FUNDS FINAL EXAM (Client Education, Nutrition, Tissue Integrity, Surgical Patient)

8. The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in _____ day(s). 1. 4 2. 2 3. 1 4. 7

1. 4 days

16. Which of the following would be the most important piece of assessment data to gather with regard to wound healing? 1. muscular strength assessment 2. sleep assessment 3. Pulse ox assessment 4. Sensation assessment

3. Pulse ox assessment

9. The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? 1. eschar 2. slough 3. granulation 4. purulent drainage

3. granulation

26. The nurse is completing an assessment of the skin's integrity, which includes a.Pressure points. b.All pulses. c.Breath sounds. d.Bowel sounds.

A. Pressure points

42. A 36-year-old female diabetic client is having an elective breast augmentation procedure done. Which of the following tests must be done on the day of surgery 1. Complete blood count 2. Blood glucose 3. Serum electrolytes 4. Coagulation studies

ANS: 2 blood glucose

37. The initial client education related nursing action by the preadmission nurse is to: 1. Respond to questions presented by the family regarding the client's surgery 2. Call the client before the surgery to restate presurgery routine 3. Provide the client with a list of preoperative requirements 4. Arrange a time for presurgical blood work to be drawn

ANS: 2. call the client before the surgery to restate presurgery routine

1. The nurse determines that the clients wound may be infected. To perform an aerobic wound culture, the nurse should: 1. Collect the superficial drainage 2. Collect the culture before cleansing the wound 3. Obtain a culturette tube and use sterile technique 4. Use the same technique as for collecting an anaerobic culture

ANS: 3

2. Pressure ulcers form primarily as a result of: 1. Nitrogen buildup in the underlying tissues 2. Prolonged illness or disease 3. Tissue ischemia 4. Poor nutrition

ANS: 3

16. The nurse recognizes that skin integrity can be compromised by being exposed to body fluids. The greatest risk exists for the client who has exposure to 1. Urine 2. Purulent exudates 3. Pancreatic fluids 4. Serosanguineous drainage

ANS: 3 Pancreatic fluids

34. Which of the following statements made by the nurse shows the most thorough understanding of the therapeutic value of testing a reddened area on the heel of a mobility - impaired client for blanching 1. If it blanches, the problem isnt too bad 2. When it stays red, the damage is great 3. Non blanching hyperemia is a poor indicator of healing 4. blanching denotes an attempt to deliver blood to the site

ANS: 4

17. The nurse is preparing to assist the patient in using the incentive spirometer. Which nursing intervention should the nurse provide first? a.Perform hand hygiene. b.Explain use of the mouthpiece. c.Instruct the patient to inhale slowly. d.Place in the reverse Trendelenburg position.

ANS: A

39. The nurse demonstrates postoperative exercises for a patient. In which order will the nurse instruct the patient to perform the exercises?1. Turning2. Breathing3. Coughing4. Leg exercises a.4, 1, 2, 3 b.1, 2, 3, 4 c.2, 3, 4, 1 d.3, 1, 4, 2

ANS: A

18. The nurse is assessing a patient for nutritional status. In doing so, the nurse must a.Choose a single objective tool that fits the patient's condition. b.Combine multiple objective measures with subjective measures. c.Forego the assessment in the presence of chronic disease. d.Use the Mini Nutritional Assessment for pediatric patients.

ANS: B

20. Dysphagia refers to difficulty when swallowing. Of the following causes of dysphagia, which is considered neurogenic? a.Myasthenia gravis b.Stroke c.Candidiasis d.Muscular dystrophy

ANS: B

1. The nurse notes a reddened area on the right heel that does not turn lighter in color when pressed with a finger. Which term will the nurse use to describe this area? a. Reactive hyperemia b. Secondary erythema c. Blanchable hyperemia d. Nonblanchable erythema

ANS: D

14. In teaching mothers-to-be about infant nutrition, the nurse instructs patients to a.Give cow's milk during the first year of life. b.Supplement breast milk with corn syrup. c.Add honey to infant formulas for increased energy. d.Remember that breast milk or formula is sufficient for the first 4 to 6 months.

ANS: D

4. The nurse is caring for a patient in preadmission testing. The patient has been assigned a physical status classification by the American Society of Anesthesiologists of ASA III. Which assessment will support this classification? a.Normal, healthy patient b.Denial of any major illnesses or conditions c.Poorly controlled hypertension with implanted pacemaker d.Moribund patient not expected to survive without the operation

ANS:C

44. The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission. The nurse has implemented interventions for this nursing diagnosis. Upon reassessment, which Braden score would be the best sign that the risk for skin breakdown is decreasing? a.12 b.13 c.20 d.23

D. 23

17. The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse? a.Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results. b.Notify the charge nurse about the change in status and the potential for infection. c.Notify the physician by utilizing Situation, Background, Assessment, and Recommendation (SBAR). d.Notify the wound care nurse about the change in status and the potential for infection.

1. Complete the head to toe assessment

2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is 1. Pressure 2. Resistance 3. Stress 4. Weight

1. Pressure

15. A patient has developed a decubitus ulcer. What laboratory data would be important to gather? 1. Serum albumin 2. Creatinine Kinase 3. Vitamin E 4. Potassium

1. Serum albumin

5. The nurse has important information to share with a parent who has brought his child to the emergency department. The nurse discovers that the parent, who appears very anxious, has just learned his son will require surgery. The most effective teaching approach in this situation is: 1. Telling 2. Trusting 3. Participating 4. Group teaching

1. Telling The telling approach is useful when limited information must be taught. If a client is highly anxious but it is vital for information to be given, telling can be effective. The entrusting approach provides the client the opportunity to manage self-care. The nurse observes the client's progress and remains available to assist without introducing more new information. This would not be the most effective teaching approach in this situation. Participating involves the nurse and client setting objectives and becoming involved in the learning process together. This would not be the most effective teaching approach in this emergency situation. Group teaching would not be the most effective teaching approach in this situation. A person who is anxious would benefit more from individual instruction.

14. Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence? 1. complaint by patient that something has given way 2. protrusion of visceral organs through a wound opening 3. chronic drainage of fluid through the incision site 4. drainage that is odorous and purulent

1. complaint by the patient that something has given way

6. A client, after being taught of the clinical manifestations of inflammation to enable early detection of a complication of a surgical wound states, "I will look at the wound four times a day and tell my surgeon if it looks red or swollen." Her statement is an example of: 1. Attitudes 2. Application 3. Analysis 4. Evaluation

2. Application Application involves using abstract, newly learned ideas in a concrete situation. The client who is taught the clinical manifestations of inflammation and who will assess for signs such as redness or edema is using newly learned information in a concrete manner. Attitude has to do with affective learning. The client is not expressing an attitude, but is applying new knowledge in a concrete way. Analysis involves breaking down information into organized parts. The client is not demonstrating analysis. Evaluation is a judgment of the worth of a body of information for a given purpose. The client is not expressing judgment.

11. The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by 1. Tertiary intention 2. Secondary intention 3. Partial thickness repair 4. Primary intention

2. Secondary intention

14. In the postoperative period, the nurse recognizes that an early sign of malignant hyperthermia is: 1. Fever 2. Tachycardia 3. Muscle relaxation 4. Skin Pallor

2. Tachycardia

3. Which nursing observation would indicate that the patient was at risk for pressure ulcer formation? 1. The patient ate two thirds of breakfast 2. The patient has fecal incontinence 3. The patient has a raised red rash on the right shin 4. The patient's capillary refill is less than 2 seconds

2. the patient has fecal incontinence

19. The nurse is completing an assessment on an individual who has a stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following? a."I think I will be ready to go home early next week." b."I am so weak and tired, I want to feel better." c."I am ready for my bath and linen change as soon as possible." d."I am hoping there will be something good for dinner tonight."

3. "I am ready for my bath and linen change as soon as possible."

7. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of 1. Primary intention 2. Partial thickness wound repair 3. Full thickness wound repair 4. Tertiary intention

3. Full thickness wound repair

4. The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer? 1. Stage I pressure ulcer 2. Healing stage II Pressure ulcer 3. Healing stage III Pressure ulcer 4. Stage III Pressure ulcers

3. Healing stage III pressure ulcer

18. The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a meal plan that includes increased 1. Fat 2. Carbs 3. Protein 4. Vitamin E

3. Protein

3. The nurse established the following objective for the client who was unable to void: The client's intake will be at least 1000 mL between 7 AM and 3:30 PM. Feedback showing success is indicated by the client: 1. Voiding at least 1000 mL during the shift 2. Verbalizing abdominal comfort without pressure 3. Having adequate fluid intake and urinary output 4. Drinking 240 mL of fluid five or six times during the shift

4. Drinking 240 mL of fluid five or six times during the shift The nurse evaluates success by observing the client's performance of each expected behavior. Feedback indicating success in this situation is the client drinking 240 mL of fluid five or six times during the shift. This would be a fluid intake of 1200-1440 mL, meeting the objective of at least 1000 mL during the designated time period. Voiding at least 1000 mL is not the objective. The objective is to have the client drink at least 1000 mL. Verbalizing abdominal comfort without pressure is not an evaluation of the objective regarding specific fluid intake. Having adequate intake and output is not accurate feedback indicating success. The term adequate is not quantified.

7. The client continues to ask questions about a surgical wound. The client states, "I think I would like help the first time I look at my wound." This is an example of: 1. Adaptation 2. Perception 3. Organizing 4. Guided response

4. Guided response A guided response is the performance of an act under the guidance of an instructor. The client who is seeking help is demonstrating a guided response. Adaptation occurs when a person is able to change a motor response when unexpected problems arise. The client is not exhibiting adaptation. Perception is being aware of objects or qualities through the use of sense organs. This situation is not an example of perception. Organizing is developing a value system by identifying and organizing values and resolving conflicts. This situation is not an example of organizing.

6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging an ulcer on this patient? 1. Cotton Tipped applicator 2. Disposable measuring tape 3. Sterile gloves 4. Halogen Light

4. Halogen light

10. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by 1. Tertiary intention 2. Secondary intention 3. Partial thickness repair 4. Primary intention

4. Primary intention

12. Which nursing observation would indicate that a wound healed by secondary intention? 1. minimal scar tissue 2. minimal loss of tissue function 3. permanent dark redness at site 4. Scarring can be severe

4. Scarring can be severe

4. There are a variety of teaching methodologies fro a nurse to choose from to use with clients. For a toddler, the nurse should use: 1. Role-playing 2. Problem-solving 3. Independent learning 4. Simple explanations and pictures

4. Simple explanations and procedures Effective teaching methodologies for the toddler include simple explanations and picture books that describe a story of children in a hospital or clinic. Role-playing is an appropriate teaching methodology for the preschooler. Problem-solving is an appropriate teaching methodology for the adolescent. Independent learning is best used as a teaching methodology for the young or middle adult.

2. a nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. the surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurseto initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following ndings should the nurse expect? (select all that apply.) a. Increase in incisional pain B. Fever and chills c. reddened wound edges d. Increase in serosanguineousdrainage e. decrease in thirst

A, B, C

1. The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care understands the need for a multidisciplinary approach. The nurse evaluates the need for several consults. Which of the following should always be included in the consults? (Select all that apply.) a.Registered dietitian b.Enterostomal and wound care nurse c.Physical therapist d.Case management personnel e.Chaplainf.Pharmacist

A, B, C, D

3. The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.) a."Can you easily change your position?" b."Do you have sensitivity to heat or cold?" c."How often do you need to use the toilet?" d."Is movement painful?" e."What medications do you take?" f."Have you ever fallen?"

A, B, C, D

5. The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. The nurse's responsibilities and activities before applying the bandage and binder include which of the following? (Select all that apply.) a.Inspecting the skin for abrasions and edema b.Covering exposed wounds c.Assessing condition of current dressings d.Assessing the skin at underlying areas for circulatory impairment e.Marking the sites of all abrasions f.Cleansing the area with hydrogen peroxide

A, B, C, D

2. The nurse is caring for a patient with wound healing by tertiary intention. Which factors does the nurse recognize as influencing wound healing? (Select all that apply.) a.Nutrition b.Evisceration c.Tissue perfusion d.Infection e.Hemorrhage f.Age

A, C, D, F

5. a nurse is caring for an olderadult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (select all that apply.) a. Keep the head of the bed elevated 30°. B. Massage the client's bony prominences frequently. c. apply cornstarch liberally to the skin after bathing. d. Have the client sit on a gel cushion when in a chair. e. reposition the client at least every 3 hr while in bed.

A, D

3. a nurse educator is reviewing the wound healing process with a group of nurses. the nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (select all that apply.) a. stage III pressure ulcer B. sutured surgical incision c. casted bone fracture d. laceration sealed with adhesive e. open burn area

A, E

36. The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial interventions should the nurse select to decrease this risk? a.Gentle cleaners and thorough drying of the skin b.Absorbent pads and garments c.Positioning with use of pillows d.Therapeutic beds and mattresses

A. Gentle cleaners and thorough drying of the skin

39. The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage a.I. b.II. c.III. d.IV.

A. I

30. The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign? a.Ineffective tissue perfusion b.Risk for infection c.Imbalanced nutrition: less than body requirements d.Acute pain

A. Ineffective tissue perfusion

20. A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, the next best step is to a.Inspect the wound for bleeding. b.Inspect the wound for foreign bodies. c.Determine the size of the wound. d.Determine the need for a tetanus antitoxin injection.

A. Inspect the wound for bleeding.

24. The client is brought into the emergency department with a knife wound. The nurse correctly documents the clients wound as a(n): 1. Contusion wound 2. Clean wound 3. Acute Wound 4. Intentional wound

ANS 3. Acute wound

18. A client who receives general or regional anesthesia in an ambulatory surgery center: 1. Has to meet identified criteria in order to be discharged home 2. Will remain in the phase I recovery area longer than a hospitalized client 3. Is allowed to ambulate as soon as being admitted to the recovery area 4. Is immediately given liberal amounts of fluid to promote the excretion of anesthesia

ANS: 1

32. Which of the following interventions is mostly likely to minimize the cause of a pressure ulcer on the left buttock of a client who is comatose 1. Turn and position the client at least every 2 hours 2. Use a lift sheet when moving the client up in bed 3. Change wet, soiled clothing as promptly as it is detected 4. Keep the head of the clients bed elevated to less than 30 degrees

ANS: 1

36. When changing the soiled linen on the bed of a client who is comatose, the nurse notices a reddened, blanchable area approximately 2 cm in diameter on her left buttock. The nurses initial skin breakdown intervention is to 1. Position the client on her right side 2. Finishing providing fresh, dry linen to the clients bed 3. include a 2 hour turning schedule in the clients care plan 4. measure the area in order to describe it in the nurses notes

ANS: 1

40. The nurse knows that the client is most likely going to arrive for the surgical procedure having adhered to the required bowel preparation 1. The client understands the need for the laxative 2. The laxative ordered is pleasant tasting 3. The bowel preparation is an uncomplicated process 4. The client has the appropriate support at home

ANS: 1

5. Upon changing the clients dressing, the nurse notes that the wound appears to be granulating. An appropriate noncytotoxic cleansing agent selected by the nurse is: 1. Sterile saline 2. Hydrogen peroxide 3. Povidone-iodine 4. Sodium hypochlorite

ANS: 1

8. When turning a client, the nurse notices a reddened area on the coccyx. What skin care interventions should the nurse use on this area? 1. Clean the area with mild soap, dry and add a protective moisturizer 2. Apply a dilute hydrogen peroxide and water mixture and use a heat lamp to the area 3. Soak the area in normal saline solution 4. Wash the area with an astringent and paint it with povidone iodine

ANS: 1

9. The client will have an incision in the lower left abdomen. Which of the following measures by the nurse will help decrease discomfort in the incisional area when the client coughs postoperatively? 1 Applying a splint directly over the lower abdomen 2 Keeping the client flat with her feet flexed 3 Turning the client onto the right side 4 Applying pressure above and below the incision

ANS: 1

28. When a client newly diagnosed with type 2 diabetes mellitus selects a lunch menu that correlates with the number of carbohydrates he is allowed for that meal, this is an example of: 1. Cognitive learning 2. Affective learning 3. Impaired learning 4. Psychomotor learning

ANS: 1 Cognitive learning includes all intellectual behaviors and requires thinking. The remaining options are involved with expression of feelings and acceptance of attitudes, opinions, or values or acquiring skills that require the integration of mental and muscular activity. Impairing learning involves alteration to the normal learning process that requires alterations in methods and techniques.

31. A client has been recently told that the primary cancer has metastasized and the cancer is considered terminal. When the nurse offers to discuss palliative care options the client replies, "I can't understand why you all want to upset me by bringing the topic up. Now please just leave me alone." The nurse recognizes this response as: 1. Anger 2. Disbelief 3. Bargaining 4. Acceptance

ANS: 1 In this example, the client blames others and complains. The client often directs anger toward the nurse or others. The remaining options are other stages of the grieving process.

14. In planning to teach an older adult client, the nurse should incorporate which teaching method or principle into the plan? 1. Keep teaching sessions short. 2. Teach in the early morning or late evening. 3. Put as much as possible into each teaching session. 4. Focus on teaching a family member or caregiver instead.

ANS: 1 Keeping teaching sessions short is an appropriate method when teaching an older adult client. The older adult should be taught when the client is alert and rested, not early morning or late evening. The teaching session should not be filled with numerous topics. The older adult client is capable of learning and should be the focus. A family member or caregiver may be included in teaching, but the older adult client should not be excluded.

26. Which of the following actions is the primary nursing responsibility regarding client education? 1. Providing accurate, current, relevant information 2. Answering the client's questions regarding health-related issues 3. Assessing the individual client's readiness and motivation to learn 4. Identifying areas where clients are in need of educational information

ANS: 1 Nurses have an ethical responsibility to teach their clients (Redman, 2005, 2007). The information needs to be accurate, complete, and relevant to the client's needs. The remaining options are factors that affect learning and so require the nurse's attention but are not as primary as providing information that is accurate, current, and relevant to the client's needs.

15. The nurse has completed an assessment on the client and identified the following nursing diagnoses. Which one of the following nursing diagnoses indicates a need to postpone teaching that was planned? 1. Activity intolerance related to pain 2. Ineffective management of treatment regimen 3. Noncompliance with prescribed exercise plan 4. Knowledge deficit regarding impending surgery

ANS: 1 Pain, fatigue, or anxiety can interfere with the ability to pay attention and participate. The nursing diagnosis of activity intolerance related to pain indicates a need to postpone teaching. Teaching may be delayed until the nursing diagnosis is resolved or the health problem is controlled. Ineffective management of treatment regimen does not indicate a need to postpone teaching. Ineffective management of treatment regimen reinforces the need for teaching. Noncompliance with prescribed exercise plan does not indicate a need to postpone teaching. The client who is noncompliant may require further teaching. Knowledge deficit regarding impending surgery does not indicate a need to postpone teaching. A knowledge deficit reinforces the need for teaching.

24. Which of the following teaching topics is an example of health maintenance and promotion and illness prevention? 1. Glucose monitoring at home 2. Living with rheumatoid arthritis 3. Stress management's impact on depression 4. What to expect after hip replacement surgery

ANS: 1 Promoting healthy behavior through education allows clients to assume more responsibility for their health. Greater knowledge results in better health maintenance habits. When clients become more health conscious, they are more likely to seek early diagnosis of health problems. The remaining options address restoration of health and coping with impaired functioning, whereas stress management is a topic that relates to the promotion of health and the prevention of illness.

22. The nurse recognizes that the client's teaching plan is most directly driven by: 1. The client's identified learning needs 2. The complexity of the client's health needs 3. The client's readiness and motivation to learn 4. The presence of cultural or physical barriers

ANS: 1 Teaching is most effective when it responds to the learner's needs. While assessing and diagnosing a client's health care problems, the nurse identifies the need for education that in turn generates the teaching plan. The remaining options reflect factors that will affect both the teaching plan and the client's learning.

12. The nurse is evaluating the responses of clients to teaching sessions. An example of an evaluation of a client's attainment of a cognitive skill is: 1. Client explains that the medication should be taken with meals 2. Client looks at the surgical incision without requiring prompting 3. Client uses crutches appropriately to move both up and down stairs 4. Client independently capable of dressing self after eating breakfast

ANS: 1 The client who is able to explain that the medication should be taken with meals is demonstrating attainment of a cognitive skill. The client who is able to look at the surgical incision without prompting is demonstrating attainment of affective learning. The client who uses crutches appropriately is demonstrating attainment of a psychomotor skill. The client who dresses self after breakfast is most likely demonstrating attainment of psychomotor learning.

9. The nurse is demonstrating to the client how to put on anti-embolitic stockings. In the middle of the lesson the client asks, "Why have my feet been swelling?" The nurse stops and responds to the client. Which of the following is the teaching principle that the nurse should follow? 1. Timing 2. Setting priorities 3. Building on existing knowledge 4. Organizing the teaching materials

ANS: 1 The nurse who stops a demonstration of applying anti-embolitic stockings to answer a client's question is following the teaching principle of timing. If the client has a question, it is important to answer the question immediately, so the client may return his or her focus to the task being taught. Setting priorities is important to conserve the time and energy of the client and nurse. The nurse who stops to answer a question is not setting priorities. A client learns best on the basis of preexisting cognitive abilities and knowledge. This situation is not an example of building on existing knowledge. Organizing teaching materials means the nurse considers the order of information to present. This is not an example of organizing teaching materials.

31. A client with a history of sleep apnea has had a same-day surgery procedure that will require the administration of morphine postoperatively to manage pain. This client will be assessed most appropriately by the perioperative nurse for the risk for respiratory complications by frequently 1. Listening to breath sounds 2. Monitoring pulse oximetry 3. Evaluating spirometer use 4. Counting respirations per minute

ANS: 1 listening to breath sounds

28. Which of the following preoperative assessment findings would most likely delay a planned procedure requiring general anesthetic 1. a cough and low grade fever 2. The pulse ox reading 97% on room air 3. A blood pressure that is 10 systolic points higher than the baseline 4. The client reports of being so nervous about this procedure

ANS: 1 Cough and low grade fever

29. A 74-year-old is accompanied by his daughter to the ambulatory surgery department for the surgical removal of a suspicious skin lesion. The client has experienced dysphasia since a cerebral vascular accident 3 years ago. The most effective way for the nurse to secure the necessary preoperative interview information is to: 1. Question the clients daughter 2. Review the clients past medical records 3. Present the questions in a simple format 4. Rely on the clients preadmission survey

ANS: 1 question the clients daughter

10. Upon inspection of the clients wound, the nurse notes that it appears infected and has a large amount of exudate. An appropriate dressing for the nurse to select based on the wound assessment is 1. Foam 2. Hydrogel 3. Hydrocolloid 4. Transparent film

ANS: 1 Foam

47. Given a rationale for preoperative and postoperative procedures, the client is better prepared to participate in care. For which of the following should the nurse provide instruction and rationale? 1. Incentive spirometry 2. Specific details regarding the progression of diet 3. Working the call button for the nurse 4. Using the PCA pump

ANS: 1 Incentive Spirometry

41. Which surgical classification would be the most appropriate for a cardiac catheterization scheduled on a 44 year old male client who is in the hospital with chest pain? 1. Major 2. Minor 3. Ablative 4. Elective

ANS: 1 Major surg

14. Following a head injury, the client has thin drainage coming from the left ear. The nurse describes this drainage as: 1. Serous 2. Purulent 3. Cerebrospinal fluid 4. Serosanguineous

ANS: 1 Serous

13. The nurse is completing the preoperative checklist for an adult client who is scheduled for an operative procedure later in the morning. Which of the following preoperative assessment findings for this client indicates a need to contact the anesthesiologist? 1. Temp is 100F 2. Pulse is 90 bpm 3. Respiratory rate is 20 bpm 4. Blood pressure is 130/74 mmHg

ANS: 1 Temp is 100F

40. Which of the following assessment findings is most representative of a stage II pressure ulcer: 1. A blister 2. Undermining 3. Nonblanchable redness 4. Visible subcutaneous fat

ANS: 1 a blister

23. A client who is scheduled for surgery is found to have thrombocytopenia. A specific postoperative concern for the nurse for this client is: 1 Hemorrhage 2 Wound infection 3 Fluid imbalance 4 Respiratory depression

ANS: 1 hemorrhage

1. When discussing the details of having a procedure done in a facility's ambulatory surgery department, the nurse includes which of the following as advantages? (Select all that apply.) 1. Facilitates faster postsurgical recovery 2. Reduces hospital oriented expenses 3. Allows for more one on one attention by staff 4. Cuts preparation time for surgical procedures 5. Minimizes risk for acquiring a nosocomial infection 6. The anesthetic drugs used result in faster wake up time

ANS: 1, 2, 5, 6

1. A 43 - year -old client is scheduled to have a gastrectomy. Which of the following is a major preoperative concern? 1 The clients brother had a tonsillectomy at age 11. 2 The client smokes a pack of cigarettes a day. 3 The client has an intravenous (IV) infusion. 4 The client has a history of employment as a computer programmer

ANS: 2

10. The nurse is evaluating the client in the hospitals postanesthesia care unit (PACU) and determines that the Aldrete score is 8. Based on this assessment, the nurse anticipates that the client will: 1 Be sent to the intensive care unit 2 Be discharged back to his or her room on the nursing unit 3 Remain in the PACU until the score improves 4 Return to the operating room for surgical evaluation

ANS: 2

3. The nurse notes a clients skin is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as: 1. Stage I 2. Stage II 3. Stage III 4. Stage IV

ANS: 2

32. A client scheduled for an ambulatory surgery procedure requiring anesthetics arrives with a low - grade fever and a productive sough. The postponement of the procedure is most likely a result of the 1. Clients increased the risk for a respiratory tract infection 2. Possibility of a respiratory complication during anesthesia 3. Increased risk for the clients infecting staff and other clients 4. Clients impaired resistance as a result of respiratory tract infection

ANS: 2

33. Which of the following goals is most appropriate for a preoperative client with a nursing diagnosis of deficient knowledge regarding preoperative requirements related to lack of exposure to information? 1. Client will understand the need for scheduled surgery before leaving the providers office 2. Client will understand the preoperative routines of surgical care before leaving providers office 3. Client will present for drawing of preoperative laboratory blood at least 48 hours before scheduled surgery 4. Client will be able to successfully accomplish the preoperative bowel preparation by morning of scheduled surgery

ANS: 2

35. Which of the following client evaluations is most reflective of compliance for a preoperative client with a nursing diagnosis of deficient knowledge regarding preoperative requirements related to lack of exposure to information? 1. Client will present for scheduled blood laboratory work 48 hours before surgery 2. Clients preoperative blood laboratory work results are present on preoperative chart 3. Client will share the preoperative routines of surgical care with family to facilitate compliance 4. Client will understand the preoperative routines of surgical care before leaving providers office

ANS: 2

45. A 24 year old male client has been scheduled to undergo surgery for an ACL repair of his right knee. The client states that he is confused about what the surgeon will be doing. The best response from the nurse is: 1. The surgeon went over this procedure with you in his office 2. Let me get the surgeon to talk with you before we proceed so that you fully understand what will be happening 3. To share with the client what he can expect in regard to the procedure 4. This is just a simple procedureyou should feel much better afterwards

ANS: 2

6. A client requires wound debridement. The nurse is aware that which one of the following statements is correct regarding this procedure? 1. It allows the healthy tissue to regenerate 2. When performed by autolytic means, the wound is irrigated 3. Mechanical methods involve direct surgical removal of the eschar layer of the wound 4. Enzymatic debridement may be implemented independently by the nurse whenever it is required

ANS: 2

7. The nurse prepares to irrigate the clients wound. The primary reason for this procedure is to: 1. Decrease scar formation 2. Remove debris from the wound 3. Improve circulation from the wound 4. Decrease irritation from wound drainage

ANS: 2

8. Which of the following statements most accurately reflects nursing accountability in the intraoperative phase? 1 I would like to see the client have a regional anesthetic rather than a general anesthetic. 2 There seems to be a missing sponge, so a recount should be done of all the sponges that have been removed. 3 Did the client receive the medications and sign the consent? 4 The client looks to be reactive and stable.

ANS: 2

8. There are many factors are assessed before teaching the client to learn insulin injection sites, but the most important factor for the nurse to assess first is the: 1. Previous knowledge level of the client 2. Willingness of the client to want to learn the injection sites 3. Financial resources available to the client for the equipment 4. Intelligence and developmental level of the individual client

ANS: 2 If a person does not want to learn, it is unlikely that learning will occur. Motivation is the first factor the nurse should assess before teaching. To determine learning needs, the nurse should assess the client's previous knowledge level. However, this would not be the most important factor for the nurse to assess first. Assessing the financial resources available to the client for obtaining equipment is important; however, it is not the most important factor for the nurse to assess first. Assessing the client's physical and cognitive ability to learn is important. However, it is not the most important factor for the nurse to assess first.

30. A client has been recently told that the primary cancer has metastasized, and the cancer is considered terminal. When the nurse offers to discuss palliative care options, the client replies, "I'm going to have the reports reevaluated by another doctor; I feel fine and I think a mistake has been made." The nurse recognizes this response as: 1. Anger 2. Disbelief 3. Bargaining 4. Acceptance

ANS: 2 In this example, the client avoids discussion of the illness, choosing to believe a mistake has been made. The remaining options are other stages of the grieving process.

21. The nurse is preparing the discharge teaching materials on newly prescribed drugs to a client diagnosed to be in the early stage of Alzheimer's disease. The nurse best deals with the client's cognitive deficits by: 1. Providing written material to supplement the discussion 2. Arranging for family to be present during the discussion 3. Presenting the material in two short but focused sessions 4. Requiring the client to restate the information in her own words

ANS: 2 The client's family needs to understand and accept many changes in the patient's physical and/or cognitive capabilities. The family's ability to provide support results in part from education, which begins as soon as the nurse identifies the client's needs and the family displays a willingness to help. The remaining options may support retention of material but not as effectively as including family in the educational sharing.

21. The client has a stage IV pressure ulcer. In accordance with the Agency for Healthcare Research and Quality (AHRQ), the nurse recommends that the client should have a(n): 1. Foam mattress 2. Air fluidized bed 3. Rotokinetic bed 4. Static support surface

ANS: 2 Air fluidized bed

12. A client comes to the emergency department following an injury. The nurse implements appropriate first aid for the client when 1. Removing any penetrating objects 2. Elevating an affected part that is bleeding 3. Vigorously cleaning areas of abrasion or laceration 4. Keeping any puncture wounds from bleeding

ANS: 2 Elevating an affected part that is bleeding

16. The female client on the surgical unit is being prepared for abdominal surgery with general anesthesia. In preparing this client for surgery, the nurse should 1. Leave all of her jewelry in tact 2. Provide her with sips of water for a dry mouth 3. Remove her makeup and nail polish 4. Remove her hearing aid before transport to the OR

ANS: 3

18. When cleaning a wound, the nurse should: 1. Wash over the wound twice and discard that swab 2. Move from the outer region of the wound toward the center 3. Start at the drainage site and move outward with circular motions 4. Use an antiseptic solution followed by a normal saline rinse

ANS: 3

20. After discharge from the post anesthesia care unit (PACU), the client returned to the surgical nursing unit at 10:00 AM. It is now 11:30 AM, and the client is not experiencing any complications or difficulties. The nurse will plan to measure the clients vital signs: 1. Every 15 minutes 2. Every 30 minutes 3. Every 1 hour 4. Every 4 hours

ANS: 3

22. Upon admission to the postanesthesia care unit (PACU), the client who has no orthopedic or neurological restrictions is positioned with the: 1. Bed flat and the clients arms to the sides 2. Clients neck flexed and body positioned laterally 3. Head of the bed slightly elevated with the clients head to the side 4. Clients arms crossed over the chest and the bed in high fowlers position

ANS: 3

25. Which of the following state ments made by a nurse reflects the greatest insight into the responsibility an ambulatory care nurse has to the clients family? 1 A clients family deserves the attention of the nursing staff. 2 Family is important to my client, and so family is important to me. 3 I consider myself as having several clients: the surgical client and all the family thats present. 4 I am responsible for keeping the family informed of the status of their loved one both during and after the procedure

ANS: 3

27. The perioperative nurse realizes that the most effective means of evaluating the clients understanding of previous teaching is to: 1. Provide written material on the subject to be reviewed after discharge 2. Reinforce the material with family as the procedure is being performed 3. Discuss it with the client and family in the immediate preoperative period 4. Offer to answer any questions that the client or family have just before discharge

ANS: 3

29. A client on the medical unit is taking steroids and also has a wound from a minor injury. To promote wound healing for this client, the nurse recommends that which of the following be specifically added 1. Iron 2. Folic acid 3. Vitamin A 4. B complex vitamins

ANS: 3

31. The primary reason an older adult client is more likely to develop a pressure ulcer on the elbow as compared to a middle-age adult is 1. A reduced skin elasticity is common in the older adult 2. The attachment between the epidermis and dermis is weaker 3. The older client has less subcutaneous padding on the elbows 4. Older adults have a poor diet that increases risk for pressure ulcers

ANS: 3

33. Which of the following statements made by the nurse shows the greatest insight into the need to manage the risk factors that contribute to the formation of a pressure ulcer 1. Her diet needs to include more protein and less sugary foods 2. She needs to be moved more gently and with attention to her skin 3. We need to decrease the time she spends with the weight of her body resting on her hip 4. The urinary incontinency makes the risk for developing a pressure ulcer so much greater for her

ANS: 3

35. Which of the following nursing documentation best reflects the observable assessment of skin breakdown on the heel of an African American client 1. 2 cm area of scaly dry skin located on the client's right heel 2. 2 cm area of nonblanching erythema located on the clients right heel 3. 2 cm area purplish blue in color surrounded by lighter colored skin located on right heel 4. 2 cm area of blanching erythema located on the clients right heel; entire foot warm to the touch

ANS: 3

37. Although all of the following represent poor transfer techniques, which is most likely to result in a shearing injury to the skin of an older adult client 1. Only on staff member positioning an immobile client 2. allowing the heels to be dragged as the client is being positioned 3. Failing to lower the head of the bed before moving the client upward 4. Neglecting to use a lift sheet when moving the client to the head of the bed

ANS: 3

38. Which of the following clients has the greatest risk for friction-induced skin breakdown 1. A client who is obese and is frequently incontinent of both urine and feces 2. A client who insists she is comfortable only when positioned on her left side 3. A client who is cognitively impaired and comforts herself by wringing her hands 4. An immobile client who slides down the in the recliner where he spends the morning hours

ANS: 3

4. The client has rheumatoid arthritis, is prone to skin breakdown, and is also somewhat immobile because of arthritic discomfort. Which of the following is the best intervention for the clients skin integrity? 1. having the client sit up in a chair for 4 hours intervals 2. Keeping the head of the bed in a high fowlers position to increase circulation 3. Keeping a written schedule of turning and positioning 4. Encouraging the client to perform pelvic muscle training exercises several times a day

ANS: 3

46. A 47 year old female client has been scheduled to undergo surgery for removal of her gallbladder. Preoperatively the nurse is teaching the client what to expect when she wakes up in the postanesthesia care center. The nurse tells the client that her vision may be blurry due to which of the following reasons? 1. The clients blood pressure may be high from the postoperative pain. 2. The client may be slow to arouse from the anesthesia, causing her vision to be blurred upon waking. 3.The anesthesia provider applies ointment to clients eyes to prevent corneal damage. 4. The lighting in the postanesthesia area will be subdued, causing the client to have blurred vision upon waking.

ANS: 3

48. The nurse is very busy and needs to delegate some tasks to the nursing assistive personnel (NAP). Which of the following would be the most appropriate task to delegate? 1. Post op client teaching 2. Demonstrating postoperative exercises 3. Transporting the preop client from the unit to the holding area 4. Reviewing the preop assessment to make sure that the clients vital signs have been documented

ANS: 3

16. There are a variety of teaching methodologies that may be utilized to meet the client's needs. Which teaching method is best applied to a cognitive learning need? 1. Modeling of behavior 2. Discussion of feelings 3. Computer-assisted instruction 4. Demonstration of a procedure

ANS: 3 An independent project such as computer-assisted instruction is an appropriate teaching method for cognitive learning. Modeling of behavior is an appropriate teaching method for psychomotor learning. Discussion of feelings is an appropriate teaching method for affective learning. Demonstration is an appropriate teaching method for psychomotor learning.

19. While teaching the client about management of his heart disease, a nurse might use a strategy that is implemented to promote learning in the affective domain such as: 1. Asking the client what he believes he needs to know about the diagnosis 2. Providing brochures both on current exercises and on nutrition guidelines 3. Encouraging the client to personally discuss his feelings about his health status 4. Having the client return-demonstrate self-measurement of his own blood pressure

ANS: 3 An intervention to promote learning in the affective domain would be encouraging the client to discuss his feelings about his health status. Asking the client what he believes he needs to know about the diagnosis would be an intervention to promote learning in the cognitive domain. Providing brochures on current exercises and nutrition guidelines would be an intervention to promote learning in the cognitive domain. Having the client return-demonstrate self-measurement of his blood pressure would be an intervention to promote learning in the psychomotor domain.

13. The nurse evaluates which of the following statements as an indication that the client is not ready to learn at this time? 1. "I need to understand more about the reason for the colostomy." 2. "I will find out more about that when the support group meets." 3. "There's no sense in showing me that now. I'm too sick right now." 4. "Please be sure to tell me if I am completing all the steps correctly."

ANS: 3 Readiness to learn is related to the stage of grieving. This response by the client is demonstrating anger. The client is unwilling to learn at this time. The client has not yet reached the acceptance state of grieving in which learning can occur. This statement indicates the client is ready to learn and desires to find out more to gain understanding. This statement indicates the client is willing to learn. The client who requests feedback is expressing readiness to learn.

29. Which of the following statement best reflects the nurse's appropriate attention to a client's need for self-efficacy? 1. "What can I do to help you lose the weight?" 2. "Are you really ready to start a regular exercise regimen?" 3. "After you watch me demonstrate this inhaler, you will have no problems using it at all." 4. "Come on; with all the self-help products out there, you will be able to stop smoking."

ANS: 3 Self-efficacy refers to a person's perceived ability to successfully complete a task. When people believe that they are able to execute a particular behavior, they are more likely to actually perform the behavior consistently and correctly. Although the other options are related to behavioral change to achieve a goal, they do not support the client by both encouragement and providing the skills necessary to be successful.

11. Different topics are presented in the information sessions that are held in the outpatient clinic. In planning for a session on health maintenance/illness prevention, the nurse should select a topic on: 1. Use of assistive devices, such as canes 2. Self-help devices for post-CVA clients 3. Stress management techniques for working parents 4. Environmental alterations for clients in wheelchairs

ANS: 3 Stress management techniques for working parents is an appropriate topic for health maintenance/illness prevention. Use of assistive devices, such as canes, is not a health maintenance/illness prevention topic. It is a coping with impaired function topic. Self-help devices for post-CVAclients is not a health maintenance/illness prevention topic. It is a coping with impaired function topic. Environmental alterations for clients in wheelchairs is not a health maintenance/illness prevention topic. It is a coping with impaired function topic.

17. For a functionally illiterate client, the nurse particularly focuses on: 1. Using intricate analogies and examples 2. Avoiding lengthy return demonstrations 3. Incorporating familiar nonmedical terminology 4. Providing longer learning sessions with the client

ANS: 3 When teaching a functionally illiterate client, the nurse should use simple terminology, avoiding medical jargon. The nurse should incorporate familiar terminology to enhance the client's understanding. The nurse should use simple analogies and real life examples. The nurse should ask for return demonstrations as this provides the opportunity to clarify instructions and time to review procedures. Although teaching sessions may be kept short, they should be scheduled at more frequent intervals.

30. A client who has type 2 diabetes is scheduled for the removal of a skin lesion on his right shoulder at an ambulatory surgery unit. The nursing diagnosis the client is at greatest risk for postoperatively is: 1. Risk for injury 2. Risk for infection 3. Impaired wound healing 4. Imbalanced nutrition: less than body requirments

ANS: 3 Impaired wound healing

43. A 48 year old male client with a history of chronic obstructive pulmonary disease (COPD) is scheduled for an inguinal hernia repair. The nurse instructs that client that he can expect the health care provider to order which of the following tests before surgery? 1. Human immunodeficiency virus antibody 2. Prolactin level 3. Pulmonary function test 4. Glucose tolerance test

ANS: 3 Pulmonary function test

30. When asked what the role of the skin is in maintaining homeostasis, the answer that reflects the greatest insight is: 1. Our body needs vitamin D, and without healthy skin we cannot utilize it into a form we can use 2. Without skin we would not be able to enjoy the sense of touch that is so important to us as humans 3. The skin is a barrier that is quite good at keeping disease causing pathogens from getting into our body 4. It is the pain with its pain receptors that alert us to danger so that we can take appropriate action in order to be safe

ANS: 3 The skin is a barrier that is quite good at keeping disease causing pathogens from getting into our body

4. The nurse is working in a postoperative care unit in an ambulatory surgery center. Of the following clients that have come to have surgery, the client at the greatest risk during surgery is a: 1. 78 year old taking analgesics 2. 43 year old taking an antihypertensive agent 3. 27 year old taking an anticoagulant 4. 10 year old taking an antibiotic

ANS: 3 27 year old taking an anticoagulant

20. The nurse is aware that application of cold is indicated for the client with: 1. Menstrual cramping 2. An infected wound 3. A fractured ankle 4. Degenerative joint disease

ANS: 3 A fractured ankle

2. An appendectomy is appropriately documented by the nurse as: 1. Diagnostic surgery 2 Palliative surgery 3 Ablative surgery 4 Reconstructive surgery

ANS: 3 Ablative Surgery

39. The nurse recognizes which of the following as the greatest barrier to meeting a preoperative clients nursing diagnosis of deficient knowledge regarding surgical procedure 1. Effects of preop medication 2. Complicated nature of the information 3. Fear or anxiety regarding the procedure 4. Emotional denial regarding surgical outcomes

ANS: 3 Fear or anxiety regarding the procedure

11. A client has a healing abdominal wound.The wound has minimal exudate and collagen formation. The wound is identified by the nurse as being in which phase of healing? 1. Primary intention 2. Inflammatory phase 3. Proliferative phase 4. Secondary intention

ANS: 3 Proliferative phase

15. The client tells the nurse that blowing into this tube thing (incentive spirometer) is a ridiculous waste of time. The nurse explains that the specific purpose of the therapy is to: 1. Directly remove excess secretions from the lungs 2. Increase pulmonary circulation 3. Promote lung expansion 4. Stimulate the cough reflex

ANS: 3 Promote lung expansion

19. Following abdominal surgery, the nurse suspects that the client may be having internal bleeding. Which of the following findings is indicative of this complication? 1. Increased blood pressure 2. Incisional pain 3. Abdominal distension 4. Increased urinary output

ANS: 3 abdominal distension

26. To reduce pressure points that may lead to pressure ulcers, the nurse should: 1. Position the client directly on the trochanter when side lying 2. Use a donut device for the client when sitting up 3. Elevate the head of the bed as little as possible 4. Massage over the bony prominences

ANS: 3 elevate the head of the bead as little as possible

11. A client is in the postanesthesia care unit (PACU) recovering from a vagotomy and pyloroplasty. Which of the following is a normal expectation of the client in this stage of recovery? 1. Returned normal bowel sounds on auscultation 2. Pain that is relieved with noninvasive comfort measures 3. Voluntary bladder control and function 4. A subdued level of consciousness and neurological function

ANS: 4

12. The client is scheduled for abdominal surgery and has just received the preoperative medications. The nurse should: 1. Keep the client quiet 2. Obtain the consent 3. Prepare the skin at the surgical site 4. Place the side rails up on the bed or stretcher

ANS: 4

13. The nurse is concerned that the clients midsternal wound is at risk for dehiscence. Which of the following is the best intervention to prevent this complication? 1. Administering antibiotics to prevent infection 2. Using appropriate sterile technique when changing the dressing 3. Keeping sterile towels and extra dressing supplies near the clients bed 4. Placing a pillow over the incision site when the client is deep breathing or coughing

ANS: 4

15. Which nursing entry is most complete in describing a clients wound? 1. Wound appears to be healing well. Dressing dry and intact 2. Wound well approximated with minimal drainage 3. Drainage size of quarter; wound pink, 4 4s applied 4. Incisional edges approximated without redness or drainage; two 4x4s applied

ANS: 4

17. The client is scheduled for a dressing change. When removing the adhesive tape used to secure the dressing, the nurse should lift the edge and hold the tape 1. At a 45 degree angle to the skin surface while pulling away from the wound 2. At a right angle to the skin surface while pulling toward the wound 3. At a right angle to the skin surface while pulling away from the wound 4. Parallel to the skin surface while pulling toward the wound

ANS: 4

17. The client asks the nurse the purpose of having medications demerol and vistaril given before surgery. The nurse should inform the client that these particular medications: 1. Reduce preoperative fear 2. Promote emptying of the stomach 3. Reduce body secretions 4. Ease the induction of the anesthesia

ANS: 4

26. Which of the following statements made by a nurse reflects the greatest insight into the planning needs of a same-day surgical experience? 1 Time is a precious resource in same-day surgery units; being organized allows for the best utilization of time. 2 Everything must be checked and verified as being ready before the client is admitted into the surgical area. 3 With only a few hours from time of admission to the beginning of the procedure, things have to be effectively organized 4. I take the time to review the clients pre-admission and preopertative date in order to formulate the most individualized plan of care possible

ANS: 4

34. Which of the following client outcomes is most therapeutic for a preoperative client with a nursing diagnosis of deficient knowledge regarding preoperative requirements related to lack of exposure to information? 1. client will share the preoperative routines of surgical care with family to facilitate compliance. 2. Client will understand the preoperative routines of surgical care before leaving providers office 3. Client will call laboratory to schedule appointment for preoperative blood draw for required testing 4. Client will present for drawing of preoperative laboratory blood at least 48 hours before scheduled surgery

ANS: 4

36. Which of the following best describes the primary nursing role regarding a clients consent to surgery immediately before surgery? 1. Explaining the procedure to the client in a fashion that is easily understood 2. Placing the signed consent in the clients medical record 3. Ensuring that the client understands the possible risks of the procedure before signing the consent 4. Reviewing the clients surgical consent as a part of the routine preoperative checklist

ANS: 4

38. Which of the following statements made by the nurse shows the most informed understanding of the role of family in the clients postoperative recovery? 1. The family will be the ones you will be dealing with regarding postop needs 2. When the family is more relaxed about caring for the client, the client is more relaxed 3. The more the family understands what to expect during recovery, the more comfortable they are in caring for the client 4. Teaching the family what they need to know before the surgery will maximize their effectiveness regarding the clients postoperative care

ANS: 4

44. A 64 year old male client has been scheduled to undergo surgery for a total knee replacement. The client would like to be able to use his own blood for the surgery, if needed. The nurse explains that there are several advantages to the clients having an autologous infusion, but there are some drawbacks as well. Which of the following would be considered a drawback to an autologous infusion 1. The client has decreased risk for contracting HIV 2. There is a decreased risk for infection 3. The client has less risk for a transfusion reaction 4. The client may have a decreased hemoglobin and hematocrit level on the day of the surgery

ANS: 4

18. In preparing a teaching plan for adult clients in a cancer support group, the nurse incorporates evidence-based information. The nurse recognizes that evidence obtained about adult learners has identified that this group prefers: 1. Computer-assisted instruction 2. Traditional classroom settings 3. Long sessions with plenty of technical information 4. Interesting personal communication techniques

ANS: 4 Adults have a wide variety of personal and life experiences to employ. Therefore adult learning is enhanced when they are encouraged to use these experiences to solve problems. Evidence-based information indicates that adult clients prefer interactive, personal communication with nurses or physicians. Evidence-based information indicates computer-assisted learning is not a preferred method of instruction by many adult learners. As clients become more comfortable with computers, this preference may change. Evidence-based information indicates that not all clients are comfortable in class settings or in support groups. Other educational opportunities should be available. Adult learners prefer short teaching sessions without a great deal of technical information.

23. The nurse recognizes that the primary goal of a client's teaching plan is to: 1. Facilitate a knowledge-based client decision-making process 2. Provide information that brings about informed client consent 3. Enhance the client's sense of personal control regarding his or her health care 4. Therapeutically affect the client's health, wellness, and independence

ANS: 4 Creating a well-designed, comprehensive teaching plan that fits a client's unique learning needs ultimately helps clients make informed decisions about their care and results in clients becoming healthier and more independent. The remaining options affect the primary goal by enhancing decision making, providing for informed consent, and bringing about a sense of personal control.

10. Clients give various responses to teaching sessions. For the nurse, an example of an evaluation of a psychomotor skill is: 1. Client states side effects of a medication 2. Client responds appropriately to eye contact 3. Client independently plans an exercise program 4. Client demonstrates the proper use of a walking cane

ANS: 4 Determining whether the client is able to demonstrate a newly learned skill is an example of an evaluation of a psychomotor skill. Psychomotor learning involves acquiring skills that require the integration of mental and muscular activity, such as walking with a cane. Having the client state side effects of a medication is an example of an evaluation of cognitive learning. Determining whether a client responds appropriately to eye contact is an example of evaluation of affective learning. The client who planned an exercise program is demonstrating cognitive learning.

25. Which of the following teaching topics is an example of restoration of health? 1. Glucose monitoring at home 2. Living with rheumatoid arthritis 3. Stress management's impact on depression 4. What to expect after hip replacement surgery

ANS: 4 Injured or ill clients need information and skills to help them regain or maintain their levels of health. The remaining options address health maintenance and promotion and illness prevention and coping with impaired functioning while what to expect after hip replacement surgery is a topic that relates to the restoration of health and function.

27. When a client newly diagnosed with type 2 diabetes mellitus assumes responsibility for checking her blood glucose level four times a day, this is an example of: 1. Cognitive learning 2. Affective learning 3. Impaired learning 4. Psychomotor learning

ANS: 4 Psychomotor learning involves acquiring skills that require the integration of mental and muscular activity. The remaining options are involved with expression of feelings and acceptance of attitudes, opinions, or values or the acquisition of knowledge. Impaired learning involves alteration to the normal learning process that requires alterations in methods and techniques.

20. The nurse is preparing to present a teaching session on skin protection for a group of older adults at a senior center. A principle that has been found to be most effective in teaching older adults is: 1. Moving the group along at a predetermined pace 2. Providing information in longer teaching sessions 3. Speaking very slowly and in a louder tone of voice 4. Beginning and ending each session with important information

ANS: 4 The nurse should begin and end each teaching session with important information because clients are more likely to remember information that is taught early in the teaching session, and key points can be summarized at the end. Repetition also reinforces learning. The group should not be moved along at a predetermined pace. Clients may have questions that would go unanswered if there were a predetermined pace. Or, sometimes teaching sessions have to be stopped after the nurse observes a client's loss of concentration such as nonverbal cues of poor eye contact or slumped posture. Shorter (approximately 20 minutes), frequent sessions are more easily tolerated and retain the client's interest in the material. The nurse should face the client and speak in a low tone of voice for the older adult with a hearing problem.

9. A client with a large abdominal wound requires a dressing change every 4 hours. The client will be discharged to the home setting, where the dressing care will be continued. Which fo the following is true concerning this clients wound healing process? 1. An antiseptic agent is best followed with a rinse of sterile saline solution 2. A heat lamp should be used every 2 hours to rid the wound 3. Sterile technique should be emphasized to the client and family 4. A dressing covering will allow the wound area to remain moist

ANS: 4 A dressing covering will allow the wound area to remain moist

28. In reviewing the clients nutritional intake, the nurse wants to recommend intake of foods that will specifically promote collagen synthesis and capillary wall integrity. The nurse suggests that the client eat 1. Fish 2. Eggs 3. Liver 4. Citrus Fruits

ANS: 4 Citrus fruits

3. An obese client is admitted for abdominal surgery. The nurse recognizes that this client is more susceptible to the postoperative complication of : 1. Anemia 2. Seizures 3. Protein loss 4. Dehiscence

ANS: 4 Dehiscence

21. The client had surgery in the morning that involved the right femoral artery. To assess the clients circulation status to the right leg, the nurse will make sure to check the pulse at the: 1 Radial artery 2 Ulnar artery 3 Brachial artery 4 Dorsalis pedis artery

ANS: 4 Dorsalis pedis artery

7. The nurse is evaluating the outcome "Client describes surgical procedures and postoperative treatment" and determines the client has not achieved this outcome. The nurse should 1. obtain the consent, because this is expected 2. teach the client all about the procedure 3. Ask the unit manager to assist with a teaching plan 4. INform the surgeon so that information can be provided

ANS: 4 Inform the surgeon

25. The nurse is planning a program on wound healing and includes information that smoking influences healing by: 1. Suppressing protein synthesis 2. Creating increased tissue fragility 3. Depressing bone marrow function 4. Reducing functional hemoglobin in the blood

ANS: 4 Reduction functional hemoglobin in the blood

6. The nurse is completing the preoperative checklist for an adult female client who is scheduled for an operative procedure later in the morning. Which of the following preoperative assessment findings for this client indicates a need to contact the surgeon 1. Hemoglobin 14g/100mL 2. Blood urea nitrogen (BUN) 15 mg/ 100mL 3. Platelets 300,000/mm3 4. Serum creatinine 3.2 mg / 100mL

ANS: 4 Serum creatinine 3.2 mg/ 100mL

19. The client has a large, deep wound on the sacral region. The nurse correctly packs the wound by: 1. Filling two thirds of the wound cavity 2. Leaving saline soaked folded gauze squares in place 3. Putting the dressing in very tightly 4. Extending only to the upper edge of the wound

ANS: 4 extending only to the upper edge of the wound

5. A 92 year old client is scheduled for a colectomy, which normal physiological change that accompanies the aging process increases this clients risk for surgery ? 1. An increased tactile sensation 2. An increased metabolic rate 3. A relaxation of arterial walls 4. Reduced glomerular filtration rate

ANS: 4 reduced GFR

13. Which nursing assessment will indicate the patient is performing diaphragmatic breathing correctly? a.Hands placed on the border of the rib cage with fingers extended will touch as the chest wall contracts. b.Hands placed on the chest wall with fingers extended will separate as the chest wall contracts. c.The patient will feel upward movement of the diaphragm during inspiration. d.The patient will feel downward movement of the diaphragm during expiration.

ANS: A

19. The nurse is providing preoperative teaching for the ambulatory surgery patient who will be having a cyst removed from the right arm. Which will be the best explanation for diet progression after surgery? a."Start with clear liquids, soup, and crackers. Advance to a normal diet as tolerated." b."Stay with ice chips for several hours. After that, you can have whatever you want." c."Stay on clear liquids for 24 hours. Then you can progress to a normal diet." d."Start with clear liquids for 2 hours and then full liquids for 2 hours. Then progress to a normal diet."

ANS: A

22. In determining the nutritional status of a patient and developing a plan of care, it is important to evaluate the patient according to a.Published standards. b.Nursing professional standards. c.Absence of family input. d.Patient input only.

ANS: A

22. The nurse is reviewing the surgical consent with the patient during preoperative education and finds the patient does not understand what procedure will be completed. What is the nurse's best next step? a.Notify the health care provider about the patient's question. b.Explain the procedure that will be completed. c.Continue with preoperative education. d.Ask the patient to sign the form.

ANS: A

23. During preoperative assessment for a 7:30 AM (0730) surgery, the nurse finds the patient drank a cup of coffee this morning. The nurse reports this information to the anesthesia provider. Which action does the nurse anticipate next? a.A delay in or cancellation of surgery b.Questions regarding components of the coffee c.Additional questions about why the patient had coffee d.Instructions to determine what education was provided in the preoperative visit

ANS: A

25. The nurse has completed a preoperative assessment for a patient going to surgery and gathers assessment data. Which will be the most important next step for the nurse to take? a.Notify the operating suite that the patient has a latex allergy. b.Document that the patient had a bath at home this morning. c.Administer the ordered preoperative intravenous antibiotic. d.Ask the nursing assistive personnel to obtain vital signs.

ANS: A

29. The nurse is caring for a patient in the operating suite. Which outcome will be most appropriate for this patient at the end of the intraoperative phase? a.The patient will be free of burns at the grounding pad. b.The patient will be free of nausea and vomiting. c.The patient will be free of infection. d.The patient will be free of pain.

ANS: A

31. The nurse is assessing a postoperative patient with a history of obstructive sleep apnea for airway obstruction. Which assessment finding will best alert the nurse to this complication? a.Drop in pulse oximetry readings b.Moaning with reports of pain c.Shallow respirations d.Disorientation

ANS: A

32. The nurse is caring for a patient in the operating suite who is experiencing hypercarbia, tachypnea, tachycardia, premature ventricular contractions, and muscle rigidity. Which condition does the nurse suspect the patient is experiencing? a.Malignant hyperthermia b.Fluid imbalance c.Hemorrhage d.Hypoxia

ANS: A

33. The nurse is caring for a postoperative patient who has had a minimally invasive carpel tunnel repair. The patient has a temperature of 97° F and is shivering. Which reason will the nurse most likely consider as the primary cause when planning care? a.Anesthesia lowers metabolism. b.Surgical suites have air currents. c.The patient is dressed only in a gown. d.The large open body cavity contributed to heat loss.

ANS: A

35. The nurse is caring for a patient in the postanesthesia care unit. The patient asks for a bedpan and states to the nurse, "I feel like I need to go to the bathroom, but I can't." Which nursing intervention will be most appropriate initially? a.Assess the patient for bladder distention. b.Encourage the patient to wait a minute and try again. c.Inform the patient that everyone feels this way after surgery. d.Call the health care provider to obtain an order for catheterization.

ANS: A

38. The nurse is caring for a group of patients. Which patient will the nurse see first? a.A patient who had cataract surgery is coughing. b.A patient who had vascular repair of the right leg is not doing right leg exercises. c.A patient after knee surgery is wearing intermittent pneumatic compression devices and receiving heparin. d.A patient after surgery has vital signs taken every 15 minutes twice, every 30 minutes twice, hourly for 2 hours then every 4 hours.

ANS: A

6. The nurse is caring for a patient in the postanesthesia care unit who has undergone a left total knee arthroplasty. The anesthesia provider has indicated that the patient received a left femoral peripheral nerve block. Which assessment will be an expected finding for this patient? a.Sensation decreased in the left leg b.Patient report of pain in the left foot c.Pulse decreased at the left posterior tibia d.Left toes cool to touch and slightly cyanotic

ANS: A

7. Fats are composed of triglycerides and fatty acids. Triglycerides a.Are made up of three fatty acids. b.Can be saturated. c.Can be monounsaturated. d.Can be polyunsaturated.

ANS: A

8. The nurse is completing a medication history for the surgical patient in preadmission testing. Which medication should the nurse instruct the patient to hold (discontinue) in preparation for surgery according to protocol? a.Warfarin b.Vitamin C c.Prednisone d.Acetaminophen

ANS: A

1. The energy needed to maintain life-sustaining activities for a specific period of time at rest is known as a.BMR. b.REE. c.Nutrients. d.Nutrient density.

ANS: A BMR

1. The nurse is participating in a "time-out." In which activities will the nurse be involved? (Select all that apply.) a.Verify the correct site. b.Verify the correct patient. c.Verify the correct procedure. d.Perform "time-out" after surgery. e.Perform the actual marking of the operative site.

ANS: A, B, C

6. The operating room nurse is providing a hand-off report to the postanesthesia care unit (PACU) nurse. Which components will the operating room nurse include? (Select all that apply.) a.IV fluids b.Vital signs c.Insurance data d.Family location e.Anesthesia provided f.Estimated blood loss

ANS: A, B, E, F

4. The nurse is preparing for a patient who will be going to surgery. The nurse screens for risk factors that can increase a person's risks in surgery. What risk factors are included in the nurse's screening? (Select all that apply.) a.Age b.Race c.Obesity d.Nutrition e.Pregnancy f.Ambulatory surgery

ANS: A, C, D, E

3. The nurse is caring for a postoperative patient with an incision. Which actions will the nurse take to decrease wound infections? (Select all that apply.) a.Maintain normoglycemia. b.Use a straight razor to remove hair. c.Provide bath and linen change daily. d.Perform first dressing change 2 days postoperatively. e.Perform hand hygiene before and after contact with the patient. f.Administer antibiotics within 60 minutes before surgical incision.

ANS: A, E

10. The ChooseMyPlate program includes guidelines for a.Children younger than 2 years. b.Balancing calories. c.Increasing portion size. d.Decreasing water consumption

ANS: B

10. The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Which priority goal is the nurse trying to achieve? a.Manage pain b.Prevent atelectasis c.Reduce healing time d.Decrease thrombus formation

ANS: B

12. When teaching a patient about current dietary guidelines for the general population, the nurse explains referenced daily intakes (RDIs) and daily reference values (DRVs), otherwise known as daily values. In providing this information, the nurse understands that daily values a.Have replaced recommended daily allowances (RDAs). b.Have provided a more understandable format of RDAs for the public. c.Are based on percentages of a diet consisting of 1200 kcal/day. d.Are not usually easy to find computer experience is required.

ANS: B

14. The nurse is caring for a postoperative patient with an abdominal incision. The nurse provides a pillow to use during coughing. Which activity is the nurse promoting? a.Pain relief b.Splinting c.Distraction d.Anxiety reduction

ANS: B

20. The nurse explains the pain relief measures available after surgery during preoperative teaching for a surgical patient. Which comment from the patient indicates the need for additional education on this topic? a."I will be asked to rate my pain on a pain scale." b."I will have minimal pain because of the anesthesia." c."I will take the pain medication as the provider prescribes it." d."I will take my pain medications before doing postoperative exercises."

ANS: B

24. The nurse has administered a preoperative medication to the patient going to surgery. Which action will the nurse take next? a.Notify the operating suite that the medication has been given. b.Instruct the patient to call for help to go to the restroom. c.Waste any unused medication according to policy. d.Ask the patient to sign the consent for surgery.

ANS: B

27. The circulating nurse is caring for a patient intraoperatively. Which primary role of the circulating nurse will be implemented? a.Suturing the surgical incision in the OR suite b.Managing patient care activities in the OR suite c.Assisting with applying sterile drapes in the OR suite d.Handing sterile instruments and supplies to the surgeon in the OR suite

ANS: B

30. The nurse is concerned about the skin integrity of the patient in the intraoperative phase of surgery. Which action will the nurse take to minimize skin breakdown? a.Encouraging the patient to bathe before surgery b.Securing attachments to the operating table with foam padding c.Periodically adjusting the patient during the surgical procedure d.Measuring the time a patient is in one position during surgery

ANS: B

36. The postanesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgical floor. Before leaving the floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this nursing action? a.This is done to complete the first action in a head-to-toe assessment. b.This is done to compare and monitor for vital sign variation during transport. c.This is done to ensure that the medical-surgical nurse checks on the postoperative patient. d.This is done to follow hospital policy and procedure for care of the surgical patient.

ANS: B

37. The nurse is caring for a patient who will undergo a removal of a lung lobe. Which level of care will the patient require immediately post procedure? a.Acute care—medical-surgical unit b.Acute care—intensive care unit c.Ambulatory surgery d.Ambulatory surgery—extended stay

ANS: B

5. Knowing that protein is required for tissue growth, maintenance, and repair, the nurse must understand that for optimal tissue healing to occur, the patient must be in a.Negative nitrogen balance. b.Positive nitrogen balance. c.Total dependence on protein for kcal production. d.Neutral nitrogen balance.

ANS: B

5. The patient has presented to the ambulatory surgery center to have a colonoscopy. The patient is scheduled to receive moderate sedation (conscious sedation) during the procedure. How will the nurse interpret this information? a.The procedure results in loss of sensation in an area of the body. b.The procedure requires a depressed level of consciousness. c.The procedure will be performed on an outpatient basis. d.The procedure necessitates the patient to be immobile.

ANS: B

6. In providing diet education for a patient on a low-fat diet, it is important for the nurse to understand that with few exceptions a.Saturated fats are found mostly in vegetable sources. b.Saturated fats are found mostly in animal sources. c.Unsaturated fats are found mostly in animal sources. d.Linoleic acid is a saturated fatty acid.

ANS: B

7. The nurse is preparing a patient for surgery. Which goal is a priority for assessing the patient before surgery? a.Plan for care after the procedure. b.Establish a patient's baseline of normal function. c.Educate the patient and family about the procedure. d.Gather appropriate equipment for the patient's needs.

ANS: B

9. The nurse is prescreening a surgical patient in the preadmission testing unit. The medication history indicates that the patient is currently taking an anticoagulant. Which action should the nurse take when consulting with the health care provider? a.Ask for a radiological examination of the chest. b.Ask for an international normalized ratio (INR). c.Ask for a blood urea nitrogen (BUN). d.Ask for a serum sodium (Na).

ANS: B

2. The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patient's laboratory tests and allergies and prepares the patient for surgery. In which perioperative nursing phase is the nurse working? a.Perioperative b.Preoperative c.Intraoperative d.Postoperative

ANS: B Reviewing the patient's laboratory tests and allergies is done before surgery in the preoperative phase. Perioperative means before, during, and after surgery. Intraoperative means during the surgical procedure in the operating suite; postoperative means after the surgery and could occur in the postanesthesia care unit, in the ambulatory surgical area, or on the hospital unit.

2. The nurse is using a forced air warmer for a surgical patient preoperatively. Which goals is the nurse trying to achieve? (Select all that apply.) a.Induce shivering. b.Reduce blood loss. c.Induce pressure ulcers. d.Reduce cardiac arrests. e.Reduce surgical site infection.

ANS: B, D, E

5. The nurse is providing preoperative education and reviews with the patient what it will be like to be in the surgical environment. Which points should the nurse include in the teaching session? (Select all that apply.) a.The operative suite will be very dark. b.The family is not allowed in the operating suite. c.The operating table or bed will be comfortable and soft. d.The nurses will be there to assist you through this process. e.The surgical staff will be dressed in special clothing with hats and masks.

ANS: B, D, E

1. The nurse is caring for a surgical patient, when the family member asks what perioperative nursing means. How should the nurse respond? a.Perioperative nursing occurs in preadmission testing. b.Perioperative nursing occurs primarily in the postanesthesia care unit. c.Perioperative nursing includes activities before, during, and after surgery. d.Perioperative nursing includes activities only during the surgical procedure.

ANS: C

11. The nurse is caring for a postoperative patient on the medical-surgical floor. Which activity will the nurse encourage to prevent venous stasis and the formation of thrombus? a.Diaphragmatic breathing b.Incentive spirometry c.Leg exercises d.Coughing

ANS: C

15. To counter obesity in adolescents, increasing physical activity is often more important than curbing intake. Sports and regular, moderate to intense exercise necessitate dietary modifications to meet increased energy needs for adolescents. The nurse understands that these modifications include a.Decreasing carbohydrates to 25% to 30% of total intake. b.Decreasing protein intake to .75 g/kg/day. c.Ingesting water before and after exercise. d.Providing vitamin and mineral supplements.

ANS: C

16. In providing prenatal care to a patient, the nurse teaches the expectant mother that a.Protein intake needs to decrease to preserve kidney function. b.Calcium intake is especially important in the first trimester. c.Folic acid is needed to help prevent birth defects and anemia. d.The mother should take in as many extra vitamins and minerals as possible.

ANS: C

17. The patient is an 80-year-old male who is visiting the clinic today for his routine physical examination. The patient's skin turgor is fair, but he has been complaining of fatigue and weakness. The skin is warm and dry, pulse rate is 126 beats per minute, and urinary sodium level is slightly elevated. After assessment, the nurse should recommend that the patient a.Decrease his intake of milk and dairy products to decrease the risk of osteoporosis. b.Drink more grapefruit juice to enhance vitamin C intake and medication absorption. c.Drink more water to prevent further dehydration. d.Eat more meat because meat is the only source of usable protein.

ANS: C

2. In general, when energy requirements are completely met by kilocalorie (kcal) intake in food a.Weight increases. b.Weight decreases. c.Weight does not change. d.Kilocalories are not a factor.

ANS: C

21. The nurse is making a preoperative education appointment with a patient. The patient asks if a family member should come to the appointment. Which is the best response by the nurse? a."There is no need for an additional person at the appointment." b."Your family can come and wait with you in the waiting room." c."We recommend including family members at this appointment." d."It is required that you have a family member at this appointment."

ANS: C

23. In creating a plan of care to meet the nutritional needs of the patient, the nurse needs to explore the patient's feelings about weight and food. The nurse must do this to a.Determine which category of plan to use. b.Set realistic goals for the patient. c.Mutually plan goals with patient and team. d.Prevent the need for a dietitian consult.

ANS: C

26. The nurse is preparing a patient for a surgical procedure on the right great toe. Which action will be most important to include in this patient's preparation? a.Place the patient in a clean surgical gown. b.Ask the patient to remove all hairpins and cosmetics. c.Ascertain that the surgical site has been correctly marked. d.Determine where the family will be located during the procedure.

ANS: C

34. The nurse is monitoring a patient in the postanesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which action will be most appropriate for the nurse to take? a.Encourage copious amounts of water. b.Start an additional intravenous (IV) line. c.Measure and record all intake and output. d.Weigh the patient and compare with preoperative weight.

ANS: C

8. The patient has been diagnosed with cardiovascular disease and placed on a low-fat diet. The patient asks the nurse, "How much fat should I have? I guess the less fat, the better." The nurse needs to explain that a.Fats have no significance in health and the incidence of disease. b.All fats come from external sources so can be easily controlled. c.Deficiencies occur when fat intake falls below 10% of daily nutrition. d.Vegetable fats are the major source of saturated fats and should be avoided.

ANS: C

11. The nurse is providing nutrition teaching to a Korean patient. In doing so, the nurse must understand that the focus of the teaching should be on a.Changing the patient's diet to a more conventional American diet. b.Discouraging the patient's ethnic food choices. c.Food preferences of the patient, including racial and ethnic choices. d.Comparing the patient's ethnic preferences with American dietary choices.

ANS: C.

13. The nurse is teaching the patient about dietary guidelines. In discussing the four components of dietary reference intakes (DRIs), it is important to understand that a.The estimated average requirement (EAR) is appropriate for 100% of the population. b.The recommended dietary allowance (RDA) meets the needs of the individual. c.Adequate intake (AI) determines the nutrient requirements of the RDA. d.The tolerable upper intake level (UL) is not a recommended level of intake.

ANS: D

15. The nurse is encouraging a reluctant postoperative patient to deep breathe and cough. Which explanation can the nurse provide that may encourage the patient to comply? a."If you don't deep breathe and cough, you will get pneumonia." b."You will need to cough only a few times during this shift." c."Let's try clearing the throat because that will work just as well." d."Deep breathing and coughing will clear out the anesthesia."

ANS: D

16. The nurse and the nursing assistive personnel are assisting a postoperative patient to turn in bed. To assist in minimizing discomfort, which instruction should the nurse provide to the patient? a."Close your eyes and think about something pleasant." b."Hold your breath and count to three." c."Grab my shoulders with your hands." d."Place your hand over your incision."

ANS: D

18. The nurse and the nursing assistive personnel (NAP) are caring for a group of postoperative patients who need turning, coughing, deep breathing, incentive spirometer, and leg exercises. Which task will the nurse assign to the NAP? a.Teach postoperative exercises. b.Do nothing associated with postoperative exercises. c.Document in the medical record when exercises are completed. d.Inform the nurse if the patient is unwilling to perform exercises

ANS: D

21. The patient is elderly and has been diagnosed with Imbalanced nutrition: less than body requirements. Her treatment regimen should include having the nurse a.Encourage weight gain as rapidly as possible. b.Encourage large meals three times a day. c.Decrease fluid intake to prevent feeling full. d.Encourage fiber intake.

ANS: D

28. The nurse is caring for a patient in the preoperative holding area of an ambulatory surgery center. Which nursing action will be most appropriate for this area? a.Count the sterile surgical instruments. b.Empty the urinary drainage bag. c.Check the surgical dressing. d.Apply a warm blanket.

ANS: D

3. In determining kcal expenditure, the nurse knows that carbohydrates and proteins provide 4 kcal of energy per gram ingested. The nurse also knows that fats provide _____ kcal per gram. a.3 b.4 c.6 d.9

ANS: D

3. The nurse is caring for a patient in the postanesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. How will the nurse classify this procedure? a.Major b.Urgent c.Elective d.Emergency

ANS: D

4. Some proteins are manufactured in the body, but others are not. Those that must be obtained through diet are known as a.Amino acids. b.Dispensable amino acids. c.Triglycerides. d.Indispensable amino acids.

ANS: D

19. The patient has a calculated body mass index (BMI) of 34. This would classify the patient as a.Unclassifiable. b.Normal weight. c.Overweight. d.Obese.

ANS: D OBESES

7. The nurse is caring for a group of postoperative patients on the surgical unit. Which patient assessments indicate the nurse needs to follow up? (Select all that apply.) a.Patient with abdominal surgery has patent airway. b.Patient with knee surgery has approximated incision. c.Patient with femoral artery surgery has strong pedal pulse. d.Patient with lung surgery has 20 mL/hr of urine output via catheter. e.Patient with bladder surgery has bloody urine within the first 12 hours. f.Patient with appendix surgery has thready pulse and blood pressure is 90/60.

ANS: D, F

9. The ChooseMyPlate program was developed to replace MyFoodPyramid as a basic guide for buying food and meal preparations. This system was developed by the a.Food and Drug Administration. b.1990 Nutrition Labeling and Education Act. c.Referenced daily intakes (RDIs). d.U.S. Department of Agriculture.

ANS: D.

12. The nurse is caring for a preoperative patient. The nurse teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurse's best next step? a.Encourage the patient to practice at a later date. b.Assess for the presence of anxiety, pain, or fatigue. c.Ask the patient why exercises are not being done. d.Evaluate the educational methods used to educate the patient.

ANS; B

28. The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility, which intervention is most important for the nurse to complete? a.Encourage the patient to sit up in the chair. b.Provide analgesic medication as ordered. c.Explain the risks of immobility to the patient. d.Turn the patient every 3 hours while in bed.

B Provide analgesic medication as ordered.

32. The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. The nurse consults a a.Respiratory therapist. b.Registered dietitian. c.Chaplain. d.Case manager.

B Registered dietitian.

1. a nurse is caring for an adolescent client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. the clientis tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requestspain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. the nurse should recognize that the client has which of the following risk factors for impaired wound healing? (select all that apply.) a. extremes in age B. Impaired circulation c. Impaired/suppressed immune system d. Malnutrition e. Poor wound care

B, C

4. The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment? (Select all that apply.) a.Mobility b.Hyperemia c.Induration d.Blanching e.Temperature of skin f.Nutritional status

B, C, D, E

3. a nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. the nurse should include which of the following? (select all that apply.) a. range of motion B. skin color c. edema d. skin lesions e. skin temperature

B, C, E

6. The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity. Which of the following outcomes when met indicate progression toward goals? (Select all that apply.) a.Ask whether patient's expectations are being met. b.Prevent injury to the skin and tissues. c.Obtain the patient's perception of interventions. d.Reduce injury to the skin. e.Reduce injury to the underlying tissues. f.Restore skin integrity.

B, D, E, F

1. The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include A. A diet low in calories and fat. b.Alteration in level of consciousness. c.Shortness of breath. d.Muscular pain.

B. Alterations in levels of consciousness

22. The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. What would be the nurse's next best step? a.Remove the drain; a drain is no longer needed. b.Call the physician; a blockage is present in the tubing. c.Call the charge nurse to look at the drain. d.As long as the evacuator is compressed, do nothing.

B. Call the physician; a blockage is present in the tubing.

35. The home health nurse is caring for a patient with impaired skin integrity in the home. The nurse is reviewing dressing changes with the caregiver. Which intervention assists in managing the expenses associated with long-term wound care? a.Sterile technique b.Clean dressings and no touch technique c.Double bagging of contaminated dressings d.Ability of the caregiver

B. Clean dressings and no touch technique

40. The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What should the nurse do to decrease the patient's anxiety? a.Tell the patient to close his eyes. b.Explain the procedure. c.Turn on the television. d.Ask the family to leave the room.

B. Explain the procedure

5. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage A. I B. II C. III D. IV

B. II

21. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which of these actions should the nurse take first? a.Don sterile gloves. b.Provide analgesic medications as ordered. c.Avoid accidentally removing the drain. d.Gather supplies.

B. Provide analgesic medications as ordered

42. The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. What is the best explanation for the nurse to use when teaching the patient the reason for the binder? a.The binder creates pressure over the abdomen. b.The binder supports the abdomen. c.The binder reduces edema at the surgical site. d.The binder secures the dressing in place.

B. The binder supports the abdomen

41. The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included? a.Allowing the solution to flow from the most contaminated to the least contaminated b.Scrubbing vigorously when applying solutions to the skin c.Cleansing in a direction from the least contaminated area d.Utilizing clean gauge and clean gloves to cleanse a site

C. Cleansing in a direction from the least contaminated area

43. The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the procedure, which intervention should the nurse implement? a.Monitor vital signs every 15 minutes. b.Apply brace to right knee. c.Elevate right knee and apply ice. d.Check pulses in right foot.

C. Elevate right knee and apply ice

29. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns which of the following nursing diagnoses? a.Readiness for enhanced nutrition b.Impaired physical mobility c.Impaired skin integrity d.Chronic pain

C. Impaired skin integrity

25. The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the nurse question? a.Use a low-air-loss therapy unit. b.Consult a dietitian. c.Irrigate with hydrogen peroxide. d.Utilize hydrogel dressing.

C. Irrigate with hydrogen peroxide.

37. The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair? a.At least 3 hours b.Not longer than 30 minutes c.Less than 2 hours d.As long as the patient remains comfortable

C. Less than 2 hours

The client has been informed that he can be discharged once he can irrigate his colostomy independently. The client requests the nurse to observe his irrigation technique. Which of the following learning motives is the client displaying? A. Physical Need B. Social Activity C. Task Mastery D. Evaluation stance

C. Task mastery Task mastery motives are based on needs such as achievement and competence. The client who must demonstrate irrigating his colostomy independently in order to be discharged is displaying the learning motive of task mastery. A physical motive may be seen in the client who desires to return to a level of physical normalcy. A social motive is the need for connection, social approval, or self-esteem. An evaluation stance would be determining whether the outcomes of the teaching-leaning process met the client's goal. Evaluation is not a learning motive.

33. The nurse is caring for a patient with a stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. What is the best goal for this patient? a.The patient's family will demonstrate specific care of the wound site. b.The patient will state what to look for with regard to an infection. c.The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound. d.The patient's family members will wash their hands when visiting the patient.

C. The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound.

34. The nurse is caring for a postpartum patient. The patient has an episiotomy after experiencing birth. The physician has ordered heat to treat this condition, and the nurse is providing this treatment. This patient is at risk for a.Infection. b.Impaired skin integrity. c.Trauma. d.Imbalanced nutrition.

C. Trauma

38. The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. What is the best method for repositioning the patient? a.Obtain assistance and use the drawsheet to place the patient into the new position. b.Place the patient in a 30-degree supine position. c.Utilize a transfer sliding board and assistance to slide the patient into the new position. d.Elevate the head of the bed 45 degrees.

C. Utilize a transfer sliding board and assistance to slide the patient into the new position.

13. The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the patient was experiencing a complication of wound healing? 1. The incision site has started to itch 2. The incision site is approximated 3. The patient has pain at the incision site 4. The incision has a mass, bluish in color

D. The incision has a mass, bluish color

2. An industrial nurse is planning to give an informative talk on hypertension to employees in honor of "heart month." He plans to teach individuals how to take their blood pressure measurements. Which information is important for him to ask the planning committee before this presentation? A. Ages of all employees involved B. Names of employees who are married C. Number of employees with high blood pressure D. Type of room available and number of participants

D. Type of room available and number of participants The number of persons being taught, the need for privacy, the room temperature, the room lighting, noise, the room ventilation, and the room furniture are important factors when choosing the setting. The ideal setting helps the client focus on the learning task. Knowing the specific ages of all the people involved is not as important as providing an environment conducive to learning. It is not necessary to know the names of employees who are married to teach individuals how to take their blood pressure. Whether an employee has high blood pressure should not be as important to the teacher as providing an environment conducive to learning. Having high blood pressure may be a motivating factor for employees to learn how to take their blood pressure, because of its personal relevance.

23. The nurse is caring for a patient who has a stage IV pressure ulcer awaiting plastic surgery consultation. Which of the following specialty beds would be most appropriate? a.Standard mattress b.Nonpowered redistribution air mattress c.Low-air-loss therapy unit d.Lateral rotation

b. Nonpowered redistribution air mattress

24. The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes a.Monitoring of the wound. b.Irrigation of the wound. c.Débridement of the wound. d.Management of drainage

c. Débridement of the wound.

31. The nurse is caring for a patient with a stage III pressure ulcer. The nurse has assigned a nursing diagnosis of Risk for infection. Which intervention would be most important for this patient? a.Teach the family how to manage the odor associated with the wound. b.Discuss with the family how to prepare for care of the patient in the home. c.Encourage thorough handwashing of all individuals caring for the patient. d.Encourage increased quantities of carbohydrates and fats.

c. Encourage thorough handwashing of all individuals caring for the patient