inadequate hydration
d. Poor personal hygiene

 

 

ANS:  A

The ability to perform strenuous work decreases with age. The ciliary action responsible for movement of secretions from the lung is compromised because of epithelial atrophy.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 141            OBJ:   3

TOP:   Physiologic Change                        KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A nurse is caring for an older person whose renal changes make it impossible to concentrate or dilute urine. For what is this patient at the greatest risk?
a. Urinary infection
b. Dehydration
c. Incontinence
d. Renal failure

 

 

ANS:  B

The kidney’s ability to concentrate urine is a major defense against dehydration.

 

DIF:    Cognitive Level: Application          REF:   p. 142            OBJ:   3

TOP:   Physiologic Renal Change              KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Which assessment is the greatest priority to report when considering the gastrointestinal (GI) changes that take place in the geriatric patient?
a. 24-hour urinary output of 1450 mL
b. 24-hour dietary intake of 75% of meals
c. Last bowel movement 4 days ago
d. Weight loss of 2 lb since admission 2 months ago

 

 

ANS:  C

GI changes include bloating, diarrhea, pernicious anemia, and constipation.

 

DIF:    Cognitive Level: Application          REF:   p. 143            OBJ:   3

TOP:   Physiologic Change                        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. Which assessment made by the nurse is a major sign of renal changes related to age?
a. Hematuria
b. Nocturia
c. Urgency incontinence
d. Renal calculi

 

 

ANS:  C

Urgency incontinence is related to several age-related changes in the urinary musculature. Renal calculi and hematuria are pathologic symptoms and are not age related. Nocturia is not specifically related to aging.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 142            OBJ:   3

TOP:   Physiologic Change                        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What should be the most significant assessment when gathering data concerning the musculoskeletal system?
a. Slow gait
b. Degree of motion of all joints
c. Enlarged joints
d. Crepitus in joints

 

 

ANS:  B

Determine mobility by assessing the range of motion in all joints; in addition, look for signs of inflammation and pain associated with mobility.

 

DIF:    Cognitive Level: Application          REF:   p. 143            OBJ:   3

TOP:   Physiologic Change                        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. What is the most appropriate nursing intervention for a patient with presbycusis?
a. Speak clearly and distinctly while facing the patient.
b. Announce your presence when entering the patient’s room.
c. Place needed articles within easy reach.
d. Orient the patient to time and place as needed.

 

 

ANS:  A

Presbycusis is hearing loss. Get the patient’s attention so that the patient can concentrate on what you are saying or read lips.

 

DIF:    Cognitive Level: Application          REF:   p. 143            OBJ:   3

TOP:   Physiologic Change                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. What should the nurse suspect a patient is developing when he is observed holding his Bible 6 inches from his face and turns his head to read out of the corner of his eyes?
a. Cataracts
b. Glaucoma
c. Presbyopia
d. Macular degeneration

 

 

ANS:  D

The leading cause of new blindness in old age is macular degeneration, which results in the loss of central vision.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 144            OBJ:   3

TOP:   Macular Degeneration                    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What is true regarding the chemosensory changes observed in older adults?
a. They are directly related to the aging process.
b. They are most often caused by disease.
c. They begin in the fifth decade of life.
d. They affect more women than men.

 

 

ANS:  B

Major changes in the ability to taste are often caused by disease or a side effect of certain drugs.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 144            OBJ:   3

TOP:   Chemosensory Change                   KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A nurse explains to family members that the final developmental stage is ego integrity. What should occur in the older adult, according to Erikson, if this stage is not mastered?
a. Needs to repeat a previous stage
b. Experiences despair
c. Inability to advance past the present stage
d. Experiences disappointment

 

 

ANS:  B

The final developmental task is ego versus despair. This negative resolution is often seen as depression and social withdrawal.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 145            OBJ:   3

TOP:   Psychosocial Factors                                 KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Growth and Development

 

  1. What is the best nursing action when assisting an older patient to relieve the discomfort of pruritus related to dry skin?
a. Encourage the patient to talk to the primary care physician about the problem.
b. Encourage the patient to take a tepid bath and use moisturizers.
c. Teach the patient that pruritus is an expected consequence of aging.
d. Establishing a medication regimen to control the discomfort.

 

 

ANS:  B

Because pruritus is caused by loss of oils in the skin, the patient should be encouraged to take tepid baths; use moisturizers; and avoid overuse of antiperspirants, soaps, perfumes, and long hot baths.

 

DIF:    Cognitive Level: Application          REF:   p. 142            OBJ:   3

TOP:   Physiologic Change                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A newly admitted 72-year-old resident of a long-term care facility naps frequently during the day, stating that he is tired. What is the best action by the nurse?
a. Obtain an order from the primary caregiver for a sedative.
b. Ask the patient if he is sleeping well at night.
c. Plan activities to keep the patient awake during the day.
d. Tell the patient that he cannot take any more naps.

 

 

ANS:  B

Determining if or the reason why the patient is not sleeping at night will help the nurse implement the appropriate nursing actions. Depression may be interfering with adapting to the long-term facility.

 

DIF:    Cognitive Level: Application          REF:   p. 146            OBJ:   4

TOP:   Psychosocial Factors                                 KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. What is the best reason that drug toxicity can occur as a result of an age-related change in the liver?
a. Increased liver size
b. Decreased liver enzyme activity
c. Rapid blood flow through the liver
d. Fluid accumulation in the portal vein

 

 

ANS:  B

Decreased liver enzyme activity does not prepare the drug for excretion. The liver size is decreased in older persons; blood flow through the liver is also decreased.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 147            OBJ:   3

TOP:   Decreased Liver Function               KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A 77-year-old recently admitted to a long-term care facility refuses to join in activities or go to the dining room for meals. How should the nurse interpret this behavior?
a. Stubbornness
b. Depression
c. Fear
d. Exhaustion

 

 

ANS:  B

Some older people respond to loss by losing their sense of personal identity and fulfillment. They have a deterioration in self-esteem and become depressed.

 

DIF:    Cognitive Level: Analysis               REF:   p. 146            OBJ:   5

TOP:   Psychosocial Factors                                 KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Psychosocial Integrity: Physiological Adaptation

 

MULTIPLE RESPONSE

 

  1. Which concepts are the basis of the error theories of aging? (Select all that apply.)
a. The rate of aging is related to the rate of living.
b. Aging is a result of purposeful events governed by genetic structure.
c. External events cause damage to cells.
d. The organism becomes immune to the body’s restorative processes.
e. Cumulative damage causes organ malfunction.

 

 

ANS:  A, C, E

Aging is a result of progressive damage to cells, which results in organ failure or error.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 140            OBJ:   3

TOP:   Aging Theories                               KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What are included in age-related cardiovascular changes? (Select all that apply.)
a. Cardiac murmurs
b. Widened pulse pressure
c. Pulse decreasing in force
d. Dyspnea
e. Chest pain

 

 

ANS:  A, B, C

Murmurs, widening pulse pressure, and decreasing force of pulse are all associated with age-related changes. Dyspnea and chest pain are not anticipated changes in the cardiovascular system.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 141            OBJ:   3

TOP:   Cardiovascular Changes                 KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

Chapter 21: Immobility

Linton: Introduction to Medical-Surgical Nursing, 6th Edition

 

MULTIPLE CHOICE

 

  1. What negative effects does immobilization have on the musculoskeletal system?
a. Demineralization of bone
b. Increase in aerobic capacity
c. Increased muscle oxidation
d. Lengthening of muscle fibers

 

 

ANS:  A

Immobilization has negative effects on the musculoskeletal system such as demineralization of bone, a decrease in aerobic capacity, a decrease in muscle oxidation, and shortening of muscle fibers.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 326            OBJ:   1

TOP:   Effects of Immobility                               KEY:              Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What should the nurse be aware is the best prevention of immobility-related disorders?
a. Dietary supplements
b. Fluids
c. Adequate fiber
d. Exercise

 

 

ANS:  D

Exercise will help reduce the patient’s risk of immobility-related disorders.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 326-327     OBJ:   2

TOP:   Preventing Complications of Immobility

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A nurse’s assessment reveals an area of erythema on an immobilized patient’s sacrum. What is the initial nursing action?
a. Apply a wet-to-dry dressing.
b. Massage the reddened area.
c. Reposition the patient.
d. Rub the area with alcohol.

 

 

ANS:  C

The first intervention is to reposition the patient with follow-up to ensure that the patient is repositioned often.

 

DIF:    Cognitive Level: Application          REF:   p. 331            OBJ:   5

TOP:   Treatment of Pressure Ulcers          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A nurse is providing discharge instructions to the family of an older adult patient who is unable to get out of bed. What should the nurse instruct the family regarding the most effective way to prevent urinary incontinence associated with immobility?
a. Use absorbent underpads.
b. Set up a toileting program.
c. Restrict fluid intake to 500 mL per 24 hours.
d. Restrict fluids after dinner and throughout the night.

 

 

ANS:  B

Patients should have scheduled toileting times with adjustments in the schedule based on the patient’s voiding patterns. Studies have been inconclusive regarding the effectiveness of limiting fluids.

 

DIF:    Cognitive Level: Application          REF:   p. 334            OBJ:   6

TOP:   Urinary Incontinence                                KEY:              Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. The care plan of an older adult patient states that the patient should be monitored while in the bathroom because of a history of vasovagal reflex. What should the nurse assess with this patient?
a. Extremely elevated blood pressure after ambulation
b. Nausea and vomiting after a meal
c. Lightheadedness and fainting during defecation
d. Inability to urinate

 

 

ANS:  C

Constipated individuals may strain to defecate, causing an increase in intraabdominal pressure. This is called the Valsalva maneuver or vasovagal reflex, and it can lead to cardiovascular alterations.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 333            OBJ:   6

TOP:   Vasovagal Reflex                           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What is the most effective intervention to prevent constipation in a patient who recently sustained a fractured femur and is currently in traction?
a. Get the patient up and to the bathroom at least twice each day.
b. Administer enemas each day until the patient has a bowel movement.
c. Administer pain medication to prevent pain during defecation.
d. Encourage a high-fiber diet and increased amounts of fluids.

 

 

ANS:  D

Inactivity, decreased fluid intake, and a lack of adequate fiber in the diet can combine to cause constipation. Activity is not an option for this patient, but encouraging a high-fiber diet and increased fluids can help prevent or relieve constipation.

 

DIF:    Cognitive Level: Application          REF:   p. 333            OBJ:   6

TOP:   Constipation   KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse caring for a patient who has been prescribed bed rest for 1 week notices a reddened area on the patient’s left hip. The skin is intact, but when the nurse presses on the area, the redness does not fade. How should this area of pressure be classified?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV

 

 

ANS:  A

The major characteristic of a stage I pressure ulcer is erythema (redness) that does not blanch when pressed.

 

DIF:    Cognitive Level: Analysis               REF:   p. 331            OBJ:   4

TOP:   Stages of Pressure Areas                 KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What action should the nurse implement when positioning an immobile patient?
a. Ensure that the patient’s knees and hips are flexed.
b. Visualize how a person looks while standing and try to have the patient achieve that position while lying down.
c. Reposition the patient no more often than every 4 hours.
d. Always position the patient on his or her back with the head raised to prevent aspiration.

 

 

ANS:  B

Positioning should be done to maintain joints in their functional positions so they are not abnormally flexed or extended.

 

DIF:    Cognitive Level: Application          REF:   p. 328            OBJ:   2

TOP:   Positioning     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. What intervention is most appropriate to prevent respiratory complications resulting from immobility?
a. Suction every 4 to 6 hours.
b. Administer pain medications as frequently as possible.
c. Teach the patient the technique of pursed lip breathing.
d. Reposition the patient, and encourage him or her to cough and deep breathe at least every 2 hours.

 

 

ANS:  D

When a person remains immobile or does not take deep breaths, thick secretions can accumulate and pool in the lower respiratory structures.

 

DIF:    Cognitive Level: Application          REF:   p. 333            OBJ:   6

TOP:   Respiratory Complications             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk

 

  1. A nurse transcribes a discharge order for the patient with left-sided weakness after having a stroke indicating to teach the patient to perform range-of-motion exercises on affected extremities. The patient asks why she needs to do range-of-motion exercises. What is the nurse’s best response?
a. “Because the physician has ordered it.”
b. “You will regain full use of your arm and leg if you will do the exercises correctly.”
c. “They prevent the muscles and tendons from shortening and becoming unmovable.”
d. “It will give you something to do because you can’t work anymore.”

 

 

ANS:  C

Muscular activity maintains range of motion by allowing the joint to remain flexible and functional. When little or no movement of a joint occurs, the muscles shorten and lose their elasticity.

 

DIF:    Cognitive Level: Application          REF:   p. 328            OBJ:   2

TOP:   Exercises        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A nurse assesses a patient’s risk for developing a pressure ulcer using the Norton scale. The patient’s score is 18. What nursing action should be implemented?
a. Call the physician immediately.
b. Implement a pressure ulcer prevention program.
c. Document the score.
d. Order an alternating air mattress.

 

 

ANS:  C

If the total score on the Norton scale is greater than 14, then little risk exists for the development of pressure ulcers. If the total score is less than 14, then significant risk exists.

 

DIF:    Cognitive Level: Application          REF:   p. 330            OBJ:   3

TOP:   Norton Scale                                   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A patient in traction with a fractured hip is diagnosed with a stage I pressure ulcer. She asks the nurse how a pressure ulcer could occur after only 2 days of immobility. On what knowledge should the nurse base a response?
a. “Erythema can occur in 1 to 2 hours even in a person with healthy skin and adequate circulation.”
b. “It takes several days for a pressure ulcer to form.”
c. “The pressure ulcer probably occurred when you fell.”
d. “The cause of pressure ulcers isn’t really known.”

 

 

ANS:  A

Because of impaired blood flow, capillaries in the area of pressure can become congested, and erythema can occur in 1 to 2 hours.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 329            OBJ:   3

TOP:   Pressure Ulcers                               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A patient is complaining to the nurse that he feels the need to have a bowel movement but has not been able to defecate. He has had cramping and even a small amount of brown watery stool. What should the nurse recognize these symptoms as?
a. Diarrhea
b. Fecal incontinence
c. Fecal impaction
d. Flatulence

 

 

ANS:  C

Symptoms of a fecal impaction include painful defecation, a feeling of fullness in the rectum, abdominal distention, and sometimes cramps and a watery stool.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 333            OBJ:   6

TOP:   Fecal Impaction                              KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. During the shift report, a nurse is told that a patient she will be caring for has a stage II pressure ulcer. What should the nurse expect to visualize during the dressing change?
a. Ulcer that appears black with possible signs of infection
b. Shallow ulcer that appears blistered, cracked, or abraded
c. Craterlike sore with a distinct outer margin formed as the epidermis thickens and rolls over the edge toward the ulcer base
d. Redness of skin with no ulceration

 

 

ANS:  B

In a stage II pressure ulcer, some skin loss in the epidermis and dermis has occurred.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 331            OBJ:   4

TOP:   Stages of Pressure Ulcers                KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. When preparing a plan care for an older adult patient, a nurse should consider the common problems associated with immobility. What should these problems be classified as?
a. Environmental and intellectual
b. Internal and external
c. Mental and medical
d. Physical and psychosocial

 

 

ANS:  D

Immobility can have a profound impact on both the mind and the body. Psychosocial problems include depression, fear, anxiety, social withdrawal, and apathy. Physically, immobility can have an adverse effect on every body system.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 325            OBJ:   1

TOP:   Problems Associated with Immobility

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. How does the National Pressure Ulcer Advisory Panel prefer to refer to skin breakdown?
a. Bed sores
b. Pressure ulcers
c. Decubitus ulcers
d. Decubiti

 

 

ANS:  B

Decubitus means lying down; therefore, decubitus ulcers and bed sores are associated with lying in a bed. Skin breakdown can also develop from sitting.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 329            OBJ:   1

TOP:   Pressure Ulcers                               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A patient complains that his “bottom” is sore. The nurse assesses the area and finds an open area on the sacrum that appears blistered. What action should the nurse implement?
a. Document the cause of the burn.
b. Clean with alcohol, apply moisturizer, and cover with a set dressing.
c. Massage the area to promote circulation.
d. Clean with mild soap, dry, and apply a light dressing.

 

 

ANS:  D

If pressure ulcers develop despite all preventive measures, proper and early treatment improves the chance for reversal. A stage II ulcer should be cleaned with mild soap and water or with sterile normal saline, patted dry, and covered with a dressing that allows airflow.

 

DIF:    Cognitive Level: Application          REF:   p. 332            OBJ:   4

TOP:   Pressure Ulcers                               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. A nurse is performing a wet-to-dry dressing change on a stage IV pressure ulcer. What is the purpose of this type of dressing?
a. Keep the wound moist.
b. Prevent infection.
c. Débride necrotic tissue.
d. Increase circulation to the tissue.

 

 

ANS:  C

Wet-to-dry dressings and a whirlpool are used for small amounts of débridement of necrotic tissue. Débridement is necessary to promote granulation of new, healthy tissue.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 332            OBJ:   5

TOP:   Wet-to-Dry Dressing                       KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nursing assistant is bathing a patient who has a stage I pressure ulcer on the right shoulder. What action by the health care team could cause that the tissue to become more damaged?
a. Positioning the patient on the left side
b. Massaging the reddened area
c. Cleaning the area with mild soap and water
d. Positioning the patient in a prone position

 

 

ANS:  B

Any type of massage around or on a reddened area of skin can damage fragile capillaries.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 331            OBJ:   5

TOP:   Treatment of Pressure Ulcers          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse is planning the care of a patient who is immobile. Why should the nurse consider this patient to be at risk for urinary tract infection?
a. Urine will pool in the bladder when the patient remains in a supine position.
b. The patient is likely to have urinary incontinence.
c. The patient’s appetite may be decreased.
d. The patient may not be able to move quickly enough to get to the bathroom.

 

 

ANS:  A

If the body remains in a supine position for even a few days, the flow becomes sluggish, and the urine pools in the bladder, which will increase the risk of a urinary tract infection.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 334            OBJ:   6

TOP:   Urinary Tract Infection                   KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. What should the nurse instruct a patient in a wheelchair to do to decrease risk for pressure ulcers?
a. Use a ring pillow on the seat of the chair.
b. Lift the weight of the body using the arms of the wheelchair every 15 minutes.
c. Scoot forward and back in the seat to stimulate circulation.
d. Wear underwear that holds moisture close to skin.

 

 

ANS:  B

Using the arms of the wheelchair to lift the weight off the buttocks and coccyx is beneficial to reduce the risk of pressure ulcers in patients using wheelchairs.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 330            OBJ:   5

TOP:   Pressure Ulcer in a Wheelchair       KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A nurse is instructing a patient on performing isometric exercises. What instruction should the nurse include?
a. Contract the muscle for several seconds, then relax the muscle for a few seconds, and contract it again.
b. Perform full range-of-motion exercises of each joint.
c. Have a family member perform full range-of-motion exercises on each of the patient’s joints.
d. Stand in front of a wall and push with the arms without bending the elbow.

 

 

ANS:  A

Isometric exercises maintain muscle tone without moving the joint. This type of exercise is helpful in maintaining muscle strength after a fracture.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 328            OBJ:   2

TOP:   Isometric Exercises                         KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A nurse is talking with a patient who recently became paraplegic as a result of a cervical spinal cord injury. When some home equipment is discussed, the patient becomes angry and says, “I don’t need to worry about any kind of home equipment.” What is the best response by the nurse?
a. “I know you will be walking soon, but you may need some equipment until then.”
b. “There is very little chance that you will ever walk.”
c. “Tell me what it is about this equipment that bothers you.”
d. “Let me call the physician to come explain your injuries to you.”

 

 

ANS:  C

The nurse should use therapeutic communication techniques to explore the patient’s feelings.

 

DIF:    Cognitive Level: Application          REF:   p. 326            OBJ:   1

TOP:   Therapeutic Communication          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. During a skin integrity assessment, a nurse notices an area on the right heel that is black and draining purulent, foul-smelling exudate. How should the nurse document this as a pressure ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV

 

 

ANS:  D

In a stage IV pressure ulcer, full-thickness skin loss has occurred with extensive destruction of the deeper underlying muscle and, possibly, the bone tissue.

 

DIF:    Cognitive Level: Analysis               REF:   p. 331-332     OBJ:   4

TOP:   Stages of Pressure Ulcers                KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. What is the classification of incontinence in older adults related to the inability to get to the bathroom in time?
a. Stress incontinence
b. Urge incontinence
c. Functional incontinence
d. Sporadic incontinence

 

 

ANS:  C

Functional incontinence occurs when the older adult patient cannot move quickly enough to reach the toilet in time.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 334            OBJ:   6

TOP:   Functional Incontinence                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. Which are characteristics of a stage I pressure ulcer? (Select all that apply.)
a. The area is regular and well defined.
b. Tissue hardening is present.
c. Swelling has occurred at the site.
d. The condition is reversible.
e. Nonblanching erythema is observed.

 

 

ANS:  B, C, D, E

A stage I ulcer has irregular and poorly defined margins, with swelling and hardening at the site of the nonblanching erythema. At this stage, the ulcer is reversible.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 331            OBJ:   4

TOP:   Characteristics of Stage I Pressure Ulcer

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What should a nurse document when assessing a new pressure ulcer? (Select all that apply.)
a. Precise measurement of the ulcer
b. Location of the wound and its description
c. Color of the ulcer
d. Amount and characteristics of the drainage
e. Probable cause of the ulcer

 

 

ANS:  A, B, C, D

Documentation should include the precise location, color, size, shape, and drainage, as well as treatment applications.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 331-332     OBJ:   4

TOP:   Documentation of Pressure Ulcers KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. What therapeutic reasons exist that explain why a patient might become immobile? (Select all that apply.)
a. Reduction of the workload of the heart
b. Fear of falling
c. Reversal of the effects of gravity
d. Bereavement
e. Healing of a fracture

 

 

ANS:  A, C, E

A reduction of the heart’s workload, a reversal of the effects of gravity (as in the treatment of a hernia or prolapse), and the healing of a fracture are all therapeutic reasons for immobilization. The fear of falling and bereavement are not therapeutic reasons.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 325            OBJ:   1

TOP:   Therapeutic Rationale for Immobilization

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

COMPLETION

 

  1. A home health nurse instructs a family about boosting the patient in bed so that a(n) _____ type of skin injury will not occur.

 

ANS:

shearing force

Shearing force injuries occur when a patient is dragged up in bed, causing the skin to be abraded against the bed linens.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 329            OBJ:   1

TOP:   Shear Force    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance

 

  1. A nurse evaluates the effectiveness of the treatment for a stage III pressure ulcer as satisfactory when the bed of the ulcer is pink, indicating the presence of _____, which is an indicator of tissue perfusion.

 

ANS:

granulation tissue

The appearance of healthy pink granulation tissue in the bed of a pressure ulcer is a positive sign for improved perfusion and the beginning of closure.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 332            OBJ:   5

TOP:   Presence of Granulation Tissue      KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse takes into consideration that such emotions as worry, anxiety, and depression can contribute to the common nutritional problem of _____.

 

ANS:

anorexia

Anorexia can be caused by emotional factors such as worry, anxiety, and depression.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 333            OBJ:   6

TOP:   Anorexia        KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. When bacteria are localized at the site of a stage III pressure ulcer, it is said to be _____.

 

ANS:

colonized

Colonized bacteria are those who are in one location, such as an ulcer, and not systemic.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 332            OBJ:   3

TOP:   Colonization of bacteria                 KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The negative impact of immobilization on a patient depends on the duration, degree, and type of _____.

 

ANS:

mobility limitation

Duration, degree, and type of mobility limitation have the greatest impact. The other choices may affect the impact of immobilization when the mobility limitation becomes an issue.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 325            OBJ:   2

TOP:   Impact of Immobility                                KEY:              Nursing Process Step: N/A

MSC:  NCLEX: N/A

Chapter 31: Acute Disorders of the Lower Respiratory Tract

Linton: Introduction to Medical-Surgical Nursing, 6th Edition

 

MULTIPLE CHOICE

 

  1. A patient asks the nurse how air goes from the nose to the lung. The nurse draws the route according to which sequence?
a. Trachea, larynx, bronchi
b. Pharynx, trachea, bronchi, alveoli
c. Bronchi, trachea, bronchioles
d. Larynx, trachea, alveoli, bronchi

 

 

ANS:  B

The route of inspired air is pharynx, trachea, bronchi, and alveoli.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 558            OBJ:   N/A

TOP:   Physiology of Ventilation               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse charts that a patient has had periods of tachypnea during the night. What does this means in regard to the respiration rate?
a. Below 12 breaths/min
b. Uneven, with periods of apnea
c. Gradually deepening, then shallow, and then periods of apnea
d. Above 20 breaths/min

 

 

ANS:  D

Tachypnea is a respiration rate above 20 breaths/min. Option a describes bradypnea, option b describes Biot respirations, and option c describes Cheyne-Stokes respirations.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 559            OBJ:   1

TOP:   Respiration Rate                             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A 90-year-old patient complains to the nurse of shortness of breath after walking up a flight of stairs. What age-related change should the nurse explain results in this problem?
a. Flexible rib cage
b. High-arched diaphragm
c. Increased chest movement
d. Enlarged bronchioles

 

 

ANS:  D

Enlarged bronchioles require the inspiration of greater amounts of air. Other age-related changes make increased inspiration difficult.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 558            OBJ:   2

TOP:   Age-Related Changes                                KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What should the nurse exclude when documenting the findings in the functional assessment portion of the nursing assessment for a patient with a respiratory disorder?
a. Occupation
b. Usual diet
c. Smoking history
d. Previous respiratory disorders

 

 

ANS:  D

Previous respiratory disorders are assessed in the medical history portion of the assessment.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 560            OBJ:   1

TOP:   Respiratory Assessment                  KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. To auscultate breath sounds in the right middle lobe from the anterior aspect, the nurse should place the diaphragm of the stethoscope at which intercostal space?
a. Second
b. Third
c. Fourth
d. Fifth

 

 

ANS:  D

The fifth intercostal space is the optimal position for auscultating the right middle lobe.

 

DIF:    Cognitive Level: Application          REF:   p. 561            OBJ:   3

TOP:   Breath Sounds                                           KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What should the nurse suspect regarding the bronchus when auscultating coarse crackles in the lower right lobe?
a. Partially filled with fluid
b. Narrowed by spasm
c. Partially filled with thick mucus
d. Completely obstructed

 

 

ANS:  A

Coarse crackles are indicative of fluid in the bronchi. Many times these sounds can be cleared by coughing.

 

DIF:    Cognitive Level: Application          REF:   p. 561            OBJ:   1

TOP:   Breath Sounds                                           KEY:              Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A worried patient asks the nurse to explain the advantage of a fluoroscopy. What is the nurse’s best response regarding fluoroscopy?
a. Shows respiratory function in motion
b. Helps the physician evaluate ventilation-perfusion ratio
c. Allows the physician to take tissue samples
d. Facilitates the removal of fluid from the bronchi

 

 

ANS:  A

A fluoroscopy allows the visualization of both lungs while the patient is in the process of ventilation.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 563            OBJ:   3

TOP:   Diagnostic Tests                             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. Which nursing intervention is inappropriate in the immediate postprocedure care of a patient who has had a fiberoptic bronchoscopy?
a. Place the patient in a semi-Fowler position.
b. Offer fluids to assess swallowing ability.
c. Assess for diminished breath sounds.
d. Assess for stridor.

 

 

ANS:  B

Patients are placed on nothing by mouth diet until the gag reflex returns.

 

DIF:    Cognitive Level: Application          REF:   p. 564            OBJ:   3

TOP:   Diagnostic Tests                             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Reduction of Risk

 

  1. What is the importance of the nurse closely monitoring bilateral breath sounds and chest movement after a thoracentesis?
a. Fluid may quickly accumulate as a result of inflammation.
b. The lung may have been punctured during the procedure.
c. Severe bronchospasm may cause atelectasis.
d. Asthma may result after the procedure.

 

 

ANS:  B

A possibility exists that the lung could have been punctured during the procedure. Bronchospasm, fluid collection, and asthma are not concerns related to a thoracentesis.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 564 | p. 569

OBJ:   3                    TOP:   Diagnostic Tests

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. Which nursing assessment indicates a positive reading of a tuberculin (TB) skin test?
a. 1 day after injection with a 10-mm area of redness and swelling
b. 2 days after injection with a 5-mm area of redness and swelling
c. 4 days after injection with a 3-mm area of redness and swelling
d. 5 days after injection with a 2-mm area of redness and swelling

 

 

ANS:  B

A positive reading of a TB skin test is an area of redness and swelling of 5 mm or larger 24 to 48 hours after injection.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 564            OBJ:   3

TOP:   Diagnostic Tests                             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A nurse performs an Allen test before performing the arterial stick for an arterial blood gas. What does this test assess?
a. Respiratory function
b. Tidal volume
c. Concentration of oxygen
d. Perfusion of the hand

 

 

ANS:  D

The perfusion of the hand by the radial and ulnar arteries is assessed because the puncture of the radial artery might cause it to occlude.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 565            OBJ:   3

TOP:   Diagnostic Tests                             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. A patient who is severely dyspneic and cyanotic enters the emergency department. What rate should a nurse administer oxygen to the patient?
a. 2 L to preserve the hypoxic drive
b. 6 L to relieve the dyspnea
c. 8 L, humidified, to liquefy secretions
d. 10 L, humidified aerosol, to dilate the bronchi

 

 

ANS:  A

Low-dose oxygen is a safe initial dose to ensure that the hypoxic drive be preserved, especially for a patient whose history is unknown.

 

DIF:    Cognitive Level: Application          REF:   p. 572            OBJ:   4

TOP:   Oxygen Administration                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. Which assessment indicates to the nurse that the chest tube in a water seal drainage device is working correctly?
a. Constant bubbling in the suction control chamber
b. Decrease of accumulation in the drainage chamber
c. Fluctuation of the column of water in the water seal
d. Constant bubbling in the water seal chamber

 

 

ANS:  C

The fluctuation of the level in the water seal indicates patency of the tubes with the reinflating lung. Constant bubbling in the wet suction control is normal. Constant bubbling in the water seal indicates an air leak. Decreasing drainage is normal.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 575-576     OBJ:   4

TOP:   Water Seal Drainage                       KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. Which assessment by the nurse at the bedside of a patient with a chest tube attached to a water seal drainage device should require intervention?
a. Dependent loops in the chest tube
b. Patient in a semi-Fowler position
c. Changing level of water in the water seal chamber
d. Increased level of drainage to 20 mL in 8 hours

 

 

ANS:  A

Dependent loops in the chest tube can collect drainage and occlude the system.

 

DIF:    Cognitive Level: Application          REF:   p. 575-576     OBJ:   4

TOP:   Water Seal Drainage                       KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A home health nurse that is caring for an 88-year-old patient with severe hypertension in addition to a respiratory problem notices several drugs on the bedside table. Which medication should the nurse suggest the patient avoid?
a. Aspirin
b. Colace
c. Expectorant
d. Decongestant

 

 

ANS:  D

Decongestants increase the blood pressure.

 

DIF:    Cognitive Level: Application          REF:   p. 578            OBJ:   5

TOP:   Respiratory Drugs                           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. How should a nurse position a patient who had a left pneumonectomy in the morning in an effort to enhance gas exchange?
a. On the right side
b. On the left side
c. In a semi-Fowler position
d. In a flat position with a small pillow

 

 

ANS:  C

Elevation of the head helps gas exchange in the patient with a new pneumonectomy. A complete side-lying position on the unaffected side may cause mediastinal shift.

 

DIF:    Cognitive Level: Application          REF:   p. 577            OBJ:   5

TOP:   Postpneumonectomy                                 KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A patient with acute bronchitis is being discharged with a prescription for an antimicrobial medication to be taken for the next 14 days. What should the nurse stress when providing discharge teaching?
a. Take the drug on an empty stomach before meals.
b. Complete the entire course as prescribed.
c. Maintain a thorough oral hygiene regimen.
d. Maintain a daily fluid intake of 500 mL.

 

 

ANS:  B

The entire course of the prescription should be taken to destroy the pathogen completely; otherwise, the pathogen may become resistant to the drug.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 583            OBJ:   6

TOP:   Acute Bronchitis                             KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. Which group of patients should a nurse advise to have a vaccination with conjugated pneumococcal?
a. Adults with diabetes
b. Persons 65 years and older
c. Parents of children younger than 24 months
d. Persons with cardiovascular disorders

 

 

ANS:  C

The conjugated product is especially designed for young children. Unconjugated vaccine is recommended for older adults and those with cardiovascular disorders.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 585            OBJ:   5

TOP:   Pneumonia Vaccine                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. What action should a nurse implement to reduce the risk of aspiration in a patient receiving continuous enteral feedings at a rate of 70 mL/hr?
a. Check the position of the tube during every shift.
b. Notify the charge nurse or physician about a residual volume of 20 mL.
c. Elevate the patient’s head during and for 10 minutes after feeding.
d. Position the patient on the left side after the feeding.

 

 

ANS:  B

A residual of more than 20% of the hourly rate should be reported so that the rate can be reduced (70 mL multiplied by 0.20 = 14).

 

DIF:    Cognitive Level: Application          REF:   p. 588            OBJ:   5

TOP:   Aspiration Pneumonia                    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. What symptoms should a nurse expect to see in a patient with hypoxemia?
a. Restlessness, tachycardia, and tachypnea
b. Bradycardia, cyanosis, and restlessness
c. Dyspnea, flushed face, and tachycardia
d. Cyanosis, nausea, and bradycardia

 

 

ANS:  A

The universal symptoms of hypoxemia, regardless of cause, are restlessness, tachycardia, and tachypnea.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 571 | p. 592

OBJ:   6                    TOP:   Hypoxemia    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A patient comes to the emergency department with a sucking chest wound. Which type of dressing should the nurse apply to begin the process of lung reinflation?
a. Petroleum dressing covered with an airtight bandage
b. No dressing at all
c. Pillow weighted down with a sandbag
d. Air-occlusive dressing taped on three sides (vented dressing)

 

 

ANS:  D

The vented dressing occludes air from entering but allows air to escape, avoiding a tension pneumothorax and mediastinal shift.

 

DIF:    Cognitive Level: Application          REF:   p. 589            OBJ:   6

TOP:   Pneumothorax Care                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. What should a nurse prepare when assessing paradoxical movement in a patient with a flail chest who has significant dyspnea?
a. Thoracotomy
b. Intubation
c. Thoracentesis
d. Body cast

 

 

ANS:  B

A patient with an unstable chest usually requires intubation and mechanical ventilation.

 

DIF:    Cognitive Level: Application          REF:   p. 592-293     OBJ:   6

TOP:   Flail Chest      KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. Which intervention would be inappropriate for decreasing the risk of further emboli in a patient with a pulmonary embolism?
a. Carefully applying compression stockings
b. Performing passive range-of-motion exercises, especially of the lower limbs
c. Placing pillows under the knees to elevate the legs
d. Ambulating frequently

 

 

ANS:  C

Nothing should be placed under the knees; doing so might impair circulation.

 

DIF:    Cognitive Level: Application          REF:   p. 594            OBJ:   6

TOP:   Pulmonary Embolism                                KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. How should a nurse position a patient during a thoracentesis?
a. Side-lying with bed in a Trendelenburg position
b. High Fowler position with feet elevated
c. Sitting on the side of the bed bent over bedside table
d. Prone with the bed elevated

 

 

ANS:  C

The patient sits on the side of the bed and leans the upper torso over the bedside table with the head resting on folded arms or pillows. If the patient is unable to sit up, then a side-lying position with the head of the bed elevated 30 degrees may be used.

 

DIF:    Cognitive Level: Application          REF:   p. 569            OBJ:   3

TOP:   Thoracentesis                                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. How does the ventilator function of positive end-expiratory pressure assist the patient?
a. Keeps pressure in the lungs after expiration
b. Delivers 100% oxygen on inspiration
c. Allows the patient to control expiratory pressure
d. Delivers an inhalant medication under positive pressure

 

 

ANS:  A

The positive end-expiratory pressure setting keeps the pressure in the lungs above the atmospheric pressure, which prevents atelectasis.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 574-575     OBJ:   3

TOP:   Mechanical Ventilators                   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

MULTIPLE RESPONSE

 

  1. How should a nurse explain that the breathing pattern has been altered when a patient complains of tachypnea? (Select all that apply.)
a. Increased pH levels stimulate chemoreceptors in the aorta and carotid arteries, which stimulates the phrenic nerve.
b. Decreased oxygen level signals the phrenic nerve to alter the respiration rate.
c. Muscles of respiration respond to the stimulus.
d. The brain has become hypoxic and causes an alteration in the respiration rate.
e. Deflated lung tissue results in an altered respiration rate.

 

 

ANS:  B, C

A decreased oxygen level stimulates the phrenic nerve to signal the muscles of respiration to do the work of breathing. A decreasing pH level is the stimulus to the chemoreceptors. Neither the brain nor the lungs signal for tachypnea.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 558            OBJ:   1

TOP:   Respiration Center                          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What assessment findings would indicate respiratory dysfunction when examining a patient with respiratory difficulty? (Select all that apply.)
a. Flushed facial skin
b. Cyanotic nail beds
c. Abdominal distention
d. Curved spine
e. Clubbed fingers

 

 

ANS:  B, C, E

Clues to respiratory dysfunction are a distended abdomen, cyanotic nail beds, and clubbed fingers from inadequate oxygenation.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 563            OBJ:   1

TOP:   Clues to Respiratory Dysfunction   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. Which instructions should a nurse provide to a patient just before a scheduled spirometry test? (Select all that apply.)
a. Avoid smoking 4 to 6 hours before test.
b. Do not use bronchodilator medications for at least 4 hours.
c. Exercise for a few minutes.
d. Drink 2 glasses of fluid.
e. Avoid eating.

 

 

ANS:  A, B

Patients should not smoke, use bronchodilators, or exercise just before the test. Normal-sized meals and drinking fluids do not adversely affect the test.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 567            OBJ:   3

TOP:   Spirometry     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

COMPLETION

 

  1. Assessment of 24-year-old driver after an automobile accident, who is complaining of right-sided chest pain and is dyspneic, reveals the following:
  • Respirations: 26 breaths/min
  • Significant pain on inspiration
  • Hand is pressed to the rib area; large bruise is forming on the right chest
  • Blood pressure: 182/98 mm Hg

Based on these assessments, the nurse suspects _____.

 

ANS:

fractured ribs

The placement of the bruise and the pain on inspiration are the main clues to the rib fracture.

 

DIF:    Cognitive Level: Analysis               REF:   p. 592            OBJ:   5

TOP:   Rib Fracture   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse computes the number of “pack years” of a 24-year-old man who has smoked packs of cigarettes every day since he was 15 years old. This patient has _____ pack years.

 

ANS:

13.5

Pack years are calculated by multiplying the number of years of smoking by the number of packs smoked each day. A 24-year-old patient who has smoked since he was 15 years of age = 9 years multiplied by 1.5 = 13.5.

 

DIF:    Cognitive Level: Application          REF:   p. 560            OBJ:   1

TOP:   Pack Years     KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

OTHER

 

  1. What instructions should a nurse give to a patient when teaching deep breathing and coughing techniques? (Place the options in the appropriate sequence. Separate letters by a comma and space as follows: A, B, C, D.)
  2. Place the hand on the abdomen to check the rise and fall.
  3. Inhale through the nose, pause 1 to 3 seconds, and then exhale through the mouth.
  4. Assume a semi-Fowler position.
  5. Take 4 to 6 deep breaths.
  6. Cough deeply.

 

ANS:

C, A, B, D, E

The exercise is performed in a sequence to ensure open bronchioles and a good deep cough.

 

DIF:    Cognitive Level: Application          REF:   p. 570            OBJ:   3

TOP:   Deep Breathing and Coughing        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

Chapter 41: Liver, Gallbladder, and Pancreatic Disorders

Linton: Introduction to Medical-Surgical Nursing, 6th Edition

 

MULTIPLE CHOICE

 

  1. For which complication should a nurse be careful to monitor a patient after a liver biopsy?
a. Headache
b. Muscle cramps
c. Bleeding
d. Respiratory distress

 

 

ANS:  C

Liver biopsy places the patient at risk for hemorrhage. Liver disorders make patients especially vulnerable to hemorrhage.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 854-855     OBJ:   2

TOP:   Liver Biopsy                                   KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. What is pruritus related to in the patient diagnosed with hepatitis?
a. Decreased fat intake
b. Poor appetite and therefore poor protein intake
c. Accumulation of bile salts under the skin
d. Altered urinary output of bile

 

 

ANS:  C

Bile salts accumulate under the skin, causing irritation.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 858            OBJ:   3

TOP:   Hepatitis         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A young woman with severe jaundice has a nursing diagnosis of “Altered body image, related to jaundice.” The patient says, “Will I always be this horrible color?” What is the best response by the nurse?
a. “Yes, but your sclera will return to their previous white color.”
b. “No. The color will fade gradually as liver inflammation decreases.”
c. “Yes, but cosmetics can disguise the color.”
d. “No. The color will change to freckles.”

 

 

ANS:  B

Jaundice causes patients to be self-conscious and reclusive because of the change in physical appearance. Patients can be reassured that the color improves as liver function improves, usually in 2 to 4 weeks.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 860            OBJ:   3

TOP:   Hepatitis and Jaundice                    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity: Coping and Adaptation

 

  1. What action should a nurse implement to prevent complications in a patient with hepatitis who has been prescribed bedrest?
a. Raise the knee gatch to prevent the patient from sliding down in bed.
b. Provide undisturbed periods of 6 hours to encourage rest.
c. Restrict fluids.
d. Encourage turning, coughing, and deep breathing every 2 hours.

 

 

ANS:  D

The nurse must encourage measures that will prevent pneumonia and improve impaired skin integrity because of the increased risk factors associated with bedrest.

 

DIF:    Cognitive Level: Application          REF:   p. 859            OBJ:   5

TOP:   Bedrest for Hepatitis                       KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. Which sign indicates that the need for increased fluid intake would be contraindicated in a patient diagnosed with a hepatic disorder?
a. Low blood pressure
b. Increased urinary output
c. Signs of edema
d. Bradycardia

 

 

ANS:  C

Edema may indicate fluid overload; therefore, question the intake, as well as electrolyte and cardiac status.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 859            OBJ:   5

TOP:   Fluid Volume and Hepatitis            KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. What intervention should a nurse implement when assessing a patient with jaundice who has been given the nursing diagnosis of impaired skin integrity?
a. Sedate the patient.
b. Apply mittens or socks to the hands.
c. Restrain the hands.
d. Distract the patient with conversation.

 

 

ANS:  B

Jaundice causes itching, which can cause the patient to scratching and create a break in the skin. Mittens provide some comfort without causing further skin impairment.

 

DIF:    Cognitive Level: Application          REF:   p. 859            OBJ:   5

TOP:   Jaundice         KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. Which vaccination does the Occupational Health and Safety Administration (OSHA) require all health care providers to receive?
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. All strains of hepatitis

 

 

ANS:  B

OSHA requires that all health care providers be vaccinated against hepatitis B.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 860            OBJ:   2

TOP:   OSHA Requirements                                 KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. What is the meaning of a dropping bilirubin level in a patient diagnosed with hepatitis?
a. Red blood cell destruction is decreasing.
b. Liver function is improving.
c. Kidneys are compensating for liver dysfunction.
d. Kupffer cell damage is continuing.

 

 

ANS:  B

As liver function improves, the bilirubin level will decrease because of the liver’s ability to conjugate and excrete the bilirubin. The flow of bile out of the liver increases.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 862            OBJ:   3

TOP:   Liver Disease                                  KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A goal of medical treatment for patients with cirrhosis is to prevent complications and limit cell damage. A major approach is to promote rest. What rationale supports this approach?
a. Allows time for a transplant
b. Allows the liver to regenerate
c. Prevents red cell destruction
d. Decreases the risk of trauma

 

 

ANS:  B

With rest, the liver will regenerate healthy tissue and return to normal functioning. Rest must include other measures to promote healing, such as dietary measures and no alcohol.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 862            OBJ:   5

TOP:   Cirrhosis        KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What is necessary to restrict when the ammonia level of a patient diagnosed with cirrhosis continues to rise?
a. Protein
b. Carbohydrates
c. Fats
d. Water-soluble vitamins

 

 

ANS:  A

Ammonia is the waste product of protein breakdown. Decreasing protein intake will decrease the end product.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 862            OBJ:   5

TOP:   Cirrhosis        KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. What actions should a nurse implement to correctly assess the progress of ascites on a daily basis?
a. Daily weights and abdominal girth measurements
b. Intake-output and electrolyte levels
c. Blood pressure and pulse
d. Daily temperatures and oxygen levels

 

 

ANS:  A

Daily weights and abdominal girth measurements will accurately measure the fluid accumulating in the peritoneal cavity.

 

DIF:    Cognitive Level: Application          REF:   p. 867            OBJ:   3

TOP:   Ascites           KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A patient with ascites is scheduled for a LeVeen peritoneal-venous shunt. The patient asks why this needs to be done instead of a paracentesis. What is the best response by the nurse?
a. “It helps the kidneys retain needed sodium.”
b. “It will decrease the need for analgesics.”
c. “This procedure will prevent the loss of protein.”
d. “The risk of infection is lessened with this procedure.”

 

 

ANS:  C

Fluids containing protein are returned to the vascular compartment to retain important elements such as albumin. The retention of albumin reduces fluid accumulation.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 864            OBJ:   3

TOP:   Ascites           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. A high ammonia level contributes to hepatic encephalopathy. Which nursing implementation needs to be added to the nursing care plan as this level continues to increase?
a. Mouth care
b. Increased frequency of neurologic checks
c. Oxygen saturation monitoring
d. Intake and output

 

 

ANS:  B

As the ammonia level rises, the patient becomes at greater risk for confusion and hepatic coma related to encephalopathy.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 862            OBJ:   5

TOP:   Seizure Precautions                        KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A nurse is educating a patient diagnosed with hepatitis A. What should the nurse instruct this patient to avoid sharing?
a. Food
b. Bodies
c. Needles
d. Housing

 

 

ANS:  A

Hepatitis A is spread from contact with saliva, which can be transmitted by shared food or drinks.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 856            OBJ:   3

TOP:   Hepatitis A     KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. Which dietary selection should lead the nurse to conclude that the dietary teaching is successful for a patient on a low-sodium diet?
a. Bologna sandwich with tomato juice
b. Hotdog on a bun with pickle relish and skim milk
c. Baked chicken, white rice, and apple juice
d. Peanut butter and jelly sandwich with tomato soup

 

 

ANS:  C

A meal of baked chicken, white rice, and apple juice has the lowest sodium levels.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 867-868     OBJ:   3

TOP:   Nutrition: Low-Sodium Diet           KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. Which nursing measure takes priority in relation to the care of a patient with a gastroesophageal balloon tube?
a. Deflate the balloon periodically.
b. Advance the tube as instructed.
c. Monitor respiratory status.
d. Withhold medications that could decrease restlessness.

 

 

ANS:  C

Because of the close proximity of the esophagus and trachea, any upward movement of the tube could cause airway obstruction.

 

DIF:    Cognitive Level: Application          REF:   p. 866            OBJ:   4

TOP:   Esophageal Balloon                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. Which instruction should be given to a patient with portal hypertension to reduce the threat of hemorrhage?
a. Eat bland foods.
b. Avoid straining to have a bowel movement.
c. Increase fluid intake.
d. Use an electric razor to shave.

 

 

ANS:  B

Straining can increase pressure and may cause the dilated vessels in the gastrointestinal tract to bleed. Shaving with an electric razor does not prevent serious bleeding.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 862            OBJ:   3

TOP:   Portal Hypertension                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. What precaution should a nurse initiate when caring for a patient with hepatitis B?
a. Reverse isolation
b. Standard precautions
c. Respiratory precautions
d. Enteric precautions

 

 

ANS:  B

Standard precautions protect the nurse from organisms that may be in all body fluids.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 856-858     OBJ:   5

TOP:   Hepatitis B     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. A patient was positive for hepatitis B virus, although she had the disease 4 years ago and now is symptom free. What is the nurse aware is true regarding this patient?
a. Is likely to have hepatitis B again
b. Now has noninfectious hepatitis
c. Is an infectious carrier and always will be
d. Is at risk for hepatitis E

 

 

ANS:  C

A certain percentage of persons who have had hepatitis B convert to carriers. They have the live virus, which causes no symptoms in them, but they are able to transmit the disease and always will be infectious.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 858            OBJ:   3

TOP:   Carrier State for Hepatitis B            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe, Effective Care Environment: Safety and Infection Control

 

  1. A nurse is providing information on the medication Pancrease (lipase, protease, amylase) to a patient diagnosed with pancreatitis. Which important instruction should the nurse be sure to include?
a. Taken before meals
b. Sprinkled on warm food
c. Mixed with juice
d. Taken 1 hour after eating

 

 

ANS:  C

Pancreatic enzyme medication takes the place of enzymes missing from the damaged pancreas. The drug should be mixed with juice or applesauce or sprinkled on cold food, but it should not be chewed because it will irritate the mouth and lips.

 

DIF:    Cognitive Level: Application          REF:   p. 882            OBJ:   3

TOP:   Administration of Pancreatic Replacement

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Pharmacological Therapies

 

  1. A patient in acute pain is admitted with pancreatitis. A nurse reviews a laboratory report showing an elevation that is diagnostic for acute pancreatitis. Which laboratory report did the nurse most likely review?
a. Serum bilirubin
b. Serum calcium
c. Serum lipids
d. Serum amylase

 

 

ANS:  D

Serum amylase is the most significant of the diagnostic findings.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 880            OBJ:   1

TOP:   Pancreatitis     KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What is the highest nursing priority outcome when planning the care for the patient with pancreatitis?
a. Patient claims satisfaction with pain control.
b. Patient states an understanding of medications needed on discharge.
c. Patient’s activity level tolerance shows an increase.
d. Patient can maintain a normal bowel pattern.

 

 

ANS:  A

Pain control is the most important priority.

 

DIF:    Cognitive Level: Analysis               REF:   p. 882            OBJ:   5

TOP:   Pancreatitis     KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

  1. What should a nurse often find in the medical history of a patient diagnosed with pancreatic disease?
a. Liver disorders
b. Drug abuse
c. Alcohol abuse
d. Excessive sugar intake

 

 

ANS:  C

Pancreatic disease is often related to alcohol abuse.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 877            OBJ:   5

TOP:   Pancreatic Disease                          KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Which observation by a nurse would indicate blocked flow of bile from the liver to the intestine?
a. Clay-colored stools
b. Jaundice
c. High blood pressure
d. Tachycardia

 

 

ANS:  A

Bile is unable to get to feces to give it the normal brown color.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 872            OBJ:   3

TOP:   Biliary Disease                               KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. Which chronic condition is related to the presence of chronic pancreatitis?
a. Chronic obstructive pulmonary disease (COPD)
b. Urinary tract infection (UTI)
c. Diabetes mellitus (DM)
d. Arteriosclerotic heart disease (ASD)

 

 

ANS:  C

Patients with chronic pancreatitis are at risk for developing DM because of the destruction of the insulin-secreting cells in the pancreas.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 880            OBJ:   3

TOP:   Chronic Pancreatitis                        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. Which risk is significantly increased in patients diagnosed with liver disease?
a. Urinary infections
b. Systemic infection
c. Drug toxicity
d. Drug allergy

 

 

ANS:  C

Because many drugs are metabolized in the liver and a diseased liver does not adequately clear the system of drugs, drug toxicity is an ongoing problem.

 

DIF:    Cognitive Level: Comprehension   REF:   p. 861 | p. 858

OBJ:   3                    TOP:   Risk for Drug Toxicity

KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. What should a nurse include in the discharge teaching for a patient after a laparoscopic procedure for cholelithiasis?
a. Take water-soluble vitamins.
b. Follow a low-fat diet.
c. Expect light-colored stools for several days.
d. Keep dressing over the T-tube dry.

 

 

ANS:  B

After the laparoscopic procedure, the patient is to follow a low-fat diet and take fat-soluble vitamins. Placement of the T-tube is not done with the laparoscopic procedure.

 

DIF:    Cognitive Level: Application          REF:   p. 875            OBJ:   2

TOP:   Laparoscopic Procedure for Cholelithiasis

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Basic Care and Comfort

 

MULTIPLE RESPONSE

 

  1. Which drugs and herbal remedies are considered harmful to the liver? (Select all that apply.)
a. Comfrey (herbal remedy)
b. Promethazine (Phenergan)
c. Acetaminophen (Tylenol)
d. Oral contraceptive (Yaz)
e. Lavender (herbal remedy)

 

 

ANS:  A, C

Herbal remedies of comfrey, borage, coltsfoot, and chaparral can harm the liver. The over-the-counter drug Tylenol is also hepatoxic.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 850            OBJ:   1

TOP:   Hepatoxic Drugs                             KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

COMPLETION

 

  1. A nurse reminds a patient with liver disease that the level of _____ in the blood is an indicator of the how well the liver is functioning.

 

ANS:

bilirubin

The level of indirect bilirubin indicates the effectiveness of the metabolism of proteins by the liver.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 852            OBJ:   1

TOP:   Bilirubin as an Indicator of Liver Function

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

  1. A nurse explains to a patient that when the blood sugar level drops, the liver is capable of converting the stored glycogen to glucose by the process of _____.

 

ANS:

glycogenesis

The conversion of glycogen to glucose by the liver is called glycogenesis.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 849            OBJ:   3

TOP:   Glycogenesis                                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. A nurse is alert for bleeding in a patient with hepatic disorders because the inflamed liver may not be able to synthesize two clotting factors, which are _____ and _____.

 

ANS:

prothrombin; fibrinogen

fibrinogen; prothrombin

Prothrombin and fibrinogen, which are necessary components for blood clotting, are deficit in liver disorders, leading to bleeding episodes.

 

DIF:    Cognitive Level: Knowledge          REF:   p. 850            OBJ:   1

TOP:   Liver Production of Prothrombin and Fibrinogen

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity: Physiological Adaptation

 

  1. In assessing a dark-skinned patient for jaundice, the nurse would assess the _____ for a yellow color.

 

ANS:

sclera

Jaundice can be assessed by the yellow pigment on the sclera of a dark-skinned person.

 

DIF:    Cognitive Level: Application          REF:   p. 851            OBJ:   1

TOP:   Assessing Jaundice in Dark-Skinned Persons

KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

 

 

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