Test Bank Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 13th 13e edition





Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 13th 13e edition – Test Bank



1. The public health nurse is presenting a health promotion class to a group of new mothers. How should the nurse best define health?
  A) Health is being disease free.
  B) Health is having fulfillment in all domains of life.
  C) Health is having psychological and physiological harmony.
  D) Health is being connected in body, mind, and spirit.
  Ans: D
  The World Health Organization (WHO) defines health in the preamble to its constitution as a “state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity.” The other answers are incorrect because they are not congruent with the WHO definition of health.



2. A nurse is speaking to a group of prospective nursing students about what it is like to be a nurse. What is one characteristic the nurse would cite as necessary to possess to be an effective nurse?
  A) Sensitivity to cultural differences
  B) Team-focused approach to problem-solving
  C) Strict adherence to routine
  D) Ability to face criticism
  Ans: A
  To promote an effective nurse-patient relationship and positive outcomes of care, nursing care must be culturally competent, appropriate, and sensitive to cultural differences. Team-focused nursing and strict adherence to routine are not characteristics needed to be an effective nurse. The ability to handle criticism is important, but to a lesser degree than cultural competence.



3. With increases in longevity, people have had to become more knowledgeable about their health and the professional health care that they receive. One outcome of this phenomenon is the development of organized self-care education programs. Which of the following do these programs prioritize?
  A) Adequate prenatal care
  B) Government advocacy and lobbying
  C) Judicious use of online communities
  D) Management of illness
  Ans: D
  Organized self-care education programs emphasize health promotion, disease prevention, management of illness, self-care, and judicious use of the professional health care system. Prenatal care, lobbying, and Internet activities are secondary.



4. The home health nurse is assisting a patient and his family in planning the patient’s return to work after surgery and the development of postsurgical complications. The nurse is preparing a plan of care that addresses the patient’s multifaceted needs. To which level of Maslow’s hierarchy of basic needs does the patient’s need for self-fulfillment relate?
  A) Physiologic
  B) Transcendence
  C) Love and belonging
  D) Self-actualization
  Ans: D
  Maslow’s highest level of human needs is self-actualization, which includes self-fulfillment, desire to know and understand, and aesthetic needs. The other answers are incorrect because self-fulfillment does not relate directly to them.



5. The view that health and illness are not static states but that they exist on a continuum is central to professional health care systems. When planning care, this view aids the nurse in appreciating which of the following?
  A) Care should focus primarily on the treatment of disease.
  B) A person’s state of health is ever-changing.
  C) A person can transition from health to illness rapidly.
  D) Care should focus on the patient’s compliance with interventions.
  Ans: B
  By viewing health and illness on a continuum, it is possible to consider a person as being neither completely healthy nor completely ill. Instead, a person’s state of health is ever-changing and has the potential to range from high-level wellness to extremely poor health and imminent death. The other answers are incorrect because patient care should not focus just on the treatment of disease. Rapid declines in health and “compliance” with treatment are not key to this view of health.



6. A group of nursing students are participating in a community health clinic. When providing care in this context, what should the students teach participants about disease prevention?
  A) It is best achieved through attending self-help groups.
  B) It is best achieved by reducing psychological stress.
  C) It is best achieved by being an active participant in the community.
  D) It is best achieved by exhibiting behaviors that promote health.
  Ans: D
  Today, increasing emphasis is placed on health, health promotion, wellness, and self-care. Health is seen as resulting from a lifestyle oriented toward wellness. Nurses in community health clinics do not teach that disease prevention is best achieved through attending self-help groups, by reducing stress, or by being an active participant in the community, though each of these activities is consistent with a healthy lifestyle.



7. A nurse on a medical-surgical unit has asked to represent the unit on the hospital’s quality committee. When describing quality improvement programs to nursing colleagues and members of other health disciplines, what characteristic should the nurse cite?
  A) These programs establish consequences for health care professionals’ actions.
  B) These programs focus on the processes used to provide care.
  C) These programs identify specific incidents related to quality.
  D) These programs seek to justify health care costs and systems.
  Ans: B
  Numerous models seek to improve the quality of health care delivery. A commonality among them is a focus on the processes that are used to provide care. Consequences, a focus on incidents, and justification for health care costs are not universal characteristics of quality improvement efforts.



8. Nurses in acute care settings must work with other health care team members to maintain quality care while facing pressures to care for patients who are hospitalized for shorter periods of time than in the past. To ensure positive health outcomes when patients return to their homes, what action should the nurse prioritize?
  A) Promotion of health literacy during hospitalization
  B) Close communication with insurers
  C) Thorough and evidence-based discharge planning
  D) Participation in continuing education initiatives
  Ans: C
  Following discharges that occur after increasingly short hospital stays, nurses in the community care for patients who need high-technology acute care services as well as long-term care in the home. This is dependent on effective discharge planning to a greater degree than continuing education, communication with insurers, or promotion of health literacy.



9. You are admitting a patient to your medical unit after the patient has been transferred from the emergency department. What is your priority nursing action at this time?
  A) Identifying the immediate needs of the patient
  B) Checking the admitting physician’s orders
  C) Obtaining a baseline set of vital signs
  D) Allowing the family to be with the patient
  Ans: A
  Among the nurse’s important functions in health care delivery, identifying the patient’s immediate needs and working in concert with the patient to address them is most important. The other nursing functions are important, but they are not the most important functions.



10. A nurse on a postsurgical unit is providing care based on a clinical pathway. When performing assessments and interventions with the aid of a pathway, the nurse should prioritize what goal?
  A) Helping the patient to achieve specific outcomes
  B) Balancing risks and benefits of interventions
  C) Documenting the patient’s response to therapy
  D) Staying accountable to the interdisciplinary team
  Ans: A
  Pathways are an EBP tool that is used primarily to move patients toward predetermined outcomes. Documentation, accountability, and balancing risks and benefits are appropriate, but helping the patient achieve outcomes is paramount.



11. Staff nurses in an ICU setting have noticed that their patients required lower and fewer doses of analgesia when noise levels on the unit were consciously reduced. They informed an advanced practice RN of this and asked the APRN to quantify the effects of noise on the pain levels of hospitalized patients. How does this demonstrate a role of the APRN?
  A) Involving patients in their care while hospitalized
  B) Contributing to the scientific basis of nursing practice
  C) Critiquing the quality of patient care
  D) Explaining medical studies to patients and RNs
  Ans: B
  Research is within the purview of the APRN. The activity described does not exemplify explaining studies to RNs, critiquing care, or involving patients in their care.



12. Nurses now have the option to practice in a variety of settings and one of the fastest growing venues of practice for the nurse in today’s health care environment is home health care. What is the main basis for the growth in this health care setting?
  A) Chronic nursing shortage
  B) Western focus on treatment of disease
  C) Nurses’ preferences for day shifts instead of evening or night shifts
  D) Discharge of patients who are more critically ill
  Ans: D
  With shorter hospital stays and increased use of outpatient health care services, more nursing care is provided in the home and community setting. The other answers are incorrect because they are not the basis for the growth in nursing care delivered in the home setting.



13. Nurses have different educational backgrounds and function under many titles in their practice setting. If a nurse practicing in an oncology clinic had the goal of improving patient outcomes and nursing care by influencing the patient, the nurse, and the health care system, what would most accurately describe this nurse’s title?
  A) Nursing care expert
  B) Clinical nurse specialist
  C) Nurse manager
  D) Staff nurse
  Ans: B
  Clinical nurse specialists are prepared as specialists who practice within a circumscribed area of care (e.g., cardiovascular, oncology). They define their roles as having five major components: clinical practice, education, management, consultation, and research. The other answers are incorrect because they are not the most accurate titles for this nurse.



14. Nursing continues to recognize and participate in collaboration with other health care disciplines to meet the complex needs of the patient. Which of the following is the best example of a collaborative practice model?
  A) The nurse and the physician jointly making clinical decisions.
  B) The nurse accompanying the physician on rounds.
  C) The nurse making a referral on behalf of the patient.
  D) The nurse attending an appointment with the patient.
  Ans: A
  The collaborative model, or a variation of it, promotes shared participation, responsibility, and accountability in a health care environment that is striving to meet the complex health care needs of the public. The other answers are incorrect because they are not examples of a collaborative practice model.



15. A hospice nurse is caring for a patient who is dying of lymphoma. According to Maslow’s hierarchy of needs, what dimension of care should the nurse consider primary in importance when caring for a dying patient?
  A) Spiritual
  B) Social
  C) Physiologic
  D) Emotional
  Ans: C
  Maslow ranked human needs as follows: physiologic needs; safety and security; sense of belonging and affection; esteem and self-respect; and self-actualization, which includes self-fulfillment, desire to know and understand, and aesthetic needs. Such a hierarchy of needs is a useful framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions. The other answers are incorrect because they are not of primary importance when caring for a dying patient, though each should certainly be addressed.



16. A nurse is planning a medical patient’s care with consideration of Maslow’s hierarchy of needs. Within this framework of understanding, what would be the nurse’s first priority?
  A) Allowing the family to see a newly admitted patient
  B) Ambulating the patient in the hallway
  C) Administering pain medication
  D) Teaching the patient to self-administer insulin safely
  Ans: C
  In Maslow’s hierarchy of needs, pain relief addresses the patient’s basic physiologic need. Activity, such as ambulation, is a higher level need above the physiologic need. Allowing the patient to see family addresses a higher level need related to love and belonging. Teaching the patient is also a higher level need related to the desire to know and understand and is not appropriate at this time, as the basic physiologic need of pain control must be addressed before the patient can address these higher level needs.



17. A medical-surgical nurse is aware of the scope of practice as defined in the state where the nurse provides care. This nurse’s compliance with the nurse practice act demonstrates adherence to which of the following?
  A) National Council of Nursing’s guidelines for care
  B) National League for Nursing’s Code of Conduct
  C) American Nurses Association’s Social Policy Statement
  D) Department of Health and Human Service’s White Paper on Nursing
  Ans: C
  Nurses have a responsibility to carry out their role as described in the Social Policy Statement to comply with the nurse practice act of the state in which they practice and to comply with the Code of Ethics for Nurses as spelled out by the ANA (2001) and the International Council of Nurses (International Council of Nurses [ICN], 2006). The other answers are incorrect; the Code of Ethics for nursing is not included in the ANA’s white paper. The DHHS has not published a white paper on nursing nor has the NLN published a specific code of conduct.



18. Nursing is, by necessity, a flexible profession. It has adapted to meet both the expectations and the changing health needs of our aging population. What is one factor that has impacted the need for certified nurse practitioners (CNPs)?
  A) The increased need for primary care providers
  B) The need to improve patient diagnostic services
  C) The push to drive institutional excellence
  D) The need to decrease the number of medical errors
  Ans: A
  CNPs who are educationally prepared with a population focus in adult-gerontology or pediatrics receive additional focused training in primary care or acute care. CNPs help meet the need for primary care providers. Diagnostic services, institutional excellence, and reduction of medical errors are congruent with the CNP role, but these considerations are the not primary impetus for the increased role for CNPs.



19. A nurse is providing care for a patient who is postoperative day one following a bowel resection for the treatment of colorectal cancer. How can the nurse best exemplify the QSEN competency of quality improvement?
  A) By liaising with the members of the interdisciplinary care team
  B) By critically appraising the outcomes of care that is provided
  C) By integrating the patient’s preferences into the plan of care
  D) By documenting care in the electronic health record in a timely fashion
  Ans: B
  Evaluation of outcomes is central to the QSEN competency of quality improvements. Each of the other listed activities is a component of quality nursing care, but none clearly exemplifies quality improvement activities.



20. Professional nursing expands and grows because of factors driven by the changing needs of health care consumers. Which of the following is a factor that nurses should reflect in the planning and provision of health care?
  A) Decreased access to health care information by individuals
  B) Gradual increases in the cultural unity of the American population
  C) Increasing mean and median age of the American population
  D) Decreasing consumer expectations related to health care outcomes
  Ans: C
  The decline in birth rate and the increase in lifespan due to improved health care have resulted in fewer school-age children and more senior citizens, many of whom are women.

The population has become more culturally diverse as increasing numbers of people from different national backgrounds enter the country. Access to information and consumer expectations continue to increase.



21. A public health nurse has been commissioned to draft a health promotion program that meets the health care needs and expectations of the community. Which of the following focuses is most likely to influence the nurse’s choice of interventions?
  A) Management of chronic conditions and disability
  B) Increasing need for self-care among a younger population
  C) A shifting focus to disease management
  D) An increasing focus on acute conditions and rehabilitation
  Ans: A
  In response to current priorities, health care must focus more on management of chronic conditions and disability than in previous times. The other answers are incorrect because the change in focus of health care is not an increasing need for self-care among our aging population; our focus is shifting away from disease management, not toward it; and we are moving away from the management of acute conditions to managing chronic conditions.



22. A community health nurse has witnessed significant shifts in patterns of disease over the course of a four-decade career. Which of the following focuses most clearly demonstrates the changing pattern of disease in the United States?
  A) Type 1 diabetes management
  B) Treatment of community-acquired pneumonia
  C) Rehabilitation from traumatic brain injuries
  D) Management of acute Staphylococcus aureus infections
  Ans: A
  Management of chronic diseases such as diabetes is a priority focus of the current health care environment. This supersedes the treatment of acute infections and rehabilitation needs.



23. The ANA has identified several phenomena toward which the focus of nursing care should be directed, and a nurse is planning care that reflects these priorities. Which of the nurse’s actions best demonstrates these priorities?
  A) Encouraging the patient’s dependence on caregivers
  B) Fostering the patient’s ability to make choices
  C) Teaching the patient about nurses’ roles in the health care system
  D) Assessing the patient’s adherence to treatment
  Ans: B
  The ANA identifies several focuses for nursing care and research, including the ability to make choices. The other answers are incorrect because they are not phenomena identified by the ANA.



24. The role of the certified nurse practitioner (CNP) has become a dominant role for nurses in all levels of health care. Which of the following activities are considered integral to the CNP role? Select all that apply.
  A) Educating patients and family members
  B) Coordinating care with other disciplines
  C) Using direct provision of interventions
  D) Educating registered nurses and practical nurses
  E) Coordinating payment plans for patients
  Ans: A, B, C
  This role is a dominant one for nurses in primary, secondary, and tertiary health care settings and in home care and community nursing. Nurses help patients meet their needs by using direct intervention, by teaching patients and family members to perform care, and by coordinating and collaborating with other disciplines to provide needed services. The other answers are incorrect because NPs do not commonly perform education of nurses and they do not focus on matters related to payment.



25. The ANA has identified central characteristics of nursing practice that are applicable across the wide variety of contexts in which nurses practice. A nurse can best demonstrate these principles by performing which of the following actions?
  A) Teaching the public about the role of nursing
  B) Taking action to control the costs of health care
  C) Ensuring that all of his or her actions exemplify caring
  D) Making sure to carry adequate liability insurance
  Ans: C
  The ANA emphasizes the fact that caring is central to the practice of the registered nurse. The ANA does not identify teaching the public about nursing, controlling costs, or maintaining insurance as a central tenet of nursing practice.



26. A nurse has accepted a position as a clinical nurse leader (CNL), a new role that has been launched within the past decade. In this role, the nurse should prioritize which of the following activities?
  A) Acting as a spokesperson for the nursing profession
  B) Generating and disseminating new nursing knowledge
  C) Diagnosing and treating health problems that have a predictable course
  D) Helping patients to navigate the health care system
  Ans: D
  The CNL is a nurse generalist with a master’s degree in nursing and a special background in clinical leadership, educated to help patients navigate through the complex health care system. The other answers are incorrect because they are not what nursing has identified as the CNL role.



27. Our world is connected by a sophisticated communication system that makes much health information instantly accessible, no matter where the patient is being treated. This instant access to health information has impacted health care delivery strategies, including the delivery of nursing care. What is one way the delivery of health care has been impacted by this phenomenon?
  A) Brisk changes as well as swift obsolescence
  B) Rapid change that is nearly permanent
  C) Limitations on the settings where care can be provided
  D) Increased need for social acceptance
  Ans: A
  The sophisticated communication systems that connect most parts of the world, with the capability of rapid storage, retrieval, and dissemination of information, have stimulated brisk change as well as swift obsolescence in health care delivery strategies. The other answers are incorrect because, although we have rapid change in the delivery of nursing care, it does not last a long time; it is evolving as health care itself evolves. Giving nursing care has not become easier, it becomes more complex with every change; and it does not need to be more socially acceptable; it needs to be more culturally sensitive.



28. With the changing population of health care consumers, it has become necessary for nurses to work more closely with other nurses, as when acute care nurses collaborate with public health and home health nurses. What nursing function has increased in importance because of this phenomenon?
  A) Prescribing medication
  B) Performing discharge planning
  C) Promoting family involvement
  D) Forming collegial relationships
  Ans: B
  The importance of effective discharge planning and quality improvement cannot be overstated. The other answers are incorrect because giving medication and family involvement in the patient’s care have not grown in importance. Making and maintaining collegial relationships has become a necessity in working in the health care delivery system. Effective discharge planning aids in getting patients out of the inpatient setting sooner, cutting costs, and making rehabilitation in the community and home setting possible.



29. A nurse has integrated the principles of evidence-based practice into care. EBP has the potential to help the nurse achieve what goal?
  A) Increasing career satisfaction
  B) Obtaining federal grant money
  C) Ensuring high quality patient care
  D) Enhancing the public’s esteem for nursing
  Ans: C
  Quality improvement is the ultimate goal of EBP. Career satisfaction, public esteem, and grant money are not priorities.



30. A case manager has been hired at a rural hospital that has a combined medical-surgical unit. When defining this new role, which of the following outcomes should be prioritized by the hospital’s leadership?
  A) Decreased need for physician services
  B) Improved patient and family education
  C) Increased adherence to the principles of EBP
  D) Increased coordination of health services
  Ans: D
  Case management is a system of coordinating health care services to ensure cost-effectiveness, accountability, and quality care. The case manager coordinates the care of a caseload of patients through facilitating communication between nurses, other health care personnel who provide care, and insurance companies. Reducing the need for physician services is not a central goal. Education and EBP are consistent with case management, but they are not central to this particular role.



31. A hospital’s current quality improvement program has integrated the principles of the Institute for Healthcare Improvement (IHI) 5 Million Lives Campaign. How can the hospital best achieve the campaign goals of reducing preventable harm and death?
  A) By adhering to EBP guidelines
  B) By reducing nurse-to-patient ratios and increasing accountability
  C) By having researchers from outside the facility evaluate care
  D) By involving patients and families in their care planning
  Ans: A
  The 5 Million Lives Campaign posits that if evidence-based guidelines it advocated were voluntarily implemented by U.S. hospitals, 5 million lives would be saved from either harm or death over a two-year period. Nurse-to-patient ratios, family participation, and independent evaluation are not stated components of the campaign.



32. Over the past several decades, nursing roles have changed and expanded in many ways. Which of the following factors has provided the strongest impetus for this change?
  A) The need to decrease the cost of health care
  B) The need to improve the quality of nursing education
  C) The need to increase the number of nursing jobs available
  D) The need to increase the public perception of nursing
  Ans: A
  The role of the nurse has expanded to improve the distribution of health care services and to decrease the cost of health care. The other answers are incorrect because the expansion of roles in nursing did not occur to improve education, increase the number of nursing jobs, or increase public perception.



33. Advanced practice nursing roles have grown in number and in visibility in recent years. What characteristic sets these nurses apart from the registered nurse?
  A) Collaboration with other health care providers
  B) Education that goes beyond that of the RN
  C) Advanced documentation skills
  D) Ability to provide care in the surgical context
  Ans: B
  There is wide variety in APRN roles. However, a commonality is that they require education beyond that of the professional RN. All nurses collaborate with other health care providers to provide nursing care to their patients. Advanced documentation skills are not what sets advanced practice nurses apart from the staff nurse. RNs have the ability to provide care in the operating room.



34. CNPs are educated as specialists in areas such as family care, pediatrics, or geriatrics. In most states, what right do CNPs have that RNs do not possess?
  A) Perform health interventions independently
  B) Make referrals to members of other health disciplines
  C) Prescribe medications
  D) Perform surgery independently
  Ans: C
  In most states, nurse practitioners have prescriptive authority. Surgery is beyond the CNP scope of practice and all professional nurses may perform interventions and make certain referrals.



35. A team of community health nurses are planning to draft a proposal for a program that will increase the community’s alignment with the principles contained in the Healthy People 2020 report. Which of the following activities would best demonstrate the priorities identified in this report?
  A) Addressing determinants of health such as clean environments and safety in the community
  B) Lobbying for increased funding to the county hospital where many residents receive primary care
  C) Collaborating with health professionals in neighboring communities to pool resources and increase efficiencies
  D) Creating clinical placements where nursing students and members of other health disciplines can gain experience in a community setting
  Ans: A
  Healthy People 2020 addresses social determinants of health such as safety and the state of the environment. This report does not specifically address matters such as hospital funding, nursing education, or resource allocation.



36. A nurse is aware that an increasing emphasis is being placed on health, health promotion, wellness, and self-care. Which of the following activities would best demonstrate the principles of health promotion?
  A) A discharge planning initiative between acute care and community care nurses
  B) Collaboration between several schools of nursing in an urban area
  C) Creation of a smoking prevention program undertaken in a middle school
  D) Establishment of a website where patients can check emergency department wait-times
  Ans: C
  Smoking prevention is a clear example of health promotion. Each of the other listed activities has the potential to be beneficial, but none is considered health promotion.



37. A group of nursing students are learning about recent changes in the pattern of disease in the United States. Which of the following statements best describes these current changes?
  A) Infectious diseases continue to decrease in incidence and prevalence.
  B) Chronic illnesses are becoming increasingly resistant to treatment.
  C) Most acute, infectious diseases have been eradicated.
  D) Most, but not all, communicable diseases are declining.
  Ans: D
  Although some infectious diseases have been controlled or eradicated, others are on the rise. Antibiotic resistance is a more serious problem in acute, not chronic, illnesses.



38. The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) are evaluating a large, university medical center according to core measures. Evaluators should perform this evaluation in what way?
  A) By auditing the medical center’s electronic health records
  B) By performing focus groups and interviews with care providers from numerous disciplines
  C) By performing statistical analysis of patient satisfaction surveys
  D) By comparing the center’s patient outcomes to best practice indicators
  Ans: D
  Core measures are used to gauge how well a hospital gives care to its patients who are admitted to seek treatment for a specific disease or who need a specific treatment as compared to evidence-based guidelines and standards of care. Benchmark standards of quality are used to compare the care or treatment patients receive with the best practice standards. Patient satisfaction is considered, but this is not the only criterion.



39. Leadership of a medical unit have been instructed to integrate the principles of the Quality and Safety Education for Nurses (QSEN) competency of quality improvement. What action should the unit’s leaders take?
  A) Provide access to online journals and Web-based clinical resources for nursing staff.
  B) Use flow charts to document the processes of care that are used on the unit.
  C) Enforce continuing education requirements for all care providers.
  D) Reduce the use of chemical and physical restraints on the unit.
  Ans: B
  One of the quality improvement skills is to use tools, such as flow charts and cause-effect diagrams, to make processes of care explicit. Each of the other listed actions has the potential to benefit patients and care givers, but none is an explicit knowledge, skill, or attitude associated with this QSEN competency.



40. The IOM Report Health Professions Education: A Bridge to Quality issued a number of challenges to the educational programs that teach nurses and members of other health professions. According to this report, what activity should educational institutions prioritize?
  A) More clearly delineate each profession’s scope of practice during education
  B) Move toward developing a single health curriculum that can be adapted for any health profession
  C) Include interdisciplinary core competencies into curricula
  D) Elicit input from patients and families into health care curricula
  Ans: C
  Health Professions Education: A Bridge to Quality challenged health professions’ education programs to integrate interdisciplinary core competencies into their respective curricula to include patient-centered care, interdisciplinary teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics. This report did not specify clearer definitions of scope of practice, patient input, or a single curriculum.


1. A nurse has been offered a position on an obstetric unit and has learned that the unit offers therapeutic abortions, a procedure which contradicts the nurse’s personal beliefs. What is the nurse’s ethical obligation to these patients?
  A) The nurse should adhere to professional standards of practice and offer service to these patients.
  B) The nurse should make the choice to decline this position and pursue a different nursing role.
  C) The nurse should decline to care for the patients considering abortion.
  D) The nurse should express alternatives to women considering terminating their pregnancy.
  Ans: B
  To avoid facing ethical dilemmas, nurses can follow certain strategies. For example, when applying for a job, a nurse should ask questions regarding the patient population. If a nurse is uncomfortable with a particular situation, then not accepting the position would be the best option. The nurse is only required by law (and practice standards) to provide care to the patients the clinic accepts; the nurse may not discriminate between patients and the nurse expressing his or her own opinion and providing another option is inappropriate.



2. A terminally ill patient you are caring for is complaining of pain. The physician has ordered a large dose of intravenous opioids by continuous infusion. You know that one of the adverse effects of this medicine is respiratory depression. When you assess your patient’s respiratory status, you find that the rate has decreased from 16 breaths per minute to 10 breaths per minute. What action should you take?
  A) Decrease the rate of IV infusion.
  B) Stimulate the patient in order to increase respiratory rate.
  C) Report the decreased respiratory rate to the physician.
  D) Allow the patient to rest comfortably.
  Ans: C
  End-of life issues that often involve ethical dilemmas include pain control, “do not resuscitate” orders, life-support measures, and administration of food and fluids. The risk of respiratory depression is not the intent of the action of pain control. Respiratory depression should not be used as an excuse to withhold pain medication for a terminally ill patient. The patient’s respiratory status should be carefully monitored and any changes should be reported to the physician.



3. An adult patient has requested a “do not resuscitate” (DNR) order in light of his recent diagnosis with late stage pancreatic cancer. The patient’s son and daughter-in-law are strongly opposed to the patient’s request. What is the primary responsibility of the nurse in this situation?
  A) Perform a “slow code” until a decision is made.
  B) Honor the request of the patient.
  C) Contact a social worker or mediator to intervene.
  D) Temporarily withhold nursing care until the physician talks to the family.
  Ans: B
  The nurse must honor the patient’s wishes and continue to provide required nursing care. Discussing the matter with the physician may lead to further communication with the family, during which the family may reconsider their decision. It is not normally appropriate for the nurse to seek the assistance of a social worker or mediator. A “slow code” is considered unethical.



4. An elderly patient is admitted to your unit with a diagnosis of community-acquired pneumonia. During admission the patient states, “I have a living will.” What implication of this should the nurse recognize?
  A) This document is always honored, regardless of circumstances.
  B) This document specifies the patient’s wishes before hospitalization.
  C) This document that is binding for the duration of the patient’s life.
  D) This document has been drawn up by the patient’s family to determine DNR status.
  Ans: B
  A living will is one type of advance directive. In most situations, living wills are limited to situations in which the patient’s medical condition is deemed terminal. The other answers are incorrect because living wills are not always honored, they are not binding for the duration of the patient’s life, and they are not drawn up by the patient’s family.



5. A nurse has been providing ethical care for many years and is aware of the need to maintain the ethical principle of nonmaleficence. Which of the following actions would be considered a contradiction of this principle?
  A) Discussing a DNR order with a terminally ill patient
  B) Assisting a semi-independent patient with ADLs
  C) Refusing to administer pain medication as ordered
  D) Providing more care for one patient than for another
  Ans: C
  The duty not to inflict as well as prevent and remove harm is termed nonmaleficence. Discussing a DNR order with a terminally ill patient and assisting a patient with ADLs would not be considered contradictions to the nurse’s duty of nonmaleficence. Some patients justifiably require more care than others.



6. You have just taken report for your shift and you are doing your initial assessment of your patients. One of your patients asks you if  an error has been made in her medication. You know that an incident report was filed yesterday after a nurse inadvertently missed a scheduled dose of the patient’s antibiotic. Which of the following principles would apply if you give an accurate response?
  A) Veracity
  B) Confidentiality
  C) Respect
  D) Justice
  Ans: A
  The obligation to tell the truth and not deceive others is termed veracity. The other answers are incorrect because they are not obligations to tell the truth.



7. A nurse has begun creating a patient’s plan of care shortly after the patient’s admission. It is important that the wording of the chosen nursing diagnoses falls within the taxonomy of nursing. Which organization is responsible for developing the taxonomy of a nursing diagnosis?
  A) American Nurses Association (ANA)
  C) National League for Nursing (NLN)
  D) Joint Commission
  Ans: B
  NANDA International is the official organization responsible for developing the taxonomy of nursing diagnoses and formulating nursing diagnoses acceptable for study. The ANA, NLN, and Joint Commission are not charged with the task of developing the taxonomy of nursing diagnoses.



8. In response to a patient’s complaint of pain, the nurse administered a PRN dose of hydromorphone (Dilaudid). In what phase of the nursing process will the nurse determine whether this medication has had the desired effect?
  A) Analysis
  B) Evaluation
  C) Assessment
  D) Data collection
  Ans: B
  Evaluation, the final step of the nursing process, allows the nurse to determine the patient’s response to nursing interventions and the extent to which the objectives have been achieved.



9. A medical nurse has obtained a new patient’s health history and completed the admission assessment. The nurse has followed this by documenting the results and creating a care plan for the patient. Which of the following is the most important rationale for documenting the patient’s care?
  A) It provides continuity of care.
  B) It creates a teaching log for the family.
  C) It verifies appropriate staffing levels.
  D) It keeps the patient fully informed.
  Ans: A
  This record provides a means of communication among members of the health care team and facilitates coordinated planning and continuity of care. It serves as the legal and business record for a health care agency and for the professional staff members who are responsible for the patient’s care. Documentation is not primarily a teaching log; it does not verify staffing; and it is not intended to provide the patient with information about treatments.



10. The nurse is caring for a patient who is withdrawing from heavy alcohol use and who is consequently combative and confused, despite the administration of benzodiazepines. The patient has a fractured hip that he suffered in a traumatic accident and is trying to get out of bed. What is the most appropriate action for the nurse to take?
  A) Leave the patient and get help.
  B) Obtain a physician’s order to restrain the patient.
  C) Read the facility’s policy on restraints.
  D) Order soft restraints from the storeroom.
  Ans: B
  It is mandatory in most settings to have a physician’s order before restraining a patient. Before restraints are used, other strategies, such as asking family members to sit with the patient, or utilizing a specially trained sitter, should be tried. A patient should never be left alone while the nurse summons assistance.



11. A patient admitted with right leg thrombophlebitis is to be discharged from an acute-care facility. Following treatment with a heparin infusion, the nurse notes that the patient’s leg is pain-free, without redness or edema. Which step of the nursing process does this reflect?
  A) Diagnosis
  B) Analysis
  C) Implementation
  D) Evaluation
  Ans: D
  The nursing actions described constitute evaluation of the expected outcomes. The findings show that the expected outcomes have been achieved. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the nurse puts the care plan into action. This nurse’s actions do not constitute diagnosis.



12. During report, a nurse finds that she has been assigned to care for a patient admitted with an opportunistic infection secondary to AIDS. The nurse informs the clinical nurse leader that she is refusing to care for him because he has AIDS. The nurse has an obligation to this patient under which legal premise?
  A) Good Samaritan Act
  B) Nursing Interventions Classification (NIC)
  C) Patient Self-Determination Act
  D) ANA Code of Ethics
  Ans: D
  The ethical obligation to care for all patients is clearly identified in the first statement of the ANA Code of Ethics for Nurses. The Good Samaritan Act relates to lay people helping others in need. The NIC is a standardized classification of nursing treatment that includes independent and collaborative interventions. The Patient Self-Determination Act encourages people to prepare advance directives in which they indicate their wishes concerning the degree of supportive care to be provided if they become incapacitated.



13. An emergency department nurse is caring for a 7-year-old child suspected of having meningitis. The patient is to have a lumbar puncture performed, and the nurse is doing preprocedure teaching with the child and the mother. The nurse’s action is an example of which therapeutic communication technique?
  A) Informing
  B) Suggesting
  C) Expectation-setting
  D) Enlightening
  Ans: A
  Informing involves providing information to the patient regarding his or her care. Suggesting is the presentation of an alternative idea for the patient’s consideration relative to problem solving. This action is not characterized as expectation-setting or enlightening.



14. The nurse, in collaboration with the patient’s family, is determining priorities related to the care of the patient. The nurse explains that it is important to consider the urgency of specific problems when setting priorities. What provides the best framework for prioritizing patient problems?
  A) Availability of hospital resources
  B) Family member statements
  C) Maslow’s hierarchy of needs
  D) The nurse’s skill set
  Ans: C
  Maslow’s hierarchy of needs provides a useful framework for prioritizing problems, with the first level given to meeting physical needs of the patient. Availability of hospital resources, family member statements, and nursing skill do not provide a framework for prioritization of patient problems, though each may be considered.



15. A medical nurse is caring for a patient who is palliative following metastasis. The nurse is aware of the need to uphold the ethical principle of beneficence. How can the nurse best exemplify this principle in the care of this patient?
  A) The nurse tactfully regulates the number and timing of visitors as per the patient’s wishes.
  B) The nurse stays with the patient during his or her death.
  C) The nurse ensures that all members of the care team are aware of the patient’s DNR order.
  D) The nurse liaises with members of the care team to ensure continuity of care.
  Ans: B
  Beneficence is the duty to do good and the active promotion of benevolent acts. Enacting the patient’s wishes around visitors is an example of this. Each of the other nursing actions is consistent with ethical practice, but none directly exemplifies the principle of beneficence.



16. The care team has deemed the occasional use of restraints necessary in the care of a patient with Alzheimer’s disease. What ethical violation is most often posed when using restraints in a long-term care setting?
  A) It limits the patient’s personal safety.
  B) It exacerbates the patient’s disease process.
  C) It threatens the patient’s autonomy.
  D) It is not normally legal.
  Ans: C
  Because safety risks are involved when using restraints on elderly confused patients, this is a common ethical problem, especially in long-term care settings. By definition, restraints limit the individual’s autonomy. Restraints are not without risks, but they should not normally limit a patient’s safety. Restraints will not affect the course of the patient’s underlying disease process, though they may exacerbate confusion. The use of restraints is closely legislated, but they are not illegal.



17. While receiving report on a group of patients, the nurse learns that a patient with terminal cancer has granted power of attorney for health care to her brother. How does this affect the course of the patient’s care?
  A) Another individual has been identified to make decisions on behalf of the patient.
  B) There are binding parameters for care even if the patient changes her mind.
  C) The named individual is in charge of the patient’s finances.
  D) There is a document delegating custody of children to other than her spouse.
  Ans: A
  A power of attorney is said to be in effect when a patient has identified another individual to make decisions on her behalf. The patient has the right to change her mind. A power-of-attorney for health care does not give anyone the right to make financial decisions for the patient nor does it delegate custody of minor children.



18. In the process of planning a patient’s care, the nurse has identified a nursing diagnosis of Ineffective Health Maintenance related to alcohol use. What must precede the determination of this nursing diagnosis?
  A) Establishment of a plan to address the underlying problem
  B) Assigning a positive value to each consequence of the diagnosis
  C) Collecting and analyzing data that corroborates the diagnosis
  D) Evaluating the patient’s chances of recovery
  Ans: C
  In the diagnostic phase of the nursing process, the patient’s nursing problems are defined through analysis of patient data. Establishing a plan comes after collecting and analyzing data; evaluating a plan is the last step of the nursing process and assigning a positive value to each consequence is not done.



19. You are following the care plan that was created for a patient newly admitted to your unit. Which of the following aspects of the care plan would be considered a nursing implementation?
  A) The patient will express an understanding of her diagnosis.
  B) The patient appears diaphoretic.
  C) The patient is at risk for aspiration.
  D) Ambulate the patient twice per day with partial assistance.
  Ans: D
  Implementation refers to carrying out the plan of nursing care. The other listed options exemplify goals, assessment findings, and diagnoses.



20. The physician has recommended an amniocentesis for an 18-year-old primiparous woman. The patient is 34 weeks’ gestation and does not want this procedure. The physician is insistent the patient have the procedure. The physician arranges for the amniocentesis to be performed. The nurse should recognize that the physician is in violation of what ethical principle?
  A) Veracity
  B) Beneficence
  C) Nonmaleficence
  D) Autonomy
  Ans: D
  The principle of autonomy specifies that individuals have the ability to make a choice free from external constraints. The physician’s actions in this case violate this principle. This action may or may not violate the principle of beneficence. Veracity centers on truth-telling and nonmaleficence is avoiding the infliction of harm.



21. During discussion with the patient and the patient’s husband, you discover that the patient has a living will. How does the presence of a living will influence the patient’s care?
  A) The patient is legally unable to refuse basic life support.
  B) The physician can override the patient’s desires for treatment if desires are not evidence-based.
  C) The patient may nullify the living will during her hospitalization if she chooses to do so.
  D) Power-of-attorney may change while the patient is hospitalized.
  Ans: C
  Because living wills are often written when the person is in good health, it is not unusual for the patient to nullify the living will during illness. A living will does not make a patient legally unable to refuse basic life support. The physician may disagree with the patient’s wishes, but he or she is ethically bound to carry out those wishes. A power-of-attorney is not synonymous with a living will.



22. Your older adult patient has a diagnosis of rheumatoid arthritis (RA) and has been achieving only modest relief of her symptoms with the use of nonsteroidal anti-inflammatory drugs (NSAIDs). When creating this patient’s plan of care, which nursing diagnosis would most likely be appropriate?
  A) Self-care deficit related to fatigue and joint stiffness
  B) Ineffective airway clearance related to chronic pain
  C) Risk for hopelessness related to body image disturbance
  D) Anxiety related to chronic joint pain
  Ans: A
  Nursing diagnoses are actual or potential problems that can be managed by independent nursing actions. Self-care deficit would be the most likely consequence of rheumatoid arthritis. Anxiety and hopelessness are plausible consequences of a chronic illness such as RA, but challenges with self-care are more likely. Ineffective airway clearance is unlikely.



23. You are writing a care plan for an 85-year-old patient who has community-acquired pneumonia and you note decreased breath sounds to bilateral lung bases on auscultation. What is the most appropriate nursing diagnosis for this patient?
  A) Ineffective airway clearance related to tracheobronchial secretions
  B) Pneumonia related to progression of disease process
  C) Poor ventilation related to acute lung infection
  D) Immobility related to fatigue
  Ans: A
  Nursing diagnoses are not medical diagnoses or treatments. The most appropriate nursing diagnosis for this patient is “ineffective airway clearance related to copious tracheobronchial secretions.” “Pneumonia” and “poor ventilation” are not nursing diagnoses. Immobility is likely, but is less directly related to the patient’s admitting medical diagnosis and the nurse’s assessment finding.



24. You are providing care for a patient who has a diagnosis of pneumonia attributed to Streptococcus pneumonia infection. Which of the following aspects of nursing care would constitute part of the planning phase of the nursing process?
  A) Achieve SaO2 ³ 92% at all times.
  B) Auscultate chest q4h.
  C) Administer oral fluids q1h and PRN.
  D) Avoid overexertion at all times.
  Ans: A
  The planning phase entails specifying the immediate, intermediate, and long-term goals of nursing action, such as maintaining a certain level of oxygen saturation in a patient with pneumonia. Providing fluids and avoiding overexertion are parts of the implementation phase of the nursing process. Chest auscultation is an assessment.



25. You are the nurse who is caring for a patient with a newly diagnosed allergy to peanuts. Which of the following is an immediate goal that is most relevant to a nursing diagnosis of “deficient knowledge related to appropriate use of an EpiPen”?
  A) The patient will demonstrate correct injection technique with today’s teaching session.
  B) The patient will closely observe the nurse demonstrating the injection.
  C) The nurse will teach the patient’s family member to administer the injection.
  D) The patient will return to the clinic within 2 weeks to demonstrate the injection.
  Ans: A
  Immediate goals are those that can be reached in a short period of time. An appropriate immediate goal for this patient is that the patient will demonstrate correct administration of the medication today. The goal should specify that the patient administer the EpiPen. A 2-week time frame is inconsistent with an immediate goal.



26. A recent nursing graduate is aware of the differences between nursing actions that are independent and nursing actions that are interdependent. A nurse performs an interdependent nursing intervention when performing which of the following actions?
  A) Auscultating a patient’s apical heart rate during an admission assessment
  B) Providing mouth care to a patient who is unconscious following a cerebrovascular accident
  C) Administering an IV bolus of normal saline to a patient with hypotension
  D) Providing discharge teaching to a postsurgical patient about the rationale for a course of oral antibiotics
  Ans: C
  Although many nursing actions are independent, others are interdependent, such as carrying out prescribed treatments, administering medications and therapies, and collaborating with other health care team members to accomplish specific, expected outcomes and to monitor and manage potential complications. Irrigating a wound, administering pain medication, and administering IV fluids are interdependent nursing actions and require a physician’s order. An independent nursing action occurs when the nurse assesses a patient’s heart rate, provides discharge education, or provides mouth care.



27. A nurse has been using the nursing process as a framework for planning and providing patient care. What action would the nurse do during the evaluation phase of the nursing process?
  A) Have a patient provide input on the quality of care received.
  B) Remove a patient’s surgical staples on the scheduled postoperative day.
  C) Provide information on a follow-up appointment for a postoperative patient.
  D) Document a patient’s improved air entry with incentive spirometric use.
  Ans: D
  During the evaluation phase of the nursing process, the nurse determines the patient’s response to nursing interventions. An example of this is when the nurse documents whether the patient’s spirometry use has improved his or her condition. A patient does not do the evaluation. Removing staples and providing information on follow-up appointments are interventions, not evaluations.



28. An audit of a large, university medical center reveals that four patients in the hospital have current orders for restraints. You know that restraints are an intervention of last resort, and that it is inappropriate to apply restraints to which of the following patients?
  A) A postlaryngectomy patient who is attempting to pull out his tracheostomy tube
  B) A patient in hypovolemic shock trying to remove the dressing over his central venous catheter
  C) A patient with urosepsis who is ringing the call bell incessantly to use the bedside commode
  D) A patient with depression who has just tried to commit suicide and whose medications are not achieving adequate symptom control
  Ans: C
  Restraints should never be applied for staff convenience. The patient with urosepsis who is frequently ringing the call bell is requesting assistance to the bedside commode; this is appropriate behavior that will not result in patient harm. The other described situations could plausibly result in patient harm; therefore, it is more likely appropriate to apply restraints in these instances.



29. A patient has been diagnosed with small-cell lung cancer. He has met with the oncologist and is now weighing the relative risks and benefits of chemotherapy and radiotherapy as his treatment. This patient is demonstrating which ethical principle in making his decision?
  A) Beneficence
  B) Confidentiality
  C) Autonomy
  D) Justice
  Ans: C
  Autonomy entails the ability to make a choice free from external constraints. Beneficence is the duty to do good and the active promotion of benevolent acts. Confidentiality relates to the concept of privacy. Justice states that cases should be treated equitably.



30. A patient with migraines does not know whether she is receiving a placebo for pain management or the new drug that is undergoing clinical trials. Upon discussing the patient’s distress, it becomes evident to the nurse that the patient did not fully understand the informed consent document that she signed. Which ethical principle is most likely involved in this situation?
  A) Sanctity of life
  B) Confidentiality
  C) Veracity
  D) Fidelity
  Ans: C
  Telling the truth (veracity) is one of the basic principles of our culture. Three ethical dilemmas in clinical practice that can directly conflict with this principle are the use of placebos (nonactive substances used for treatment), not revealing a diagnosis to a patient, and revealing a diagnosis to persons other than the patient with the diagnosis. All involve the issue of trust, which is an essential element in the nurse–patient relationship. Sanctity of life is the perspective that life is the highest good. Confidentiality deals with privacy of the patient. Fidelity is promise-keeping and the duty to be faithful to one’s commitments.



31. The nursing instructor is explaining critical thinking to a class of first-semester nursing students. When promoting critical thinking skills in these students, the instructor should encourage them to do which of the following actions?
  A) Disregard input from people who do not have to make the particular decision.
  B) Set aside all prejudices and personal experiences when making decisions.
  C) Weigh each of the potential negative outcomes in a situation.
  D) Examine and analyze all available information.
  Ans: D
  Critical thinking involves reasoning and purposeful, systematic, reflective, rational, outcome-directed thinking based on a body of knowledge, as well as examination and analysis of all available information and ideas. A full disregard of one’s own experiences is not possible. Critical thinking does not denote a focus on potential negative outcomes. Input from others is a valuable resource that should not be ignored.



32. A care conference has been organized for a patient with complex medical and psychosocial needs. When applying the principles of critical thinking to this patient’s care planning, the nurse should most exemplify what characteristic?
  A) Willingness to observe behaviors
  B) A desire to utilize the nursing scope of practice fully
  C) An ability to base decisions on what has happened in the past
  D) Openness to various viewpoints
  Ans: D
  Willingness and openness to various viewpoints are inherent in critical thinking; these allow the nurse to reflect on the current situation. An emphasis on the past, willingness to observe behaviors, and a desire to utilize the nursing scope of practice fully are not central characteristics of critical thinkers.



33. Achieving adequate pain management for a postoperative patient will require sophisticated critical thinking skills by the nurse. What are the potential benefits of critical thinking in nursing? Select all that apply.
  A) Enhancing the nurse’s clinical decision making
  B) Identifying the patient’s individual preferences
  C) Planning the best nursing actions to assist the patient
  D) Increasing the accuracy of the nurse’s judgments
  E) Helping identify the patient’s priority needs
  Ans: A, C, D, E
  Independent judgments and decisions evolve from a sound knowledge base and the ability to synthesize information within the context in which it is presented. Critical thinking enhances clinical decision making, helping to identify patient needs and the best nursing actions that will assist patients in meeting those needs. Critical thinking does not normally focus on identify patient desires; these would be identified by asking the patient.



34. A nurse is unsure how best to respond to a patient’s vague complaint of “feeling off.” The nurse is attempting to apply the principles of critical thinking, including metacognition. How can the nurse best foster metacognition?
  A) By eliciting input from a variety of trusted colleagues
  B) By examining the way that she thinks and applies reason
  C) By evaluating her responses to similar situations in the past
  D) By thinking about the way that an “ideal” nurse would respond in this situation
  Ans: B
  Critical thinking includes metacognition, the examination of one’s own reasoning or thought processes, to help refine thinking skills. Metacognition is not characterized by eliciting input from others or evaluating previous responses.



35. The nursing instructor cites a list of skills that support critical thinking in clinical situations. The nurse should describe skills in which of the following domains? Select all that apply.
  A) Self-esteem
  B) Self-regulation
  C) Inference
  D) Autonomy
  E) Interpretation
  Ans: B, C, E
  Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Self-esteem and autonomy would not be on the list because they are not skills.



36. The nurse is providing care for a patient with chronic obstructive pulmonary disease (COPD). The nurse’s most recent assessment reveals an SaO2 of 89%. The nurse is aware that part of critical thinking is determining the significance of data that have been gathered. What characteristic of critical thinking is used in determining the best response to this assessment finding?
  A) Extrapolation
  B) Inference
  C) Characterization
  D) Interpretation
  Ans: D
  Nurses use interpretation to determine the significance of data that are gathered. This specific process is not described as extrapolation, inference, or characterization.



37. A nurse is admitting a new patient to the medical unit. During the initial nursing assessment, the nurse has asked many supplementary open-ended questions while gathering information about the new patient. What is the nurse achieving through this approach?
  A) Interpreting what the patient has said
  B) Evaluating what the patient has said
  C) Assessing what the patient has said
  D) Validating what the patient has said
  Ans: D
  Critical thinkers validate the information presented to make sure that it is accurate (not just supposition or opinion), that it makes sense, and that it is based on fact and evidence. The nurse is not interpreting, evaluating, or assessing the information the patient has given.



38. A nurse uses critical thinking every day when going through the nursing process. Which of the following is an outcome of critical thinking in nursing practice?
  A) A comprehensive plan of care with a high potential for success
  B) Identification of the nurse’s preferred goals for the patient
  C) A collaborative basis for assigning care
  D) Increased cost efficiency in health care
  Ans: A
  Critical thinking in nursing practice results in a comprehensive plan of care with maximized potential for success. Critical thinking does not identify the nurse’s goal for the patient or provide a collaborative basis for assigning care. Critical thinking may or may not lead to increased cost efficiency; the patient’s outcomes are paramount.



39. A nurse provides care on an orthopedic reconstruction unit and is admitting two new patients, both status post knee replacement. What would be the best explanation why their care plans may be different from each other?
  A) Patients may have different insurers, or one may qualify for Medicare.
  B) Individual patients are seen as unique and dynamic, with individual needs.
  C) Nursing care may be coordinated by members of two different health disciplines.
  D) Patients are viewed as dissimilar according to their attitude toward surgery.
  Ans: B
  Regardless of the setting, each patient situation is viewed as unique and dynamic. Differences in insurance coverage and attitude may be relevant, but these should not fundamentally explain the differences in their nursing care. Nursing care should be planned by nurses, not by members of other disciplines.



40. A class of nursing students is in their first semester of nursing school. The instructor explains that one of the changes they will undergo while in nursing school is learning to “think like a nurse.” What is the most current model of this thinking process?
  A) Critical-thinking Model
  B) Nursing Process Model
  C) Clinical Judgment Model
  D) Active Practice Model
  Ans: C
  To depict the process of “thinking like a nurse,” Tanner (2006) developed a model known as the clinical judgment model.



41. Critical thinking and decision-making skills are essential parts of nursing in all venues. What are examples of the use of critical thinking in the venue of genetics-related nursing? Select all that apply.
  A) Notifying individuals and family members of the results of genetic testing
  B) Providing a written report on genetic testing to an insurance company
  C) Assessing and analyzing family history data for genetic risk factors
  D) Identifying individuals and families in need of referral for genetic testing
  E) Ensuring privacy and confidentiality of genetic information
  Ans: C, D, E
  Nurses use critical thinking and decision-making skills in providing genetics-related nursing care when they assess and analyze family history data for genetic risk factors, identify those individuals and families in need of referral for genetic testing or counseling, and ensure the privacy and confidentiality of genetic information. Nurses who work in the venue of genetics-related nursing do not notify family members of the results of an individual’s genetic testing, and they do not provide written reports to insurance companies concerning the results of genetic testing.



42. A student nurse has been assigned to provide basic care for a 58-year-old man with a diagnosis of AIDS-related pneumonia. The student tells the instructor that she is unwilling to care for this patient. What key component of critical thinking is most likely missing from this student’s practice?
  A) Compliance with direction
  B) Respect for authority
  C) Analyzing information and situations
  D) Withholding judgment
  Ans: D
  Key components of critical thinking behavior are withholding judgment and being open to options and explanations from one patient to another in similar circumstances. The other listed options are incorrect because they are not components of critical thinking.



43. A group of students have been challenged to prioritize ethical practice when working with a marginalized population. How should the students best understand the concept of ethics?
  A) The formal, systematic study of moral beliefs
  B) The informal study of patterns of ideal behavior
  C) The adherence to culturally rooted, behavioral norms
  D) The adherence to informal personal values
  Ans: A
  In essence, ethics is the formal, systematic study of moral beliefs, whereas morality is the adherence to informal personal values.



44. Your patient has been admitted for a liver biopsy because the physician believes the patient may have liver cancer. The family has told both you and the physician that if the patient is terminal, the family does not want the patient to know. The biopsy results are positive for an aggressive form of liver cancer and the patient asks you repeatedly what the results of the biopsy show. What strategy can you use to give ethical care to this patient?
  A) Obtain the results of the biopsy and provide them to the patient.
  B) Tell the patient that only the physician knows the results of the biopsy.
  C) Promptly communicate the patient’s request for information to the family and the physician.
  D) Tell the patient that the biopsy results are not back yet in order  temporarily to appease him.
  Ans: C
  Strategies nurses could consider include the following: not lying to the patient, providing all information related to nursing procedures and diagnoses, and communicating the patient’s requests for information to the family and physician. Ethically, you cannot tell the patient the results of the biopsy and you cannot lie to the patient.



45. The nurse admits a patient to an oncology unit that is a site for a study on the efficacy of a new chemotherapeutic drug. The patient knows that placebos are going to be used for some participants in the study but does not know that he is receiving a placebo. When is it ethically acceptable to use placebos?
  A) Whenever the potential benefits of a study are applicable to the larger population
  B) When the patient is unaware of it and it is deemed unlikely that it would cause harm
  C) Whenever the placebo replaces an active drug
  D) When the patient knows placebos are being used and is involved in the decision-making process
  Ans: D
  Placebos may be used in experimental research in which a patient is involved in the decision-making process and is aware that placebos are being used in the treatment regimen. Placebos may not ethically be used solely when there is a potential benefit, when the patient is unaware, or when a placebo replaces an active drug.



46. The nurse caring for a patient who is two days post hip replacement notifies the physician that the patient’s incision is red around the edges, warm to the touch, and seeping a white liquid with a foul odor. What type of problem is the nurse dealing with?
  A) Collaborative problem
  B) Nursing problem
  C) Medical problem
  D) Administrative problem
  Ans: A
  In addition to nursing diagnoses and their related nursing interventions, nursing practice involves certain situations and interventions that do not fall within the definition of nursing diagnoses. These activities pertain to potential problems or complications that are medical in origin and require collaborative interventions with the physician and other members of the health care team. The other answers are incorrect because the signs and symptoms of infection are a medical complication that requires interventions by the nurse.



47. While developing the plan of care for a new patient on the unit, the nurse must identify expected outcomes that are appropriate for the new patient. What resource should the nurse prioritize for identifying these appropriate outcomes?
  A) Community Specific Outcomes Classification (CSO)
  B) Nursing-Sensitive Outcomes Classification (NOC)
  C) State Specific Nursing Outcomes Classification (SSNOC)
  D) Department of Health and Human Services Outcomes Classification (DHHSOC)
  Ans: B
  Resources for identifying appropriate expected outcomes include the NOC and standard outcome criteria established by health care agencies for people with specific health problems. The other options are incorrect because they do not exist.



48. The nurse has just taken report on a newly admitted patient who is a 15-year-old girl who is a recent immigrant to the United States. When planning interventions for this patient, the nurse knows the interventions must be which of the following? Select all that apply.
  A) Appropriate to the nurse’s preferences
  B) Appropriate to the patient’s age
  C) Ethical
  D) Appropriate to the patient’s culture
  E) Applicable to others with the same diagnosis
  Ans: B, C, D
  Planned interventions should be ethical and appropriate to the patient’s culture, age, and gender. Planned interventions do not have to be in alignment with the nurse’s preferences nor do they have to be shared by everyone with the same diagnosis.


1. You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patient’s plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patient’s health?
  A) Nutritional status
  B) Potassium balance
  C) Calcium balance
  D) Fluid volume status
  Ans: D
  A specific gravity will detect if the patient has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not directly indicated.



2. You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patient’s most recent laboratory reports, you note that the patient’s magnesium levels are high. You should prioritize assessment for which of the following health problems?
  A) Diminished deep tendon reflexes
  B) Tachycardia
  C) Cool, clammy skin
  D) Acute flank pain
  Ans: A
  To gauge a patient’s magnesium status, the nurse should check deep tendon reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with hypermagnesemia.



3. You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?
  A) Metabolic alkalosis
  B) Hypermagnesemia
  C) Hypercalcemia
  D) Hypovolemia
  Ans: D
  Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis.



4. A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid–base imbalance?
  A) Respiratory acidosis
  B) Respiratory alkalosis
  C) Increased PaCO2
  D) CNS disturbances
  Ans: B
  The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation. Acute respiratory acidosis occurs in emergency situations, such as pulmonary edema, and is exhibited by hypoventilation and decreased PaCO2. CNS disturbances are found in extreme hyponatremia and fluid overload.



5. You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results?
  A) Respiratory acidosis with no compensation
  B) Metabolic alkalosis with a compensatory alkalosis
  C) Metabolic acidosis with no compensation
  D) Metabolic acidosis with a compensatory respiratory alkalosis
  Ans: D
  A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO3 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem.



6. You are making initial shift assessments on your patients. While assessing one patient’s peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?
  A) Air emboli
  B) Phlebitis
  C) Infiltration
  D) Fluid overload
  Ans: C
  Infiltration is the administration of nonvesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli, phlebitis, and fluid overload are not indications of infiltration.



7. You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patient’s skin turgor?
  A) Overhydration is common among healthy older adults.
  B) Dehydration causes the skin to appear spongy.
  C) Inelastic skin turgor is a normal part of aging.
  D) Skin turgor cannot be assessed in patients over 70.
  Ans: C
  Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy.



8. The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?
  A) Choose a hairless site if available.
  B) Consider potential effects on the patient’s mobility when selecting a site.
  C) Have the patient briefly hold his arm over his head before insertion.
  D) Leave the tourniquet on for at least 3 minutes.
  Ans: B
  Ideally, both arms and hands are carefully inspected before choosing a specific venipuncture site that does not interfere with mobility. Instruct the patient to hold his arm in a dependent position to increase blood flow. Never leave a tourniquet in place longer than 2 minutes. The site does not necessarily need to be devoid of hair.



9. A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patient’s blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following?
  A) Hydrostatic pressure
  B) Osmosis and osmolality
  C) Diffusion
  D) Active transport
  Ans: B
  Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. Hydrostatic pressure refers to changes in water or volume related to water pressure. Diffusion is the movement of solutes from an area of greater concentration to lesser concentration; the solutes in an intact vascular system are unable to move so diffusion normally should not be taking place. Active transport is the movement of molecules against the concentration gradient and requires adenosine triphosphate (ATP) as an energy source; this process typically takes place at the cellular level and is not involved in vascular volume changes.



10. You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?
  A) Hypophosphatemia
  B) Hypocalcemia
  C) Hypermagnesemia
  D) Hyperkalemia
  Ans: B
  Tetany is the most characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and, less commonly, in the feet. Hypophosphatemia creates central nervous dysfunction, resulting in seizures and coma. Hypermagnesemia creates hypoactive reflexes and somnolence. Signs of hyperkalemia include paresthesias and anxiety.



11. A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, “A patient in renal failure partially loses the ability to regulate changes in pH.” What is the cause of this partial inability?
  A) The kidneys regulate and reabsorb carbonic acid to change and maintain pH.
  B) The kidneys buffer acids through electrolyte changes.
  C) The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.
  D) The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.
  Ans: C
  The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The lungs regulate and reabsorb carbonic acid to change and maintain pH. The kidneys do not buffer acids through electrolyte changes; buffering occurs in reaction to changes in pH. Carbonic acid works as the chemical medium to exchange O2 and CO2 in the lungs to maintain a stable pH whereas the kidneys use bicarbonate as the chemical medium to maintain a stable pH by moving and eliminating H+.



12. You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the morning’s blood work, you notice that the patient’s potassium is below reference range. You should recognize that the patient may be at risk for what imbalance?
  A) Hypercalcemia
  B) Metabolic acidosis
  C) Metabolic alkalosis
  D) Respiratory acidosis
  Ans: C
  Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This patient would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the patient’s respiratory status.



13. The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?
  A) Leave one hand ungloved to assess the site.
  B) Cleanse the skin with normal saline.
  C) Ask the patient about allergies to latex or iodine.
  D) Remove excessive hair from the selected site.
  Ans: C
  Before preparing the skin, the nurse should ask the patient if he or she is allergic to latex or iodine, which are products commonly used in preparing for IV therapy. A local reaction could result in irritation to the IV site, or, in the extreme, it could result in anaphylaxis, which can be life threatening. Both hands should always be gloved when preparing for IV insertion, and latex-free gloves must be used or the patient must report not having latex allergies. The skin is not usually cleansed with normal saline prior to insertion. Removing excessive hair at the selected site is always secondary to allergy inquiry.



14. A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2  64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?
  A) Respiratory acidosis
  B) Metabolic alkalosis
  C) Respiratory alkalosis
  D) Metabolic acidosis
  Ans: A
  The pH is below 7.40, PaCO2 is greater than 40, and the HCO3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range so it is not metabolic alkalosis. The pH of 7.21 indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis.



15. One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following?
  A) Help distinguish hyponatremia from hypernatremia
  B) Help evaluate pituitary gland function
  C) Help distinguish reduced renal blood flow from decreased renal function
  D) Help provide an effective treatment for hypertension-induced oliguria
  Ans: C
  If a patient is not excreting enough urine, the health care provider needs to determine whether the depressed renal function is the result of reduced renal blood flow, which is a fluid volume deficit (FVD or prerenal azotemia), or acute tubular necrosis that results in necrosis or cellular death from prolonged FVD. A typical example of a fluid challenge involves administering 100 to 200 mL of normal saline solution over 15 minutes. The response by a patient with FVD but with normal renal function is increased urine output and an increase in blood pressure. Laboratory examinations are needed to distinguish hyponatremia from hypernatremia. A fluid challenge is not used to evaluate pituitary gland function. A fluid challenge may provide information regarding hypertension-induced oliguria, but it is not an effective treatment.



16. The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, “I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom.” What would be the nurse’s best response?
  A) “I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup.”
  B) “Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids.”
  C) “It is normal to be a little confused following surgery, and it is safe not to urinate at night.”
  D) “If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress. ”
  Ans: B
  In elderly patients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the elderly person. There is no mention of medications in the stem of the question or any specific evidence given for the need for readmission to the hospital. Confusion is never normal, common, or expected in the elderly. Urinary retention does normally cause confusion.



17. A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurse’s most likely explanation for the low urine output?
  A) The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place.
  B) The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin.
  C) The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output.
  D) The man is having a sympathetic reaction, which has stimulated the renin–angiotensin–aldosterone system that results in diminished urine output.
  Ans: D
  Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely causing the lower urine output. The man urinating prior to his arrival to the ED is unlikely; the fall and hip injury would make his ability to urinate difficult. No assessment information indicates he has a head injury or heart failure.



18. A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site?
  A) Leave the hair intact.
  B) Shave the area.
  C) Clip the hair in the area.
  D) Remove the hair with a depilatory.
  Ans: C
  Hair can be a source of infection and should be removed by clipping; it should not be left at the site. Shaving the area can cause skin abrasions, and depilatories can irritate the skin.



19. You are the nurse evaluating a newly admitted patient’s laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)?
  A) Increased serum sodium
  B) Decreased serum potassium
  C) Decreased hemoglobin
  D) Increased platelets
  Ans: A
  Increased serum sodium causes increased thirst and the release of ADH by the posterior pituitary gland. When serum osmolality decreases and thirst and ADH secretions are suppressed, the kidney excretes more water to restore normal osmolality. Levels of potassium, hemoglobin, and platelets do not directly affect ADH release.



20. A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurse’s preceptor is going over the patient’s past lab reports with the new nurse. The nurse takes note that the patient’s PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurse’s best response?
  A) The patient’s calcium will rise dramatically due to pituitary stimulation.
  B) Oxygen will increase the patient’s intracranial pressure and create confusion.
  C) Oxygen may cause the patient to hyperventilate and become acidotic.
  D) Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.
  Ans: D
  When PaCO2 chronically exceeds 50 mm Hg, it creates insensitivity to CO2 in the respiratory medulla, and the use of oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. No information indicates the patient’s calcium will rise dramatically due to pituitary stimulation. No feedback system that oxygen stimulates would create an increase in the patient’s intracranial pressure and create confusion. Increasing the oxygen would not stimulate the patient to hyperventilate and become acidotic; rather, it would cause hypoventilation and acidosis.



21. The nurse is providing care for a patient with chronic obstructive pulmonary disease. When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process?
  A) Diffusion
  B) Osmosis
  C) Active transport
  D) Filtration
  Ans: A
  Diffusion is the natural tendency of a substance to move from an area of higher concentration to one of lower concentration. It occurs through the random movement of ions and molecules. Examples of diffusion are the exchange of oxygen and carbon dioxide between the pulmonary capillaries and alveoli and the tendency of sodium to move from the ECF compartment, where the sodium concentration is high, to the ICF, where its concentration is low. Osmosis occurs when two different solutions are separated by a membrane that is impermeable to the dissolved substances; fluid shifts through the membrane from the region of low solute concentration to the region of high solute concentration until the solutions are of equal concentration. Active transport implies that energy must be expended for the movement to occur against a concentration gradient. Movement of water and solutes occurring from an area of high hydrostatic pressure to an area of low hydrostatic pressure is filtration.



22. When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?
  A) Active transport of hydrogen ions across the capillary walls
  B) Pressure of the blood in the renal capillaries
  C) Action of the dissolved particles contained in a unit of blood
  D) Hydrostatic pressure resulting from the pumping action of the heart
  Ans: D
  An example of filtration is the passage of water and electrolytes from the arterial capillary bed to the interstitial fluid; in this instance, the hydrostatic pressure results from the pumping action of the heart. Active transport does not move water and electrolytes from the arterial capillary bed to the interstitial fluid, filtration does. The number of dissolved particles in a unit of blood is concerned with osmolality. The pressure in the renal capillaries causes renal filtration.



23. The baroreceptors, located in the left atrium and in the carotid and aortic arches, respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect?
  A) Decrease in the release of aldosterone
  B) Increase of filtration in the Loop of Henle
  C) Decrease in the reabsorption of sodium
  D) Decrease in glomerular filtration
  Ans: D
  Sympathetic stimulation constricts renal arterioles; this decreases glomerular filtration, increases the release of aldosterone, and increases sodium and water reabsorption. None of the other listed options occurs with increased sympathetic stimulation.



24. You are the nurse caring for a 77-year-old male patient who has been involved in a motor vehicle accident. You and your colleague note that the patient’s labs indicate minimally elevated serum creatinine levels, which your colleague dismisses. What can this increase in creatinine indicate in older adults?
  A) Substantially reduced renal function
  B) Acute kidney injury
  C) Decreased cardiac output
  D) Alterations in ratio of body fluids to muscle mass
  Ans: A
  Normal physiologic changes of aging, including reduced cardiac, renal, and respiratory function, and reserve and alterations in the ratio of body fluids to muscle mass, may alter the responses of elderly people to fluid and electrolyte changes and acid–base disturbances. Renal function declines with age, as do muscle mass and daily exogenous creatinine production. Therefore, high-normal and minimally elevated serum creatinine values may indicate substantially reduced renal function in older adults. Acute kidney injury is likely to cause a more significant increase in serum creatinine.



25. You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration?
  A) Extravasation of the medication
  B) Discomfort to the patient
  C) Blanching at the site
  D) Hypersensitivity reaction to the medication
  Ans: A
  Irritating medications, such as chemotherapeutic agents, can cause pain, burning, and redness at the site. Blistering, inflammation, and necrosis of tissues can occur. The extent of tissue damage is determined by the medication concentration, the quantity that extravasated, infusion site location, the tissue response, and the extravasation duration. Extravasation is the priority over the other listed consequences.



26. The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit?
  A) Diarrhea
  B) Dilute urine
  C) Increased muscle tone
  D) Joint pain
  Ans: B
  Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias (numbness and tingling), and dysrhythmias. If prolonged, hypokalemia can lead to an inability of the kidneys to concentrate urine, causing dilute urine (resulting in polyuria, nocturia) and excessive thirst. Potassium depletion suppresses the release of insulin and results in glucose intolerance. Decreased muscle strength and DTRs can be found on physical assessment. You would expect decreased, not increased, muscle strength with hypokalemia. The patient would not have diarrhea following bowel surgery, and increased bowel motility is inconsistent with hypokalemia.



27. You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance?
  A) Hypernatremia
  B) Hypomagnesemia
  C) Hypophosphatemia
  D) Hypercalcemia
  Ans: D
  The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Anorexia, nausea, vomiting, and constipation are common symptoms of hypercalcemia. Dehydration occurs with nausea, vomiting, anorexia, and calcium reabsorption at the proximal renal tubule. Abdominal and bone pain may also be present. Primary manifestations of hypernatremia are neurologic and would not include abdominal pain and dehydration. Tetany is the most characteristic manifestation of hypomagnesemia, and this scenario does not mention tetany. The patient’s presentation is inconsistent with hypophosphatemia.



28. A medical nurse educator is reviewing a patient’s recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?
  A) The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance.
  B) The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.
  C) The kidneys react rapidly to compensate for imbalances in the body.
  D) The kidneys regulate the bicarbonate level in the intracellular fluid.
  Ans: B
  The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. In respiratory and metabolic alkalosis, the kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance. The kidneys obviously cannot compensate for the metabolic acidosis created by renal failure. Renal compensation for imbalances is relatively slow (a matter of hours or days).



29. The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation?
  A) Endocarditis
  B) Multiple myeloma
  C) Guillain-Barré syndrome
  D) Overdose of amphetamines
  Ans: C
  Respiratory acidosis is always due to inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations and, consequently, increased levels of carbonic acid. Acute respiratory acidosis occurs in emergency situations, such as acute pulmonary edema, aspiration of a foreign object, atelectasis, pneumothorax, overdose of sedatives, sleep apnea, administration of oxygen to a patient with chronic hypercapnia (excessive CO2 in the blood), severe pneumonia, and acute respiratory distress syndrome. Respiratory acidosis can also occur in diseases that impair respiratory muscles, such as muscular dystrophy, myasthenia gravis, and Guillain-Barré syndrome. The other listed diagnoses are not associated with respiratory acidosis.



30. The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3– 23 mEq/L. The nurse should recognize the likelihood of what acid–base disorder?
  A) Respiratory acidosis
  B) Metabolic alkalosis
  C) Respiratory alkalosis
  D) Mixed acid–base disorder
  Ans: D
  Patients can simultaneously experience two or more independent acid–base disorders. A normal pH in the presence of changes in the PaCO2 and plasma HCO3– concentration immediately suggests a mixed disorder, making the other options incorrect.



31. A patient has questioned the nurse’s administration of IV normal saline, asking whether sterile water would be a more appropriate choice than “saltwater.” Under what circumstances would the nurse administer electrolyte-free water intravenously?
  A) Never, because it rapidly enters red blood cells, causing them to rupture.
  B) When the patient is severely dehydrated resulting in neurologic signs and symptoms
  C) When the patient is in excess of calcium and/or magnesium ions
  D) When a patient’s fluid volume deficit is due to acute or chronic renal failure
  Ans: A
  IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolyte-free water can never be administered by IV because it rapidly enters red blood cells and causes them to rupture.



32. A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. What factors contribute to this phenomenon? Select all that apply.
  A) Decreased kidney mass
  B) Increased conservation of sodium
  C) Increased total body water
  D) Decreased renal blood flow
  E) Decreased excretion of potassium
  Ans: A, D, E
  Dehydration in the elderly is common as a result of decreased kidney mass, decreased glomerular filtration rate, decreased renal blood flow, decreased ability to concentrate urine, inability to conserve sodium, decreased excretion of potassium, and a decrease of total body water.



33. You are called to your patient’s room by a family member who voices concern about the patient’s status. On assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You also find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patient’s signs and symptoms?
  A) Hypocalcemia
  B) Hyponatremia
  C) Hyperchloremia
  D) Hypophosphatemia
  Ans: C
  The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride level is accompanied by a high sodium level and fluid retention. With hypocalcemia, you would expect tetany. There would not be edema with hyponatremia. Signs or symptoms of hypophosphatemia are mainly neurologic.



34. Diagnostic testing has been ordered to differentiate between normal anion gap acidosis and high anion gap acidosis in an acutely ill patient. What health problem typically precedes normal anion gap acidosis?
  A) Metastases
  B) Excessive potassium intake
  C) Water intoxication
  D) Excessive administration of chloride
  Ans: D
  Normal anion gap acidosis results from the direct loss of bicarbonate, as in diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate). Based on these facts, the other listed options are incorrect.



35. The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders?
  A) Cimetidine
  B) Maalox
  C) Potassium chloride elixir
  D) Furosemide
  Ans: A
  H2 receptor antagonists, such as cimetidine (Tagamet), reduce the production of gastric HCl, thereby decreasing the metabolic alkalosis associated with gastric suction. Maalox is an oral simethicone used to break up gas in the GI system and would be of no benefit in treating a patient in metabolic alkalosis. KCl would only be given if the patient were hypokalemic, which is not stated in the scenario. Furosemide (Lasix) would only be given if the patient were fluid overloaded, which is not stated in the scenario.



36. You are caring for a patient with a diagnosis of pancreatitis. The patient was admitted from a homeless shelter and is a vague historian. The patient appears malnourished and on day 3 of the patient’s admission total parenteral nutrition (TPN) has been started. Why would you know to start the infusion of TPN slowly?
  A) Patients receiving TPN are at risk for hypercalcemia if calories are started too rapidly.
  B) Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively.
  C) Malnourished patients who receive fluids too rapidly are at risk for hypernatremia.
  D) Patients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate
  Ans: B
  The nurse identifies patients who are at risk for hypophosphatemia and monitors them. Because malnourished patients receiving parenteral nutrition are at risk when calories are introduced too aggressively, preventive measures involve gradually introducing the solution to avoid rapid shifts of phosphorus into the cells. Patients receiving TPN are not at risk for hypercalcemia or hypernatremia if calories or fluids are started to rapidly. Digestive enzymes are not a relevant consideration.



37. You are doing discharge teaching with a patient who has hypophosphatemia during his time in hospital. The patient has a diet ordered that is high in phosphate. What foods would you teach this patient to include in his diet? Select all that apply.
  A) Milk
  B) Beef
  C) Poultry
  D) Green vegetables
  E) Liver
  Ans: A, C, E
  If the patient experiences mild hypophosphatemia, foods such as milk and milk products, organ meats, nuts, fish, poultry, and whole grains should be encouraged.



38. You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis?
  A) Hypertension
  B) Kussmaul respirations
  C) Increased DTRs
  D) Shallow respirations
  Ans: D
  If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and shallow respirations. The nurse also observes for decreased DTRs and changes in the level of consciousness. Kussmaul breathing is a deep and labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also renal failure. This type of patient is associated with decreased DTRs, not increased DTRs.



39. A patient’s most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the patient’s dietary intake of potassium. Which of the following would be a good source of potassium?
  A) Apples
  B) Asparagus
  C) Carrots
  D) Bananas
  Ans: D
  Bananas are high in potassium. Apples, carrots, and asparagus are not high in potassium.



40. The nurse is assessing the patient for the presence of a Chvostek’s sign. What electrolyte imbalance would a positive Chvostek’s sign indicate?
  A) Hypermagnesemia
  B) Hyponatremia
  C) Hypocalcemia
  D) Hyperkalemia
  Ans: C
  You can induce Chvostek’s sign by tapping the patient’s facial nerve adjacent to the ear. A brief contraction of the upper lip, nose, or side of the face indicates Chvostek’s sign. Both hypomagnesemia and hypocalcemia may be tested using the Chvostek’s sign.


1. An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. The nurse’s health education should include which of the following?
  A) Increasing fluids to avoid extracellular volume depletion from the diuretic effect of the beta-blocker
  B) Maintaining a diet high in dairy to increase protein necessary to prevent organ damage
  C) Use of strategies to prevent falls stemming from postural hypotension
  D) Limiting exercise to avoid injury that can be caused by increased intracranial pressure
  Ans: C
  Elderly people have impaired cardiovascular reflexes and are more sensitive to postural hypotension. The nurse teaches patients to change positions slowly when moving from lying or sitting positions to a standing position, and counsels elderly patients to use supportive devices as necessary to prevent falls that could result from dizziness. Lifestyle changes, such as regular physical activity/exercise, and a diet rich in fruits, vegetables, and low-fat dairy products, is strongly recommended. Increasing fluids in elderly patients may be contraindicated due to cardiovascular disease. Increased intracranial pressure is not a risk and activity should not normally be limited.



2. A patient with primary hypertension comes to the clinic complaining of a gradual onset of blurry vision and decreased visual acuity over the past several weeks. The nurse is aware that these symptoms could be indicative of what?
  A) Retinal blood vessel damage
  B) Glaucoma
  C) Cranial nerve damage
  D) Hypertensive emergency
  Ans: A
  Blurred vision, spots in front of the eyes, and diminished visual acuity can mean retinal blood vessel damage indicative of damage elsewhere in the vascular system as a result of hypertension. Glaucoma and cranial nerve damage do not normally cause these symptoms. A hypertensive emergency would have a more rapid onset.



3. A nurse is performing blood pressure screenings at a local health fair. While obtaining subjective assessment data from a patient with hypertension,  the nurse learns that the patient has a family history of hypertension and she herself has high cholesterol and lipid levels. The patient says she smokes one pack of cigarettes daily and drinks “about a pack of beer” every day. The nurse notes what nonmodifiable risk factor for hypertension?
  A) Hyperlipidemia
  B) Excessive alcohol intake
  C) A family history of hypertension
  D) Closer adherence to medical regimen
  Ans: C
  Unlike cholesterol levels, alcohol intake and adherence to treatment, family history is not modifiable.



4. The staff educator is teaching ED nurses about hypertensive crisis. The nurse educator should explain that hypertensive urgency differs from hypertensive emergency in what way?
  A) The BP is always higher in a hypertensive emergency.
  B) Vigilant hemodynamic monitoring is required during treatment of hypertensive emergencies.
  C) Hypertensive urgency is treated with rest and benzodiazepines to lower BP.
  D) Hypertensive emergencies are associated with evidence of target organ damage.
  Ans: D
  Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. Blood pressures are extremely elevated in both urgency and emergencies, but there is no evidence of target organ damage in hypertensive urgency. Extremely close hemodynamic monitoring of the patient’s BP is required in both situations. The medications of choice in hypertensive emergencies are those with an immediate effect, such as IV vasodilators. Oral doses of fast-acting agents, such as beta-adrenergic blocking agents, angiotensin-converting enzyme inhibitors, or alpha-agonists, are recommended for the treatment of hypertensive urgencies.



5. A group of student nurses are practicing taking blood pressure. A 56-year-old male student has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, he exclaims, “My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?” Which of the following responses by the nursing instructor would be best?
  A) “Yes. Hypertension is prevalent among men; it is fortunate we caught this during your routine examination.”
  B) “We will need to reevaluate your blood pressure because your age places you at high risk for hypertension.”
  C) “A single elevated blood pressure does not confirm hypertension. You will need to have your blood pressure reassessed several times before a diagnosis can be made.”
  D) “You have no need to worry. Your pressure is probably elevated because you are being tested.”
  Ans: C
  Hypertension is confirmed by two or more readings with systolic pressure of at least 140 mm Hg and diastolic pressure of at least 90 mm Hg. An age of 56 does not constitute a risk factor in and of itself. The nurse should not tell the student that there is no need to worry.



6. A 40-year-old male newly diagnosed with hypertension is discussing risk factors with the nurse. The nurse talks about lifestyle changes with the patient and advises that the patient should avoid tobacco use. What is the primary rationale behind that advice to the patient?
  A) Quitting smoking will cause the patient’s hypertension to resolve.
  B) Tobacco use increases the patient’s concurrent risk of heart disease.
  C) Tobacco use is associated with a sedentary lifestyle.
  D) Tobacco use causes ventricular hypertrophy.
  Ans: B
  Smoking increases the risk for heart disease, for which a patient with hypertension is already at an increased risk. Quitting will not necessarily cause hypertension to resolve and smoking does not directly cause ventricular hypertrophy. The association with a sedentary lifestyle is true, but this is not the main rationale for the nurse’s advice; the association with heart disease is more salient.



7. A patient has been prescribed antihypertensives. After assessment and analysis, the nurse has identified a nursing diagnosis of risk for ineffective health maintenance related to nonadherence to therapeutic regimen. When planning this patient’s care, what desired outcome should the nurse identify?
  A) Patient takes medication as prescribed and reports any adverse effects.
  B) Patient’s BP remains consistently below 140/90 mm Hg.
  C) Patient denies signs and symptoms of hypertensive urgency.
  D) Patient is able to describe modifiable risk factors for hypertension.
  Ans: A
  The most appropriate expected outcome for a patient who is given the nursing diagnosis of risk for ineffective health maintenance is that he or she takes the medication as prescribed. The other listed goals are valid aspects of care, but none directly relates to the patient’s role in his or her treatment regimen.



8. The nurse is providing care for a patient with a new diagnosis of hypertension. How can the nurse best promote the patient’s adherence to the prescribed therapeutic regimen?
  A) Screen the patient for visual disturbances regularly.
  B) Have the patient participate in monitoring his or her own BP.
  C) Emphasize the dire health outcomes associated with inadequate BP control.
  D) Encourage the patient to lose weight and exercise regularly.
  Ans: B
  Adherence to the therapeutic regimen increases when patients actively participate in self-care, including self-monitoring of BP and diet. Dire warnings may motivate some patients, but for many patients this is not an appropriate or effective strategy. Screening for vision changes and promoting healthy lifestyle are appropriate nursing actions, but do not necessarily promote adherence to a therapeutic regimen.



9. A patient newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a patient with prolonged, uncontrolled hypertension is at risk for developing what health problem?
  A) Renal failure
  B) Right ventricular hypertrophy
  C) Glaucoma
  D) Anemia
  Ans: A
  When uncontrolled hypertension is prolonged, it can result in renal failure, myocardial infarction, stroke, impaired vision, left ventricular hypertrophy, and cardiac failure. Glaucoma and anemia are not directly associated with hypertension.



10. A patient with primary hypertension complains of dizziness with ambulation.  The patient is currently on an alpha-adrenergic blocker and the nurse assesses characteristic signs and symptoms of postural hypotension. When teaching this patient about risks associated with postural hypotension, what should the nurse emphasize?
  A) Rising slowly from a lying or sitting position
  B) Increasing fluids to maintain BP
  C) Stopping medication if dizziness persists
  D) Taking medication first thing in the morning
  Ans: A
  Patients who experience postural hypotension should be taught to rise slowly from a lying or sitting position and use a cane or walker if necessary for safety. It is not necessary to teach these patients about increasing fluids or taking medication in the morning (this would increase the effects of dizziness). Patient should not be taught to stop the medication if dizziness persists because this is unsafe and beyond the nurse’s scope of practice.



11. The nurse is planning the care of a patient who has been diagnosed with hypertension, but who otherwise enjoys good health. When assessing the response to an antihypertensive drug regimen, what blood pressure would be the goal of treatment?
  A) 156/96 mm Hg or lower
  B) 140/90 mm Hg or lower
  C) Average of 2 BP readings of 150/80 mm Hg
  D) 120/80 mm Hg or lower
  Ans: B
  The goal of antihypertensive drug therapy is a BP of 140/90 mm Hg or lower. A pressure of 130/80 mm Hg is the goal for patients with diabetes or chronic kidney disease.



12. A patient in a hypertensive emergency is admitted to the ICU. The nurse anticipates that the patient will be treated with IV vasodilators, and that the primary goal of treatment is what?
  A) Lower the BP to reduce onset of neurologic symptoms, such as headache and vision changes.
  B) Decrease the BP to a normal level based on the patient’s age.
  C) Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment.
  D) Reduce the BP to £ 120/75 mm Hg as quickly as possible.
  Ans: C
  Initially, the treatment goal in hypertensive emergencies is to reduce the mean arterial pressure by 25% in the first hour of treatment, with further reduction over the next 24 hours. Lowering the BP too fast may cause hypotension in a patient whose body has adjusted to hypertension and could cause a stroke, MI, or visual changes. Neurologic symptoms should be addressed, but this is not the primary focus of treatment planning.



13. The nursing lab instructor is teaching student nurses how to take blood pressure. To ensure accurate measurement, the lab instructor would teach the students to avoid which of the following actions?
  A) Measuring the BP after the patient has been seated quietly for more than 5 minutes
  B) Taking the BP at least 10 minutes after nicotine or coffee ingestion
  C) Using a cuff with a bladder that encircles at least 80% of the limb
  D) Using a bare forearm supported at heart level on a firm surface
  Ans: B
  Blood pressures should be taken with the patient seated with arm bare, supported, and at heart level. The patient should not have smoked tobacco or taken caffeine in the 30 minutes preceding the measurement. The patient should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured and have a width of at least 40% of limb circumference. Using a cuff that is too large results in a lower BP and a cuff that is too small will give a higher BP measurement.



14. A nurse is teaching an adult female patient about the risk factors for hypertension. What should the nurse explain as risk factors for primary hypertension?
  A) Obesity and high intake of sodium and saturated fat
  B) Diabetes and use of oral contraceptives
  C) Metabolic syndrome and smoking
  D) Renal disease and coarctation of the aorta
  Ans: A
  Obesity, stress, high intake of sodium or saturated fat, and family history are all risk factors for primary hypertension. Diabetes and oral contraceptives are risk factors for secondary hypertension. Metabolic syndrome, renal disease, and coarctation of the aorta are causes of secondary hypertension.



15. The nurse is caring for an older adult with a diagnosis of hypertension who is being treated with a diuretic and beta-blocker. Which of the following should the nurse integrate into the management of this client’s hypertension?
  A) Ensure that the patient receives a larger initial dose of antihypertensive medication due to impaired absorption.
  B) Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion.
  C) Recognize that an older adult is less likely to adhere to his or her medication regimen than a younger patient.
  D) Carefully assess for weight loss because of impaired kidney function resulting from normal aging.
  Ans: B
  Elderly people have impaired cardiovascular reflexes and thus are more sensitive to extracellular volume depletion caused by diuretics. The nurse needs to assess hydration status, low BP, and postural hypotension carefully. Older adults may have impaired absorption, but they do not need a higher initial dose of an antihypertensive than a younger person. Adherence to treatment is not necessarily linked to age. Kidney function and absorption decline with age; less, rather than more antihypertensive medication is prescribed.  Weight gain is not necessarily indicative of kidney function decline.



16. A patient with secondary hypertension has come into the clinic for a routine check-up. The nurse is aware that the difference between primary hypertension and secondary hypertension is which of the following?
  A) Secondary hypertension has a specific cause.
  B) Secondary hypertension has a more gradual onset than primary hypertension.
  C) Secondary hypertension does not cause target organ damage.
  D) Secondary hypertension does not normally respond to antihypertensive drug therapy.
  Ans: A
  Secondary hypertension has a specific identified cause. A cause could include narrowing of the renal arteries, renal parenchymal disease, hyperaldosteronism, certain medications, pregnancy, and coarctation of the aorta.  Secondary hypertension does respond to antihypertensive drug therapy and can cause target organ damage if left untreated.



17. The nurse is assessing a patient new to the clinic. Records brought to the clinic with the patient show the patient has hypertension and that her current BP readings approximate the readings from when she was first diagnosed. What contributing factor should the nurse first explore in an effort to identify the cause of the client’s inadequate BP control?
  A) Progressive target organ damage
  B) Possibility of medication interactions
  C) Lack of adherence to prescribed drug therapy
  D) Possible heavy alcohol use or use of recreational drugs
  Ans: C
  Deviation from the therapeutic program is a significant problem for people with hypertension and other chronic conditions requiring lifetime management. An estimated 50% of patients discontinue their medications within 1 year of beginning to take them. Consequently, this is a more likely problem than substance use, organ damage, or adverse drug interactions.



18. A patient has come to the clinic for a follow-up assessment that will include a BP reading. To ensure an accurate reading, the nurse should confirm that the patient has done which of the following?
  A) Tried to rest quietly for 5 minutes before the reading is taken
  B) Refrained from smoking for at least 8 hours
  C) Drunk adequate fluids during the day prior
  D) Avoided drinking coffee for 12 hours before the visit
  Ans: A
  Prior to the nurse assessing the patient’s BP, the patient should try to rest quietly for 5 minutes. The forearm should be positioned at heart level. Caffeine products and cigarette smoking should be avoided for at least 30 minutes prior to the visit. Recent fluid intake is not normally relevant.



19. The nurse is providing care for a patient with a diagnosis of hypertension. The nurse should consequently assess the patient for signs and symptoms of which other health problem?
  A) Migraines
  B) Atrial-septal defect
  C) Atherosclerosis
  D) Thrombocytopenia
  Ans: C
  Hypertension is both a sign and a risk factor for atherosclerotic heart disease. It is not associated with structural cardiac defects, low platelet levels, or migraines.



20. The nurse is developing a nursing care plan for a patient who is being treated for hypertension. What is a measurable patient outcome that the nurse should include?
  A) Patient will reduce Na+ intake to no more than 2.4 g daily.
  B) Patient will have a stable BUN and serum creatinine levels.
  C) Patient will abstain from fat intake and reduce calorie intake.
  D) Patient will maintain a normal body weight.
  Ans: A
  Dietary sodium intake of no more than 2.4 g sodium is recommended as a dietary lifestyle modification to prevent and manage hypertension. Giving a specific amount of allowable sodium intake makes this a measurable goal. None of the other listed goals is quantifiable and measurable.



21. A patient with newly diagnosed hypertension has come to the clinic for a follow-up visit. The patient asks the nurse why she has to come in so often. What would be the nurse’s best response?
  A) “We do this so you don’t suffer a stroke.”
  B) “We do this to determine how your blood pressure changes throughout the day.”
  C) “We do this to see how often you should change your medication dose.”
  D) “We do this to make sure your health is stable. We’ll then monitor it at routinely scheduled intervals.”
  Ans: D
  When hypertension is initially detected, nursing assessment involves carefully monitoring the BP at frequent intervals and then at routinely scheduled intervals. The reference to stroke is frightening and does not capture the overall rationale for the monitoring regimen. Changes throughout the day are not a clinical priority for most patients. The patient must not change his or her medication doses unilaterally.



22. The hospital nurse cares for many patients who have hypertension. What nursing diagnosis is most common among patients who are being treated for this health problem?
  A) Deficient knowledge regarding the lifestyle modifications for management of hypertension
  B) Noncompliance with therapeutic regimen related to adverse effects of prescribed therapy
  C) Deficient knowledge regarding BP monitoring
  D) Noncompliance with treatment regimen related to medication costs
  Ans: B
  Deviation from the therapeutic program is a significant problem for people with hypertension and other chronic conditions requiring lifetime management. For many patients, this is related to adverse effects of medications. Medication cost is relevant for many patients, but adverse effects are thought to be a more significant barrier. Many patients are aware of necessary lifestyle modification, but do not adhere to them. Most patients are aware of the need to monitor their BP.



23. The nurse is teaching a patient about some of the health consequences of uncontrolled hypertension. What health problems should the nurse describe? Select all that apply.
  A) Transient ischemic attacks
  B) Cerebrovascular accident
  C) Retinal hemorrhage
  D) Venous insufficiency
  E) Right ventricular hypertrophy
  Ans: A, B, C
  Potential complications of hypertension include the following: left ventricular hypertrophy; MI; heart failure; transient ischemic attacks (TIAs); cerebrovascular accident; renal insufficiency and failure; and retinal hemorrhage. Venous insufficiency and right ventricular hypertrophy are not potential complications of uncontrolled hypertension.



24. The nurse is collaborating with the dietitian and a patient with hypertension to plan dietary modifications. These modifications should include which of the following?
  A) Reduced intake of protein and carbohydrates
  B) Increased intake of calcium and vitamin D
  C) Reduced intake of fat and sodium
  D) Increased intake of potassium, vitamin B12 and vitamin D
  Ans: C
  Lifestyle modifications usually include restricting sodium and fat intake, increasing intake of fruits and vegetables, and implementing regular physical activity. There is no need to increase calcium, potassium, and vitamin intake. Calorie restriction may be required for some patients, but a specific reduction in protein and carbohydrates is not normally indicated.



25. The critical care nurse is caring for a patient just admitted in a hypertensive emergency. The nurse should anticipate the administration of what medication?
  A) Warfarin (Coumadin)
  B) Furosemide (Lasix)
  C) Sodium nitroprusside (Nitropress)
  D) Ramipril (Altace)
  Ans: C
  The medications of choice in hypertensive emergencies are those that have an immediate effect. IV vasodilators, including sodium nitroprusside (Nitropress), nicardipine hydrochloride (Cardene), clevidipine (Cleviprex), fenoldopam mesylate (Corlopam), enalaprilat, and nitroglycerin, have immediate actions that are short lived (minutes to 4 hours), and they are therefore used for initial treatment. Ramipril is administered orally and would not meet the patient’s immediate need for BP management. Diuretics, such as Lasix, are not used as initial treatments and there is no indication for anticoagulants such as Coumadin.



26. A patient in hypertensive emergency is being cared for in the ICU. The patient has become hypovolemic secondary to natriuresis. What is the nurse’s most appropriate action?
  A) Add sodium to the patient’s IV fluid, as ordered.
  B) Administer a vasoconstrictor, as ordered.
  C) Promptly cease antihypertensive therapy.
  D) Administer normal saline IV, as ordered.
  Ans: D
  If there is volume depletion secondary to natriuresis caused by the elevated BP, then volume replacement with normal saline can prevent large, sudden drops in BP when antihypertensive medications are administered. Sodium administration, cessation of antihypertensive therapy, and administration of vasoconstrictors are not normally indicated.



27. During an adult patient’s last two office visits, the nurse obtained BP readings of 122/84 mm Hg and 130/88 mm Hg, respectively. How would this patient’s BP be categorized?
  A) Normal
  B) Prehypertensive
  C) Stage 1 hypertensive
  D) Stage 2 hypertensive
  Ans: B
  Prehypertension is defined systolic BP of 120 to 139 mm Hg or diastolic BP of 80 to 89 mm Hg.



28. A patient comes to the walk-in clinic complaining of frequent headaches. While assessing the patient’s vital signs, the nurse notes the BP is 161/101 mm Hg. According to JNC 7, how would this patient’s BP be defined if a similar reading were obtained at a subsequent office visit?
  A) High normal
  B) Normal
  C) Stage 1 hypertensive
  D) Stage 2 hypertensive
  Ans: D
  JNC 7 defines stage 2 hypertension as a reading ³ 160/100 mm Hg.



29. A patient has been diagnosed as being prehypertensive. What should the nurse encourage this patient to do to aid in preventing a progression to a hypertensive state?
  A) Avoid excessive potassium intake.
  B) Exercise on a regular basis.
  C) Eat less protein and more vegetables.
  D) Limit morning activity.
  Ans: B
  To prevent or delay progression to hypertension and reduce risk, JNC 7 urged health care providers to encourage people with blood pressures in the prehypertension category to begin lifestyle modifications, such as nutritional changes and exercise. There is no need for patients to limit their activity in the morning or to avoid potassium and protein intake.



30. The nurse is screening a number of adults for hypertension. What range of blood pressure is considered normal?
  A) Less than 140/90 mm Hg
  B) Less than 130/90 mm Hg
  C) Less than 129/89 mm Hg
  D) Less than 120/80 mm Hg
  Ans: D
  JNC 7 defines a blood pressure of less than 120/80 mm Hg as normal, 120 to 129/80 to 89 mm Hg as prehypertension, and 140/90 mm Hg or higher as hypertension.



31. A community health nurse teaching a group of adults about preventing and treating hypertension. The nurse should encourage these participants to collaborate with their primary care providers and regularly monitor which of the following?
  A) Heart rate
  B) Sodium levels
  C) Potassium levels
  D) Blood lipid levels
  Ans: D
  Hypertension often accompanies other risk factors for atherosclerotic heart disease, such as dyslipidemia (abnormal blood fat levels), obesity, diabetes, metabolic syndrome, and a sedentary lifestyle. Individuals with hypertension need to monitor their sodium intake, but hypernatremia is not a risk factor for hypertension. In many patients, heart rate does not correlate closely with BP. Potassium levels do not normally relate to BP.



32. A community health nurse is planning an educational campaign addressing hypertension. The nurse should anticipate that the incidence and prevalence of hypertension are likely to be highest among members of what ethnic group?
  A) Pacific Islanders
  B) African Americans
  C) Asian-Americans
  D) Hispanics
  Ans: D
  The prevalence of uncontrolled hypertension varies by ethnicity, with Hispanics and African Americans having the highest prevalence at approximately 63% and 57%, respectively.



33. The home health nurse is caring for a patient who has a comorbidity of hypertension. What assessment question most directly addresses the possibility of worsening hypertension?
  A) “Are you eating less salt in your diet?”
  B) “How is your energy level these days?”
  C) “Do you ever get chest pain when you exercise?”
  D) “Do you ever see spots in front of your eyes?”
  Ans: D
  To identify complications or worsening hypertension, the patient is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity. The heart, nervous system, and kidneys are also carefully assessed, but angina pain and decreased energy are not normally suggestive of worsening hypertension. Sodium limitation is a beneficial lifestyle modification, but nonadherence to this is not necessarily a sign of worsening symptoms.



34. A student nurse is taking care of an elderly patient with hypertension during a clinical experience. The instructor asks the student about the relationships between BP and age. What would be the best answer by the student?
  A) “Because of reduced smooth muscle tone in blood vessels, blood pressure tends to go down with age, not up.”
  B) “Decreases in the strength of arteries and the presence of venous insufficiency cause hypertension in the elderly.”
  C) “Structural and functional changes in the cardiovascular system that occur with age contribute to increases in blood pressure.”
  D) “The neurologic system of older adults is less efficient at monitoring and regulating blood pressure.”
  Ans: C
  Structural and functional changes in the heart and blood vessels contribute to increases in BP that occur with aging. Venous insufficiency does not cause hypertension, however. Increased BP is not primarily a result of neurologic changes.



35. A 55-year-old patient comes to the clinic for a routine check-up. The patient’s BP is 159/100 mm Hg and the physician diagnoses hypertension after referring to previous readings. The patient asks why it is important to treat hypertension. What would be the nurse’s best response?
  A) “Hypertension can cause you to develop dangerous blood clots in your legs that can migrate to your lungs.”
  B) “Hypertension puts you at increased risk of type 1 diabetes and cancer in your age group.”
  C) “Hypertension is the leading cause of death in people your age.”
  D) “Hypertension greatly increases your risk of stroke and heart disease.”
  Ans: D
  Hypertension, particularly elevated systolic BP, increases the risk of death, stroke, and heart failure in people older than 50 years. Hypertension is not a direct precursor to pulmonary emboli, and it does not put older adults at increased risk of type 1 diabetes or cancer. It is not the leading cause of death in people 55 years of age.



36. The nurse is reviewing the medication administration record of a patient who takes a variety of medications for the treatment of hypertension. What potential therapeutic benefits of antihypertensives should the nurse identify? Select all that apply.
  A) Increased venous return
  B) Decreased peripheral resistance
  C) Decreased blood volume
  D) Decreased strength and rate of myocardial contractions
  E) Decreased blood viscosity
  Ans: B, C, D
  The medications used for treating hypertension decrease peripheral resistance, blood volume, or the strength and rate of myocardial contraction.  Antihypertensive medications do not increase venous return or decrease blood viscosity.



37. A newly diagnosed patient with hypertension is prescribed Diuril, a thiazide diuretic. What patient education should the nurse provide to this patient?
  A) “Eat a banana every day because Diuril causes moderate hyperkalemia.”
  B) “Take over-the-counter potassium pills because Diuril causes your kidneys to lose potassium.”
  C) “Diuril can cause low blood pressure and dizziness, especially when you get up suddenly.”
  D) “Diuril increases sodium levels in your blood, so cut down on your salt.”
  Ans: C
  Thiazide diuretics can cause postural hypotension, which may be potentiated by alcohol, barbiturates, opioids, or hot weather. Diuril does not cause either moderate hyperkalemia or severe hypokalemia and it does not result in hypernatremia.



38. A patient in hypertensive urgency is admitted to the hospital. The nurse should be aware of what goal of treatment for a patient in hypertensive urgency?
  A) Normalizing BP within 2 hours
  B) Obtaining a BP of less than 110/70 mm Hg within 36 hours
  C) Obtaining a BP of less than 120/80 mm Hg within 36 hours
  D) Normalizing BP within 24 to 48 hours
  Ans: D
  In cases of hypertensive urgency, oral agents can be administered with the goal of normalizing BP within 24 to 48 hours. For patients with this health problem, a BP of £ 120/80 mm Hg may be unrealistic.



39. A patient’s medication regimen for the treatment of hypertension includes hydrochlorothiazide. Following administration of this medication, the nurse should anticipate what effect?
  A) Drowsiness or lethargy
  B) Increased urine output
  C) Decreased heart rate
  D) Mild agitation
  Ans: B
  Thiazide diuretics lower BP by reducing circulating blood volume; this results in a short-term increase in urine output. These drugs do not cause bradycardia, agitation, or drowsiness.



40. A patient’s recently elevated BP has prompted the primary care provider to prescribe furosemide (Lasix). The nurse should closely monitor which of the following?
  A) The client’s oxygen saturation level
  B) The patient’s red blood cells, hematocrit, and hemoglobin
  C) The patient’s level of consciousness
  D) The patient’s potassium level
  Ans: D
  Loop diuretics can cause potassium depletion. They do not normally affect level of consciousness, erythrocytes, or oxygen saturation.


1. A nurse is caring for a patient who has had a plaster arm cast applied. Immediately postapplication, the nurse should provide what teaching to the patient?
  A) The cast will feel cool to touch for the first 30 minutes.
  B) The cast should be wrapped snuggly with a towel until the patient gets home.
  C) The cast should be supported on a board while drying.
  D) The cast will only have full strength when dry.
  Ans: D
  A cast requires approximately 24 to 72 hours to dry, and until dry, it does not have full strength. While drying, the cast should not be placed on a hard surface. The cast will exude heat while it dries and should not be wrapped.



2. A patient broke his arm in a sports accident and required the application of a cast. Shortly following application, the patient complained of an inability to straighten his fingers and was subsequently diagnosed with Volkmann contracture. What pathophysiologic process caused this complication?
  A) Obstructed arterial blood flow to the forearm and hand
  B) Simultaneous pressure on the ulnar and radial nerves
  C) Irritation of Merkel cells in the patient’s skin surfaces
  D) Uncontrolled muscle spasms in the patient’s forearm
  Ans: A
  Volkmann contracture occurs when arterial blood flow is restricted to the forearm and hand and results in contractures of the fingers and wrist. It does not result from nerve pressure, skin irritation, or spasms.



3. A patient is admitted to the unit in traction for a fractured proximal femur and requires traction prior to surgery. What is the most appropriate type of traction to apply to a fractured proximal femur?
  A) Russell’s traction
  B) Dunlop’s traction
  C) Buck’s extension traction
  D) Cervical head halter
  Ans: C
  Buck’s extension is used for fractures of the proximal femur. Russell’s traction is used for lower leg fractures. Dunlop’s traction is applied to the upper extremity for supracondylar fractures of the elbow and humerus. Cervical head halters are used to stabilize the neck.



4. A nurse is caring for a patient who is in skeletal traction. To prevent the complication of skin breakdown in a patient with skeletal traction, what action should be included in the plan of care?
  A) Apply occlusive dressings to the pin sites.
  B) Encourage the patient to push up with the elbows when repositioning.
  C) Encourage the patient to perform isometric exercises once a shift.
  D) Assess the pin insertion site every 8 hours.
  Ans: D
  The pin insertion site should be assessed every 8 hours for inflammation and infection. Loose cover dressings should be applied to pin sites. The patient should be encouraged to use the overhead trapeze to shift weight for repositioning. Isometric exercises should be done 10 times an hour while awake.



5. A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient?
  A) Keep the patient’s hips in abduction at all times.
  B) Keep hips flexed at no less than 90 degrees.
  C) Elevate the head of the bed to high Fowler’s.
  D) Seat the patient in a low chair as soon as possible.
  Ans: A
  The hips should be kept in abduction by an abductor pillow. Hips should not be flexed more than 90 degrees, and the head of bed should not be elevated more than 60 degrees. The patient’s hips should be higher than the knees; as such, high seat chairs should be used.



6. While assessing a patient who has had knee replacement surgery, the nurse notes that the patient has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this patient?
  A) Risk for Infection
  B) Risk for Peripheral Neurovascular Dysfunction
  C) Unilateral Neglect
  D) Disturbed Kinesthetic Sensory Perception
  Ans: B
  The hematoma may cause an interruption of tissue perfusion, so the most appropriate nursing diagnosis is Risk of Peripheral Neurovascular Dysfunction.  There is also an associated risk for infection because of the hematoma, but impaired neurovascular function is a more acute threat. Unilateral neglect and impaired sensation are lower priorities than neurovascular status.



7. A patient was brought to the emergency department after a fall. The patient is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize?
  A) “Make sure you don’t bring your knees close together.”
  B) “Try to lie as still as possible for the first few days.”
  C) “Try to avoid bending your knees until next week.”
  D) “Keep your legs higher than your chest whenever you can.”
  Ans: A
  After receiving a hip prosthesis, the affected leg should be kept abducted. Mobility should be encouraged within safe limits. There is no need to avoid knee flexion and the patient’s legs do not need to be higher than the level of the chest.



8. A patient with a fractured femur is in balanced suspension traction.  The patient needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do?
  A) Place slight additional tension on the traction cords.
  B) Release the weights and replace them immediately after positioning.
  C) Reposition the bed instead of repositioning the patient.
  D) Maintain consistent traction tension while repositioning.
  Ans: D
  Traction is used to reduce the fracture and must be maintained at all times, including during repositioning. It would be inappropriate to add tension or release the weights. Moving the bed instead of the patient is not feasible.



9. A patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurse’s best action?
  A) Administer pain medication as ordered.
  B) Assess the surgical site and the affected extremity.
  C) Reassure the patient that pain is a direct result of increased activity.
  D) Assess the patient for signs and symptoms of systemic infection.
  Ans: B
  Worsening pain after a total hip replacement may indicate dislocation of the prosthesis. Assessment of pain should include evaluation of the wound and the affected extremity. Assuming he’s anxious about discharge and administering pain medication do not address the cause of the pain. Sudden severe pain is not considered normal after hip replacement. Sudden pain is rarely indicative of a systemic infection.



10. A nurse is caring for a patient who has a leg cast. The nurse observes that the patient uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation?
  A) Allow the patient to continue to scratch inside the cast with a pencil but encourage him to be cautious.
  B) Give the patient a sterile tongue depressor to use for scratching instead of the pencil.
  C) Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists.
  D) Obtain an order for a sedative, such as lorazepam (Ativan), to prevent the patient from scratching.
  Ans: C
  Scratching should be discouraged because of the risk for skin breakdown or damage to the cast. Most patients can be discouraged from scratching if given a mild antihistamine, such as diphenhydramine, to relieve itching. Benzodiazepines would not be given for this purpose.



11. The nurse is caring for a patient who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis?
  A) Keep the affected leg in a position of adduction.
  B) Have the patient reposition himself independently.
  C) Protect the affected leg from internal rotation.
  D) Keep the hip flexed by placing pillows under the patient’s knee.
  Ans: C
  Abduction of the hip helps to prevent dislocation of a new hip joint. Rotation and adduction should be avoided. While the hip may be flexed slightly, it shouldn’t exceed 90 degrees and maintenance of flexion isn’t necessary. The patient may not be capable of safe independent repositioning at this early stage of recovery.



12. A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication?
  A) Subcutaneous emphysema
  B) Skin breakdown
  C) Compartment syndrome
  D) Disuse syndrome
  Ans: C
  Compartment syndrome may manifest as unrelenting, uncontrollable pain. This presentation of pain is not suggestive of disuse syndrome or skin breakdown. Subcutaneous emphysema is not a complication of casting.



13. The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote?
  A) Knots in the rope should not be resting against pulleys.
  B) Weights should rest against the bed rails.
  C) The end of the limb in traction should be braced by the footboard of the bed.
  D) Skeletal traction may be removed for brief periods to facilitate the patient’s independence.
  Ans: A
  Knots in the rope should not rest against pulleys, because this interferes with traction. Weights are used to apply the vector of force necessary to achieve effective traction and should hang freely at all times. To avoid interrupting traction, the limb in traction should not rest against anything. Skeletal traction is never interrupted.



14. The orthopedic surgeon has prescribed balanced skeletal traction for a patient. What advantage is conferred by balanced traction?
  A) Balanced traction can be applied at night and removed during the day.
  B) Balanced traction allows for greater patient movement and independence than other forms of traction.
  C) Balanced traction is portable and may accompany the patient’s movements.
  D) Balanced traction facilitates bone remodeling in as little as 4 days.
  Ans: B
  Often, skeletal traction is balanced traction, which supports the affected extremity, allows for some patient movement, and facilitates patient independence and nursing care while maintaining effective traction. It is not portable, however, and it cannot be removed. Bone remodeling takes longer than 4 days.



15. The nursing care plan for a patient in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a patient’s lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?
  A) Increased warmth of the calf
  B) Decreased circumference of the calf
  C) Loss of sensation to the calf
  D) Pale-appearing calf
  Ans: A
  Signs of DVT include increased warmth, redness, swelling, and calf tenderness. These findings are promptly reported to the physician for definitive evaluation and therapy. Signs and symptoms of a DVT do not include a decreased circumference of the calf, a loss of sensation in the calf, or a pale-appearing calf.



16. A nurse is providing discharge education to a patient who is going home with a cast on his leg. What teaching point should the nurse emphasize in the teaching session?
  A) Using crutches efficiently
  B) Exercising joints above and below the cast, as ordered
  C) Removing the cast correctly at the end of the treatment period
  D) Reporting signs of impaired circulation
  Ans: D
  Reporting signs of impaired circulation is critical; signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. For this reason, this education is a priority over exercise and crutch use. The patient does not independently remove the cast.



17. A patient with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the patient’s cast care?
  A) “Cover the cast with a blanket until the cast dries.”
  B) “Keep your right leg elevated above heart level.”
  C) “Use a clean object to scratch itches inside the cast.”
  D) “A foul smell from the cast is normal after the first few days.”
  Ans: B
  The leg should be elevated to promote venous return and prevent edema. The cast shouldn’t be covered while drying because this will cause heat buildup and prevent air circulation. No foreign object should be inserted inside the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.



18. An elderly patient’s hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse’s priority assessment?
  A) The presence of leg shortening
  B) The patient’s complaints of pain
  C) Signs of neurovascular compromise
  D) The presence of internal or external rotation
  Ans: C
  Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture.



19. A nurse is caring for a patient who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the patient’s statements would indicate to the nurse that the patient requires further teaching?
  A) “I’ll need to keep several pillows between my legs at night.”
  B) “I need to remember not to cross my legs. It’s such a habit.”
  C) “The occupational therapist is showing me how to use a ‘sock puller’ to help me get dressed.”
  D) “I will need my husband to assist me in getting off the low toilet seat at home.”
  Ans: D
  To prevent hip dislocation after a total hip replacement, the patient must avoid bending the hips beyond 90 degrees. Assistive devices, such as a raised toilet seat, should be used to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Likewise, teaching the patient to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a patient get dressed without flexing the hips beyond 90 degrees.



20. A nurse is admitting a patient to the unit who presented with a lower extremity fracture. What signs and symptoms would suggest to the nurse that the patient may have aperoneal nerve injury?
  A) Numbness and burning of the foot
  B) Pallor to the dorsal surface of the foot
  C) Visible cyanosis in the toes
  D) Inadequate capillary refill to the toes
  Ans: A
  Peroneal nerve injury may result in numbness, tingling, and burning in the feet. Cyanosis, pallor, and decreased capillary refill are signs of inadequate circulation.



21. A patient has suffered a muscle strain and is complaining of pain that she rates at 6 on a 10-point scale. The nurse should recommend what action?
  A) Taking an opioid analgesic as ordered
  B) Applying a cold pack to the injured site
  C) Performing passive ROM exercises
  D) Applying a heating pad to the affected muscle
  Ans: B
  Most pain can be relieved by elevating the involved part, applying cold packs, and administering analgesics as prescribed. Heat may exacerbate the pain by increasing blood circulation, and ROM exercises would likely be painful. Analgesia is likely necessary, but NSAIDs would be more appropriate than opioids.



22. A patient has had a brace prescribed to facilitate recovery from a knee injury. What are the potential therapeutic benefits of a brace? Select all that apply.
  A) Preventing additional injury
  B) Immobilizing prior to surgery
  C) Providing support
  D) Controlling movement
  E) Promoting bone remodeling
  Ans: A, C, D
  Braces (i.e., orthoses) are used to provide support, control movement, and prevent additional injury. They are not used to immobilize body parts or to facilitate bone remodeling.



23. A nurse is assessing the neurovascular status of a patient who has had a leg cast recently applied. The nurse is unable to palpate the patient’s dorsalis pedis or posterior tibial pulse and the patient’s foot is pale. What is the nurse’s most appropriate action?
  A) Warm the patient’s foot and determine whether circulation improves.
  B) Reposition the patient with the affected foot dependent.
  C) Reassess the patient’s neurovascular status in 15 minutes.
  D) Promptly inform the primary care provider.
  Ans: D
  Signs of neurovascular dysfunction warrant immediate medical follow-up. It would be unsafe to delay. Warming the foot or repositioning the patient may be of some benefit, but the care provider should be informed first.



24. A physician writes an order to discontinue skeletal traction on an orthopedic patient. The nurse should anticipate what subsequent intervention?
  A) Application of a walking boot
  B) Application of a cast
  C) Education on how to use crutches
  D) Passive range of motion exercises
  Ans: B
  After skeletal traction is discontinued, internal fixation, casts, or splints are then used to immobilize and support the healing bone. The use of a walking boot, crutches, or ROM exercises could easily damage delicate, remodeled bone.



25. A patient has just begun been receiving skeletal traction and the nurse is aware that muscles in the patient’s affected limb are spastic. How does this change in muscle tone affect the patient’s traction prescription?
  A) Traction must temporarily be aligned in a slightly different direction.
  B) Extra weight is needed initially to keep the limb in proper alignment.
  C) A lighter weight should be initially used.
  D) Weight will temporarily alternate between heavier and lighter weights.
  Ans: B
  The traction weights applied initially must overcome the shortening spasms of the affected muscles. As the muscles relax, the traction weight is reduced to prevent fracture dislocation and to promote healing. Weights never alternate between heavy and light.



26. A nurse is planning the care of a patient who will require a prolonged course of skeletal traction. When planning this patient’s care, the nurse should prioritize interventions related to which of the following risk nursing diagnoses?
  A) Risk for Impaired Skin Integrity
  B) Risk for Falls
  C) Risk for Imbalanced Fluid Volume
  D) Risk for Aspiration
  Ans: A
  Impaired skin integrity is a high-probability risk in patients receiving traction. Falls are not a threat, due to the patient’s immobility. There are not normally high risks of fluid imbalance or aspiration associated with traction.



27. A nurse is caring for a patient receiving skeletal traction. Due to the patient’s severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications?
  A) Perform chest physiotherapy once per shift and as needed.
  B) Teach the patient to perform deep breathing and coughing exercises.
  C) Administer prophylactic antibiotics as ordered.
  D) Administer nebulized bronchodilators and corticosteroids as ordered.
  Ans: B
  To prevent these complications, the nurse should educate the patient about performing deep-breathing and coughing exercises to aid in fully expanding the lungs and clearing pulmonary secretions. Antibiotics, bronchodilators, and steroids are not used on a preventative basis and chest physiotherapy is unnecessary and implausible for a patient in traction.



28. The nurse has identified the diagnosis of Risk for Impaired Tissue Perfusion Related to Deep Vein Thrombosis in the care of a patient receiving skeletal traction. What nursing intervention best addresses this risk?
  A) Encourage independence with ADLs whenever possible.
  B) Monitor the patient’s nutritional status closely.
  C) Teach the patient to perform ankle and foot exercises within the limitations of traction.
  D) Administer clopidogrel (Plavix) as ordered.
  Ans: C
  The nurse educates the patient how to perform ankle and foot exercises within the limits of the traction therapy every 1 to 2 hours when awake to prevent DVT. Nutrition is important, but does not directly prevent DVT. Similarly, independence with ADLs should be promoted, but this does not confer significant prevention of DVT, which often affects the lower limbs. Plavix is not normally used for DVT prophylaxis.



29. A patient is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions?
  A) Use of a cardiopulmonary bypass machine
  B) Postoperative blood salvage
  C) Prophylactic blood transfusion
  D) Autologous blood donation
  Ans: D
  Many patients donate their own blood during the weeks preceding their surgery. Autologous blood donations are cost effective and eliminate many of the risks of transfusion therapy. Orthopedic surgery does not necessitate cardiopulmonary bypass and blood is not salvaged postoperatively. Transfusions are not given prophylactically.



30. The nurse is helping to set up Buck’s traction on an orthopedic patient.  How often should the nurse assess circulation to the affected leg?
  A) Within 30 minutes, then every 1 to 2 hours
  B) Within 30 minutes, then every 4 hours
  C) Within 30 minutes, then every 8 hours
  D) Within 30 minutes, then every shift
  Ans: A
  After skin traction is applied, the nurse assesses circulation of the foot or hand within 15 to 30 minutes and then every 1 to 2 hours.



31. A nurse is assessing a patient who is receiving traction. The nurse’s assessment confirms that the patient is able to perform plantar flexion. What conclusion can the nurse draw from this finding?
  A) The leg that was assessed is free from DVT.
  B) The patient’s tibial nerve is functional.
  C) Circulation to the distal extremity is adequate.
  D) The patient does not have peripheral neurovascular dysfunction.
  Ans: B
  Plantar flexion demonstrates function of the tibial nerve. It does not demonstrate the absence of DVT and does not allow the nurse to ascertain adequate circulation. The nurse must perform more assessments on more sites in order to determine an absence of peripheral neurovascular dysfunction.



32. A nurse is caring for a patient in skeletal traction. In order to prevent bony fragments from moving against one another, the nurse should caution the patient against which of the following actions?
  A) Shifting one’s weight in bed
  B) Bearing down while having a bowel movement
  C) Turning from side to side
  D) Coughing without splinting
  Ans: C
  To prevent bony fragments from moving against one another, the patient should not turn from side to side; however, the patient may shift position slightly with assistance. Bearing down and coughing do not pose a threat to bone union.



33. A nurse is caring for an older adult patient who is preparing for discharge following recovery from a total hip replacement. Which of the following outcomes must be met prior to discharge?
  A) Patient is able to perform ADLs independently.
  B) Patient is able to perform transfers safely.
  C) Patient is able to weight-bear equally on both legs.
  D) Patient is able to demonstrate full ROM of the affected hip.
  Ans: B
  The patient must be able to perform transfers and to use mobility aids safely. Each of the other listed goals is unrealistic for the patient who has undergone recent hip replacement.



34. A nurse is caring for a patient who is recovering in the hospital following orthopedic surgery. The nurse is performing frequent assessments for signs and symptoms of infection in the knowledge that the patient faces a high risk of what infectious complication?
  A) Cellulitis
  B) Septic arthritis
  C) Sepsis
  D) Osteomyelitis
  Ans: D
  Infection is a risk after any surgery, but it is of particular concern for the postoperative orthopedic patient because of the risk of osteomyelitis. Orthopedic patients do not have an exaggerated risk of cellulitis, sepsis, or septic arthritis when compared to other surgical patients.



35. A patient is being prepared for a total hip arthroplasty, and the nurse is providing relevant education. The patient is concerned about being on bed rest for several days after the surgery. The nurse should explain what expectation for activity following hip replacement?
  A) “Actually, patients are only on bed rest for 2 to 3 days before they begin walking with assistance.”
  B) “The physical therapist will likely help you get up using a walker the day after your surgery.”
  C) “Our goal will actually be to have you walking normally within 5 days of your surgery.”
  D) “For the first two weeks after the surgery, you can use a wheelchair to meet your mobility needs.”
  Ans: B
  Patients post-THA begin ambulation with the assistance of a walker or crutches within a day after surgery. Wheelchairs are not normally utilized. Baseline levels of mobility are not normally achieved until several weeks after surgery, however.



36. A patient has recently been admitted to the orthopedic unit following total hip arthroplasty. The patient has a closed suction device in place and the nurse has determined that there were 320 mL of output in the first 24 hours. How should the nurse best respond to this assessment finding?
  A) Inform the primary care provider promptly.
  B) Document this as an expected assessment finding.
  C) Limit the patient’s fluid intake to 2 liters for the next 24 hours.
  D) Administer a loop diuretic as ordered.
  Ans: B
  Drainage of 200 to 500 mL in the first 24 hours is expected. Consequently, the nurse does not need to inform the physician. Fluid restriction and medication administration are not indicated.



37. A nurse is reviewing a patient’s activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation?
  A) Straining during a bowel movement
  B) Bending down to put on socks
  C) Lifting items above shoulder level
  D) Transferring from a sitting to standing position
  Ans: B
  Bending to put on socks or shoes can cause hip dislocation. None of the other listed actions poses a serious threat to the integrity of the new hip.



38. A 91-year-old patient is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the patient’s plan of care. What intervention is most justified in the care of this patient?
  A) Administration of prophylactic antibiotics
  B) Total parenteral nutrition (TPN)
  C) Use of a pressure-relieving mattress
  D) Use of a Foley catheter until discharge
  Ans: C
  Older adults have a heightened risk of skin breakdown; use of a pressure-reducing mattress addresses this risk. Older adults do not necessarily need TPN and the Foley catheter should be discontinued as soon as possible to prevent urinary tract infections. Prophylactic antibiotics are not a standard infection prevention measure.



39. A nurse is emptying an orthopedic surgery patient’s closed suction drainage at the end of a shift. The nurse notes that the volume is within expected parameters but that the drainage has a foul odor. What is the nurse’s best action?
  A) Aspirate a small amount of drainage for culturing.
  B) Advance the drain 1 to 1.5 cm.
  C) Irrigate the drain with normal saline.
  D) Inform the surgeon of this finding.
  Ans: D
  The nurse should promptly notify the surgeon of excessive or foul-smelling drainage.  It would be inappropriate to advance the drain, irrigate the drain, or aspirate more drainage.



40. A nurse is planning the care of a patient who has undergone orthopedic surgery. What main goal should guide the nurse’s choice of interventions?
  A) Improving the patient’s level of function
  B) Helping the patient come to terms with limitations
  C) Administering medications safely
  D) Improving the patient’s adherence to treatment
  Ans: A
  Improving function is the overarching goal after orthopedic surgery. Some patients may need to come to terms with limitations, but this is not true of every patient. Safe medication administration is imperative, but this is not a goal that guides other aspects of care. Similarly, adherence to treatment is important, but this is motivated by the need to improve functional status.


1. A patient with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse’s most plausible conclusion based on this assessment finding?
  A) The patient should withhold his next scheduled dose of insulin.
  B) The patient should promptly eat some protein and carbohydrates.
  C) The patient’s insulin levels are inadequate.
  D) The patient would benefit from a dose of metformin (Glucophage).
  Ans: C
  Ketones in the urine signal that there is a deficiency of insulin and that control of type 1 diabetes is deteriorating. Withholding insulin or eating food would exacerbate the patient’s ketonuria. Metformin will not cause short-term resolution of hyperglycemia.



2. A patient presents to the clinic complaining of symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes?
  A) Fasting plasma glucose greater than or equal to 126 mg/dL
  B) Random plasma glucose greater than 150 mg/dL
  C) Fasting plasma glucose greater than 116 mg/dL on 2 separate occasions
  D) Random plasma glucose greater than 126 mg/dL
  Ans: A
  Criteria for the diagnosis of diabetes include symptoms of diabetes plus random plasma glucose greater than or equal to 200 mg/dL, or a fasting plasma glucose greater than or equal to 126 mg/dL.



3. A patient newly diagnosed with type 2 diabetes is attending a nutrition class. What general guideline would be important to teach the patients at this class?
  A) Low fat generally indicates low sugar.
  B) Protein should constitute 30% to 40% of caloric intake.
  C) Most calories should be derived from carbohydrates.
  D) Animal fats should be eliminated from the diet.
  Ans: C
  Currently, the ADA and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommend that for all levels of caloric intake, 50% to 60% of calories should be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein.Low fat does not automatically mean low sugar. Dietary animal fat does not need to be eliminated from the diet.



4. A nurse is providing health education to an adolescent newly diagnosed with type 1 diabetes mellitus and her family. The nurse teaches the patient and family that which of the following nonpharmacologic measures will decrease the body’s need for insulin?
  A) Adequate sleep
  B) Low stimulation
  C) Exercise
  D) Low-fat diet
  Ans: C
  Exercise lowers blood glucose, increases levels of HDLs, and decreases total cholesterol and triglyceride levels.  Low fat intake and low levels of stimulation do not reduce a patient’s need for insulin. Adequate sleep is beneficial in reducing stress, but does not have an effect that is pronounced as that of exercise.



5. A medical nurse is caring for a patient with type 1 diabetes. The patient’s medication administration record includes the administration of regular insulin three times daily. Knowing that the patient’s lunch tray will arrive at 11:45, when should the nurse administer the patient’s insulin?
  A) 10:45
  B) 11:15
  C) 11:45
  D) 11:50
  Ans: B
  Regular insulin is usually administered 20–30 min before a meal. Earlier administration creates a risk for hypoglycemia; later administration creates a risk for hyperglycemia.



6. A patient has just been diagnosed with type 2 diabetes.  The physician has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose. What type of oral antidiabetic agent did the physician prescribe for this patient?
  A) A sulfonylurea
  B) A biguanide
  C) A thiazolidinedione
  D) An alpha glucosidase inhibitor
  Ans: B
  Sulfonylureas exert their primary action by directly stimulating the pancreas to secrete insulin and therefore require a functioning pancreas to be effective. Biguanides inhibit the production of glucose by the liver and are in used in type 2 diabetes to control blood glucose levels. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Alpha glucosidase inhibitors work by delaying the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.



7. A diabetes nurse educator is teaching a group of patients with type 1 diabetes about “sick day rules.” What guideline applies to periods of illness in a diabetic patient?
  A) Do not eliminate insulin when nauseated and vomiting.
  B) Report elevated glucose levels greater than 150 mg/dL.
  C) Eat three substantial meals a day, if possible.
  D) Reduce food intake and insulin doses in times of illness.
  Ans: A
  The most important issue to teach patients with diabetes who become ill is not to eliminate insulin doses when nausea and vomiting occur. Rather, they should take their usual insulin or oral hypoglycemic agent dose, then attempt to consume frequent, small portions of carbohydrates. In general, blood sugar levels will rise but should be reported if they are greater than 300 mg/dL.



8. The nurse is discussing macrovascular complications of diabetes with a patient. The nurse would address what topic during this dialogue?
  A) The need for frequent eye examinations for patients with diabetes
  B) The fact that patients with diabetes have an elevated risk of myocardial infarction
  C) The relationship between kidney function and blood glucose levels
  D) The need to monitor urine for the presence of albumin
  Ans: B
  Myocardial infarction and stroke are considered macrovascular complications of diabetes, while the effects on vision and renal function are considered to be microvascular.



9. A school nurse is teaching a group of high school students about risk factors for diabetes. Which of the following actions has the greatest potential to reduce an individual’s risk for developing diabetes?
  A) Have blood glucose levels checked annually.
  B) Stop using tobacco in any form.
  C) Undergo eye examinations regularly.
  D) Lose weight, if obese.
  Ans: D
  Obesity is a major modifiable risk factor for diabetes. Smoking is not a direct risk factor for the disease. Eye examinations are necessary for persons who have been diagnosed with diabetes, but they do not screen for the disease or prevent it. Similarly, blood glucose checks do not prevent the diabetes.



10. A 15-year-old child is brought to the emergency department with symptoms of hyperglycemia and is subsequently diagnosed with diabetes. Based on the fact that the child’s pancreatic beta cells are being destroyed, the patient would be diagnosed with what type of diabetes?
  A) Type 1 diabetes
  B) Type 2 diabetes
  C) Non–insulin-dependent diabetes
  D) Prediabetes
  Ans: A
  Beta cell destruction is the hallmark of type 1 diabetes. Non–insulin-dependent diabetes is synonymous with type 2 diabetes, which involves insulin resistance and impaired insulin secretion, but not beta cell destruction. Prediabetes is characterized by normal glucose metabolism, but a previous history of hyperglycemia, often during illness or pregnancy.



11. A newly admitted patient with type 1 diabetes asks the nurse what caused her diabetes. When the nurse is explaining to the patient the etiology of type 1 diabetes, what process should the nurse describe?
  A) “The tissues in your body are resistant to the action of insulin, making the glucose levels in your blood increase.”
  B) “Damage to your pancreas causes an increase in the amount of glucose that it releases, and there is not enough insulin to control it.”
  C) “The amount of glucose that your body makes overwhelms your pancreas and decreases your production of insulin.”
  D) “Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down.”
  Ans: D
  Type 1 diabetes is characterized by the destruction of pancreatic beta cells, resulting in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia. Also, glucose derived from food cannot be stored in the liver and remains circulating in the blood, which leads to postprandial hyperglycemia. Type 2 diabetes involves insulin resistance and impaired insulin secretion. The body does not “make” glucose.



12. An occupational health nurse is screening a group of workers for diabetes. What statement should the nurse interpret as suggestive of diabetes?
  A) “I’ve always been a fan of sweet foods, but lately I’m turned off by them.”
  B) “Lately, I drink and drink and can’t seem to quench my thirst.”
  C) “No matter how much sleep I get, it seems to take me hours to wake up.”
  D) “When I went to the washroom the last few days, my urine smelled odd.”
  Ans: B
  Classic clinical manifestations of diabetes include the “three Ps”: polyuria, polydipsia, and polyphagia. Lack of interest in sweet foods, fatigue, and foul-smelling urine are not suggestive of diabetes.



13. A diabetes educator is teaching a patient about type 2 diabetes. The educator recognizes that the patient understands the primary treatment for type 2 diabetes when the patient states what?
  A) “I read that a pancreas transplant will provide a cure for my diabetes.”
  B) “I will take my oral antidiabetic agents when my morning blood sugar is high.”
  C) “I will make sure to follow the weight loss plan designed by the dietitian.”
  D) “I will make sure I call the diabetes educator when I have questions about my insulin.”
  Ans: C
  Insulin resistance is associated with obesity; thus the primary treatment of type 2 diabetes is weight loss. Oral antidiabetic agents may be added if diet and exercise are not successful in controlling blood glucose levels. If maximum doses of a single category of oral agents fail to reduce glucose levels to satisfactory levels, additional oral agents may be used. Some patients may require insulin on an ongoing basis or on a temporary basis during times of acute psychological stress, but it is not the central component of type 2 treatment. Pancreas transplantation is associated with type 1 diabetes.



14. A diabetes nurse educator is presenting the American Diabetes Association (ADA) recommendations for levels of caloric intake. What do the ADA’s recommendations include?
  A) 10% of calories from carbohydrates, 50% from fat, and the remaining 40% from protein
  B) 10% to 20% of calories from carbohydrates, 20% to 30% from fat, and the remaining 50% to 60% from protein
  C) 20% to 30% of calories from carbohydrates, 50% to 60% from fat, and the remaining 10% to 20% from protein
  D) 50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein
  Ans: D
  Currently, the ADA and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association) recommend that for all levels of caloric intake, 50% to 60% of calories come from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein.



15. An older adult patient with type 2 diabetes is brought to the emergency department by his daughter. The patient is found to have a blood glucose level of 623 mg/dL. The patient’s daughter reports that the patient recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority?
  A) Administration of antihypertensive medications
  B) Administering sodium bicarbonate intravenously
  C) Reversing acidosis by administering insulin
  D) Fluid and electrolyte replacement
  Ans: D
  The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration. Antihypertensive medications are not indicated, as hypotension generally accompanies HHS due to dehydration. Sodium bicarbonate is not administered to patients with HHS, as their plasma bicarbonate level is usually normal. Insulin administration plays a less important role in the treatment of HHS because it is not needed for reversal of acidosis, as in diabetic ketoacidosis (DKA).



16. A nurse is caring for a patient with type 1 diabetes who is being discharged home tomorrow. What is the best way to assess the patient’s ability to prepare and self-administer insulin?
  A) Ask the patient to describe the process in detail.
  B) Observe the patient drawing up and administering the insulin.
  C) Provide a health education session reviewing the main points of insulin delivery.
  D) Review the patient’s first hemoglobin A1C result after discharge.
  Ans: B
  Nurses should assess the patient’s ability to perform diabetes related self-care as soon as possible during the hospitalization or office visit to determine whether the patient requires further diabetes teaching. While consulting a home care nurse is beneficial, an initial assessment should be performed during the hospitalization or office visit. Nurses should directly observe the patient performing the skills such as insulin preparation and infection, blood glucose monitoring, and foot care. Simply questioning the patient about these skills without actually observing performance of the skill is not sufficient. Further education does not guarantee learning.



17. An elderly patient comes to the clinic with her daughter. The patient is a diabetic and is concerned about foot care. The nurse goes over foot care with the patient and her daughter as the nurse realizes that foot care is extremely important. Why would the nurse feel that foot care is so important to this patient?
  A) An elderly patient with foot ulcers experiences severe foot pain due to the diabetic polyneuropathy.
  B) Avoiding foot ulcers may mean the difference between institutionalization and continued independent living.
  C) Hypoglycemia is linked with a risk for falls; this risk is elevated in older adults with diabetes.
  D) Oral antihyperglycemics have the possible adverse effect of decreased circulation to the lower extremities.
  Ans: B
  The nurse recognizes that providing information on the long-term complications—especially foot and eye problems—associated with diabetes is important. Avoiding amputation through early detection of foot ulcers may mean the difference between institutionalization and continued independent living for the elderly person with diabetes. While the nurse recognizes that hypoglycemia is a dangerous situation and may lead to falls, hypoglycemia is not directly connected to the importance of foot care. Decrease in circulation is related to vascular changes and is not associated with drugs administered for diabetes.



18. A diabetic educator is discussing “sick day rules” with a newly diagnosed type 1 diabetic. The educator is aware that the patient will require further teaching when the patient states what?
  A) “I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours.”
  B) “If I cannot eat a meal, I will eat a soft food such as soup, gelatin, or pudding six to eight times a day.”
  C) “I will call the doctor if I am not able to keep liquids in my body due to vomiting or diarrhea.”
  D) “I will call the doctor if my blood sugar is over 300 mg/dL or if I have ketones in my urine.”
  Ans: A
  The nurse must explanation the “sick day rules” again to the patient who plans to stop taking insulin when sick. The nurse should emphasize that the patient should take insulin agents as usual and test one’s blood sugar and urine ketones every 3 to 4 hours. In fact, insulin-requiring patients may need supplemental doses of regular insulin every 3 to 4 hours. The patient should report elevated glucose levels (greater than 300 mg/dL or as otherwise instructed) or urine ketones to the physician. If the patient is not able to eat normally, the patient should be instructed to substitute soft foods such a gelatin, soup, and pudding. If vomiting, diarrhea, or fever persists, the patient should have an intake of liquids every 30 to 60 minutes to prevent dehydration.



19. Which of the following patients with type 1 diabetes is most likely to experience adequate glucose control?
  A) A patient who skips breakfast when his glucose reading is greater than 220 mg/dL
  B) A patient who never deviates from her prescribed dose of insulin
  C) A patient who adheres closely to a meal plan and meal schedule
  D) A patient who eliminates carbohydrates from his daily intake
  Ans: C
  The therapeutic goal for diabetes management is to achieve normal blood glucose levels without hypoglycemia. Therefore, diabetes management involves constant assessment and modification of the treatment plan by health professionals and daily adjustments in therapy (possibly including insulin) by patients. For patients who require insulin to help control blood glucose levels, maintaining consistency in the amount of calories and carbohydrates ingested at meals is essential. In addition, consistency in the approximate time intervals between meals, and the snacks, help maintain overall glucose control. Skipping meals is never advisable for person with type 1 diabetes.



20. A 28-year-old pregnant woman is spilling sugar in her urine. The physician orders a glucose tolerance test, which reveals gestational diabetes. The patient is shocked by the diagnosis, stating that she is conscientious about her health, and asks the nurse what causes gestational diabetes. The nurse should explain that gestational diabetes is a result of what etiologic factor?
  A) Increased caloric intake during the first trimester
  B) Changes in osmolality and fluid balance
  C) The effects of hormonal changes during pregnancy
  D) Overconsumption of carbohydrates during the first two trimesters
  Ans: C
  Hyperglycemia and eventual gestational diabetes develops during pregnancy because of the secretion of placental hormones, which causes insulin resistance. The disease is not the result of food intake or changes in osmolality.



21. A medical nurse is aware of the need to screen specific patients for their risk of hyperglycemic hyperosmolar syndrome (HHS). In what patient population does hyperosmolar nonketotic syndrome most often occur?
  A) Patients who are obese and who have no known history of diabetes
  B) Patients with type 1 diabetes and poor dietary control
  C) Adolescents with type 2 diabetes and sporadic use of antihyperglycemics
  D) Middle-aged or older people with either type 2 diabetes or no known history of diabetes
  Ans: D
  HHS occurs most often in older people (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes.



22. A nurse is caring for a patient newly diagnosed with type 1 diabetes. The nurse is educating the patient about self-administration of insulin in the home setting. The nurse should teach the patient to do which of the following?
  A) Avoid using the same injection site more than once in 2 to 3 weeks.
  B) Avoid mixing more than one type of insulin in a syringe.
  C) Cleanse the injection site thoroughly with alcohol prior to injecting.
  D) Inject at a 45º angle.
  Ans: A
  To prevent lipodystrophy, the patient should try not to use the same site more than once in 2 to 3 weeks. Mixing different types of insulin in a syringe is acceptable, within specific guidelines, and the needle is usually inserted at a 90º angle. Cleansing the injection site with alcohol is optional.



23. A patient with type 2 diabetes achieves adequate glycemic control through diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however, the patient has required insulin injections on two occasions. The nurse would identify what likely cause for this short-term change in treatment?
  A) Alterations in bile metabolism and release have likely caused hyperglycemia.
  B) Stress has likely caused an increase in the patient’s blood sugar levels.
  C) The patient has likely overestimated her ability to control her diabetes using nonpharmacologic measures.
  D) The patient’s volatile fluid balance surrounding surgery has likely caused unstable blood sugars.
  Ans: B
  During periods of physiologic stress, such as surgery, blood glucose levels tend to increase, because levels of stress hormones (epinephrine, norepinephrine, glucagon, cortisol, and growth hormone) increase. The patient’s need for insulin is unrelated to the action of bile, the patient’s overestimation of previous blood sugar control, or fluid imbalance.



24. A physician has explained to a patient that he has developed diabetic neuropathy in his right foot. Later that day, the patient asks the nurse what causes diabetic neuropathy. What would be the nurse’s best response?
  A) “Research has shown that diabetic neuropathy is caused by fluctuations in blood sugar that have gone on for years.”
  B) “The cause is not known for sure but it is thought to have something to do with ketoacidosis.”
  C) “The cause is not known for sure but it is thought to involve elevated blood glucose levels over a period of years.”
  D) “Research has shown that diabetic neuropathy is caused by a combination of elevated glucose levels and elevated ketone levels.”
  Ans: C
  The etiology of neuropathy may involve elevated blood glucose levels over a period of years. High blood sugars (rather than fluctuations or variations in blood sugars) are thought to be responsible. Ketones and ketoacidosis are not direct causes of neuropathies.



25. A patient with type 2 diabetes has been managing his blood glucose levels using diet and metformin (Glucophage). Following an ordered increase in the patient’s daily dose of metformin, the nurse should prioritize which of the following assessments?
  A) Monitoring the patient’s neutrophil levels
  B) Assessing the patient for signs of impaired liver function
  C) Monitoring the patient’s level of consciousness and behavior
  D) Reviewing the patient’s creatinine and BUN levels
  Ans: D
  Metformin has the potential to be nephrotoxic; consequently, the nurse should monitor the patient’s renal function. This drug does not typically affect patients’ neutrophils, liver function, or cognition.



26. A patient with a longstanding diagnosis of type 1 diabetes has a history of poor glycemic control. The nurse recognizes the need to assess the patient for signs and symptoms of peripheral neuropathy. Peripheral neuropathy constitutes a risk for what nursing diagnosis?
  A) Infection
  B) Acute pain
  C) Acute confusion
  D) Impaired urinary elimination
  Ans: A
  Decreased sensations of pain and temperature place patients with neuropathy at increased risk for injury and undetected foot infections. The neurologic changes associated with peripheral neuropathy do not normally result in pain, confusion, or impairments in urinary function.



27. A patient has been brought to the emergency department by paramedics after being found unconscious. The patient’s Medic Alert bracelet indicates that the patient has type 1 diabetes and the patient’s blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention?
  A) IV administration of 50% dextrose in water
  B) Subcutaneous administration of 10 units of Humalog
  C) Subcutaneous administration of 12 to 15 units of regular insulin
  D) IV bolus of 5% dextrose in 0.45% NaCl
  Ans: A
  In hospitals and emergency departments, for patients who are unconscious or cannot swallow, 25 to 50 mL of 50% dextrose in water (D50W) may be administered IV for the treatment of hypoglycemia. Five percent dextrose would be inadequate and insulin would exacerbate the patient’s condition.



28. A diabetic nurse is working for the summer at a camp for adolescents with diabetes. When providing information on the prevention and management of hypoglycemia, what action should the nurse promote?
  A) Always carry a form of fast-acting sugar.
  B) Perform exercise prior to eating whenever possible.
  C) Eat a meal or snack every 8 hours.
  D) Check blood sugar at least every 24 hours.
  Ans: A
  The following teaching points should be included in information provided to the patient on how to prevent hypoglycemia: Always carry a form of fast-acting sugar, increase food prior to exercise, eat a meal or snack every 4 to 5 hours, and check blood sugar regularly.



29. A nurse is teaching basic “survival skills” to a patient newly diagnosed with type 1 diabetes. What topic should the nurse address?
  A) Signs and symptoms of diabetic nephropathy
  B) Management of diabetic ketoacidosis
  C) Effects of surgery and pregnancy on blood sugar levels
  D) Recognition of hypoglycemia and hyperglycemia
  Ans: D
  It is imperative that newly diagnosed patients know the signs and symptoms and management of hypo- and hyperglycemia. The other listed topics are valid points for education, but are not components of the patient’s immediate “survival skills” following a new diagnosis.



30. A nurse is conducting a class on how to self-manage insulin regimens. A patient asks how long a vial of insulin can be stored at room temperature before it “goes bad.” What would be the nurse’s best answer?
  A) “If you are going to use up the vial within 1 month it can be kept at room temperature.”
  B) “If a vial of insulin will be used up within 21 days, it may be kept at room temperature.”
  C) “If a vial of insulin will be used up within 2 weeks, it may be kept at room temperature.”
  D) “If a vial of insulin will be used up within 1 week, it may be kept at room temperature.”
  Ans: A
  If a vial of insulin will be used up within 1 month, it may be kept at room temperature.



31. A patient has received a diagnosis of type 2 diabetes. The diabetes nurse has made contact with the patient and will implement a program of health education. What is the nurse’s priority action?
  A) Ensure that the patient understands the basic pathophysiology of diabetes.
  B) Identify the patient’s body mass index.
  C) Teach the patient “survival skills” for diabetes.
  D) Assess the patient’s readiness to learn.
  Ans: D
  Before initiating diabetes education, the nurse assesses the patient’s (and family’s) readiness to learn. This must precede other physiologic assessments (such as BMI) and providing health education.



32. A student with diabetes tells the school nurse that he is feeling nervous and hungry.  The nurse assesses the child and finds he has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL (2.8 mmol/L).  What should the school nurse administer?
  A) A combination of protein and carbohydrates, such as a small cup of yogurt
  B) Two teaspoons of sugar dissolved in a cup of apple juice
  C) Half of a cup of juice, followed by cheese and crackers
  D) Half a sandwich with a protein-based filling
  Ans: C
  Initial treatment for hypoglycemia is 15 g concentrated carbohydrate, such as two or three glucose tablets, 1 tube glucose gel, or 0.5 cup juice. After initial treatment, the nurse should follow with a snack including starch and protein, such as cheese and crackers, milk and crackers, or half of a sandwich. It is unnecessary to add sugar to juice, even it if is labeled as unsweetened juice, because the fruit sugar in juice contains enough simple carbohydrate to raise the blood glucose level and additional sugar may result in a sharp rise in blood sugar that will last for several hours.



33. A patient with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the patient’s initial phase of treatment?
  A) Monitoring the patient for dysrhythmias
  B) Maintaining and monitoring the patient’s fluid balance
  C) Assessing the patient’s level of consciousness
  D) Assessing the patient for signs and symptoms of venous thromboembolism
  Ans: B
  In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. The nurse should monitor the patient for dysrhythmias, decreased LOC and VTE, but restoration and maintenance of fluid balance is the highest priority.



34. A patient has been living with type 2 diabetes for several years, and the nurse realizes that the patient is likely to have minimal contact with the health care system. In order to ensure that the patient maintains adequate blood sugar control over the long term, the nurse should recommend which of the following?
  A) Participation in a support group for persons with diabetes
  B) Regular consultation of websites that address diabetes management
  C) Weekly telephone “check-ins” with an endocrinologist
  D) Participation in clinical trials relating to antihyperglycemics
  Ans: A
  Participation in support groups is encouraged for patients who have had diabetes for many years as well as for those who are newly diagnosed. This is more interactive and instructive than simply consulting websites. Weekly telephone contact with an endocrinologist is not realistic in most cases. Participation in research trials may or may not be beneficial and appropriate, depending on patients’ circumstances.



35. A patient with type 1 diabetes mellitus is seeing the nurse to review foot care. What would be a priority instruction for the nurse to give the patient?
  A) Examine feet weekly for redness, blisters, and abrasions.
  B) Avoid the use of moisturizing lotions.
  C) Avoid hot-water bottles and heating pads.
  D) Dry feet vigorously after each bath.
  Ans: C
  High-risk behaviors, such as walking barefoot, using heating pads on the feet, wearing open-toed shoes, soaking the feet, and shaving calluses, should be avoided.

Socks should be worn for warmth. Feet should be examined each day for cuts, blisters, swelling, redness, tenderness, and abrasions. Lotion should be applied to dry feet but never between the toes. After a bath, the patient should gently, not vigorously, pat feet dry to avoid injury.



36. A diabetes nurse is assessing a patient’s knowledge of self-care skills. What would be the most appropriate way for the educator to assess the patient’s knowledge of nutritional therapy in diabetes?
  A) Ask the patient to describe an optimally healthy meal.
  B) Ask the patient to keep a food diary and review it with the nurse.
  C) Ask the patient’s family what he typically eats.
  D) Ask the patient to describe a typical day’s food intake.
  Ans: B
  Reviewing the patient’s actual food intake is the most accurate method of gauging the patient’s diet.



37. The most recent blood work of a patient with a longstanding diagnosis of type 1 diabetes has shown the presence of microalbuminuria. What is the nurse’s most appropriate action?
  A) Teach the patient about actions to slow the progression of nephropathy.
  B) Ensure that the patient receives a comprehensive assessment of liver function.
  C) Determine whether the patient has been using expired insulin.
  D) Administer a fluid challenge and have the test repeated.
  Ans: A
  Clinical nephropathy eventually develops in more than 85% of people with microalbuminuria. As such, educational interventions addressing this microvascular complication are warranted. Expired insulin does not cause nephropathy, and the patient’s liver function is not likely affected. There is no indication for the use of a fluid challenge.



38. A nurse is assessing a patient who has diabetes for the presence of peripheral neuropathy. The nurse should question the patient about what sign or symptom that would suggest the possible development of peripheral neuropathy?
  A) Persistently cold feet
  B) Pain that does not respond to analgesia
  C) Acute pain, unrelieved by rest
  D) The presence of a tingling sensation
  Ans: D
  Although approximately half of patients with diabetic neuropathy do not have symptoms, initial symptoms may include paresthesias (prickling, tingling, or heightened sensation) and burning sensations (especially at night). Cold and intense pain are atypical early signs of this complication.



39. A diabetic patient calls the clinic complaining of having a “flu bug.” The nurse tells him to take his regular dose of insulin. What else should the nurse tell the patient?
  A) “Make sure to stick to your normal diet.”
  B) “Try to eat small amounts of carbs, if possible.”
  C) “Ensure that you check your blood glucose every hour.”
  D) “For now, check your urine for ketones every 8 hours.”
  Ans: B
  For prevention of DKA related to illness, the patient should attempt to consume frequent small portions of carbohydrates (including foods usually avoided, such as juices, regular sodas, and gelatin). Drinking fluids every hour is important to prevent dehydration. Blood glucose and urine ketones must be assessed every 3 to 4 hours.



40. A patient is brought to the emergency department by the paramedics. The patient is a type 2 diabetic and is experiencing HHS. The nurse should identify what components of HHS? Select all that apply.
  A) Leukocytosis
  B) Glycosuria
  C) Dehydration
  D) Hypernatremia
  E) Hyperglycemia
  Ans: B, C, D, E
  In HHS, persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes. To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space. With glycosuria and dehydration, hypernatremia and increased osmolarity occur. Leukocytosis does not take place.




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