Med-Surge Chapters 1-14

1.9 Which statement, made by a LPN/LVN during a patient interaction, indicates a therapeutic response.

"Are you saying that your cast is uncomfortable? Tell me more about your discomfort?"

5.11 Which patient statement to the nurse indicates a need for further teaching regarding the use of a patient-controlled analgesia (PCA) pump?

"I need to call the nurse when i need pain medication."

4.6 The nurse reinforces the importance of turning, coughing, and deep breathing to a preoperative patient. Which patient statement indicates a need for further instruction?

"I would lie still in bed to reduce the risk of injuring my surgical wound."

7.7 A patient with chronic pain requiring further measures to decrease pain asks the nurse, "what is a TENS unit?" What is the best nursing response?

"It provides a small electrical stimulus to the skin around the area of pain."

6.7 The need for protective isolation and the parameters are being explained to the patient. She wails, "How can i hug my children when i am locked up in this room?" An appropriate response by the nurse would be:

"It wont be long before you can hug them again, we need to keep you safe from infection."

2.5 When caring for a older woman who developed a 5-cm pressure ulcer on her sacrum because of being immobilized and incontinent, an appropriate expected outcome for the problem of altered skin integrity would be:

"Patient will demonstrate a decrease in size of the ulcer within 1 week."

5.10 The patient is prescribed anti-embolisms stocking before discharge. The patient asks the nurse, "Why do i need these stockings?" The best response would be?

"These help prevent formation of clots in the legs."

4.9 While transferring from the preoperative area to the surgical suite, the patient asks, "Am I going to make it?" An appropriate response by a nurse would be:

"You seem anxious. Tell me more about how you are feeling."

5.4 The nurse knows that care for the patient having spinal anesthesia differs from that of the patient undergoing general anesthesia in that during recovery: (select all that apply)

- Muscles in the lower part of the body will be flaccid immediately after surgery -The patient is able to eat immediately upon return to the nursing unit. -The patient will be alert upon entry to the PACU.

2.10 When evaluating for side effects of the action of "administer anticoagulant," which patient statement(s) would strongly correlate with a side effect problem? (select all that apply)

-"I have noticed some blood streaking in my bowel movements." -"I readily bruise whenever I bump into anything." -"I notice some blood when i floss my teeth."

7.2 In determining the patient's perception of pain, which question's by the nurse would be useful in assessing pain? (select all that apply)

-"where are you hurting?" -"what pain control measures have worked in the past?" -"how would you describe your pain?" -"what were you doing before the onset of the pain?"

3.2 Which patient's can be considered at high risk for fluid and electrolyte imbalance? (select all that apply)

-A 45-year-old woman with thyroid crisis -A 35-year-old trauma victim on a ventilator -A 30-year-old woman complaining of persistent diarrhea

4.4 In discussing options for fluid resuscitation during major surgery, the provider indicated availability of bloodless surgery. Bloodless surgery may include which interventions? (select all that apply)

-Administration of Epogen -Administration of volume expanders -Autologous transfusion

5.9 What actions by the nurse would be appropriate when caring for a postoperative patient with Jackson-Pratt would drain? (select all that apply)

-Assess the wound drain for patency. -Measure amount of drainage. -compress the bulb to reestablish pressure. -Notify the surgeon when there is no drainage.

9.2 A 33-year-old man is admitted to the rehabilitation unit after a spinal cord injury from a motorcycle accident. What interventions can the nurse perform to optimize the man's resilience? (select all that apply)

-Assist the patient in identifying strategies that he has used to problem-solve in the past. -Refer the patient to a support group

1.1 Which of the following is within the role of the LPN /LVN? (select all that apply)

-Changing a dressing on a postoperative patient -Collaborating with the physical therapist on how to motivate the patient to ambulate. -Advocating for a patient with a physician when prescribed pain medication is insufficient. -Teaching the patient about the side effects of new medications.

1.5 QSEN prepares the nurse to: (select all that apply)

-Consider safety factors at all times when delivering care. -Apply evidence-based practice to the care of patients. -Use informatics to collaborate and communicate with the health care team. -Note ways that quality of care might be improved.

2.9 Using critical thinking, choose the nursing actions that should be implemented when addressing the needs of an older patient with the problem diagnosis of Altered nutrition due to poor dentition? (select all that apply)

-Encourage more fluid intake if not contraindicated by the medical condition -Inspect the oral cavity and the condition of mucous membranes and teeth. -Monitor daily caloric intake and weekly weights.

3.3 An older adult man is admitted for severe disorientation, confusion, and general weakness. His spouse reports that he is not able to tolerate any food or fluids and has had several episodes of vomiting and diarrhea. Which imbalance is the patient most likely experiencing?

-Hypokalemia -Hyponatremia

4.2 Surgical risk factors include: (select all that apply)

-Obesity -Malnutrition -diabetes mellitus -dehydration -smoking or excessive alcohol use -cardiovascular or respiratory problems

5.5 The nurse knows that an older adult patient who had open reduction and internal fixation of the right femur is at risk for infection because of the surgical incision and repair and lessened immunity that occurs in older age. A desired result of interventions for this risk would be that the:

-Patient will not develop a wound infection before discharge.

6.10 Cross infection among members of the household who take care of a relative with a severe infection can be prevented by which behavior(s)? (select all that apply)

-Practicing good hand hygiene -using a diluted bleach to clean surfaces. -sealing used dressings in impermeable bags.

9.7 After failure of less restrictive measures, the nurse decides to apply physical restraints to a confused older adult man. Which measures must the nurse include to ensure safe use of physical restraints? (select all that apply)

-Promptly attend to the toileting needs of the patient. -Ensure adequate nutrition and hydration. -Provide frequent range-of-motion

10.3 Testing for antibodies is indicated for which immunization? (select all that apply)

-Rabies -Botulism -tetanus

1.3 In caring for patients with pressure ulcers, which task would be most appropriate to assign to the nursing assistant?

-Reposition the patient every 2 hours.

2.4 Assessing a patient's sleep patterns should include which aspects? (select all that apply)

-Rituals associated with sleep -Feelings of restfulness -Diet choices -Urinary habits

1.6 In the process of developing evidence-based practice, after developing and asking a clinical question, the next step is to:

-Search for and collect sources of evidence.

3.1 What should nurses monitor when a patient is receiving a diuretic regularly? (select all that apply)

-Skin turgor and integrity -Daily weight -Electrolyte status

5.8 While caring for the postoperative patient, the nurse must reinforce which measures to reduce the incidence of complications? (select all that apply)

-Use the incentive spirometer every hour while awake -turn or change positions every 2 hours -Assess for pain and provide prompt relief

4.3 Regarding informed consent for a surgical procedure, the nurse is responsible for which aspect(s) (select all that apply)

-Verifying that the consent has been signed and witnessed before sending the patient to surgery. -Administering any preoperative medications after verification that the consent has been signed -Answering general questions regarding postoperative care

7.5 A Mexican American woman who was in a minor automobile accident along with her 5-year-old son has a minor laceration on her arm that is not deep. Her son is being examined in the next room. The woman is moaning about the pain in her arm. Factors possibly influencing her perception of pain are probably?: (select all that apply)

-blood smearing her skirt and blouse from where her arm brushed them -her Mexican American ethnicity and recent entry into the United States -Worry about her son possibly sustaining a severe injury in the accident.

8.2 A 40-year-old woman is scheduled for external radiation therapy for breast cancer. To help the patient cope with her illness and the effects of radiation therapy, what should the nurse help her to focus on? (select all that apply)

-complying with scheduled radiation therapies -protecting the skin by applying lotions -understanding the therapeutic effects and side effects of the treatment.

7.7 A terminally ill female patient reminiscing about the good old days becomes increasingly confused. She talks about seeing relatives who have died. Which nursing interventions would be appropriate? (select all that apply)

-discuss the patients behaviors with the family -encourage the family to talk to the patient in quiet tones -promote a calm environment.

9.9 The nurse suspects early complications of immobility in a 45-year-old patient admitted for multiple stab wounds to the chest. What sign would the nurse most likely find. (select all that apply)

-generalized weakness -moist breath sounds -limited range of motion

3.6 The new patient on the floor has been diagnosed with gastroenteritis. What would be the most critical level to assess?

-potassium

8.3 The nurse reinforces patient instructions regarding neutropenic precautions. Important topics should include which of the following? (select all that apply)

-pregnancy -diet restrictions -hand hygiene

Cefazolin (Ancef) 1 g IV is ordered to infuse over 1 hour during surgery. It has been mixed in a 50 mL piggyback bag. If the tubing delivers 15gtt/mL, how many drops per minute should be infused.

12.5 or 13 gtt/min

3.8 At the beginning of the shift, there is 410 mL of fluid is the IV bag. A piggyback medication containing 150 mL is hung at 12:00 noon to run over 30 minutes. You hang a new bag of 1000 mL at 1:00 P.M. to run at 125 mL/hr. At the count for the total amount of fluid infused during your shift ending at 7:00 P.M. is:

1310 mL

4.1 An advantage of robotic surgery is that the surgeon has:

Ability to make precise movements of the instruments.

8.4 Your patient will begin chemotherapy next week. Based on the understanding of the effects of chemotherapy, what patient education would be appropriate?

Advise the patient to use good birth control methods, because most chemotherapeutic agents are teratogenic.

10.7 While caring for an immunocompromised patient, which action by a nursing assistant indicates a need for instruction and supervision by a licensed nurse?

Allowing all family member in the patient's room at all times.

2.6 Assessing a risk for falls would be considered high priority for a patient with a problem of:

Altered mobility due to knee arthritis

9.8 During a home visit, the nurse finds scatter rugs all over the house, the kitchen sink full of dirt dishes, a strong odor from the toilet, and several outdated food items in the pantry and refrigerator. The 76-year-old patient is coherent with occasional forgetfulness, disheveled with stained clothing, and generally ungroomed. A possible nursing would be:

Altered self-care ability

5.13 After a surgical procedure, a priority point for the nurse to emphasize to the patient when performing discharge teaching for self-care is:

Always washing the hands before starting a dressing change.

2.1 Which critical thinking skill is important to apply when formulating a nursing care plan?

Analyzing the data to determine appropriate nursing diagnoses.

2.3 The assessment technique of percussion is used by the nurse to:

Assess for air in the intestine.

7.12 A long-term care nurse is caring for an older adult male patient who appears to be withdrawn and quiet. He grimaces whenever he is touched. The most appropriate nursing action would be to:

Assess for underlying causes of the patient's behavior

5.7 One measure by the nurse to promote early patient ambulation and a return to independence in activities of daily living is to:

Assist the patient to walk to a chair in front of the sink to bathe areas easily reached.

7.11 The nurse is assigned to care for a patient with an epidural for analgesia. Which sign or symptom related to this treatment would require immediate provider notification?

Blood pressure 80/60 mm Hg

10.2 The nurse demonstrates understanding of passive natural immunity when he makes which statement?

Breast-feeding is the best way to enhance the infant's immunity

5.6 To promote wound healing, the nurse instructs the postoperative patient to eat foods high in protein. Which food choice by the patient warrants further patient teaching?

Caesar salad with French bread and milk

2.2 Critical thinking is useful to the nursing process because it:

Can provide a better outcome for the patient.

6.5 When administering an order antimicrobial for an infection, the nurse should check the lab results for:

Culture and sensitivity

10.4 During a health promotion outreach for older adults, the nurse discusses the physiologic changes in aging that increase susceptibility to infection. Which statement is true?

Decreased cilia in the lungs provide a more hospitable environment to harmful organisms.

6.2 During an assessment, the nurse notes fever, fatigue, general weakness, cold and clammy skin, nausea, vomiting, and diarrhea. What is the prominent nursing problem?

Dehydration

2.7 The nurse is collecting data from an older patient with a history of fractures who has just had a gallbladder surgery. Along with a focused assessment, the nurse should include:

Determining orientation to person, place, and time.

5.12 A 38-year-old woman who has undergone bilateral radical mastectomy is withdrawn and quiet. She is afebrile with no apparent complaints of pain. Her dressings are dry and intact. Pulses are full on both upper extremities. Considering the data, the major problem at this time would be:

Distress over loss of her breasts.

7.1 The nurse administers ketoralac (toradol) 30 mg IM to a 30-year-old male patient. The gate control theory indicates that the next nursing action to assist in pain control would be to:

Encourage an activity that will provide distraction

3.4 In planning for a patient with congestive heart failure, you choose the problem statement: fluid volume excess due to altered cardiac output. the Problem statement would most likely be supported by which sign or symptom?

Fine crackles in the lung sounds

1.4 The LPN/LVN in the hospital practices under the state's Nurse Practice Act, the Standards of Practice and the ________. ( fill in the blank)

Hospital policies and procedures

10.8 During the data collection process, a patient indicates, "i take garlic pills to reduce my risk for cancer." What is an appropriate nursing response?

How much and how often do you take your garlic pills?

5.3 On arrival from the PACU, the patient complains of severe thirst. The nurse finds that the patient is increasing restless, tachypneic, and tachycardic. Considering the findings, what would the nurse likely suspect.

Hypovolemia

2.8 When evaluating a patient understanding regarding the use of an incentive spirometer, which statement confirms a need for more teaching?

I need to slightly tilt the incentive spirometer to reduce effort

7.4 A patient who has osteoarthritis is experiencing right knee pain daily. The nurse knows that this type of pain usually has the best result if treated by:

Ibuprofen

10.5 A patient is newly diagnosed with an autoimmune thyroid disease. When the nurse discusses the patient's questions and concerns, the patient asks, "what did the provider mean by autoimmune disease?" What is the most appropriate response?

Immune defenses are attacking the normal body cells.

3.10 You respond to a patient complaining of pain, burning, and wetness over the peripheral IV site. On assessment, you find that the IV insertion site is tender and cool to touch. These are signs and symptoms of:

Infiltration.

4.10 During major surgery, the patient is considered at risk for:

Injury related to placement in one position for extended period of time.

1.10 The nurse finds a confused patient with a history of falls attempting to get out of bed. To maintain the patient's self-esteem and safety, the nurse's intervention should be to:

Install a bed alarm to notify staff.

8.9 A patient is scheduled for bone marrow biopsy to confirm diagnosis of leukemia. As the nurse reinforces provider instructions regarding the procedure, an appropriate nursing statement regarding bone marrow biopsy would be:

It introduces a needle to aspirate tissue samples.

8.10 A patient who recently had chemotherapy for lung cancer complains of uncontrollable nausea and vomiting with accompanying loss of appetite. An appropriate problem statement would be:

It requires a surgical incision.

9.6 A 78-year-old woman is admitted with sudden onset of confusion and disorientation during the early evenings. Her family indicates that she generally alert and oriented during the day. The nurse would likely recommend.

Keeping soft lighting without shadows during the evening.

5.6 Before chemotherapy, a female patient expresses concerns regarding hair loss. She says that her partner will no longer lover her because she will not be as attractive. An appropriate nursing statement would be:

Lack of power over effects of chemotherapy

9.1 An 85-year-old diabetic man with a fractured hip has begun ambulating with a walker. He likes his independence, and the nurse is concerned that he may fall after having been immobile. The nurse instructs him to please call for assistance when he gets out of bed. Wat can the nurse do to help decrease his fall risk?

Make sure the patient knows how to use the call system and that the call bell is within reach.

8.1 There are two types of tumors: benign and malignant. A difference between the two types is:

Malignant cells do not know when to stop multiplicity, whereas benign cells are large and irregular.

9.3 The nurse gives discharge instructions to an 80-year-old Asian woman who had open heart surgery. After detaining the importance of increasing activity, the patient smiles and nods her head. The nurse understands that the patient:

May not understand instructions

6.1 The nurse is admitting a patient with an infected abdominal wound. Wound cultures are positive for methicillin-resistant Staphylococcus aureus. Appropriate nursing care for this patient includes:

Monitoring temperature and white blood cell count

7.6 An appropriate short-term outcome written by the nurse for a patient with acute pain after surgery would be:

Pain will be adequately controlled with a PCA pump

6.4 The nurse is observing a nursing student who must perform a dressing change for a patient. The nurse would intervene if the student:

Prepares supplies, dons sterile gloves, and removes the old dressing.

7.3 The nurse realizes that chronic pain may be handled differently from acute pain to:

Provide the best pain relief with the least side effects and chance of addiction

7.8 The family members attending to the needs of a dying patient express distress regarding the noisy breathing. An important nursing action would be to:

Reassure family members

9.5 The nurse provides discharge instructions regarding home safety to a 78-year-old woman. Which patient statement indicates a need for further teaching.

Scatter rugs would be useful in decreasing glare from shiny floors.

9.10 The nurse reinforces the use of an incentive spirometer to a patient with a blunt chest injury. Understanding of nursing instructions is clear when the patient.

Seals the mouthpiece during exhalation.

8.5 Pain is not unique to cancer but is a common occurrence in cancer patients. An important point to keep in mind when employing pain control efforts is to:

Seek a combination of interventions to offer the best pain control.

4.5 While reviewing the morning vital signs of a preoperative patient, which patient information warrants immediate notification of the surgeon?

Serum potassium 3.2 mEq/L

6.8 Which intervention would the nurse implement for a patient with active pulmonary tuberculosis who is socially isolated related to imposed airborne precautions?

Suggest alternative means of contact, such as email and phone calls.

7.10 A 25-year-old patient complains of moderate pain at his incision site. The nurse administers morphine sulfate IM. The most appropriate nursing action after the injection would be to:

Suggest he play solitaire or watch something interesting on TV.

6.3 Which patient instruction is most critical to a patient being discharged on antibiotic therapy?

Take all the antibiotics as prescribed.

3.7 You appropriately elicit a sign of hypocalcemia by:

Tapping the face about 1 inch from the ear.

1.8 The reason that Medicare will not pay for care for a deep vein thrombosis on a patient in the hospital after a knee replacement is:

The deep vein thrombosis is considered preventable.

3.9 Which would be the most accurate way to assess for dehydration in elderly patient?

Urine output

1.7 One-way nurses apply National Patient Safety Goals to patients is to:

Use two ways to identify patients each time before administering a medication.

6.6 The nurse assumes the care of a patient with active pulmonary tuberculosis. Before entering the patient's room, the appropriate nursing action would be to don ____________________.

a properly fit-tested N-95 respirator mask

7.8 A patient is discharged with a prescription for oral oxycodone with acetaminophen tablets. The nurse should inquire about all other medications the patient will be taking at home, looking for the possible presence of more ____________. (fill in the blank)

acetaminophen

7.9 Before the nurse administers and opioid analgesic to a patient,the most important nursing action is to:

assess the rate and depth of respiration

10.1 ________________ is the administration of weak or attenuated microorganisms to stimulate the production of antibodies without causing a full-blown disease.

passive artificial immunity

9.4 The nurse admits a 70-year-old woman who has diminished hearing and has bilateral cataracts. The patient is taking anti hypertensive medications. A priority nursing problem would be:

potential for injury

10.6 A nurse is assessing the condition of a sacral pressure ulcer on an immobilized patient. which sign or symptom indicates the presence of infection?

purulent drainage

4.11 The person in the operating room responsible for labeling and handling surgical specimens correctly is the _________________. (fill in the blank)

scrub nurse or scrub technician.

4.8 When teaching a patient using an incentive spirometer, the nurse determines that the patient's technique is correct if the patient is:

taking slow, deep breaths and holding each for at least 3 seconds.

4.12 After same-day surgery, the patient is ready to go home when:

the patient is alert, ambulatory, and able to empty the bladder.