EXAM 1 Questions for 1920 - Adult Med Surg I

15. A nurse is caring for a client who reports nausea and vomiting 2 days postoperative after hysterectomy.Which of the following actions should the nurse perform first? A. Assess bowel sounds. B. Administer antiemetic medication. C. Restart prescribed IV fluids. D. Insert a prescribed nasogastric tube.

A .CORRECT: Using the nursing process, the first step is to assess the client. Assessing bowel sounds is the correct action by the nurse.

65. Which of the following patients would be more likely to have the highest risk of developing malignant melanoma? A) A fair-skinned woman who uses a tanning booth regularly. B) An African American patient with a family history of cancer. C) A Hispanic male with a history of psoriasis and eczema that responded poorly to treatment. D) An adult who required phototherapy as an infant for the treatment of hyperbilirubinemia.

A) A fair-skinned woman who uses a tanning booth regularly. Risk factors for malignant melanoma include a fair complexion and exposure to ultraviolet light. Psoriasis, eczema, short-duration phototherapy and a family history of other cancers are less likely to be linked to malignant melanoma.

62. Which of the following interventions would be most helpful in managing a patient newly admitted with cellulitis of the right foot? A) Applying warm, moist heat. B) Limiting ambulation to three times daily. C) Keeping the foot at or below heart level. D) Wrapping the foot snugly in warm blankets.

A) Applying warm, moist heat. The application of warm, moist heat speeds the resolution of inflammation and infection when accompanied by appropriate antibiotic therapy. It does this by increasing local circulation to the affected area to bring macrophages to the area and carry off cellular debris.

61. The nurse would assess a patient admitted with cellulitis for which of the following localized signs? A) Pain. B) Fever. C) Chills. D) Malaise

A) Pain. Pain, redness, heat, and swelling are all localized signs of cellulitis. Fever, chills, and malaise are generalized, systemic manifestations of inflammation and infection.

60. In a patient admitted with cellulitis of the left foot, which of the following clinical manifestations would you expect to find on assessment of the left foot? A) Redness and swelling. B) Pallor and poor turgor. C) Cyanosis and coolness. D) Edema and brown skin discoloration.

A) Redness and swelling. Cellulitis is a diffuse, acute inflammation of the skin. It is characterized by redness, swelling, and heat in the affected area. These changes accompany the processes of inflammation and infection.

66. The nurse should teach a patient who is taking which of the following drugs to avoid prolonged sun exposure? A) Tetracycline. B) Ipratropium. C) Morphine sulfate. D) Oral contraceptives.

A) Tetracycline. Several antibiotics, including tetracycline, may cause photosensitivity. This is not the case with ipratropium, morphine, or oral contraceptives.

63. Which of the following laboratory results is the best indicator that a patient with cellulitis is recovering from this infection? A) WBC of 8200/μl. B) WBC of 2900/μl. C) WBC of 16,300/μl. D) WBC of 12,700/μl.

A) WBC of 8200/μl. The normal white blood cell count is generally 4000 to 11,000/μl. For this reason, the patient's level would be returning to normal if it was 8200/μl, indicating recovery from cellulitis.

77. Dermatologic manifestation(s) of Cushing syndrome can include (select all that apply): A) acne. B) telangiectasia. C) increased sweating. D) brown pigmentation in the legs.

A) acne. B) telangiectasia

74. A mother and her two children have been diagnosed with pediculosis corporis at a health care center. An appropriate measure in teating this condition is: A) applying pyrethrins to the body. B) topical application of griseofulvin. C) moist compresses applied frequently. D) administration of systemic antibiotics.

A) applying pyrethrins to the body.

78. Important patient teaching after a chemical peel includes: A) avoidance of sun exposure. B) application of firm bandages. C) limitation of vigorous exercise. D) use of ice to relieve discomfort.

A) avoidance of sun exposure.

72. In teaching a patient with malignant melanoma about this disorder, the nurse recognizes that the prognosis of the patient is most dependent on. A) the thickness of the lesion. B) the degree of color change in the lesion. C) how much the lesion has spread superficially. D) the amount of ulceration present in the lesion.

A) the thickness of the lesion.

69. Which of the following safe sun practices would the nurse include in the teaching care plan for a patient who has photosensitivity? (select all that apply). A) wear protective clothing. B) apply sunscreen liberally and often. C) tanning booths decrease the likelihood of sunburn. D) avoid exposure to the sun, especially during midday. E) wear any sunscreen as long as it is purchased at a drugstore.

A) wear protective clothing. B) apply sunscreen liberally and often. D) avoid exposure to the sun, especially during midday.

7. A nurse is providing preoperative teaching to a client who is to have abdominal surgery. Which of the following statements should the nurse make? SATA. A. "Take your heart meds with a sip of water before surgery". B. "Splint the ab incision w/ a pillow when coughing and deep breathing". C. "Bed rest is recommended for the first 48 hrs". D. "Antiembolism stockings are applied before surgery". E. "You may eat solid foods up to 4 hrs before surgery".

A. "Take your heart meds with a sip of water before surgery". B. "Splint the ab incision w/ a pillow when coughing and deep breathing". D. "Antiembolism stockings are applied before surgery". - Cardiac meds are allowed with clear liquid, client should splint and deep breathe after surgery, early ambulation, antiembolism stockings, and ROM exercises are encouraged to prevent DVT, client should be NPO 6 hours prior.

2. A nurse is assisting an anesthesiologist in the delivery of nitrous oxide by face mask to a client during the induction of anesthesia. Which of the following is the priority nursing action? A. Assess O2 saturation. B. Measure BP. C. Palpate pulse rate. D. Check temp.

A. Assess O2 saturation. - The greatest risk for injury during anesthesia is hypoxia, the priority action is to maintain and ensure a patent airway.

46. A nurse in a provider's office is assessing a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? a. Superficial thickness. b. Superficial partial thickness. c. Deep partial thickness. d. Full thickness.

A. CORRECT: A sunburn is a superficial thickness burn. Superficial burns damage the top layer of the skin. B. A superficial partial‐thickness burn results from flames or scalds. This damages the entire epidermis layer of the skin. C. A deep partial‐thickness burn can result from contact with hot grease. This affects the deep layers of the skin. D. A full‐thickness burn can result from contact with hot tar. This affects the dermis and sometimes the subcutaneous fat layer.

11. A nurse is reviewing the health records of several clients in the postanesthesia care unit to identify risk factors that can lead to postoperative complications. Which of the following clients are at risk for complications? (Select all that apply). A. A client who has a WBC of 22,500/uL. B. a client who uses a insulin pump. C. A client who takes Warfarin daily. D. A client who has heart failure. E. A client who has a BMI of 26.

A. CORRECT: An increased WBC indicates an underlying infection and places the client at risk for postoperative complications. B. CORRECT:An insulin pump indicates the client has type 1 diabetes mellitus and places the client at risk of postoperative complications. C. CORRECT:A client who takes warfarin daily is at risk for bleeding and postoperative complications. D. CORRECT:Receiving a bowel prep to cleanse the colon can cause dehydration and places the client at risk for complications.

41. A nurse is providing information about a new prescription for corticosteroid cream to a client who has mild psoriasis. Which of the following should the nurse include in the information? (Select all that apply.) A. Apply an occlusive dressing after application. B. Apply three to four times per day. C. Wear gloves after application to lesions on the hands. D. Avoid applying in skin folds. E. Use medication continuously over a period of several months.

A. CORRECT: An occlusive dressing can enhance the efficacy of the topical corticosteroid on the exposed lesions. C. CORRECT: Gloves worn after the medication can enhance the efficacy of the topical corticosteroid on the exposed lesions of the hands. D. CORRECT: Corticosteroid cream applied to lesions in skin folds increases the risk of yeast infections. B. INCORRECT: Corticosteroid cream is applied twice daily to prevent development of local and systemic adverse effects. E. INCORRECT: Corticosteroid cream used continuously can increase the risk for development of local and systemic adverse effects.

48. A nurse is assessing a client who sustained deep partial‐thickness and full‐thickness burns over 40% of his body 24 hr ago. Which of the following are findings should the nurse expect? (Select all that apply.) A. Dyspnea. B. Bradycardia. C. Hyperkalemia. D. Hyponatremia. E. Decreased hematocrit.

A. CORRECT: Dyspnea can occur during the initial phase following a burn due to airway injury and uid shifts. C. CORRECT: Hyperkalemia occurs during the initial phase following a burn as a result of leakage of uid from the intracellular space. D. CORRECT: Hyponatremia occurs during the initial phase of a burn as a result in sodium retention in the interstitial space. B. Tachycardia occurs during the initial phase following a burn due to sympathetic nervous system compensation. E. Hct increases during the initial phase of a burn due to hemo-concentration.

38. A nurse is instructing a client on home care after a culture for a bacterial infection and cellulitis. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Bathe with antibacterial soap. B. Apply antibacterial topical medication to the crusted exudate. C. Apply warm compresses to the affected area. D. Cover affected area with snug fitting clothing. E. Allow lesions to dry before applying topical medication.

A. CORRECT: The client should use antibacterial soap to reduce the bacteria count on the skin. C. CORRECT: The client should apply warm compresses to the affected area to promote comfort. E. CORRECT: The client should dry the area well before applying a topical medication to allow for spreading the medication more effectively. B. INCORRECT: The client should apply topical medication directly to the moist lesion bed. The medication will not penetrate the crusted exudate. D. INCORRECT: The client should wear loose-fitting clothes to avoid irritating the lesion.

50. A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Limit visitors in the client's room. B. Encourage fresh vegetables in the diet. C. Increase protein intake. D. Instruct the client to consume 2,000 calories/day. E. Restrict fresh flowers in the room.

A. CORRECT: The nurse should limit the number of visitors and limit the amount of time they can visit to decrease the risk of infection. C. CORRECT: The client should increase protein consumption, which promotes wound healing and prevents tissue breakdown. E. CORRECT: Flowers should not be in the client's room due to the bacteria they carry, which increase the risk for infection. B. The client should restrict consumption of fresh vegetables due to the presence of bacteria on the surface and the increased risk for infection. D. The client should consume up to 5,000 calories/day because caloric needs double or triple beginning 4 to 12 days following the burn.

14. A nurse is planning care for a client to prevent postoperative atelectasis (collapsed lung). Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Encourage the use of the incentive spirometer every 2 hours. B. Instruct to splint incision when coughing and deep breathing. C. Reposition the client every 2 hours. D. Administer antibiotic therapy. E. Assist with early ambulation.

A. CORRECT: The use of the incentive spirometer every 2 hours expands the lungs and prevents atelectasis. B. CORRECT: Incisional splinting with a pillow or blanket supports the incision during coughing and deep breathing which prevents atelectasis. C. CORRECT: Repositioning the client every 2 hours will cause the client to deep breathe and expand the lungs to prevent atelectasis. E. CORRECT: Early ambulation expands the lungs through deep breathing and prevents atelectasis..

12. A nurse is caring for a female client who manifests indications of hypovolemia while in the PACU. Which of the following findings requires action by the nurse? (Select all that apply.) A. Urine output less than 25 mL/hour B. Hematocrit 48%. C. BUN 24 mg/dL. D. Tenting of skin over the sternum. E. Apical pulse rate 62/min.

A. CORRECT:Urine output less than 25 mL/hr is a manifestation of hypovolemia and requires intervention by IV fluid therapy. B. CORRECT: Hematocrit of 48% indicates concentrated blood volume and is a manifestation of hypovolemia, requiring intervention by IV fluid therapy. C. CORRECT:BUN of 24 mg/dL indicates decreased kidney function and can be a manifestation of hypovolemia, requiring intervention with IV fluid therapy. D. CORRECT:Tenting of skin indicates decreased or absent skin turgor due to dehydration, requiring intervention with IV fluid therapy.

9. A nurse is caring for a client who is scheduled for an exploratory laparotomy. The client's temp is 39C (102.2F) orally. Which of the following actions should the nurse take? A. Inform the surgeon. B. Transfer client to preoperative unit. C. Apply ice packs to groin. D. Encourage client to increase intake of clear liquids.

A. Inform the surgeon. - Surgeon should be immediately notified to determine if procedure should be canceled. Applying ice packs is not an appropriate intervention if the underlying cause of the elevated temp is infection. Client should be limiting intake prior to surgery, NPO of clear liquids 2 hours prior.

3. A nurse is caring for a client who develops malignant hyperthermia. Which of the following actions should the nurse take? Select All That Apply. A. Infuse iced IV fluids. B. Provide 100% O2. C. Place cooling blanket on client. D. Treat complication while continuing surgery. E. Administer IV dantrolene.

A. Infuse iced IV fluids. B. Provide 100% O2. C. Place cooling blanket on client. E. Administer IV dantrolene. - Measures to cool down patient and maintain a patent airway is priority. Administer IV dantrolene which is a muscle relaxant that treats malignant hyperthermia. The procedure should be canceled immediately.

67. The nurse would recognize which of the following patients as likely to have the poorest prognosis? A) A 60-year-old diagnosed with nodular ulcerative basal cell carcinoma. B) A 59-year-old man who is being treated for stage IV malignant melanoma. C) A 70-year-old woman who has been diagnosed with late squamous cell carcinoma. D) A 51-year-old woman whose biopsy has revealed superficial squamous cell carcinoma.

B) A 59-year-old man who is being treated for stage IV malignant melanoma. Late detection of malignant melanoma is associated with a poor outcome. Basal cell carcinomas often have very effective treatment success rates. Although late SCC has worse outcomes than superficial SCC, these are both exceeded in mortality by late-stage malignant melanoma.

64. Which of the following assessment findings of a 70-year-old male patient's skin should the nurse prioritize? A) The patient's complaint of dry skin that is frequently itchy. B) The presence of an irregularly shaped mole that the patient states is new. C) The presence of veins on the back of the patient's leg that are blue and tortuous. D) The presence of a rash on the patient's hand and forearm to which the patient applies a corticosteroid ointment.

B) The presence of an irregularly shaped mole that the patient states is new. Although all of the noted assessment findings are significant, the presence of an irregular mole that is new is suggestive of a neoplasm and warrants immediate follow-up.

73. The nurse identifies that a patient with a diagnosis of which of the following disorders is most at risk for spreading the disease? A) tinea pedis. B) impetigo on the face. C) candidiasis of the nails. D) psoriasis on the palms and soles.

B) impetigo on the face.

76. During assessment of a patient, you note an area of red, sharply defined plaques covered with silvery scales that are mildly itchy on the patient's knees and elbows. You recognize this finding as: A) lentigo. B) psoriasis. C) actinic keratosis. D) seborrheic keratosis.

B) psoriasis.

70. In teaching a patient who is using topical corticosteroids to treat acute dermatitis, the nurse should tell the patient that (select all that apply). A) the cream form is the most efficient system of delivery. B) short-term use of topical corticosteroids usually does not cause systemic side effects. C) creams and ointments should be applied with a glove in a small amounts to prevent further infection. D) abruptly discontinuing the use of topical corticosteroids may cause a reappearance of the detmatitis. E) systemic side effects may be experienced from topical corticosteroids if the person is malnourished.

B) short-term use of topical corticosteroids usually does not cause systemic side effects. D) abruptly discontinuing the use of topical corticosteroids may cause a reappearance of the detmatitis.

45. A nurse is caring for a client who has contact dermatitis and has a new prescription for diphenhydramine. For which adverse effects should the nurse monitor? A. Elevated blood glucose levels. B. Anorexia and Urinary retention. C. Increased salivation. D. Insomnia.

B. Anorexia and urinary retention. Monitor the client for anorexia, which is a possible adverse side effect. Glucocorticoids can increase blood glucose levels. However, this is not an adverse effect of diphenhydramine. Monitor the client for dry mouth and excessive drowsiness.

37. A nurse in a clinic is preparing to obtain a skin specimen from a client who has a suspected herpes infection. Which of the following actions should the nurse take? (Select all that apply.) A. Scrape the site with a wooden tongue depressor. B. Puncture the crusted area with a sterile needle. C. Swab the crusted area with a sterile cotton-tipped applicator. D. Place cotton-tipped applicator in culturette tube. E. Place culturette tube in ice.

B. CORRECT: Exudate under the crusted area should be collected. The crust or scab should bepunctured or lifted to obtain a reliable specimen. D. CORRECT: The cotton-tipped applicator is placed in liquid fixative within the culturette tube. .E. CORRECT: The culturette tube is immediately placed in ice when obtaining a viral specimen. A. INCORRECT: A wooden tongue depressor is used to scrape cells of a skin lesion to test for a fungus. C. INCORRECT: Swab the moist lesion bed under the crust with a sterile cotton-tipped applicator toobtain a reliable specimen.

A nurse is teaching a client who has a history of psoriasis about photo chemotherapy and ultraviolet light (PUVA) treatments. Which of the following should the nurse include in the teaching? A. Apply coal tar before each treatment. B. Administer a psoralen medication before the treatment. C. Use this treatment every evening. D. Remove the scales gently following each treatment.

B. CORRECT: PUVA treatment involves the administration of a medication, such as a psoralen, to enhance photosensitivity. A. INCORRECT: PUVA treatment does not involve the use of coal tar. C. INCORRECT: PUVA treatments are completed two to three times each week and not on consecutive days. D. INCORRECT: Removal of scales may cause bleeding and is not recommended when treating psoriasis.

43. A nurse is educating a client on the use of calcipotriene topical medication for the treatment of psoriasis. Which of the following laboratory values should the nurse monitor? A. Potassium. B. Calcium. C. Sodium. D. Chloride.

B. Calcium. PUVA treatment involves the administration of a medication (psoralen) to enhance photosensativity.

4. A nurse is caring for a client who develops a systemic toxic reaction following a regional block. Which of the following actions should the nurse take? A. Monitor serum creatinine levels. B. Provide airway support. C. Turn client to the right side. D. Administer 0.9% sodium chloride 500 ml bolus.

B. Provide airway support. - Systemic shock reaction causes CNS: depression, priority action is to provide airway support. ABGs should be monitored instead of creatinine, turning client would not improve condition, fluid bolus would make it worse because hypertension is one of the manifestations.

79. In teaching a patient who is using topical corticosteroids to treat acute dermatitis, the nurse should tell the patient that (select all that apply): A. the cream for is the most effective system of delivery. B. short-term use of the topical corticosteroid usually does not cause systemic side effects. C. creams and ointments should be applied with a glove in small amounts to prevent further infection. D. abruptly discontinuing the use of topical corticosteroids may cause a reappearance of the dermatitis. E. systemic side effects may be experienced from topical corticosteroids if the person is malnourished.

B. short-term use of the topical corticosteroid usually does not cause systemic side effects. D. abruptly discontinuing the use of topical corticosteroids may cause a reappearance of the dermatitis.

75. A common site for the lesions associated with atopic dermatitis is the: A) buttocks. B) temporal area. C) antecubital space. D) plantar surface of the feet.

C) antecubital space.

39. A nurse is providing discharge instructions to a client who had a skin biopsy with sutures. The nurse should identify that which of the following client statements indicates that the teaching has been effective? A. "I can expect redness around the site for 5 to 7 days." B. "I will most likely have a fever for the first few days." C. "I should apply an antibiotic ointment to the area." D. "I will make a return appointment in 3 days for removal of my sutures."

C. Antibiotic ointment is applied as prescribed by the provider to prevent infection. A. INCORRECT: The client should report redness, pain, drainage, or warmth at the biopsy site to the provider. B: INCORRECT: A fever is an indication of an infection, and the provider should be notified. D. INCORRECT: Removal of the sutures following a biopsy is done 7 to 10 days postprocedure.

40. A nurse is providing teaching to a client about a new prescription for clotrimazole (Lotrimin). Which of the following should the nurse include in the teaching? A. "It reduces the discomfort of a herpetic infection." B. "This is a cream to treat a bacterial infection." C. "Apply the topical medication for up to 2 weeks." D. "Allow the area to remain moist before applying."

C. CORRECT: Clotrimazole is a medication used to treat a fungal infection and is applied for 1 to 2 weeks after the infection is resolved. A. INCORRECT: Clotrimazole is not an antiviral medication to treat a herpetic infection. It is used to treat a fungal infection. B. INCORRECT: Clotrimazole is not an antibacterial medication. It is used to treat a fungal infection. D. INCORRECT: Clotrimazole is an anti-fungal medication and should be applied to a clean,dry surface.

A nurse is preparing to administer fentanyl to a client who sustained deep partial‐thickness and full‐thickness burns over 60% of his body 24 hr ago. The nurse should plan to use which of the following routes to administer the medication?. A. Subcutaneous. B. Oral. C. Intravenous. D. Transdermal.

C. CORRECT: The nurse should use the IV route to administer pain medication for rapid absorption and fast pain relief during the resuscitation phase. A. The nurse should not give subcutaneous injections due to the difficulty of absorption from tissue during the resuscitation phase. B. The nurse should not give oral (including buccal, sublingual) medications due to decreased motility in the gastrointestinal tract during the resuscitation phase. D. The nurse should not use the transdermal route of administration due to delays in absorption during the resuscitation phase.

47. A nurse is caring for a client who has sustained burns over 35% of his total body surface area. Of this total, 20% are full‐thickness burns on the arms, face, neck, and shoulders. The client's voice has become hoarse. He has a brassy cough and is drooling. The nurse should identify these findings as indications that the client has which of the following? A. Pulmonary edema. B. Bacterial pneumonia. C. Inhalation injury. D. Carbon monoxide poisoning.

C. CORRECT: Wheezing and hoarseness indicate inhalation injury with impending loss of the airway. These require immediate reporting to the provider. A. Difficulty breathing and production of pink frothy sputum indicate pulmonary edema. B. Productive cough and a fever are indicative of a bacterial infection. D. Confusion and headaches indicate carbon monoxide poisoning.

6. A nurse is assessing a client's lab values before surgery. Which of the following results should the nurse report to the provider? Select All That Apply. A. Potassium 3.9. B. Sodium 145. C. Creatinine 2.8. D. Blood glucose 235. E. WBC 17,850

C. Creatinine 2.8. D. Blood glucose 235. E. WBC 17,850. 1 Potassium and sodium are within normal limits, Creatinine is 0.6~1.3, blood glucose should be 70~110, WBCs should be 4,500~10,000.

8. A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following actions should the nurse take? (SATA) A. Explain purpose of procedure. B. Inform client of risks from procedure. C. Ensure client understands info about procedure. D. Witness client signing informed consent. E. Determine of client is capable of understanding info

C. Ensure client understands info about procedure. D. Witness client signing informed consent. E. Determine of client is capable of understanding info. - It is the providers responsibility to provide all info about procedure, the nurse's job is to clarify info already stated, witness client's is capable to sign and that the client does sign the consent form. Nurses are to document questions that clients have and report them to provider. Nurse must ensure provider gives all info.

1. A nurse administered midazolam IV bolus to a client before a procedure. His BP is 86/40 mm Hg, and his pulse is 134/min. Which of the following IV medications should the nurse administer? A. Naloxone. B. Morphine. C. Flumazenil. D. Atropine.

C. Flumazenil. - Flumazenil is the antidote for benzos, naloxone is the antidote for opioids, morphine is given for pain and atropine treats bradycardia.

5. A nurse is caring for a client who reports a headache following an epidural regional nerve block. Which of the following actions should the nurse take? A. Decrease the clients fluid intake. B. Apply pressure to the puncture site. C. Place head of bed flat. D. Instruct client to lie prone.

C. Place head of bed flat. - Client is experiencing a headache due to CSF leak. Increasing fluids would help replace CSF loss, applying pressure to site will not stop leakage as CSF composition is different from blood, keeping head of bed flat promotes dura tear to seal, lying prone will worsen the headache.

44. A nurse is providing teaching to the guardian of a child who has contact dermatitis. Which of the following information should the nurse include? A. Use fabric softener dryer sheets when drying the child's clothing. B. Apply a warm, dry compress to the rash area. C. Place the child in a bath with colloidal oatmeal. D. Leave the child's hands uncovered during the night.

C. Place the child in a bath with colloidal oatmeal. This will relieve the child's itching. The guardian should avoid the use of fabric softener dryer sheets. Liquid fabric softener can be used. The guardian should apply a cool, moist compress to the child's rash area to decrease inflammation. The unconscious scratching at night may lead to a secondary infection.

36. A nurse is caring for a client who has a suspected viral skin lesion. Which of the following laboratory findings should the nurse anticipate reviewing to confirm this diagnosis? A. Potassium hydroxide (KOH). B. Culture and sensitivity. C. Tzanck smear report. D. Biopsy.

CORRECT: C. A Tzanck smear report confirms if a skin lesion is viral in origin. A. INCORRECT: Findings of a potassium hydroxide (KOH) test reveal if skin lesions are fungalin origin. B. INCORRECT: Findings of a skin culture and sensitivity test reveal if lesions are bacterial or fungaland indicate antimicrobial medication to be used in treatment. D. INCORRECT: Findings of a biopsy report confirm or rule out if a lesion is malignant

68. Which of the following practices should the nurse teach a patient to follow when the patient is applying topical medication? A) Avoid applying medications directly on to dressings. B) Use a tongue blade whenever the patient's skin integrity allows. C) Avoid covering skin regions that have topical medication in place. D) Apply a layer of medication that is just thick enough to ensure coverage.

D) Apply a layer of medication that is just thick enough to ensure coverage. Patients should be directed to avoid applying topical medications too thickly. Medications may be applied directly on to dressings, and regions with medications may be covered. A tongue blade is not normally necessary for application.

71. A patient with psoriasis tells the nurse that she has quit her job as a receptionist because she feels her appearance is disgusting to customers. The nursing diagnosis that best describes this patient response is: A) ineffective coping related to lack of social support. B) impaired skin integrity related to presence of lesions. C) anxiety related to lack of knowledge of the disease process. D) social isolation related to decreased activities secondary to fear of rejection.

D) social isolation related to decreased activities secondary to fear of rejection.

13. A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. The client is not responding to verbal stimuli. Which of the following actions should the nurse perform first? A. Compare and contrast the peripheral pulses. B. Apply a warm blanket. C. Assess the client's dressings. D. Place the client in a lateral position.

D. CORRECT:The greatest risk to the client is injury from aspiration. The first action is to position the client laterally.

10. A preoperative nurse is caring for a client who is having a colon resection. Which of the following actions should the nurse take? A. Encourage the client to void after preoperative med admin. B. Admin antibiotics 2 hrs prior to surgery. C. Remove hair using a manual razor. D. Remove all nail polish on fingers and toes

D. Remove all nail polish on fingers and toes. - Client should void prior to preoperative meds, antibiotics should be given 1 hr prior to surgery, hair should be removed using an electric razor or chemical depilatory. Nail polish, jewelry, dentures, prosthetics, makeup and glasses should all be removed prior to procedure.

18. A 59-year-old man scheduled for a herniorrhaphy in 2 days reports that he takes ginkgo daily. What is the priority intervention? a. Inform the surgeon, since the procedure may have to be rescheduled. b. Notify the anesthesia care provider, since this herb interferes with anesthetics. c. Ask the patient if he has noticed any side effects from taking this herb supplement. d. Tell the patient to continue to take the herbal supplement up to the day before surgery.

a. Inform the surgeon, since the procedure may have to be rescheduled. Ginkgo can increase bleeding during and after surgery. The surgeon should determine how long it should be discontinued before surgery.

33. After admission of the postoperative patient to the clinical unit, which assessment data require the most immediate attention? a. O2 saturation of 85%. b. Respiratory rate of 13/min. c. Temperature of 100.4° F (38° C). d. Blood pressure of 90/60 mm Hg.

a. O2 saturation of 85%. During the initial assessment, identify signs of inadequate oxygenation and ventilation. Pulse oximetry monitoring is initiated because it provides a noninvasive means of assessing the adequacy of oxygenation. Pulse oximetry may indicate low oxygen saturation (<90% to <92%) with respiratory compromise. This necessitates prompt intervention.

26. The nurse is caring for a patient undergoing surgery for a knee replacement. What is critical to the patient's safety during the procedure (select all that apply)? a. Universal protocol is followed. b. The ACP is an anesthesiologist. c. The patient has adequate health insurance. d. The patient's family is in the surgery waiting area. e. The patient's allergies are conveyed to the surgical team.

a. Universal protocol is followed. e. The patient's allergies are conveyed to the surgical team. Intraoperative nursing care includes determining the patient's allergy status in response to food, drugs, and latex. Preventing use of the wrong site, wrong procedure, and wrong surgery has become known as the Universal Protocol. The Universal Protocol is part of a global patient safety initiative.

19. A 17-year-old patient with a leg fracture who is scheduled for surgery is an emancipated minor. She has a statement from the court for verification. Which intervention is most appropriate? a. Witness the permit after consent is obtained by the surgeon. b. Call a parent or legal guardian to sign the permit, since the patient is under 18. c. Obtain verbal consent, since written consent is not necessary for emancipated minors. d. Investigate your state's nurse practice act related to emancipated minors and informed consent.

a. Witness the permit after consent is obtained by the surgeon. An emancipated minor may sign his or her own permit. The nurse should be available to witness the signature, but no further action is required.

88. Pain management for the burn patient is most effective when (select all that apply). a. a pain rating tool is used to monitor the patient's level of pain. b. painful dressing changes are delayed until the patient's pain is completely relieved. c. the patient is informed about and has some control over the management of pain. d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). e. nonpharmacologic therapies (e.g., music therapy, distraction) replace opioids in the rehabilitation phase of a burn injury.

a. a pain rating tool is used to monitor the patient's level of pain. c. the patient is informed about and has some control over the management of pain. d. a multimodal approach is used (e.g., sustained-release and short-acting opioids, NSAIDs, adjuvant analgesics). Rationale: The use of a pain rating tool assists the nurse in the assessment, monitoring, and evaluation of the pain management plan. The more control the patient has in managing the pain, the more successful the chosen strategies are. A selected variety of medications offer better pain relief for patients with burns, whose pain can be both continuous and treatment related over varying periods of time. It is not realistic to promise a patient that pain will be completely eliminated. It is not realistic to suggest that pain will be managed (during any phase of burn care) with nonpharmacologic pain management. Such management is meant to be adjuvant and individualized.

89. A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is: a. applying pressure garments. b. repositioning the patient every 2 hours. c. performing active ROM at least every 4 hours. d. massaging the new tissue with water-based moisturizers.

a. applying pressure garments. Rationale: Pressure can help keep a scar flat and reduce hypertrophic scarring. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments.

83. When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply). a. blisters. b. exposed fascia. c. exposed muscles. d. intact nerve endings. e. red, shiny, wet appearance.

a. blisters. d. intact nerve endings. e. red, shiny, wet appearance. Rationale: The appearance of partial-thickness (deep) burns may include fluid-filled vesicles (blisters) that are red, shiny, or wet (if vesicles have ruptured). Patients may have severe pain caused by exposure of nerve endings and may have mild to moderate edema.

27. The nurse's primary responsibility for the care of the patient undergoing surgery is: a. developing an individualized plan of nursing care for the patient. b. carrying out specific tasks related to surgical policies and procedures. c. ensuring that the patient has been assessed for safe administration of anesthesia. d. performing a preoperative history and physical assessment to identify patient needs.

a. developing an individualized plan of nursing care for the patient.A primary role of the nurse is to assess the patient to develop an individual plan of care.

86. To maintain a positive nitrogen balance in a major burn, the patient must. a. eat a high-protein, high-carbohydrate diet. b. increase normal caloric intake by about three times. c. eat at least 1500 calories/day in small, frequent meals. d. eat a gluten-free diet for the chemical effect on nitrogen balance.

a. eat a high-protein, high-carbohydrate diet. Rationale: The patient should be encouraged to eat high-protein, high-carbohydrate foods to meet increased caloric needs. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Failure to supply adequate calories and protein leads to malnutrition and delays in healing.

29. When positioning a patient in preparation for surgery, the nurse understands that injury to the patient is most likely to occur as a result of: a. incorrect musculoskeletal alignment. b. loss of perception of pain or pressure. c. pooling of blood in peripheral vessels. d. disregarding the patient's need for modesty.

a. incorrect musculoskeletal alignment. Whatever position is required for the procedure, great care is taken to prevent injury to the patient. Because anesthesia blocks the sensory nerve impulses, the patient does not feel pain or discomfort or sense stress placed on the nerves, muscles, bones, and skin. Improper positioning can result in muscle strain, joint damage, pressure ulcers, nerve damage, and other untoward effects.

57. Persons with dark skin are more likely to develop: a. keloids. b. wrinkles. c. skin rashes. d. skin cancer

a. keloids. Rationale: Persons with dark skin are predisposed to certain skin and hair conditions, such as keloids, which are over-growths of collagenous tissue at the site of a skin injury.

56. To assess the skin for temperature and moisture, the most appropriate technique for the nurse to use is: a. palpation. b. inspection. c. percussion. d. auscultation.

a. palpation. Rationale: Using the back of your hand to palpate the patient's skin is the best way to assess the temperature of the skin.

82. The injury that is least likely to result in a full-thickness burn is: a. sunburn. b. scald injury. c. chemical burn. d. electrical injury.

a. sunburn. Rationale: Full-thickness burns may be caused by contact with flames, scalding liquids, chemicals, tar, or electrical current.

16. An overweight patient (BMI 28.1 kg/m2) is scheduled for a laparoscopic cholecystectomy at an outpatient surgery setting. The nurse knows that: a. surgery will involve multiple small incisions. b. this setting is not appropriate for this procedure. c. surgery will involve removing a portion of the liver. d. the patient will need special preparation because of obesity.

a. surgery will involve multiple small incisions. Many operative procedures are performed as ambulatory surgery (i.e., same-day or outpatient surgery). Obesity is not a contraindication to surgery in the outpatient setting. This patient is not classified as obese on the basis of the BMI. The case implied that a laparoscopic technique will be used that involves several small incisions and meets the requirement of a minimally invasive technique.

55. The nurse assessed the patient's skin lesions as firm, edematous, irregularly shaped with a variable diameter. They would be called: a. wheals. b. papules. c. pustules. d. plaques.

a. wheals. Rationale: A wheal is a firm, edematous, irregularly shaped area with variable diameter. Examples include insect bites and urticaria.

17. The patient tells the nurse in the preoperative setting that she has noticed she has a reaction when wearing rubber gloves. What is the most appropriate intervention? a. Notify the surgeon so that the case can be cancelled. b. Ask additional questions to assess for a possible latex allergy. c. Notify the OR staff immediately so that latex-free supplies can be used. d. No intervention is needed because the patient's rubber sensitivity has no bearing on surgery.

b. Ask additional questions to assess for a possible latex allergy. The nurse should ask additional screening questions to determine the patient's risk for a latex allergy. Latex precaution protocols should be used for patients identified as having a positive latex allergy test result or a history of signs and symptoms related to latex exposure. Many health care facilities have created latex-free product carts that can be used for patients with latex allergies.

59. Diagnostic testing is recommended for skin lesions when: a. a health history cannot be obtained. b. a more definitive diagnosis is needed. c. percussion reveals an abnormal finding. d. treatment with prescribed medication has failed.

b. a more definitive diagnosis is needed. Rationale: Biopsy is one of the most common diagnostic tests used in the evaluation of a skin lesion. A biopsy is indicated in all conditions in which a malignancy is suspected or a specific diagnosis is questionable.

22. A patient who normally takes 40 units of glargine insulin (long acting) at bedtime asks the nurse what to do about her dose the night before surgery. The best response would be to have her: a. skip her insulin altogether the night before surgery. b. get instructions from her surgeon or HCP on any insulin adjustments. c. take her usual dose at bedtime and eat a light breakfast in the morning. d. eat a moderate meal before bedtime and then take half her usual insulin dose.

b. get instructions from her surgeon or HCP on any insulin adjustments. Insulin is not usually omitted completely. The patient should obtain instructions from her HCP or surgeon about any dosage adjustments that she should make the day before and the morning of surgery (if applicable).

87. A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to. a. reapply a new dressing without disturbing the wound bed. b. observe the wound for signs of infection during dressing changes. c. apply cool compresses for pain relief in between dressing changes. d. wash the wound aggressively with soap and water three times a day.

b. observe the wound for signs of infection during dressing changes. Rationale: Infection is the most serious threat with regard to further tissue injury and possible sepsis.

25. Activities that the nurse might perform in the role of a scrub nurse during surgery include (select all that apply): a. checking electrical equipment. b. preparing the instrument table. c. passing instruments to the surgeon and assistants. d. coordinating activities occurring in the operation room. e. maintaining accurate counts of sponges, needles and instruments.

b. preparing the instrument table. c. passing instruments to the surgeon and assistants. e. maintaining accurate counts of sponges, needles and instruments. Maintaining accurate counts of sponges, needles, and instruments is a shared responsibility of the scrub nurse and circulating nurse.

51. The primary function of the skin is: a. insulation. b. protection. c. sensation. d. absorption.

b. protection. Rationale: The primary function of the skin is to protect the underlying tissues of the body by serving as a surface barrier to the external environment.

52. Age-related changes in the hair and nails include (select all that apply). a. oily scalp. b. scaly scalp. c. thinner nails. d. thicker, brittle nails. e. longitudinal nail ridging

b. scaly scalp. d. thicker, brittle nails. e. longitudinal nail ridging. Rationale: Decreased oil causes hair to become dry and coarse and the scalp to become scaly. Decreased peripheral blood supply causes nails to become thick and brittle. Longitudinal ridging in the nails may occur with aging.

24. Proper attire for the semi-restricted area of the surgery department is: a. street clothing. b. surgical attire and head cover. c. surgical attire, head cover, and mask. d. street clothing with the addition of shoe covers.

b. surgical attire and head cover. The semi-restricted area includes the surrounding support areas and corridors. Only authorized staff members are allowed access to the semi-restricted areas. All staff in the semi-restricted area must wear surgical attire and cover all head and facial hair.

31. When a patient is admitted to the PACU, what are the priority interventions the nurse performs? a. Assess the surgical site, noting presence and character of drainage. b. Assess the amount of urine output and the presence of bladder distention. c. Assess for airway patency and quality of respirations, and obtain vital signs. d. Review results of intraoperative laboratory values and medications received.

c. Assess for airway patency and quality of respirations, and obtain vital signs. Assessment in the postanesthesia care unit (PACU) begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Identification of inadequate oxygenation and ventilation or respiratory compromise necessitates prompt intervention.

81. Knowing the most common causes of household fires, which prevention strategy would the nurse focus on when teaching about fire safety? a. Set hot water temperature at 140F. b. Use only hardwired smoke detectors. c. Encourage regular home fire exit drills. d. Never permit older adults to cook unattended.

c. Encourage regular home fire exit drills. Rationale: A risk-reduction strategy for household fires is to encourage regular home fire exit drills. Hot water heaters set at 140° F (60° C) or higher are a burn hazard in the home; the temperature should be set at less than 120° F (40° C). Installation of smoke and carbon monoxide detectors can prevent inhalation injuries. Hard-wired smoke detectors do not require battery replacement; battery-operated smoke detectors may be used. Supervision of older adults who are cooking is necessary if cognitive impairment is present.

58. On inspection of a patient's dark skin, the nurse notes a blue-gray birthmark on the forehead and eye area. This assessment finding is called: a. vitiligo. b. intertrigo. c. Nevus of Ota. d. telangiectasia.

c. Nevus of Ota. Rationale: Nevus of Ota is a flat, gray to blue pigmentation on the forehead and eye area of the face; it also may involve the sclera. This condition may be found in those with dark skin.

21. A patient is scheduled for surgery requiring general anesthesia at an ambulatory surgical center. The nurse asks him when he ate last. He replies that he had a light breakfast a couple of hours before coming to the surgery center. What should the nurse do first? a. Tell the patient to come back tomorrow, since he ate a meal. b. Proceed with the preoperative checklist, including site identification. c. Notify the anesthesia care provider of when and what the patient last ate. d. Have the patient void before administering any preoperative medications.

c. Notify the anesthesia care provider of when and what the patient last ate. The nothing-by-mouth (NPO) protocol of each surgical facility should be followed. Restriction of fluids and food is designed to minimize the potential risk of pulmonary aspiration and to decrease the risk of postoperative nausea and vomiting. If a patient has not followed the NPO instructions, surgery may be delayed or cancelled. The nurse should notify the anesthesia care provider immediately.

30. IV induction for general anesthesia is the method of choice for most patients because: a. the patient is not intubated. b. the agents are nonexplosive. c. induction is rapid and pleasant. d. emergence is longer but with fewer complications.

c. induction is rapid and pleasant. Routine general anesthesia is usually established with an IV induction agent, which may be a hypnotic, anxiolytic, or dissociative agent. When used during the initial period of anesthesia, these agents induce a pleasant sleep with a rapid onset of action that patients find desirable.

35. Discharge criteria for the Phase II patient include (select all that apply): a. no nausea or vomiting. b. ability to drive self home. c. no respiratory depression. d. written discharge instructions understood. e. opioid pain medication given 45 minutes ago.

c. no respiratory depression. d. written discharge instructions understood. e. opioid pain medication given 45 minutes ago. Phase II discharge criteria that must be met include the following: all PACU discharge criteria (Phase I); no IV opioid drugs administered for the past 30 minutes; patient's ability to void (if appropriate with regard to surgical procedure or orders); patient's ability to ambulate if it is not contraindicated; presence of a responsible adult to accompany or drive patient home; and written discharge instructions given and understood.

54. During the physical examination of a patient's skin, the nurse would: a. use a flashlight in a poorly lit room. b. note cool, moist skin as a normal finding. c. pinch up a fold of skin to assess for turgor. d. perform a lesion-specific examination first and then a general inspection.

c. pinch up a fold of skin to assess for turgor. Rationale: Turgor is the elasticity of the skin. The nurse should assess turgor by gently pinching an area of skin under the clavicle or on the back of the hand. Skin with good turgor should move easily when lifted and should immediately return to its original position when released.

32. A patient is admitted to the PACU after major abdominal surgery. During the initial assessment the patient tells the nurse he thinks he is going to "throw up." A priority nursing intervention would be to: a. increase the rate of the IV fluids. b. obtain vital signs, including O2 saturation. c. position patient in lateral recovery position. d. administer antiemetic medication as ordered.

c. position patient in lateral recovery position. If the patient is nauseated and may vomit, place the patient in a lateral recovery position to keep the airway open and reduce the risk of aspiration if vomiting occurs.

53. When assessing the nutritional-metabolic pattern in relation to the skin, the nurse questions the patient regarding: a. joint pain. b. the use of moisturizing shampoo. c. recent changes in wound healing. d. self-care habits related to daily hygiene.

c. recent changes in wound healing. Rationale: When assessing the nutritional-metabolic pattern, the nurse asks the following questions: "Describe any changes in the condition of your skin, hair, nails, and mucous membranes. Have you noticed any recent changes in the way sores or wounds heal? Have you had any weight loss or dietary changes, including supplemental vitamins and minerals?"

23. Preoperative considerations for older adults include (select all that apply): a. using only large-print educational materials. b. speaking louder for patients with hearing aids. c. recognizing that sensory deficits may be present. d. providing warm blankets to prevent hypothermia. e. teaching important information early in the morning.

c. recognizing that sensory deficits may be present.d. providing warm blankets to prevent hypothermia. Many older adults have sensory deficits. Preoperative and operating rooms are cool; warm blankets should be provided as needed.

90. A patient is recovering from second- and third-degree burns over 30% of his body and the burn care team is planning for discharge. The first action the nurse should take when meeting with the patient would be to: a. arrange a return-to-clinic appointment and prescription for pain medications. b. teach the patient and the caregiver proper wound care to be performed at home. c. review the patient's current health care status and readiness for discharge to home. d. give the patient written information and websites for information for burn survivors

c. review the patient's current health care status and readiness for discharge to home. Rationale: Recovery from a burn injury to 30% of total body surface area (TBSA) takes time and is exhausting, both physically and emotionally, for the patient. The burn care team may think that a patient is ready for discharge, but the patient may not have any idea that discharge is being contemplated in the near future. Patients are often very fearful about how they will manage at home. The patient would benefit from the nurse's careful review of his or her progress and readiness for discharge; then the nurse should outline the plans for support and follow-up after discharge

85. Fluid and electrolyte shifts that occur during the early emergent phase of a burn injury include. a. adherence of albumin to vascular walls. b. movement of potassium into the vascular space. c. sequestering of sodium and water in interstitial fluid. d. hemolysis of red blood cells from large volumes of rapidly administered fluid.

c. sequestering of sodium and water in interstitial fluid. Rationale: During the emergency phase, sodium rapidly shifts to the interstitial spaces and remains there until edema formation ceases.

84. A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is he most appropriate for the nurse to take next? a. Encourage the patient to cough and auscultate the lungs again. b. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas. c. Document the findings and continue to monitor the patient's breathing. d. Anticipate the need for endotracheal intubation and notify the physician.

d. Anticipate the need for endotracheal intubation and notify the physician. Rationale: Inhalation injury results in exposure of the respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide (CO). The nurse should anticipate the need for intubation and mechanical ventilation because this patient is demonstrating signs of severe respiratory distress.

34. A 70-kg postoperative patient has an average urine output of 25 mL/hr during the first 8 hours. The priority nursing intervention(s) given this assessment would be to: a. perform a straight catheterization to measure the amount of urine in the bladder. b. notify the physician and anticipate obtaining blood work to evaluate renal function. c. continue to monitor the patient because this is a normal finding during this time period. d. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound.

d. evaluate the patient's fluid volume status since surgery and obtain a bladder ultrasound. Because of the possibility of infection associated with catheterization, the nurse should first try to validate that the bladder is full. The nurse should consider fluid intake during and after surgery and should determine bladder fullness by percussion, by palpation, or by a portable bladder ultrasound study to assess the volume of urine in the bladder and avoid unnecessary catheterization.

20. A priority nursing intervention to assist a preoperative patient in coping with fear of postoperative pain would be to: a. inform the patent that pain medication will be available. b. teach the patient to use guided imagery to help manage pain. c. describe the type of pain expected with the patient's particular surgery. d. explain the pain management plan, including the use of a pain rating scale.

d. explain the pain management plan, including the use of a pain rating scale. If a patient has fear of pain and discomfort after surgery, the nurse should reassure the patient that a pain management plan will be in place. The nurse should teach the patient to ask for medications after surgery when pain is present and assure him or her that taking these medications will not contribute to an addiction. The nurse should instruct the patient on the use of some form of pain rating scale (e.g., 0 to 10, FACES) and to request pain medication before the pain becomes severe.

28. When scrubbing at the scrub sink, the nurse should: a. scrub from elbows to hands. b. scrub without mechanical friction. c. scrub for a minimum of 10 minutes. d. hold the hands higher than the elbows.

d. hold the hands higher than the elbows. To perform a surgical scrub, the fingers and hands should be scrubbed first, progressing to the forearms and elbows. The hands should be held away from surgical attire and higher than the elbows at all times to prevent contamination from clothing or from detergent suds and water draining from the unclean area above the elbows to the clean and previously scrubbed areas of the hands and fingers.

80. 3. A patient with acne vulgaris tells the nurse that she has quit her job as a receptionist because she believes her facial appearance is unattractive to customers. The nursing diagnosis that best describes this patient response is: a. ineffective coping related to lack of social support. b. impaired skin integrity related to presence of lesions. c. anxiety related to lack of knowledge of the disease process. d. social isolation related to decreased activities secondary to fear of rejection.

d. social isolation related to decreased activities secondary to fear of rejection.