(Med-Surg I) Final Exam Multiple Choice Questions
Before the insertion of a radioactive cervical implant, the nurse tells the patient what to expect while it is in place. Which statement is accurate? (Select all that apply.) 1. "Nurses will always be available, but they will spend only a short time at your bedside." 2. "Personal cleanliness is essential, so you will be given a complete bed bath each day." 3. "We will be checking your vital signs at least every 4 hours." 4. "Your bed linens will be completely changed each day to minimize radioactive contamination." 5. "You should make diet choices that are low in fiber."
1. "Nurses will always be available, but they will spend only a short time at your bedside." 3. "We will be checking your vital signs at least every 4 hours." 5. "You should make diet choices that are low in fiber."
3. The health care provider has ordered that the patient's wound be irrigated. What is the primary rationale for this procedure 1. To remove debris from the wound 2. To decrease scar formation 3. To improve circulation from the wound 4. To decrease irritation from wound drainage
1. To remove debris from the wound
Which patient is more at risk for wound dehiscence? 1. The patient who smokes 2. The patient who is obese 3. The patient with a history of peripheral vascular disease 4. The patient who is immunocompromised
2. The patient who is obese
The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply. 1. Slight redness along the incision 2. The presence of purulent drainage 3. A temperature of 98.8°F (37.1°C) 4. The client states that he feels cold. 5. The client states that the incision itches. 6. Tender firmness palpable around the incision
2. The presence of purulent drainage 6. Tender firmness palpable around the incision
A patient was admitted to the orthopedic section for acute back pain. The health care provider is planning to use cutaneous stimulation management. Which is an example of this pain control method? 1. Epidural analgesia 2. Transcutaneous electric nerve stimulation (TENS) 3. Nonsteroidal antiinflammatory drugs (NSAIDs) 4. Patient-controlled analgesia
2. Transcutaneous electric nerve stimulation (TENS)
A 63-year-old patient underwent a lower anterior bowel resection yesterday. What common central nervous system analgesic is prescribed often to control pain? 1. Aspirin 2. Acetaminophen (Tylenol) 3. Morphine 4. Ibuprofen (Motrin)
Morphine
The nurse is assessing the patient's description of his back pain. He states that it is "immobilizing, intense, and on a scale of 0 to 10, it is an 8." What type of pain assessment scale is the patient using? 1. Visual analog 2. Categorical 3. Functional 4. Numeric
Numeric
What is the first step when packing a wound? 1. Assess its size, shape, and depth. 2. Prepare a sterile field. 3. Select gauze packing material. 4. Irrigate the wound
3. Select gauze packing material.
A 63-year-old patient has a diagnosis of cancer of the prostate gland with metastasis and is experiencing cachexia. How is cachexia best described? 1. Poor health, malnutrition, weakness, and emaciation 2. Increased appetite and nervousness 3. Irritability and anger 4. Depression, fear, and anxiety
1. Poor health, malnutrition, weakness, and emaciation
The nurse listens attentively while the patient describes her angina pectoris pain as radiating down her left inner arm to the little finger and upward to the jaw and the shoulder. What term is used to classify this type of pain? 1. Precisely localized 2. Referred 3. Intermittent 4. Chronic
1. Precisely localized
The nurse is caring for a client with an internal radiation implant. The nurse needs to observe which principle(s)? Select all that apply. 1. Pregnant women are not allowed into the client's room. 2. Limit the time with the client to 1 hour per 8-hour shift. 3. Wear a lead apron while delivering bedside care to the client. 4. Remove the dosimeter badge when entering the client's room. 5. Individuals younger than 16 years old are allowed in the room if they stay 6 feet away from the client
1. Pregnant women are not allowed into the client's room. 3. Wear a lead apron while delivering bedside care to the client.
When providing care to a patient with a Hemovac drain, what actions are included in the plan of care? 1. Record the appearance of the drainage in the nursing progress notes and include the amount in the fluid output calculations. 2. Clamp the tubing during patient ambulation and activity to prevent excess drainage during these times. 3. Empty the bulb drainage receptacle when it is one-fourth full. 4. Pin the bulb above the insertion site to assist in proper drainage of exudate.
1. Record the appearance of the drainage in the nursing progress notes and include the amount in the fluid output calculations.
The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which actions would the nurse take to deal with this event? Select all that apply. 1. Turn the client to the side with the knees bent. 2. Notify the registered nurse (RN) and the surgeon. 3. Apply a sterile dressing soaked with normal saline to the wound. 4. Explain to the client that obesity is a risk factor and weight loss would be a future goal. 5. Gently explore the wound with a cotton-tipped applicator to determine whether evisceration has occurred.
2. Notify the registered nurse (RN) and the surgeon. 3. Apply a sterile dressing soaked with normal saline to the wound.
The nurse is correct when identifying a patient who smokes two packs of cigarettes per day as being at most risk for which postoperative complication? 1. Infection 2. Pneumonia 3. Hypotension 4. Cardiac dysrhythmias
2. Pneumonia
A patient has a history of oat cell carcinoma of the lung and is being treated with chemotherapy. His WBC count is 2.5/mm3. What is the nurse's primary concern? 1. Prevention of hemorrhage 2. Prevention of infection 3. Prevention of dehydration 4. Prevention of electrolyte imbalance
2. Prevention of infection
When reinforcing teaching about signs/symptoms of ovarian cancer with a community group of women, the nurse emphasizes which as being a most typical manifestation of the disease? 1. Pelvic cramping 2. Sharp abdominal pain 3. Abdominal distention or fullness 4. Postmenopausal vaginal bleeding
3. Abdominal distention or fullness
A patient is receiving chemotherapy and has a low WBC count. What patient statement indicates the need for further teaching? 1. "I check my mouth after each meal." 2. "Fresh fruits and vegetables will help me get better." 3. "My husband and I have been using a vaginal lubrication before intercourse." 4. "My lips are dry and cracking. I need some lubricant."
2. "Fresh fruits and vegetables will help me get better." .
The nurse is assessing the bowel sounds of a patient who had a suprapubic prostatectomy 2 days ago. To confirm that no bowel sounds are present, the nurse would need to auscultate each quadrant for how long? 1. 1 minute 2. 3 minutes 3. 10 minutes 4. 15 minutes
2. 3 minutes
Which patient is at greatest risk for surgical and anesthetic complications? 1. A 3-year-old patient scheduled for hernia repair 2. An 80-year-old patient scheduled for exploratory laparotomy 3. An 18-year-old patient scheduled for an appendectomy 4. A 42-year-old patient scheduled for breast biopsy
2. An 80-year-old patient scheduled for exploratory laparotomy
The nurse is caring for a client after a mastectomy. Which finding would indicate that the client is experiencing a complication that may become a chronic problem related to the surgery? 1. Pain at the incisional site 2. Arm edema on the operative side 3. Sanguineous drainage in the Jackson-Pratt drain 4. Complaints of decreased sensation near the operative site
2. Arm edema on the operative side
When a patient is prepared for surgery, which interventions are appropriate during the preoperative period? (Select all that apply.) 1. Provide sips of water for a dry mouth. 2. Remove the patient's makeup and nail polish. 3. Remove the patient's gown before transport to the OR. 4. Leave on all of the patient's jewelry. 5. Teach the patient postoperative breathing and coughing exercises.
2. Remove the patient's makeup and nail polish. 5. Teach the patient postoperative breathing and coughing exercises.
A patient has been prescribed acetaminophen to manage pain after a sports injury. What information can be included in the discussion about this medication with the patient? (Select all that apply.) 1. This medication is limited to the management of mild pain. 2. The dosage of acetaminophen should be limited to 4000 mg in a 24-hour period. 3. Acetaminophen is associated with gastrointestinal upset. 4. Excessive dosages are associated with hepatotoxicity. 5. Acetaminophen works by blocking pain impulses
2. The dosage of acetaminophen should be limited to 4000 mg in a 24-hour period. 4. Excessive dosages are associated with hepatotoxicity. 5. Acetaminophen works by blocking pain impulses
During assessment of a patient after abdominal surgery, the nurse suspects internal hemorrhaging based on which finding? 1. The dressing is saturated with bright red sanguineous drainage, and the patient has an increased urinary output. 2. The dressing is dry and intact, the patient's blood pressure has decreased, and pulse and respirations have increased. 3. The dressing is saturated with serosanguineous drainage, and the patient is diaphoretic, with a decrease in pulse and respirations. 4. The dressing is dry and intact, and the patient reports shortness of breath and has an elevated temperature.
2. The dressing is dry and intact, the patient's blood pressure has decreased, and pulse and respirations have increased.
The client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value would the nurse specifically monitor during treatment with this medication? 1. Clotting time 2. Uric acid level 3. Potassium level 4. Blood glucose level
2. Uric acid level
The nursing student is discussing the gate control theory of pain. Which statement by the student indicates the need for further instruction? (Select all that apply.) 1. "The gates of the pain pathways can be opened with therapeutic massage and heat treatments." 2. "Pain has exclusive use of the pathways ahead of other stimuli, according to the theory." 3. "Distraction is beneficial in pain management, according to the theory." 4. "Pain is a manifestation of an intricate chain of electrochemical events." 5. "Memories and feelings may alter gating mechanisms."
3. "Distraction is beneficial in pain management, according to the theory." 4. "Pain is a manifestation of an intricate chain of electrochemical events." 5. "Memories and feelings may alter gating mechanisms."
The patient has just returned from the postanesthesia care unit (PACU). During report, the nurse is told that the patient has a Jackson-Pratt drain in the left lower quadrant (LLQ). The patient asks why the drain is being used. What response by the nurse is most accurate? 1. "The drain allows for the postoperative instillation of wound irrigation fluid in order to keep the wound clean." 2. "The drain is used to reduce infection in the postoperative period." 3. "Drains are used to contain and remove body fluids from the wound by mild suction." 4. "Drains are used to minimize postoperative discomfort after a surgical procedure."
3. "Drains are used to contain and remove body fluids from the wound by mild suction."
A 24-year-old patient has been receiving chemotherapy for acute lymphoblastic leukemia and has developed leukopenia. Which patient statement indicates that he understands discharge teaching concerning leukopenia? (Select all that apply.) 1. "I am cured and have no limitations." 2. "My family can catch leukopenia, so I need to be careful to not get too close to any of them." 3. "I should avoid close contact with people who might give me an infection." 4. "I need to be careful not to cut myself when shaving because I may not be able to stop the bleeding." 5. "I should avoid being in large crowds until my white blood cell count rises to an acceptable level."
3. "I should avoid close contact with people who might give me an infection." 4. "I need to be careful not to cut myself when shaving because I may not be able to stop the bleeding." 5. "I should avoid being in large crowds until my white blood cell count rises to an acceptable level."
A patient tells the nurse that "using this tube thing [incentive spirometer] is a waste of time." Which statement by the nurse best explains the purpose of the incentive spirometer? 1. "It helps by directly removing excess secretions from the lungs." 2. "It increases pulmonary circulation." 3. "It helps promote lung expansion and prevent pulmonary complications." 4. "It helps stimulate the cough reflex and keeps your lungs working."
3. "It helps promote lung expansion and prevent pulmonary complications."
A patient reports being allergic to penicillin. Which question would elicit the most useful information? 1. "When did the reaction occur?" 2. "What infection did you have that required penicillin?" 3. "What type of allergic reaction did you have?" 4. "Did you notify your physician of the allergy?"
3. "What type of allergic reaction did you have?"
The client is receiving external radiation to the neck for cancer of the larynx. The nurse monitors the client knowing that which are side/adverse effects of the external radiation? Select all that apply. 1. Dyspnea 2. Diarrhea 3. Sore throat 4. Constipation 5. Red and dry skin over neck
3. Sore throat 5. Red and dry skin over neck
The nurse is reinforcing discharge instructions to a client with cancer of the prostate after a suprapubic prostatectomy. The nurse would reinforce which discharge instruction(s)? Select all that apply. 1. Avoid driving a car for 1 week. 2. Restrict fluid intake to prevent incontinence. 3. Take the prescribed stool softener every day. 4. Avoid lifting objects heavier than 20 pounds for 6 weeks. 5. Inspect the incision on the scrotum every day for any redness. 6. Notify the primary health care provider (PHCP) if small blood clots are noticed during urination.
3. Take the prescribed stool softener every day. 4. Avoid lifting objects heavier than 20 pounds for 6 weeks.
Which statement is accurate regarding a patient who receives general or regional anesthesia in an ambulatory surgery center? 1. The patient will remain in the unit longer than a hospitalized patient. 2. The patient is allowed to ambulate as soon as he or she is admitted to the recovery area. 3. The patient's level of consciousness must be near the level of preoperative functioning before dismissal. 4. The patient is immediately given liberal amounts of fluid to promote excretion of the anesthesia.
3. The patient's level of consciousness must be near the level of preoperative functioning before dismissal.
The nurse provides skin care instructions to the client who is receiving external radiation therapy. Which statement(s) by the client indicates the need for further teaching? Select all that apply. 1. "I will handle the area gently." 2. "I will wear loose-fitting clothing." 3. "I will avoid the use of deodorants." 4. "I will limit sun exposure to 1 hour daily." 5. "I will apply moisturizer with a cotton tipped applicator for itching."
4. "I will limit sun exposure to 1 hour daily." 5. "I will apply moisturizer with a cotton tipped applicator for itching."
prescription and over-the-counter medications (including herbal remedies) taken before surgery. Which response by the nurse is most accurate? 1. "These medications may cause allergies to develop." 2. "These medications are automatically ordered postoperatively." 3. "These medications should be taken the morning of surgery with sips of water." 4. "These medications may create a greater risk for complications or interact with anesthetic agents."
4. "These medications may create a greater risk for complications or interact with anesthetic agents."
What action should the nurse implement to reduce surgical wound infection? (Select all that apply.) 1. Adhering to the principles of hand hygiene 2. Cleansing the incision from the least contaminated to the most contaminated area 3. Leaving the incision open to the air 4. Changing the dressing using sterile technique 5. Ensuring that the patient is consuming an adequate diet
4. Changing the dressing using sterile technique
The client with ovarian cancer is being treated with vincristine. The nurse monitors the client, knowing that which adverse effect is specific to this medication? 1. Diarrhea 2. Hair loss 3. Chest pain 4. Extremity numbness
4. Extremity numbness
The nurse is assisting with conducting a health-promotion program to community members regarding testicular cancer. The nurse determines that further teaching is needed if a community member states that which is a sign/symptom of testicular cancer? Select all that apply. 1. Alopecia 2. Back pain 3. Painless testicular swelling 4. A heavy sensation in the scrotum 5. Elevation in prostate-specific antigen (PSA) levels
1. Alopecia 5. Elevation in prostate-specific antigen (PSA) levels
A client arrives to the surgical nursing unit after surgery. What would be the initial nursing action after surgery? 1. Assess patency of the airway. 2. Check tubes or drains for patency. 3. Check dressing for bleeding or drainage. 4. Obtain vital signs to compare with those recorded preoperatively.
1. Assess patency of the airway.
The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase, an antineoplastic agent. The nurse consults with the registered nurse regarding the administration of the medication if which is documented in the client's history? 1. Pancreatitis 2. Diabetes mellitus 3. Myocardial infarction 4. Chronic obstructive pulmonary disease
1. Pancreatitis
What drug delivery system is used to control pain via a portable computerized pump with a chamber for a syringe? 1. Patient-controlled analgesia 2. Transcutaneous electric nerve stimulation 3. A venous access device 4. An intrathecal delivery system
1. Patient-controlled analgesia
The licensed practical nurse (LPN) is assisting the registered nurse (RN) to create a teaching plan for the client receiving an antineoplastic medication. The LPN expects which information to be included? Select all that apply. 1. Rinse mouth after meals and use a soft toothbrush. 2. Notify the PHCP if the temperature is above 101°F (37.7°C). 3. Maintain oral hygiene and inspect the mouth for sores daily. 4. A sore throat is expected so the client would suck on soothing throat lozenges. 5. Consult with a primary health care provider (PHCP) before receiving immunizations.
1. Rinse mouth after meals and use a soft toothbrush. 3. Maintain oral hygiene and inspect the mouth for sores daily. 5. Consult with a primary health care provider (PHCP) before receiving immunizations.
An alert 75-year-old patient is to undergo elective surgery. Who must sign the operative permit? 1. The patient 2. The patient and the patient's spouse 3. Either the patient or the patient's spouse 4. The patient and the surgeon
1. The patient
The nurse is assisting with caring for a client with cancer who is receiving cisplatin. Which adverse effects are associated with this medication? Select all that apply. 1. Tinnitus 2. Ototoxicity 3. Hyperkalemia 4. Hypercalcemia 5. Nephrotoxicity 6. Hypomagnesemia
1. Tinnitus 2. Ototoxicity 5. Nephrotoxicity 6. Hypomagnesemia
An obese patient is at risk for poor wound healing postoperatively for what reasons? (Select all that apply.) 1. Ventilation capacity is reduced. 2. Fatty tissue has a poor blood supply. 3. The risk for dehiscence is increased. 4. Clotting factors are delayed. 5. Thrombophlebitis risk is increased.
1. Ventilation capacity is reduced. 2. Fatty tissue has a poor blood supply. 3. The risk for dehiscence is increased. 5. Thrombophlebitis risk is increased.
Research indicates that the risk of clinically significant opioid-induced respiratory depression is 1. less than 1%. 2. 5%. 3. 20%. 4. 30%.
1. less than 1%.
The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which actions would the nurse take? Select all that apply. 1. Ask if the client is thirsty, and assist with drinking a glass of water. 2. Ask how the client feels, and inquire about any feelings of dizziness. 3. Review the client record to determine time and type of analgesia last received. 4. Assist the client to perform leg exercises, and then recheck the blood pressure and pulse rate. 5. Review the client record to note the vital signs taken in the post anesthesia care unit (PACU). 6. Review the client record to determine whether the client has voided postoperatively.
2. Ask how the client feels, and inquire about any feelings of dizziness. 3. Review the client record to determine time and type of analgesia last received. 5. Review the client record to note the vital signs taken in the post anesthesia care unit (PACU).
The student nurse is changing a patient's dressing. What action indicates the need for further education? (Select all that apply.) 1. Enclose the soiled dressing within a latex glove. 2. Clean the wound in circles toward the incision. 3. Free the tape by pulling it away from the incision. 4. Remove the soiled dressing with sterile gloves. 5. Apply the clean dressing with clean gloves
2. Clean the wound in circles toward the incision. 3. Free the tape by pulling it away from the incision. 4. Remove the soiled dressing with sterile gloves. 5. Apply the clean dressing with clean gloves
A postoperative abdominal surgery patient complains that he "felt something give way" in his incision. On assessing the wound, the nurse notes a large amount of serosanguineous drainage and that wound edges are not approximated. Intestines are protruding from the wound. What nursing action is appropriate? 1. Encourage the patient to turn, cough, and deep-breathe while splinting the opening. 2. Cover the protruding internal organs with sterile gauze moistened with normal saline. 3. Paint the open wound with an antimicrobial solution to prevent infection. 4. Reinsert the organs and apply a pressure dressing to prevent further organ protrusion.
2. Cover the protruding internal organs with sterile gauze moistened with normal saline.
A patient is being discharged, and the nurse is teaching the patient how to do daily dressing changes at home. What is the most important point to include in the teaching plan? 1. Discussion of surgical asepsis 2. Discussion of hand hygiene 3. Instruction in sterilization 4. Demonstration of gloving
2. Discussion of hand hygiene
What is the best nursing intervention to help a patient cope with fear of pain associated with surgery? 1. Describe the degree of pain expected. 2. Explain the availability of pain medication. 3. Inform the patient of the frequency of pain medication. 4. Divert the patient when talking about pain.
2. Explain the availability of pain medication.
The patient is receiving chemotherapy and has the patient problem of insufficient nutrition. What are likely reasons for this lack of nutrition related to side effects of this type of treatment? (Select all that apply.) 1. The patient indicates that she doesn't feel hungry. 2. The patient complains that she has developed small sores in her mouth. 3. The patient has developed diarrhea. 4. The patient complains that she has been nauseated. 5. The patient has been having experiencing episodes of choking during meals.
2. The patient complains that she has developed small sores in her mouth. 3. The patient has developed diarrhea. 4. The patient complains that she has been nauseated.
The nurse is caring for two patients with similar injuries. One patient expresses severe pain, and the other reports feeling fine with low levels of pain. Which statement is most correct? 1. The patient having more intense reports of pain has dysfunctional endorphins. 2. The patient having lesser levels of pain has a higher level of endorphins. 3. The patient experiencing intense pain has lower levels of endorphins. 4. The patient having elevated levels of pain has an alteration in recognition of endorphins by the hypothalamus of the brain.
2. The patient having lesser levels of pain has a higher level of endorphins.
What statements indicate that a wound has become infected? (Select all that apply.) 1. Palpation of the wound reveals serosanguinous fluid under its edges. 2. Wound cultures are positive. 3. Purulent drainage is coming from the wound area. 4. Upon removal, the nurse notes that the dressing is dry. 5. Wound edges are clean and well approximated. 6. The wound has a foul odor
2. Wound cultures are positive. 3. Purulent drainage is coming from the wound area. 6. The wound has a foul odor
On admission of a patient to the PACU from surgery, on what should the nurse place the highest priority for assessment? 1. Patient's level of consciousness 2. Condition of the surgical site 3. Adequacy of airway and breathing 4. Fluid and electrolyte balance
3. Adequacy of airway and breathing
Which phrase best describes serous drainage? 1. Fresh bleeding 2. Thick and yellow 3. Clear, watery plasma 4. Beige to brown and foul smelling
3. Clear, watery plasma
The nurse finds that the patient's incision has eviscerated. What action should the nurse take? (Select all that apply.) 1. Place the patient in high-Fowler's position. 2. Give the patient fluids to prevent shock. 3. Do not allow the patient to get out of bed. 4. Replace dressings with sterile fluffy pads. 5. Apply warm, moist sterile dressings.
3. Do not allow the patient to get out of bed. 5. Apply warm, moist sterile dressings.
After abdominal surgery, a patient is suspected of having internal bleeding. Which finding is most indicative of this complication? (Select all that apply.) 1. Increased blood pressure 2. Incisional pain 3. Increased abdominal distention 4. Increased urinary output 5. Increased respirations
3. Increased abdominal distention 5. Increased respirations
Which route is most appropriate for treating rapidly escalating severe pain? 1. Oral 2. Intramuscular (IM) 3. Intravenous (IV) 4. Transdermal
3. Intravenous (IV)
The nurse is reinforcing instructions to a client receiving external radiation therapy. The nurse determines that the client needs further teaching if the client states an intention to take which action? Select all that apply. 1. Eat a high-protein diet. 2. Avoid exposure to sunlight. 3. Wash the skin with a mild soap, and pat it dry. 4. Apply pressure on the radiated area to prevent bleeding. 5. Avoid standing within 6 feet of persons younger than the age of 18 years.
4. Apply pressure on the radiated area to prevent bleeding. 5. Avoid standing within 6 feet of persons younger than the age of 18 years.
The health care provider has ordered that all sutures on a patient with an abdominal hysterectomy be removed on the fifth postoperative day and that Steri-Strips be applied. During suture removal, the nurse notices the incision edges are slightly separating. What is the best action by the nurse? 1. Continue removing the sutures and apply the Steri-Strips. 2. Stop the suture removal and contact the health care provider immediately. 3. Continue removing the sutures and applying the Steri-Strips, then cover the incision with a dry sterile dressing. 4. Stop the suture removal, apply Steri-Strips where sutures already have been removed, and notify the health care provider.
4. Stop the suture removal, apply Steri-Strips where sutures already have been removed, and notify the health care provider.
The student nurse is correct when indicating which drain is providing suction-assisted drainage? 1. Jackson-Pratt 2. Hemovac 3. Penrose 4. Wound VAC system 5. T-tube system
3. Penrose
What statement concerning unrelieved pain is most correct? 1. Unrelieved pain is a normal expectation after major surgery. 2. Patients with cancer diagnoses can expect to experience unrelieved pain. 3. Physiologic and psychological complications can result from unrelieved pain. 4. Although unrelieved pain is stressful and annoying, it is not as important as other physical care needs.
3. Physiologic and psychological complications can result from unrelieved pain.
The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation? 1. A urinary output of 20 mL/hour 2. A temperature of 37.6°C (99.6°F) 3. A blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing
1. A urinary output of 20 mL/hour
A 42-year-old patient has palpated a small lump in her left breast. She has scheduled an appointment with her health care provider. Which test will be used to make a definite diagnosis of a benign or malignant tumor of her breast? 1. Biopsy 2. Mammography 3. Tomography 4. Ultrasonography
1. Biopsy
A 61-year-old patient is receiving chemotherapy. The patient becomes anemic and has petechiae and ecchymoses. What side effect is the patient experiencing? 1. Bone marrow suppression 2. Cardiac suppression 3. Liver toxicity 4. Pulmonary toxicity
1. Bone marrow suppression
A 52-year-old patient admitted for deep vein thrombosis of the left internal iliac vein complains of excruciating pain in his left leg. What is the most appropriate response by the nurse? 1. "Pain is what you say it is; I will assist you in whatever way I can." 2. "Your pain is an unpleasant sensation caused by inflammation of the vein and difficult to control." 3. "Your pain is one of the cardinal signs of inflammation." 4. "I know you are in pain, but it is important that we guard against possible addiction to opioids."
1. "Pain is what you say it is; I will assist you in whatever way I can."
The nurse is admitting a patient into the room on the surgical unit after abdominal surgery. There is a 1.5-cm-diameter spot of serosanguineous drainage on the dressing. What should the nurse do at this time? 1. Notify the physician of bleeding from the wound. 2. Note the amount of drainage and continue to monitor. 3. Remove the dressing to check for bleeding from the suture line. 4. Apply gentle pressure to the site for 5 minute
2. Note the amount of drainage and continue to monitor.
A 58-year-old patient with colon cancer is receiving combined radiation therapy and chemotherapy. He has developed diarrhea. The patient asks the nurse why he is now having diarrhea. What nursing response is most accurate? 1. "Your diagnosis of colon cancer has caused diarrhea." 2. "Because you are unable to eat or drink much during treatment, you are having loose stools." 3. "Radiation is very irritating to the lining of your GI tract, which may have caused diarrhea." 4. "You most likely have an imbalance in your fluid and electrolyte levels."
3. "Radiation is very irritating to the lining of your GI tract, which may have caused diarrhea."
The nurse is caring for a client who is scheduled for surgery. The client states concern about the surgical procedure. How would the nurse initially address the client's concerns? 1. Tell the client that preoperative fear is normal. 2. Explain all nursing care and possible discomfort that may result. 3. Ask the client to discuss information known about the planned surgery. 4. Provide explanations about the procedures involved in the planned surgery.
3. Ask the client to discuss information known about the planned surgery.
After surgery for a total knee replacement, a patient was given an epidural catheter for fentanyl epidural analgesia. What is the most important nursing intervention? 1. Administer additional analgesic medications as needed. 2. Change the epidural dressing every shift. 3. Assess respiratory rate. 4. Encourage ambulation.
3. Assess respiratory rate.
What is the priority responsibility of the nurse related to pain? 1. Leave the patient alone to rest. 2. Help the patient appear to not be in pain. 3. Believe what the patient says about pain. 4. Assume responsibility for eliminating the patient's pain.
3. Believe what the patient says about pain.
The nurse monitors the 4-day postoperative client who underwent abdominal surgery. Vital signs are: temperature: 37.9°C (100.2°F), pulse 104 beats per minute, respirations 22 breaths per minute, blood pressure 128/74 mm Hg. Oxygen saturation is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which postoperative problem? 1. Hypoxia 2. Atelectasis 3. Pneumonia 4. Fluid overload
3. Pneumonia
The health care provider has ordered an abdominal binder placed around a surgical patient with a new abdominal wound. What is the likely indication for this intervention? 1. Collection of wound drainage 2. Reduction of abdominal swelling 3. Reduction of stress on the abdominal incision 4. Stimulation of peristalsis from direct pressure
3. Reduction of stress on the abdominal incision
The nurse is assisting with creating a plan of care for a client with pancytopenia as a result of chemotherapy. The nurse would suggest including which in the plan of care? Select all that apply. 1. Restricting all visitors 2. Restricting fluid intake 3. Restricting fresh fruits and vegetables in the diet 4. Applying a face mask to the client if outside the client room 5. Inserting an indwelling urinary catheter to prevent skin breakdown
3. Restricting fresh fruits and vegetables in the diet 4. Applying a face mask to the client if outside the client room
Which is true regarding cancer prevention and health care promotion behaviors for patients with a diagnosis of cancer? 1. They will not decrease the risk of developing a second malignancy. 2. They will not be affected by personal choices related to diet and smoking. 3. They are increasingly important with the growing population of cancer survivors. 4. They would include only routine physical examinations.
3. They are increasingly important with the growing population of cancer survivors.
A patient is recovering from a right lobectomy. The nurse is going to assist in splinting the patient's incision so that the patient can cough and breathe deeply. When should an intramuscular analgesic be administered to achieve the most therapeutic effect? 1. After the procedure so the patient can rest 2. 15 minutes before the procedure 3. 1 hour before the procedure 4. 30 minutes before the procedure
4. 30 minutes before the procedure
Which opioid is no longer a drug of choice for managing pain because of its toxic complications, such as causing seizures? 1. Codeine 2. Morphine 3. Meperidine 4. Fentanyl
3. Meperidine
The patient has been diagnosed with terminal cancer. Which of the following is the most therapeutic approach by the nurse? 1. Anti-inflammatory agents are effective analgesics for severe pain. 2. Opioids should be withheld because they are addictive. 3. Pain is what the patient says it is. 4. One can increase one's tolerance for pain.
3. Pain is what the patient says it is.
The nurse is caring for a postoperative client who has a Jackson-Pratt drain inserted into the surgical wound. Which actions would the nurse take in the care of the drain? Select all that apply. 1. Check the drain for patency. 2. Check that the drain is decompressed. 3. Observe for bright red, bloody drainage. 4. Maintain aseptic technique when emptying. 5. Empty the drain when it is half full and every 8 to 12 hours. 6. Secure the drain by curling or folding it and taping it firmly to the body.
1. Check the drain for patency. 2. Check that the drain is decompressed. 3. Observe for bright red, bloody drainage. 4. Maintain aseptic technique when emptying. 5. Empty the drain when it is half full and every 8 to 12 hours.
A patient has received a diagnosis of stage I breast cancer. She is receiving adjuvant chemotherapy and radiation therapy after a lumpectomy. What teaching point should be included in this patient's plan of care? (Select all that apply.) 1. Chemotherapy-related hair loss is usually temporary. 2. All chemotherapeutic agents result in alopecia. 3. Hair that grows back may have a different texture and color. 4. Hair loss is most often related to radiation treatments. 5. Avoid the use of lotions on the skin at and near the site of radiation treatment, unless prescribed.
1. Chemotherapy-related hair loss is usually temporary. 3. Hair that grows back may have a different texture and color. 4. Hair loss is most often related to radiation treatments. 5. Avoid the use of lotions on the skin at and near the site of radiation treatment, unless prescribed.
The client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic studies will be prescribed? Select all that apply. 1. Chest x-ray 2. Echocardiography 3. Electrocardiography 4. Cervical radiography 5. Pulmonary function studies
1. Chest x-ray 5. Pulmonary function studies
What are the traditional purposes of a wet-to-dry dressing? (Select all that apply.) 1. Debridement 2. Cooling 3. Comfort 4. Prevention of infection 5. Maintenance of moisture at the wound bed
1. Debridement 5. Maintenance of moisture at the wound bed
The nurse is assisting with creating a plan of care for the client with multiple myeloma. Which nursing intervention needs to be included to assess for and prevent renal failure for this client? Select all that apply. 1. Encouraging fluids 2. Providing frequent oral care 3. Coughing and deep breathing 4. Monitoring the red blood cell count 5. Monitoring serum calcium and uric acid levels
1. Encouraging fluids 5. Monitoring serum calcium and uric acid levels
A patient underwent surgery for lysis of adhesions. He is transferred from the PACU to his room on the surgical floor. During the immediate postoperative period on the surgical floor, how often should the nurse measure blood pressure, pulse, and respirations? 1. Every 15 minutes 2. Every 5 minutes 3. Every 20 minutes 4. Every 30 minutes
1. Every 15 minutes
The client is admitted to the hospital with a diagnosis of suspected Hodgkin's disease. Which sign(s)/(symptom(s) of the client are associated with Hodgkin's disease? Select all that apply . 1. Fatigue 2. Joint pain 3. Weakness 4. Weight gain 5. Night sweats 6. Enlarged lymph nodes
1. Fatigue 3. Weakness 5. Night sweats 6. Enlarged lymph nodes
The nurse is assisting in creating a plan of care for a client who is scheduled for surgery. The nurse would include which activities in the nursing care plan for the client on the day of surgery? Select all that apply. 1. Have the client void before surgery. 2. Avoid oral hygiene and rinsing with mouthwash. 3. Verify that the client has not eaten for the last 24 hours. 4. Determine that the client has signed the informed consent for the surgical procedure. 5. Report immediately any slight increase in blood pressure or pulse from the client's baseline vital signs.
1. Have the client void before surgery. 4. Determine that the client has signed the informed consent for the surgical procedure.
The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which pertinent client data would the nurse report to the surgeon before the surgery? Select all that apply. 1. Is allergic to penicillin 2. Quit smoking 3 months earlier 3. History of tonsillectomy at the age of 7 years 4. Wonders if the surgery could cause incontinence 5. Takes daily multivitamin and calcium supplement 6. History of deep venous thrombosis (DVT) in right leg 10 years earlier
1. Is allergic to penicillin 2. Quit smoking 3 months earlier 4. Wonders if the surgery could cause incontinence 6. History of deep venous thrombosis (DVT) in right leg 10 years earlier
The nurse is reviewing the laboratory results of a client who is receiving chemotherapy and notes that the platelet count is 10,000 mm3. On the basis of this laboratory value, the nurse would perform which intervention(s)? Select all that apply. 1. Monitor stools for occult blood. 2. Keep away from persons who have colds or feel ill. 3. Instruct the client not to bend over at the waist or lift. 4. Floss teeth and rinse mouth with mouthwash after every meal. 5. Instruct the client to blow nose very gently without blocking either nostril.
1. Monitor stools for occult blood. 3. Instruct the client not to bend over at the waist or lift. 5. Instruct the client to blow nose very gently without blocking either nostril.
1. The nurse is caring for a client who is receiving an intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. During an inspection of the site, the nurse notes redness and swelling. The nurse needs to take which appropriate action? 1. Notify the registered nurse immediately. 2. Administer pain medication to reduce the discomfort. 3. Apply ice and maintain the infusion rate, as prescribed. 4. Elevate the extremity of the IV site, and slow the infusion.
1. Notify the registered nurse immediately.
The nurse is caring for a patient following a colon resection with a transverse colostomy. The patient is experiencing pain at the operative site and surrounding tissues. To assist this patient in the prevention of postoperative pulmonary complications, what interventions will be most helpful preoperatively? (Select all that apply.) 1. Ask the surgeon to prescribe IPPB treatment. 2. Teach and observe the patient perform leg exercises. 3. Teach and observe the patient use an incentive spirometer correctly. 4. Tell the patient that lack of an effective cough may result in pulmonary complications. 5. Ask the patient to perform a return demonstration of controlled coughing. 6. Assist the patient with splinting the incision during coughing and deep breathing. 7. Medicate the patient with pain medication at least 30 minutes before ambulation or activity
3. Teach and observe the patient use an incentive spirometer correctly. 5. Ask the patient to perform a return demonstration of controlled coughing.
The nurse has recommended the patient consider music therapy to manage pain after an upcoming surgery. What information should be provided to the patient? (Select all that apply.) 1. Music therapy works best when selections are instrumental instead of songs containing words. 2. Music therapy is successful for at least 50% of people who try it. 3. Music therapy promotes relaxation and takes the focus away from the pain being experienced. 4. Music therapy is easily a self-directed means of pain management. 5. Music therapy's success is limited to postoperative pain
2. Music therapy is successful for at least 50% of people who try it. 3. Music therapy promotes relaxation and takes the focus away from the pain being experienced. 4. Music therapy is easily a self-directed means of pain management.
When the drainage in a Hemovac reservoir is emptied, which nursing action is essential for reestablishing the negative pressure within this drainage device? 1. Fill the reservoir with sterile normal saline solution. 2. Secure the reservoir to the skin near the wound. 3. Compress the reservoir and close the vent. 4. Open the vent, allowing the reservoir to fill with air.
3. Compress the reservoir and close the vent.
The nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory finding is indicative of the massive cell destruction that occurs with the chemotherapy? 1. Anemia 2. Decreased platelets 3. Increased uric acid level 4. Decreased leukocyte count
3. Increased uric acid level
The client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. Besides treatment of the lung cancer, the nurse anticipates that which intervention(s) may be prescribed to treat the SIADH? Select all that apply . 1. Increase fluid intake 2. Decreased sodium intake 3. Institute safety measures 4. Frequent monitoring of sodium blood levels 5. Gather data about the neurological status frequently 6. Medication that is antagonistic to antidiuretic hormone (ADH)
3. Institute safety measures 4. Frequent monitoring of sodium blood levels 5. Gather data about the neurological status frequently 6. Medication that is antagonistic to antidiuretic hormone (ADH)
Which nursing entry is the most complete in its description of a 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 × 4 applied 4. Incisional edges approximated without erythema or exudate; two 4 × 4s applied
4. Incisional edges approximated without erythema or exudate; two 4 × 4s applied
The client is hospitalized for the insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. Which is the immediate nursing action? 1. Reinsert the implant into the vagina. 2. Call the primary health care provider (PHCP). 3. Pick up the implant with gloved hands and flush it down the toilet. 4. Pick up the implant with long-handled forceps and place into a lead container.
4. Pick up the implant with long-handled forceps and place into a lead container.
What is the correct procedure for the wet-to-dry dressing method? 1. Place dry gauze into the wound and remove it when it is wet. 2. Medicate the patient for pain after you change the dressing. 3. Complete this type of dressing change just once a day. 4. Place moist gauze into the wound and remove it at prescribed intervals.
4. Place moist gauze into the wound and remove it at prescribed intervals.
The nurse educator is discussing the importance of the reduction of carcinogens in primary prevention of cancer. Which risk factor is considered significant in many types of cancer? 1. Diet low in fat 2. Occasional moderate use of alcohol 3. High pollen count in the environment 4. Smoking
4. Smoking.
A patient admitted with severe cellulitis of the left breast states, "I have a severe burning pain, and it feels like my breast is on fire." She rates her pain as 7 on the 0-to-10 pain assessment scale. How would this collection of data by the nurse in assessing the patient's pain be classified 1. Deductive 2. Speculative 3. Objective 4. Subjective
4. Subjective
Which statement is correct in regard to the use of an abdominal binder? 1. It replaces the need for underlying dressings. 2. It should be kept loose for patient comfort. 3. The patient has to be sitting or standing when it is applied. 4. The patient must have adequate ventilatory capacity.
4. The patient must have adequate ventilatory capacity.
