Fundamentals Test 4

A client is to receive a transfusion of packed red blood cells (PRBCs). The nurse should prepare for the transfusion by priming the blood IV tubing with which solution? A) Lactated Ringer solution B) 5% dextrose and water C) 0.9% normal saline D) 0.45% normal saline

C

A client is receiving fresh frozen plasma (FFP). The nurse would expect to see improvement in which condition? A) Thrombocytopenia B) Oxygen deficiency C) Clotting factor deficiency D) Low hemoglobin

C

Which equipment will the nurse use to assess the length of the tract? A) Sterile gloves and lubricant. B) Sterile tape measure. C) Sterile cotton-tipped applicator. D) Sterile irrigation tray with syringe.

C

A nurse should employ which technique to maintain surgical asepsis? A) Change the sterile field after sterile water is spilled on it. B) Put on sterile gloves and then open a container of sterile saline. C) Place a sterile dressing no more than half an inch from the edge of the sterile field. D) Clean the surgical area with a circular motion, moving from the outer edge toward the center.

A

Your patient is hyperventilating from acute pain and hypoxia. Interventions to manage his pain and oxygenation will decrease his risk of which acid-base imbalance? A) Urine output B) Arterial blood gases C) Fullness of neck veins D) Level of consciousness

A) Urine output

The nurse is assessing a client following abdominal surgery. Which assessment findings should the nurse use to form a data cluster? Select all that apply. A) The client reports pain with movement. B) The client has pain over the surgical area. C) The client wants to know when he can go home. D) The client rates the pain as 8 on a scale of 0 to 10. E) The client has concerns about caring for the wound.

A, B, D

A child's immunization may cause discomfort during administration, but the benefits of protection from disease, both for the individual and society, outweigh the temporary discomforts. Which principle is involved in this situation? A) Fidelity B) Beneficence C) Nonmaleficence D) Respect for autonomy

B

What does the Braden Scale evaluate? A) Skin integrity at bony prominences, including any wounds B) Risk factors that place the patient at risk for skin breakdown C) The amount of repositioning that the patient can tolerate D) The factors that place the patient at risk for poor healing

B

You are about to administer an oral medication and you question the dosage. You should: A) Administer the medication B) Notify the physician C) Withhold the medication D) Document that the dosage appears incorrect

B) Notify the physician

Which nursing behavior is an intentional tort? A) Miscounting gauze pads during a client's surgery B) Causing a burn when applying a wet dressing to a client's extremity C) Divulging private information about a client's health status to the media D) Failing to monitor a client's blood pressure before administering an antihypertensive

C

After reviewing the results of the wound culture, which type of precautions should the nurse and staff use when caring for this client? (MRSA) A) Standard B) Droplet C) Airborne D) Contact

D

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every 4 hours. Which diet should the nurse expect the healthcare provider to prescribe to best meet this client's immediate nutritional needs? A) Low in fat and vitamin D B) High in calories and fiber C) Low in residue and bland D) High in protein and vitamin C

D

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? A) Primary B) Secondary C) Superinfection D) Nosocomial

D

After an abdominal resection for colon cancer, the client returns to her room with a Jackson-Pratt drain in place.The client's spouse asks the nurse what the purpose of the drain is Which of the following is the nurse's best response? A. "To irrigate the incision with a saline solution." B. "To prevent bacterial infection of the incision." C. "To measure the amount of fluid lost after surgery." D. "To prevent accumulation of drainage in the wound."

D. "To prevent accumulation of drainage in the wound." The accumulation of fluid in a surgical wound interferes with the healing process. A Jackson-Pratt drain promotes wound healing by allowing fluid to escape from the wound. The drain may be placed in the client's incision, or it may be placed in the wound and brought out to the skin surface through a stab wound near the incision. The drain doesn't need to be irrigated. A Jackson-Pratt drain doesn't prevent infection. Fluid from the drain is absorbed into the dressings and can't be measured accurately.

Resolution of an ethical dilemma involves discussion with the patient, the patient's family, and participants from all health care disciplines. Which of the following best describes the role of the nurse in the resolution of ethical dilemmas? A) To articulate the nurse's unique point of view, including knowledge based on clinical and psychosocial observations B) To study the literature on current research about the possible clinical interventions available for the patient in question C) To hold a point of view but realize that respect for the authority of administrators and physicians takes precedence over personal opinion. D) To allow the patient and the physician to resolve the dilemma on the basis of ethical principles without regard to personally held values or opinions.

A

Your client has a Braden scale score of 17. Which is the most appropriate nursing action? 1. Assess the client again in 24h; the score is within normal limits. 2. Implement a turning schedule; the client is at increased risk for skin breakdown. 3. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk for skin breakdown. 4. Request an order for a special low-air-loss bed; the client is at very high risk for skin breakdown.

2. Implement a turning schedule; the client is at increased risk for skin breakdown; A score ranging from 15 to 18 is considered at risk and a turning schedule is appropriate. Option 1 requires a score above 18 (normal and ongoing assessment indicated). Option 3, moderate risk, for which a transparent barrier would be appropriate, is applied to persons with scores of 13 to 14. Option 4, very high risk, is assigned for those with a score of 9 or less.

What key points should the nurse keep in mind about the legal implications of nursing practice? Select all that apply. A) Ensure that the nurse knows all the laws and that these laws are applied in the nursing practice, whenever required. B) Ensure that the primary healthcare providers' orders are followed unless they appear to be incorrect or inappropriate. C) Ensure that all incident and occurrence reports are filed only for errors that have caused injury to the client. D) Ensure that the client has given consent to any surgery or therapy voluntarily or involuntarily. E) Ensure that the nurse can makes a formal protest to the nursing administrator if he or she is asked to take care of more clients than is reasonable.

A, B, E

Your patient has severe hypercalcemia. What are your priority nursing interventions? A) Fall prevention interventions B) Teaching regarding sodium restriction C) Encouraging increased fluid intake D) Monitoring for constipation E) Explaining how to take daily weights

A, C, D

Which of the following are measures to reduce tissue damage from shear? A) Use a transfer device, e.g. transfer board B) Have head of bed elevated when transferring patient C) Have head of bed flat when re positioning patients D) Raise head of bed 60 degrees when patient positioned supine E) Raise head of bed 30 degrees when patient positioned supine

A, C, E

A healthcare provider prescribes two units of blood for a client who is bleeding. Which nursing interventions are necessary before the blood transfusion is administered? Select all that apply. A) Obtain the client's vital signs. B) Monitor hemoglobin and hematocrit levels. C) Allow the blood to reach room temperature. D) Determine typing and crossmatching of blood. E) Use a Y-type infusion set to initiate 0.9% normal saline.

A, D, E

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should immediately be taken next? A) Remove the IV B) Run a solution of 5% dextrose in water C) Run normal saline solution to keep open the vein D) Obtain a culture of the tip of the catheter device removed from the client

C) Run normal saline to keep open the vein

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? A) Stage I B) Stage II C) Stage III D) Unstageable

D

A nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated? A) Dialysis B) Osmosis C) Diffusion D) Capillarity

D

A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. What is the best response by the nurse? A) "That client is not on our unit. Thank you for calling." B) "The new privacy laws prevent me from providing any client information over the phone." C) "The client has requested that no information be given out. You'll need to call the client directly." D) "It is against the hospital's policy to provide you with any information."

D

What should the nurse do initially when obtaining consent for surgery? A) Describe the risks involved in the surgery. B) Explain that obtaining the signature is routine for any surgery. C) Witness the client's signature, which the nurse's signature will document. D) Determine whether the client's knowledge level is sufficient to give consent.

D

Which assessment do you interpret as a transfusion reaction? A) Crackles in dependent parts of lungs B) High fever, severe hypotension C) Anxiety, itching, confusion D) Chills, tachycardia, flushing

D

Which of the following describes a hydrocolloid dressing? A) A seaweed derivative that is highly absorptive B) Premoistened gauze placed over a granulating wound C) A debriding enzyme that is used to remove necrotic tissue D) A dressing that forms a gel that interacts with the wound surface

D

While caring for a client with a Hemovac portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. What is the next nursing intervention? A) Encircle the drainage on the dressing. B) Irrigate the suction tube with sterile saline. C) Clean the drainage port with an alcohol wipe. D) Compress the container before closing the port.

D

A nurse is caring for a patient who states, "I just want to die." For the nurse to comply with this request, the nurse should discuss: A) Living wills B) Assisted suicide C) Passive euthanasia D) Advance directives

D) Advance directives

A postoperative patient arrives at an ambulatory care center and states, "I am not feeling good." Upon assessment, you note an elevated temperature. An indication that the wound is infected would be: A) It has no odor B) A culture is negative C) The edges reveal the presence of fluid D) It shows purulent drainage coming from the incision site

D) It shows purulent drainage coming from the incision site

A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides A) An absorbant surface to collect wound drainage B) Decreased incidence of skin maceration C) Protection from the external environment D) Moisture needed for wound healing

D) Moisture needed for wound healing

Your patient is about to undergo a controversial orthopedic procedure. The procedure may cause periods of pain. Although nurses agree to do no harm, this procedure may be the patient's only treatment choice. This example describes the ethical principle of: A) Autonomy B) Fidelity C) Justice D) Nonmaleficence

D) Nonmaleficence

When working with an older person, you would keep in mind that the older person is most likely to experience which of following changes with aging? 1. Thinning of the epidermis 2. Thickening of the epidermis 3. Oiliness of the skin 4. Increased elasticity of the skin

1. Thinning of the epidermis, The epidermis thins with aging, and there is decreased strength and elasticity of the skin, increased dryness and scaliness of the skin, and diminished pain perception due to decreased sensation of pressure and light touch.

Three days after bariatric surgery, the client puts the call light on and states, "I felt a 'pop' in my belly after I had a coughing spell." The nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? A) Loosening of the sutures B) Sharp increase in serosanguineous drainage C) Purplish color of the incision D) Protrusion of organs through an open incision

B

Which patient do you plan to teach regarding water restriction? A) A 23-year-old with extracellular fluid volume (ECV) deficit B) A 34-year-old with hyponatremia C) A 47-year-old with hypercalcemia D) A 69-year-old

B) A 34-year-old with hyponatremia

The patient tells the nurse that she is afraid to speak up regarding her desire to end care for fear of upsetting her husband and children. Which principle in the nursing code of ethics ensures that the nurse will promote the patient's cause? A. Responsibility B.Advocacy C.Confidentiality D.Accountability

B) Advocacy

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first time surgery. Which assessment activity enabled the nurse to derive this conclusion? A) The nurse notes nonverbal signs of discomfort. B) The nurse observes the client's position in bed. C) The nurse asks the client to explain the surgery. D) The nurse asks the client to rate the severity of pain.

C

When caring for an obese client 4 to 5 days post-surgery, who has nausea and occasional vomiting and is not keeping fluids down well, which of the following would you be most concerned about? 1. Post surgical hemorrhage and anemia 2. Wound dehiscence and evisceration 3. Impaired skin integrity and decubitus ulcers 4. Loss of motility and paralytic illeus

2. Wound dehiscence and evisceration; Wound dehiscence is most likely to occur 4 to 5 days postoperatively, and risk factors include obesity, poor nutrition, multiple trauma, failure of suturing, excessive coughing, vomiting, and dehydration.

What is the rationale for performing sponge, needle, and instrument counts in the operating room? A) The hospital is not liable if a client is injured due to a retained sponge or instrument. B) The nursing student is liable for client injuries due to a retained sponge or instrument. C) A nurse is responsible for performing sponge and instrument counts as a part of routine surgical standards. D) The primary healthcare provider is responsible for providing an accurate count of sponges and instruments.

C

Which statement accurately demonstrates an act of nursing negligence? A) A nurse enters false information in the client's electronic health record to prolong treatment. B) A nurse threatens to initiate intravenous therapy by force because the client refuses to give consent. C) A nurse instructs the nursing assistive personnel to administer medication through an intravenous line. D) A nurse informs the client's family about a surgical procedure despite the client's instructions against doing so.

C

A young woman who is pregnant with a fetus exposed to multiple teratogens consents to have her fetus undergo serial PUBS (percutaneous umbilical blood sampling) to examine how exposure affects the fetus over time. Although these tests will not improve the fetus' outcomes and will expose it to some risks, the information gathered may help infants in the future. Which ethical principle is at greatest risk? A. Autonomy B. Fidelity C. Nonmaleficence D. Beneficence

C) Nonmaleficence

The nurse teaches Alexander to apply a dressing over the sacral area. Which type of dressing is most likely to be used over the stage 1 pressure ulcer? A) Transparent film dressing. This type of dressing allows for visualization of the area and protects it from shear. B) Aherent film dressing. This type of dressing is used to facilitate softening of eschar. The client's pressure ulcer is a stage 1 and thus has no eschar. C) Gauze dressing. This type of dressing is used in combination with normal saline or other prescribed medications when treating the more advanced stages of pressure ulcers. D) Hydrogel covered with a foam dressing. This type of dressing is used with stage lll or lV pressure ulcers to protect the area and absorb moisture.

A

What is the removal of devitalized tissue from a wound called? A) Debridement B) Pressure Reduction C) Negative pressure wound therapy D) Sanitization

A

What should a nurse do in order to comply with the ethic of nonmaleficence in the healthcare setting? A) The nurse should focus on doing no harm. B) The nurse should keep promises made to clients. C) The nurse should respect the autonomy of clients. D) The nurse should keep the best interests of the client in mind.

A

Which intervention is important to reduce the effect of the diarrhea on Alexander's skin? A) Apply a moisture-repellent ointment to intact skin areas. B) Rinse ulcerated areas with an alcohol-based irrigating solution. C) Position a plastic-lined pad under the buttocks. D) Apply moist heat to the area following exposure to feces.

A

Proper technique for performing a wound culture includes what? 1. Cleansing the wound prior to obtaining the specimen. 2. Swabbing for the specimen in the area with the largest collection of drainage. 3. Removing crusts or scabs with sterile forceps and then culturing the site beneath. 4. Waiting 8 hours following a dose of antibiotic to obtain the specimen.

1. Cleansing the wound prior to obtaining the specimen; Wound culture specimens should be obtained from a cleaned area of the wound. Microbes responsible for infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms. An appropriate specimen can be obtained without causing the client the discomfort of debriding. The nurse does not generally debride a wound to obtain a specimen. Once systemic antibiotics have been begun, the interval following a does will not significantly affect the concentration of wound organisms.

You assess four patients. Which patient has greatest risk for hypomagnesemia? A) A 72-year-old with chronic alcoholism B) A 79-year-old with bone cancer C) A 41-year-old with hypernatremia D) A 46-year-old with respiratory acidosis

A) A 72-year-old with chronic alcoholism

When designing a plan for pain management for a postoperative patient, the nurse assesses that the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient's priority is met. Which principle is used to encourage the nurse to monitor the patient's response to the pain? A) Fidelity B) Beneficence C) Nonmaleficence D) Respect for autonomy

A) Fidelity

What are physiologic symptoms assessed in a client with sleep deprivation? Select all that apply. A) Ptosis and blurred vision B) Agitation and hyperactivity C) Confusion and disorientation D) Increased sensitivity to pain E) Decreased auditory alertness

A, E

Which of the following is correct regarding wound debridement? A. It allows the healthy tissue to regenerate. B. When performed by autolytic means, the wound is irrigated. C. Mechanical methods involve direct surgical removal of the eschar layer of the wound. D. Enzymatic debridement may be implemented independently by the nurse whenever it is required.

A. It allows the healthy tissue to regenerate.

The nurse prepares to irrigate the client's wound. The primary reason for performing this procedure is to: A. Remove debris from the wound B. Decrease scar formation C. Improve circulation from the wound D. Decrease irritation from wound drainage

A. Remove debris from the wound

2. The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse's initial action be upon the patient's arrival? Assess the patient's pain. Assess the patient's vital signs. Check the rate of the IV infusion. Check the physician's postoperative orders.

Assess the patient's vital signs

In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel (UAP)? Monitor the patient's pain. Do the admission vital signs. Assist the patient to take deep breaths and cough. Change the dressing when there is excess drainage.

Assist the patient to take deep breaths and cough

A nurse provides teaching for a client who is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is what? A) Early ambulation B) Coughing and deep breathing C) Wearing antiembolic elastic stockings D) Maintenance of a nasogastric tube

B

A nursing student is evaluating different scenarios that are examples of following the basic health care principles. Which scenario is an example of following the principle of justice? A) A nurse obtains written consent from a client to let the surgeon perform an open-heart surgery. B) A nurse manager encourages the nurses to discuss their mistakes in order to improve the quality of care. C) A nurse determines the pros and cons of providing a backrub to a client with a spine injury in order to relieve pain. D) A nurse observes that a client is in need of spiritual help and therefore requests the services of the hospital chaplain.

B

How is the term "beneficence" in health ethics different from "nonmaleficence"? A) Beneficence refers to fairness, whereas nonmaleficence refers to the agreement to keep promises. B) Beneficence involves taking positive actions to help other,s whereas nonmaleficence is the avoidance of harm or hurt. C) Beneficence stands for all health care professionals, whereas nonmaleficence stands for nursing professionals. D) Beneficence refers to the support of a particular cause, whereas nonmaleficence refers to a willingness to respect one's professional obligations.

B

Since Donna has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when Donna changes position? A) Respiratory rate. B) Blood pressure. C) Temperature. D) Pulse rate.

B

The nurse is caring for a client before, during, and immediately after surgery. Which type of care is provided to the client? A) Care that supports physical functioning B) Care that supports homeostatic regulation C) Care that supports psychosocial functioning D) Care that provides immediate short-term help in physiological crises

B

The application of utilitarianism does not always resolve an ethical dilemma. Which of the following statements best explains why? A) Utilitarianism refers to usefulness and therefore eliminates the need to talk about spiritual values. B) In a diverse community it can be difficult to find agreement on a definition of usefulness, the focus of utilitarianism. C) Even when agreement about a definition of usefulness exists in a community, laws prohibit an application of utilitarianism. D) Difficult ethical decisions cannot be resolved by talking about the usefulness of a procedure.

B) In a diverse community it can be difficult to find agreement on a definition of usefulness, the focus of utilitarianism.

Which nursing interventions require a nurse to wear gloves? Select all that apply. A) Giving a back rub B) Cleaning a newborn immediately after delivery C) Emptying a portable wound drainage system D) Interviewing a client in the emergency department E) Obtaining the blood pressure of a client who is human immunodeficiency virus (HIV) positive

B, C

What information should the nurse provide for a client who is discharged from the health care facility with a surgical wound? Select all that apply. A) Potential drug-drug interactions B) Skill to care for the surgical wound C) Safe and effective use of medications D) List of appropriate community resources E) Need to report any change in the surgical area

B, C, D

A client who is scheduled for a surgical resection of the colon and creation of a colostomy for a bowel malignancy asks why preoperative antibiotics have been prescribed. The nurse explains that the primary purpose is to do what? A) Decrease peristalsis B) Minimize electrolyte imbalance C) Decrease bacteria in the intestines D) Treat inflammation caused by the malignancy

C

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? A) "Moderate amount of drainage." B) "No change in drainage since yesterday." C) "A 10-mm-diameter area of drainage at 1900 hours." D) "Drainage is doubled in size since last dressing change."

C

A nursing student is listing the characteristics of an ethical issue. Which point listed by the nursing student requires correction? A) An ethical issue occurs if it is perplexing and if it is not easy to think logically or make a decision. B) An ethical issue occurs if it is not possible to resolve solely through a review of scientific data. C) An ethical issue occurs if the problem aims at the greatest good for the greatest number of people. D) An ethical issue occurs if the answer to the problem has a profound relevance for areas of human concern.

C

An elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation? A) The nurse should wait for the court's order to give blood to the client. B) The nurse should proceed with the transfusion in order to save the client's life. C) The nurse should inform the primary healthcare provider and not give blood to the client. D) The nurse should explain to the family member that the client needs this transfusion.

C

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? A) Stage II B) Stage IV C) Unstageable D) Suspected deep tissue damage

C