Med. Surg Test #1 Study Questions

Maintaining an aseptic environment in the OR is essential to patient safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field? A) 2 feet B) 18 inches C) 1 foot D) 6 inches

c) 1 foot

An elderly woman diagnosed with osteoarthritis has been referred for care. The patient has difficulty ambulating because of chronic pain. When creating a nursing care plan, what intervention may the nurse use to best promote the patients mobility? A)Motivate the patient to walk in the afternoon rather than the morning. B)Encourage the patient to push through the pain in order to gain further mobility. C)Administer an analgesic as ordered to facilitate the patients mobility. D)Have another person with osteoarthritis visit the patient.

c) administer an analgesic as ordered to facilitate the patients mobility

The nurse is performing wound care on a 68-year-old postsurgical patient. Which of the following practices violates the principles of surgical asepsis? A)Holding sterile objects above the level of the nurses waist B)Considering a 1 inch (2.5 cm) edge around the sterile field as being contaminated C)Pouring solution onto a sterile field cloth D) opening the outmost flap of a sterile package away from the body

c) pouring solution onto a sterile field cloth

A patient who is recovering from a stroke expresses frustration about his care to the nurse, stating, It seems like everyone sees me as just a problem that needs fixing. This patients statement is suggestive of what model of disability? A) Biopsychosocial model b) social model c) rehabilitation mode d)interface model

c) rehabilitation model

the perioperative nurse is constantly assessing the surgical patient for s/s of complications of surgery. which symptom should first signal to the nurse the possibility that the patient is developing malignant hyperthermia? A) increased temperature B) oliguria C) tachycardia D) hypotension

c) tachycardia

A patient with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath? A) Total lung capacity B)Forced vital capacity C)Tidal volume D) residual volume

c) tidal volume

The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? A) 20 cm H2O B) 15 cm H2O C) 10 cm H2O D) 5cmH2O

A) 20 cm H2O

A circulating nurse provides care in a surgical department that has multiple surgeries scheduled for the day. The nurse should know to monitor which patient most closely during the intraoperative period because of the increased risk for hypothermia? A) A 74-year-old woman with a low body mass index B) A 17-year-old boy with traumatic injuries C) A 45-year-old woman having an abdominal hysterectomy D) A 13-year-old girl undergoing craniofacial surgery

A) A 74-year-old woman with a low body mass index

A surgical patient has just been admitted to the unit from PACU with patient-controlled analgesia (PCA). The nurse should know that the requirements for safe and effective use of PCA include what? A) A clear understanding of the need to self-dose B) An understanding of how to adjust the medication dosage C) A caregiver who can administer the medication as ordered D) An expectation of infrequent need for analgesia

A) A clear understanding of the need to self-dose

A case manager is responsible for ensuring that patients meet the criteria for diagnoses of chronic conditions in order to ensure their eligibility for federal programs. Which of these definitions may not apply for legal purposes? A) A person who is temporarily disabled but later return to full functioning. B) A person who is disabled and cannot expect a return to full functioning. C) A person whose disability is the result of a developmental disorder. D) A person whose disability is the result of a traumatic injury.

A) A person who is temporarily disabled but later return to full functioning.

An intraoperative nurse is applying interventions that will address surgical patients risks for perioperative positioning injury. Which of the following factors contribute to this increased risk for injury in the intraoperative phase of the surgical experience? Select all that apply. A) Absence of reflexes B) Diminished ability to communicate C) Loss of pain sensation D) Nausea resulting from anesthetic E) Reduced blood pressure

A) Absence of reflexes B) Diminished ability to communicate C) Loss of pain sensation

The nurse is performing the shift assessment of a postsurgical patient. The nurse finds his mental status, level of consciousness, speech, and orientation are intact and at baseline, but the patient tells you he is very anxious. What should the nurse do next? A) Assess the patients oxygen levels. B) Administer antianxiety medications. C) Page the patients the physician. D) Initiate a social work referral.

A) Assess the patients oxygen levels.

The community nurse is caring for a patient who has paraplegia following a farm accident when he was an adolescent. This patient is now 64 years old and has just been diagnosed with congestive heart failure. The patient states, Im so afraid about what is going to happen to me. What would be the best nursing intervention for this patient? A) Assist the patient in making suitable plans for his care. B) Take him to visit appropriate long-term care facilities. C) Give him pamphlets about available community resources. D) Have him visit with other patients who have congestive heart failure.

A) Assist the patient in making suitable plans for his care.

The nurse has assessed a patients family history for three generations. The presence of which respiratory disease would justify this type of assessment? A) Asthma B) Obstructive sleep apnea C) Community-acquired pneumonia D) Pulmonary edema

A) Asthma

The perioperative nurse is providing care for a patient who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The patient is reluctant to ambulate, citing the need to recover in bed. For what complication is the patient most at risk? A) Atelectasis B) Anemia C) Dehydration D) Peripheral edema

A) Atelectasis

The medical nurse who works on a pulmonology unit is aware that several respiratory conditions can affect lung tissue compliance. The presence of what condition would lead to an increase in lung compliance? A) Emphysema B) Pulmonary fibrosis C) Pleural effusion D) Acute respiratory distress syndrome (ARDS)

A) Emphysema

The OR nurse is participating in the appendectomy of a 20 year-old female patient who has a dangerously low body mass index. The nurse recognizes the patients consequent risk for hypothermia. What action should the nurse implement to prevent the development of hypothermia? A) Ensure that IV fluids are warmed to the patients body temperature. B) Transfuse packed red blood cells to increase oxygen carrying capacity. C) Place warmed bags of normal saline at strategic points around the patients body. D) Monitor the patients blood pressure and heart rate vigilantly.

A) Ensure that IV fluids are warmed to the patients body temperature.

In your role as a school nurse, you are presenting at a high school health fair and are promoting the benefits of maintaining a healthy body weight. You should refer to reductions in the risks of what diseases? Select all that apply. A) Heart disease B) Stroke C) Cancer D) Diabetes E) Hypertension

A) Heart disease B) Stroke D) Diabetes E) Hypertension

The rehabilitation nurse is working closely with a patient who has a new orthosis following a knee injury. What are the nurses responsibilities to this patient? Select all that apply. A) Help the patient learn to apply and remove the orthosis. B) Teach the patient how to care for the skin that comes in contact with the orthosis. C) Assist in the initial fitting of the orthosis. D) Assist the patient in learning how to move the affected body part correctly. E) Collaborate with the physical therapist to set goals for care.

A) Help the patient learn to apply and remove the orthosis. B) Teach the patient how to care for the skin that comes in contact with the orthosis. D) Assist the patient in learning how to move the affected body part correctly. E) Collaborate with the physical therapist to set goals for care.

The perioperative nurse has completed the presurgical assessment of an 82-year-old female patient who is scheduled for a left total knee replacement. When planning this patients care, the nurse should address the consequences of the patients aging cardiovascular system. These include an increased risk of which of the following? A) Hypervolemia B) Hyponatremia C) Hyperkalemia D) Hyperphosphatemia

A) Hypervolemia

The PACU nurse is caring for a 45-year-old male patient who had a left lobectomy. The nurse is assessing the patient frequently for airway patency and cardiovascular status. The nurse should know that the most common cardiovascular complications seen in the PACU include what? Select all that apply. A) Hypotension B) Hypervolemia C) Heart murmurs D) Dysrhythmias E) Hypertension

A) Hypotension D) Dysrhythmias E) Hypertension

The nurse is preparing an elderly patient for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the patient? A) Hypothermia B) Pulmonary edema C) Cerebral ischemia D) Arthritis

A) Hypothermia

The nurse is caring for a patient with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes what? A) Impaired gas exchange B) Collapsed bronchial structures C) Necrosis of the alveoli D) Closed bronchial tree

A) Impaired gas exchange

A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this patient is necessary. What is the main rationale for this? A) Maintaining a patent airway B) Preventing the need for suctioning C) Maintaining the sterility of the patients airway D) Increasing the patients lung compliance

A) Maintaining a patent airway

A patient on the medical unit has told the nurse that he is experiencing significant dyspnea, despite that he has not recently performed any physical activity. What assessment question should the nurse ask the patient while preparing to perform a physical assessment? A) On a scale from 1 to 10, how bad would rate your shortness of breath? B) When was the last time you ate or drank anything? C) Are you feeling any nausea along with your shortness of breath? D) Do you think that some medication might help you catch your breath?

A) On a scale from 1 to 10, how bad would rate your shortness of breath?

The OR nurse acts in the circulating role during a patients scheduled cesarean section. For what task is this nurse solely responsible? A) Performing documentation B) Estimating the patients blood loss C) Setting up the sterile tables D) Keeping track of drains and sponges

A) Performing documentation

A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply. A) Post thoracotomy B) Spontaneous pneumothorax C) Need for postural drainage D) Chest trauma resulting in pneumothorax E) Pleurisy

A) Post thoracotomy B) Spontaneous pneumothorax D) Chest trauma resulting in pneumothorax

The nurse is caring for an 88-year-old patient who is recovering from an ileac-femoral bypass graft. The patient is day 2 postoperative and has been mentally intact, as per baseline. When the nurse assesses the patient, it is clear that he is confused and has been experiencing disturbed sleep patterns and impaired psychomotor skills. What should the nurse suspect is the problem with the patient? A) Postoperative delirium B) Postoperative dementia C) Senile dementia D) Senile confusion

A) Postoperative delirium

The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. Which criterion will determine when the nurse should allow the patient to drink fluids? A) Presence of a cough and gag reflex B)Absence of nausea C)Ability to demonstrate deep inspiration D)Oxygen saturation of 92%

A) Presence of a cough and gag reflex

The nurse is discharging a patient home from an outpatient surgery center. The nurse has reviewed all of the discharge instructions with the patient and her caregiver. What else should the nurse do before discharging the patient from the facility? Select all that apply. A) Provide all discharge instructions in writing. B) Provide the nurses or surgeons contact information. C) Give prescriptions to the patient. D) Irrigate the patients incision and perform a sterile dressing change. E) Administer a bolus dose of an opioid analgesic.

A) Provide all discharge instructions in writing. B) Provide the nurses or surgeons contact information. C) Give prescriptions to the patient.

A patient has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the patient discouraged and saddened. The client states, I am recovering so slowly. I really thought I would be better by now. What nursing action should the nurse prioritize? A) Provide emotional support to the patient and family. B) Schedule a visit to the patients primary physician within 24 hours. C) Notify the physician that the patient needs a referral to a psychiatrist. D) Place a referral for a social worker to visit the patient.

A) Provide emotional support to the patient and family.

The nurse has admitted a patient who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue? A) Pulmonary function studies B) Exercise tolerance tests C) Arterial blood gas values D) Chest x-ray

A) Pulmonary function studies

The nurse is caring for a patient who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning the patient from a ventilator, the nurse is aware that the weaning of the patient will progress in what order? A) Removal from the ventilator, tube, and then oxygen B) Removal from oxygen, ventilator, and then tube C) Removal of the tube, oxygen, and then ventilator D) Removal from oxygen, tube, and then ventilator

A) Removal from the ventilator, tube, and then oxygen

The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? A) Stable vital signs and ABGs B) Pulse oximetry above 80% and stable vital signs C) Stable nutritional status and ABGs D) Normal orientation and level of consciousness

A) Stable vital signs and ABGs

An OR nurse is participating in an interdisciplinary audit of infection control practices in the surgical department. The nurse should know that a basic guideline for maintaining surgical asepsis is what? A) Sterile surfaces or articles may touch other sterile surfaces. B)Sterile supplies can be used on another patient if the packages are intact. C)The outer lip of a sterile solution is considered sterile. D) The scrub nurse may pour a sterile solution from a nonsterile bottle.

A) Sterile surfaces or articles may touch other sterile surfaces.

The ED nurse is assessing a patient complaining of dyspnea. The nurse auscultates the patients chest and hears wheezing throughout the lung fields. What might this indicate? A) The patient has a narrowed airway. B) The patient has pneumonia. C) The patient needs physiotherapy. D) The patient has a hemothorax.

A) The patient has a narrowed airway.

A patient with a spinal cord injury is being assessed by the nurse prior to his discharge home from the rehabilitation facility. The nurse is planning care through the lens of the interface model of disability. Within this model, the nurse will plan care based on what belief? A) The patient has the potential to function effectively despite his disability. B) The patients disabling condition does not have to affect his lifestyle. C) The patient will not require care from professional caregivers in the home setting. D) The patients disability is the most salient aspect of his personal identity.

A) The patient has the potential to function effectively despite his disability.

The circulating nurse in an outpatient surgery center is assessing a patient who is scheduled to receive moderate sedation. What principle should guide the care of a patient receiving this form of anesthesia? A) The patient must never be left unattended by the nurse. B) The patient should begin a course of antiemetics the day before surgery. C) The patient should be informed that he or she will remember most of the procedure. D) The patient must be able to maintain his or her own airway

A) The patient must never be left unattended by the nurse.

The perioperative nurse is preparing to discharge a female patient home from day surgery performedunder general anesthetic. What instruction should the nurse give the patient prior to the patient leaving the hospital? A) The patient should not drive herself home. B) The patient should take an OTC sleeping pill for 2 nights. C) The patient should attempt to eat a large meal at home to aid wound healing. D) The patient should remain in bed for the first 48 hours postoperative.

A) The patient should not drive herself home.

A nurse educator is reviewing the implications of the oxyhemoglobin dissociation curve with regard to the case of a current patient. The patient currently has normal hemoglobin levels, but significantly decreased SaO2 and PaO2 levels. What is an implication of this physiological state? A) The patients tissue demands may be met, but she will be unable to respond to physiological stressors. B) The patients short-term oxygen needs will be met, but she will be unable to expel sufficient CO2. C) The patient will experience tissue hypoxia with no sensation of shortness of breath or labored breathing. D) The patient will experience respiratory alkalosis with no ability to compensate.

A) The patients tissue demands may be met, but she will be unable to respond to physiological stressors.

The nurse is performing a respiratory assessment of an adult patient and is attempting to distinguish between vesicular, bronchovesicular, and bronchial (tubular) breath sounds. The nurse should distinguish between these normal breath sounds on what basis? A) Their location over a specific area of the lung B) The volume of the sounds C) Whether they are heard on inspiration or expiration D) Whether or not they are continuous breath sounds

A) Their location over a specific area of the lung

A patient who underwent a bowel resection to correct diverticula suffered irreparable nerve damage. during the case review, the team is determining if incorrect positioning may have contributed to the patients nerve damage. what surgical position places the patient at highest risk for nerve damage? A) Trendelenburg B) prone C) dorsal recumbent D) lithotomy

A) Trendelenburg

You are creating a nursing care plan for a patient who is hospitalized following right total hip replacement. What nursing action should you specify to prevent inward rotation of the patients hip when the patient is in a partial lateral position? A) Use of an abduction pillow between the patients legs B) Alignment of the head with the spine using a pillow C) Support of the lower back with a small pillow D) Placement of trochanter rolls under the greater trochanter

A) Use of an abduction pillow between the patients legs

An adult patient has just been admitted to the PACU following abdominal surgery. As the patient begins to awaken, he is uncharacteristically restless. The nurse checks his skin and it is cold, moist, and pale. The nurse concerned the patient may be at risk for what? A)Hemorrhage and shock B)Aspiration C)Postoperative infection D) hypertension and dysrhythmias

A) hemorrhage and shock

You are the nurse creating the care plan for a patient newly admitted to your rehabilitation unit. The patient is an 82-year-old patient who has had a stroke but who lived independently until this event. What is a goal that you should include in this patients nursing care plan? A) Maintain joint mobility. B) Refer to social services. C) Ambulate three times every day. D) Perform passive range of motion twice daily.

A) maintain joint mobility

The nurse is caring for an older adult patient who is receiving rehabilitation following an ischemic stroke. A review of the patients electronic health record reveals that the patient usually defers her self- care to family members or members of the care team. What should the nurse include as an initial goal when planning this patients subsequent care? A)The patient will demonstrate independent self-care. B)The patients family will collaboratively manage the patients care. C) The nurse will delegate the patients care to a nursing assistant. D)The patient will participate in a life skills program.

A) the patient will demonstrate independent self-care

The clinic nurse is caring for a patient who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The patient asks, What exactly is this test for? What would be the nurses best response? A)A PFT measures how much air moves in and out of your lungs when you breathe. B) A PFT measures how much energy you get from the oxygen you breathe. C)A PFT measures how elastic your lungs are. D)A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood.

A)A PFT measures how much air moves in and out of your lungs when you breathe.

When creating plans of nursing care for patients who are undergoing surgery using general anesthetic, what nursing diagnoses should the nurse identify? Select all that apply. A)Disturbed sensory perception related to anesthetic B)Risk for impaired nutrition: less than body requirements related to anesthesia C)Risk of latex allergy response related to surgical exposure D)Disturbed body image related to anesthesia E) anxiety related to surgical concerns

A)Disturbed sensory perception related to anesthetic C)Risk of latex allergy response related to surgical exposure E) anxiety related to surgical concerns

A patient waiting in the presurgical holding area asks the nurse, Why exactly do they have to put a breathing tube into me? My surgery is on my knee. What is the best rationale for intubation during a surgical procedure that the nurse should describe? A)The tube provides an airway for ventilation. B)The tube protects the patients esophagus from trauma. C)The patient may receive an antiemetic through the tube. D)The patients vital signs can be monitored with the tube.

A)The tube provides an airway for ventilation.

An adult patients current goals of rehabilitation focus primarily on self-care. What is a priority when teaching a patient who has self-care deficits in ADLs? A)To provide an optimal learning environment with minimal distractions B) To describe the evidence base for any chosen interventions C) To help the patient become aware of the requirements of assisted-living centers D) To ensure that the patient is able to perform self-care without any aid from caregivers

A)To provide an optimal learning environment with minimal distractions

A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? A)To remove air from the pleural space B)To drain copious sputum secretions C)To monitor bleeding around the lungs D)To assist with mechanical ventilation

A)To remove air from the pleural space

A patient asks the nurse why an infection in his upper respiratory system is affecting the clarity of his speech. Which structure serves as the patients resonating chamber in speech? A) Trachea B) Pharynx C) Paranasal sinuses D) Larynx

C) Paranasal sinuses

The nurse is assessing a newly admitted medical patient and notes there is a depression in the lower portion of the patients sternum. This patients health record should note the presence of what chest deformity? A) A barrel chest B) A funnel chest C) A pigeon chest D) Kyphoscoliosis

B) A funnel chest

What would the critical care nurse recognize as a condition that may indicate a patients need to have a tracheostomy? A) A patient has a respiratory rate of 10 breaths per minute. B) A patient requires permanent ventilation. C) A patient exhibits symptoms of dyspnea. D) A patient has respiratory acidosis.

B) A patient requires permanent ventilation.

The nurse is creating the plan of care for a patient who is status postsurgery for reduction of a femur fracture. What is the most important short-term goal for this patient? A) relief of pain B) Adequate respiratory function C) Resumption of activities of daily living (ADLs) D) Unimpaired wound healing

B) Adequate respiratory function

The nurse is performing a respiratory assessment of a patient who has been experiencing episodes of hypoxia. The nurse is aware that this is ultimately attributable to impaired gas exchange. On what factor does adequate gas exchange primarily depend? A) An appropriate perfusiondiffusion ratio B) An adequate ventilationperfusion ratio C) Adequate diffusion of gas in shunted blood D) Appropriate blood nitrogen concentration

B) An adequate ventilationperfusion ratio

The OR will be caring for a patient who will receive a transsacral block. For what patient would the use of a transsacral block be appropriate for pain control? A) A middle-aged man who is scheduled for a thoracotomy B) An older adult man who will undergo an inguinal hernia repair C) A 50-year-old woman who will be having a reduction mammoplasty D) A child who requires closed reduction of a right humerus fracture

B) An older adult man who will undergo an inguinal hernia repair

The patients surgery is nearly finished and the surgeon has opted to use tissue adhesives to close the surgical wound. This requires the nurse to prioritize assessments related to what complication? A) Hypothermia B) Anaphylaxis C) Infection D) Malignant hyperthermia

B) Anaphylaxis

The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess? A) Fluid intake for the last 24 hours B) Baseline arterial blood gas (ABG) levels C) Prior outcomes of weaning D) Electrocardiogram (ECG) results

B) Baseline arterial blood gas (ABG) levels

The physician has ordered continuous positive airway pressure (CPAP) with the delivery of a patients high-flow oxygen therapy. The patient asks the nurse what the benefit of CPAP is. What would be the nurses best response? A) CPAP allows a higher percentage of oxygen to be safely used. B) CPAP allows a lower percentage of oxygen to be used with a similar effect. C) CPAP allows for greater humidification of the oxygen that is administered. D) CPAP allows for the elimination of bacterial growth in oxygen delivery systems.

B) CPAP allows a lower percentage of oxygen to be used with a similar effect.

A patient is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what? A) Correct use of a ventilator B) Correct use of incentive spirometry C) Correct use of a mini-nebulizer D) Correct technique for rhythmic breathing

B) Correct use of incentive spirometry

The nurse doing rounds at the beginning of a shift notices a sputum specimen in a container sitting on the bedside table in a patients room. The nurse asks the patient when he produced the sputum specimen and he states that the specimen is about 4 hours old. What action should the nurse take? A) Immediately take the sputum specimen to the laboratory. B) Discard the specimen and assist the patient in obtaining another specimen. C) Refrigerate the sputum specimen and submit it once it is chilled. D) Add a small amount of normal saline to moisten the specimen.

B) Discard the specimen and assist the patient in obtaining another specimen.

While the surgical patient is anesthetized, the scrub nurse hears a member of the surgical team make an inappropriate remark about the patients weight. How should the nurse best respond? A) Ignore the comment because the patient is unconscious. B) Discourage the colleague from making such comments. C) Report the comment immediately to a supervisor. D) Realize that humor is needed in the workplace.

B) Discourage the colleague from making such comments.

The nurse is preparing to change a patients abdominal dressing. The nurse recognizes the first step is to provide the patient with information regarding the procedure. Which of the following explanations should the nurse provide to the patient? A) The dressing change is often painful, and we will be giving you pain medication prior to the procedure so you do not have to worry. B) During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to C) The dressing change should not be painful, but you can never be sure, and infection is always a concern. D) The best time for doing a dressing change is during lunch so we are not interrupted. I will provide privacy, and it should not be painful.

B) During the dressing change, I will provide privacy at a time of your choosing, it should not be painful, and you can look at the incision and help with the procedure if you want to

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity? A) Bradycardia and frontal headache B) Dyspnea and substernal pain C) Peripheral cyanosis and restlessness D) Hypotension and tachycardia

B) Dyspnea and substernal pain

The surgeons preoperative assessment of a patient has identified that the patient is at a high risk for venous thromboembolism. Once the patient is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the patients risk of developing this complication? A) Maintain the head of the bed at 45 degrees or higher. B) Encourage early ambulation. C) Encourage oral fluid intake. D) Perform passive range-of-motion exercises every 8 hours.

B) Encourage early ambulation.

A sputum study has been ordered for a patient who has developed coarse chest crackles and a fever. At what time should the nurse best collect the sample? A) Immediately after a meal B) First thing in the morning C) At bedtime D) After a period of exercise

B) First thing in the morning

The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient? A) How to milk the chest tubing B) How to splint the incision when coughing C) how to take prophylactic antibiotics correctly D) how to manage the need for fluid restriction

B) How to splint the incision when coughing

While assessing a newly admitted patient you note the following: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. What nursing diagnosis do these signs and symptoms most clearly suggest? A) Ineffective health maintenance B) Impaired physical mobility C) Disturbed sensory perception: Kinesthetic D) Ineffective role performance

B) Impaired physical mobility

Verification that all required documentation is completed is an important function of the intraoperative nurse. The intraoperative nurse should confirm that the patients accompanying documentation includes which of the following? A) Discharge planning B) Informed consent C) Analgesia prescription D) Educational resources

B) Informed consent

The anesthetist is coming to the surgical admissions unit to see a patient prior to surgery scheduled for tomorrow morning. Which of the following is the priority information that the nurse should provide to the anesthetist during the visit? A) Last bowel movement B) Latex allergy C) Number of pregnancies D) Difficulty falling asleep

B) Latex allergy

A patient is being transferred from a rehabilitation setting to a long-term care facility. During this process, the nurse has utilized the referral system? Using this system achieves what goal of the patients care? A) Minimizing costs of the patients care B) Maintaining continuity of the patients care C) Maintain the nursing care plan between diverse sites D) Keeping the primary care provider informed

B) Maintaining continuity of the patients care

The nurse is caring for a patient with lung metastases who just underwent a mediastinotomy. What should be the focus of the nurses postprocedure care? A) Assisting with pulmonary function testing (PFT) B) Maintaining the patients chest tube C) Administering oral suction as needed D) Performing chest physiotherapy

B) Maintaining the patients chest tube

An OR nurse is teaching a nursing student about the principles of surgical asepsis as a requirement in the restricted zone of the operating suite. What personal protective equipment should the nurse wear at all times in the restricted zone of the OR? A) Reusable shoe covers B) Mask covering the nose and mouth C) Goggles D) Gloves

B) Mask covering the nose and mouth

A patient is 2 hours postoperative with a Foley catheter in situ. The last hourly urine output recorded for this patient was 10 mL. The tubing of the Foley is patent. What should the nurse do? A) Irrigate the Foley with 30 mL normal saline. B) Notify the physician and continue to monitor the hourly urine output closely. C) Decrease the IV fluid rate and massage the patients abdomen. D) Have the patient sit in high-Fowlers position.

B) Notify the physician and continue to monitor the hourly urine output closely.

You are the nurse caring for a female patient who developed a pressure ulcer as a result of decreased mobility. The nurse on the shift before you has provided patient teaching about pressure ulcers and healing promotion. You assess that the patient has understood the teaching by observing what? A) Patient performs range-of-motion exercises. B) Patient avoids placing her body weight on the healing site. C) Patient elevates her body parts that are susceptible to edema. D) Patient demonstrates the technique for massaging the wound site.

B) Patient avoids placing her body weight on the healing site.

The nursing instructor is discussing the difference between ambulatory surgical centers and hospital- based surgical units. A student asks why some patients have surgery in the hospital and others are sent to ambulatory surgery centers. What is the instructors best response? A) Patients who go to ambulatory surgery centers are more independent than patients admitted to the hospital. B) Patients admitted to the hospital for surgery usually have multiple health needs. C) In most cases, only emergency and trauma patients are admitted to the hospital. D) Patients who have surgery in the hospital are those who need to have anesthesia administered.

B) Patients admitted to the hospital for surgery usually have multiple health needs.

The nurse is assessing a patient who frequently coughs after eating or drinking. How should the nurse best follow up this assessment finding? A) Obtain a sputum sample. B) Perform a swallowing assessment. C) Inspect the patients tongue and mouth. D) Assess the patients nutritional status.

B) Perform a swallowing assessment.

A patient has been diagnosed with pulmonary hypertension, in which the capillaries in the alveoli are squeezed excessively. The nurse should recognize a disturbance in what aspect of normal respiratory function? A) Acidbase balance B) Perfusion C) Diffusion D) V entilation

B) Perfusion

The nurse is caring for a patient who is postoperative day 2 following a colon resection. While turning him, wound dehiscence with evisceration occurs. What should be the nurses first response? A) Return the patient to his previous position and call the physician. B) Place saline-soaked sterile dressings on the wound. C) Assess the patients blood pressure and pulse. D) Pull the dehiscence closed using gloved hands.

B) Place saline-soaked sterile dressings on the wound.

A postoperative patient rapidly presents with hypotension; rapid, thready pulse; oliguria; and cold, pale skin. The nurse suspects that the patient is experiencing a hemorrhage. What should be the nurses first action? A) Leave and promptly notify the physician. B) Quickly attempt to determine the cause of hemorrhage. C) Begin resuscitation. D) Put the patient in the Trendelenberg position.

B) Quickly attempt to determine the cause of hemorrhage.

The surgical patient is a 35-year-old woman who has been administered general anesthesia. The nurse recognizes that the patient is in stage II (the excitement stage) of anesthesia. Which intervention would be most appropriate for the nurse to implement during this stage? A) Rub the patients back. B) Restrain the patient. C)Encourage the patient to express feelings. D)Stroke the patients hand.

B) Restrain the patient.

A surgical patient has been in the PACU for the past 3 hours. What are the determining factors for the patient to be discharged from the PACU? Select all that apply. A) Absence of pain B) Stable blood pressure C) Ability to tolerate oral fluids D) Sufficient oxygen saturation E) Adequate respiratory function

B) Stable blood pressure D) Sufficient oxygen saturation E) Adequate respiratory function

The intraoperative nurse is implementing a care plan that addresses the surgical patients risk for vomiting. Interventions that address the potential for vomiting reduce the risk of what subsequent surgical complication? A)Impaired skin integrity B)Hypoxia C)Malignant hyperthermia D) Hypothermia

B)Hypoxia

A 39-year-old patient with paraplegia has been admitted to the hospital for the treatment of a sacral ulcer. The nurse is aware that the patient normally lives alone in an apartment and manages his ADLs independently. Before creating the patients plan of care, how should the nurse best identify the level of assistance that the patient will require in the hospital? A)Make referrals for assessment to occupational therapy and physical therapy. B) Talk with the patient about the type and level of assistance that he desires. C) Obtain the patients previous medical record and note what was done during his most recent admission. D) Apply a standardized care plan that addresses the needs of a patient with paraplegia.

B) Talk with the patient about the type and level of assistance that he desires.

The nurse knows that elderly patients are at higher risk for complications and adverse outcomes during the intraoperative period. What is the best rationale for this phenomenon? A) The elderly patient has a more angular bone structure than a younger person. B) The elderly patient has reduced ability to adjust rapidly to emotional and physical stress. C) The elderly patient has impaired thermoregulatory mechanisms, which increase susceptibility to hyperthermia. D) The elderly patient has an impaired ability to decrease his or her metabolic rate.

B) The elderly patient has reduced ability to adjust rapidly to emotional and physical stress.

The OR nurse is taking the patient into the OR when the patient informs the operating nurse that his grandmother spiked a 104F temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the patient? A) The patient may be experiencing presurgical anxiety. B) The patient may be at risk for malignant hyperthermia. C) The grandmothers surgery has minimal relevance to the patients surgery. D) The patient may be at risk for a sudden onset of postsurgical infection.

B) The patient may be at risk for malignant hyperthermia.

An initiative has been launched in a large hospital to promote the use of people-first language in formal and informal communication. What is the significance to the patient when the nurse uses people-first language? A) The nurse knows more clearly who the patient is. B) The person is of more importance to the nurse than the disability. C) The patients disability is the defining characteristic of the patients life. D) The nurse knows that the patients disability is a curable condition.

B) The person is of more importance to the nurse than the disability.

A patient is having her tonsils removed. The patient asks the nurse what function the tonsils normally serve. Which of the following would be the most accurate response? A) The tonsils separate your windpipe from your throat when you swallow. B) The tonsils help to guard the body from invasion of organisms. C) The tonsils make enzymes that you swallow and which aid with digestion. D) The tonsils help with regulating the airflow down into your lungs.

B) The tonsils help to guard the body from invasion of organisms.

During the care conference for a patient who has multiple chronic conditions, the case manager has alluded to the principles of the interface model of disability. What statement is most characteristic of this model? A) This patient should be free to plan his care without our interference. B) This patient can be empowered and doesnt have to be dependent. C) This patient was a very different person before the emergence of these health problems. D) This patients physiological problems are the priority over his psychosocial status.

B) This patient can be empowered and doesnt have to be dependent.

A patient has completed the acute treatment phase of care following a stroke and the patient will now begin rehabilitation. What should the nurse identify as the major goal of the rehabilitative process? A) To provide 24-hour, collaborative care for the patient B) To restore the patients ability to function independently C) To minimize the patients time spent in acute care settings D) To promote rapport between caregivers and the patient

B) To restore the patients ability to function independently

The nurse is caring for a patient who has just been transferred to the PACU from the OR. What is the highest nursing priority? A) Assessing for hemorrhage B)Maintaining a patent airway C) Managing the patients pain D) assessing vital signs every 30 minutes

B)Maintaining a patent airway

The PACU nurse is caring for a patient who has arrived from the OR. During the initial assessment, the nurse observes that the patients skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the patient is not breathing. What is the priority intervention? A)Check the patients oxygen saturation level, continue to monitor for apnea, and perform a focused assessment. B)Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw C)assess the arterial pulses, and place the patient in the Trendelenburg position D) reintubate the patient

B) Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw

A medical patient rings her call bell and expresses alarm to the nurse, stating, Ive just coughed up this blood. That cant be good, can it? How can the nurse best determine whether the source of the blood was the patients lungs? A) Obtain a sample and test the pH of the blood, if possible. B) Try to see if the blood is frothy or mixed with mucus. C) Perform oral suctioning to see if blood is obtained. D) Swab the back of the patients throat to see if blood is present.

B) Try to see if the blood is frothy or mixed with mucus.

A patient with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a patient in this position? A) Inform that physician that the patient is in a recumbent position and anticipate an order for a portable chest x-ray. B) Turn the patient to enable assessment of all the patients lung fields. C) Avoid turning the patient, and assess the accessible breath sounds from the anterior chest wall. D) Obtain a pulse oximetry reading, and, if the reading is low, reposition the patient and auscultate breath sounds.

B) Turn the patient to enable assessment of all the patients lung fields.

While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often? A) Every 2 hours when the patient is awake B) When adventitious breath sounds are auscultated C) When there is a need to prevent the patient from coughing D) When the nurse needs to stimulate the cough reflex

B) When adventitious breath sounds are auscultated

You are admitting a patient into your rehabilitation unit after an industrial accident. The patients nursing diagnoses include disturbed sensory perception and you assess that he has decreased strength and dexterity. You know that this patient may need what to accomplish self-care? A) Advice from his family B) Appropriate assistive devices C) A personal health care aide D) An assisted-living environment

B) appropriate assistive devices

While assessing a patient who has pneumonia, the nurse has the patient repeat the letter E while the nurses auscultates. The nurse notes that the patients voice sounds are distorted and that the letter A is audible instead of the letter E. How should this finding be documented? A)Bronchophony B)Egophony C)whispered pectoriloquy D) sonorous wheezes

B) egophony

You are the rehabilitation nurse caring for a 25-year-old patient who suffered extensive injuries in a motorcycle accident. During each patient contact, what action should you perform most frequently? A) Complete a physical assessment. B) Evaluate the patients positioning. C) Plan nursing interventions. D) Assist the patient to ambulate.

B) evaluate the patients positioning

A nurse has been asked to become involved in the care of an adult patient in his fifties who has experienced a new onset of urinary incontinence. During what aspect of the assessment should the nurse explore physiologic risk factors for elimination problems? A) Physical assessment B) Health history C) Genetic history D) Initial assessment

B) health history

A nurse is giving a talk to a local community group whose members advocate for disabled members of the community. The group is interested in emerging trends that are impacting the care of people who are disabled in the community. The nurse should describe an increasing focus on what aspect of care? A) Extended rehabilitation care B) Independent living C)Acute-care center treatment D)State institutions that provide care for life

B) independent living

A 74-year-old woman experienced a cerebrovascular accident 6 weeks ago and is currently receiving inpatient rehabilitation. You are coaching the patient to contract and relax her muscles while keeping her extremity in a fixed position. Which type of exercise is the patient performing? A) Passive B) Isometric C) Resistive D) Abduction

B) isometric

The nurse is caring for a patient who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning. The nurse should prioritize assessment for which of the following? A) Sputum production B) shortness of breath C) throat discomfort D) epistaxis

B) shortness of breath

A patient underwent an open bowel resection 2 days ago and the nurses most recent assessment of the patients abdominal incision reveals that it is dehiscing. What factor should the nurse suspect may have caused the dehiscence? A) The patients surgical dressing was changed yesterday and today. B) the patient has vomited three times in the past 12 hours C) the patient has begun voiding on the commode instead of a bedpan D) the patient used PCA until this morning

B) the patient vomited three times in the past 12 hours

The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall? A) Between 10 and 15 mm Hg B)Between 15 and 20 mm Hg C)Between 20 and 25 mm Hg D) Between 25 and 30 mm Hg

B)Between 15 and 20 mm Hg

A gerontologic nurse is analyzing the data from a patients focused respiratory assessment. The nurse is aware that the amount of respiratory dead space increases with age. What is the effect of this physiological change? A) Increased diffusion of gases B)Decreased diffusion capacity for oxygen C)Decreased shunting of blood D)Increased ventilation

B)Decreased diffusion capacity for oxygen

The nurse admits a patient to the PACU with a blood pressure of 132/90 mm Hg and a pulse of 68 beats per minute. After 30 minutes, the patients blood pressure is 94/47 mm Hg, and the pulse is 110. The nurse documents that the patients skin is cold, moist, and pale. Of what is the patient showing signs? A)Hypothermia B)Hypovolemic shock C)Neurogenic shock D) Malignant hyperthermia

B)Hypovolemic shock

The nurse is caring for a patient who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the patients needs? A)Non-rebreathing mask B)Nasal cannula C)Simple mask D)Partial-rebreathing mask

B)Nasal cannula

The nurse has explained to the patient that after his thoracotomy, it will be important to adhere to a coughing schedule. The patient is concerned about being in too much pain to be able to cough. What would be an appropriate nursing intervention for this client? A) Teach him postural drainage. B)Teach him how to perform huffing. C)Teach him to use a mini-nebulizer. D)Teach him how to use a metered dose inhaler.

B)Teach him how to perform huffing.

The nursing instructor is discussing postoperative care with a group of nursing students. A student nurse asks, Why does the patient go to the PACU instead of just going straight up to the postsurgical unit? What is the nursing instructors best response? A)The PACU allows the patient to recover from anesthesia in a stimulating environment to facilitate awakening and reorientation. B)The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications. C)Frequently, patients are placed in the medicalsurgical unit to recover, but hospitals are usually short of beds, and the PACU is an excellent place to triage patients. D)Patients remain in the PACU for a predetermined time because the surgeon will often need to reinforce or alter the patients incision in the hours following surgery.

B)The PACU allows the patient to recover from the effects of anesthesia, and the patient stays in the PACU until he or she is oriented, has stable vital signs, and is without complications.

The nurse is caring for a postoperative patient who needs daily dressing changes. The patient is 3 days postoperative and is scheduled for discharge the next day. Until now, the patient has refused to learn how to change her dressing. What would indicate to the nurse the patients possible readiness to learn how to change her dressing? Select all that apply. A)The patient wants you to teach a family member to do dressing changes. B)The patient expresses interest in the dressing change. C)The patient is willing to look at the incision during a dressing change. D)The patient expresses dislike of the surgical wound. E)The patient assists in opening the packages of dressing material for the nurse.

B)The patient expresses interest in the dressing change. C)The patient is willing to look at the incision during a dressing change. E)The patient assists in opening the packages of dressing material for the nurse.

The home health nurse is caring for a postoperative patient who was discharged home on day 2 after surgery. The nurse is performing the initial visit on the patients postoperatative day 2. During the visit, the nurse will assess for wound infection. For most patients, what is the earliest postoperative day that a wound infection becomes evident? A) Day 9 B) Day 7 C) Day 5 D)Day 3

C) Day 5

The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurses first step in the suctioning process? A) Explain the suctioning procedure to the patient and reposition the patient. B) Turn on suction source at a pressure not exceeding 120 mm Hg. C) Assess the patients lung sounds and SAO2 via pulse oximeter. D) Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask.

C) Assess the patients lung sounds and SAO2 via pulse oximeter.

While assessing an acutely ill patients respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding? A) Eupnea B) Apnea C) Biots respiration D) Cheyne-Stokes

C) Biots respiration

A patient is scheduled for surgery the next day and the different phases of the patients surgical experience will require input from members of numerous health disciplines. How should the patients care best be coordinated? A) By planning care using a surgical approach B) By identifying the professional with the most knowledge of the patient C) By implementing an interdisciplinary approach to care D) By using the nursing process to guide all aspects of care and treatment

C) By implementing an interdisciplinary approach to care

As an intraoperative nurse, you are the advocate for each of the patients who receives care in the surgical setting. How can you best exemplify the principles of patient advocacy? A) By encouraging the patient to perform deep breathing preoperatively B) By limiting the patients contact with family members preoperatively C) By maintaining each of your patients privacy D) By eliciting informed consent from patients

C) By maintaining each of your patients privacy

A nurse is caring for a patient undergoing rehabilitation following a snowboarding accident. Within the interdisciplinary team, the nurse has been given the responsibility for coordinating the patients total rehabilitative plan of care. What nursing role is this nurse performing? A) Patient educator B) Caregiver C) Case manager D) Patient advocate

C) Case manager

A 68-year-old patient is scheduled for a bilateral mastectomy. The OR nurse has come out to the holding area to meet the patient and quickly realizes that the patient is profoundly anxious. What is the most appropriate intervention for the nurse to apply? A) Reassure the patient that modern surgery is free of significant risks. B) Describe the surgery to the patient in as much detail as possible. C) Clearly explain any information that the patient seeks. D) Remind the patient that the anesthetic will render her unconscious.

C) Clearly explain any information that the patient seeks.

The nurse just received a postoperative patient from the PACU to the medicalsurgical unit. The patient is an 84-year-old woman who had surgery for a left hip replacement. Which of the following concerns should the nurse prioritize for this patient in the first few hours on the unit? A) Beginning early ambulation B) Maintaining clean dressings on the surgical site C) Close monitoring of neurologic status D) Resumption of normal oral intake

C) Close monitoring of neurologic status

The nurse is caring for an elderly patient in the PACU. The patient has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of lidocaine. For what complication related to the administration of large doses of lidocaine in the elderly should the nurse assess? A)Decreased urine output and hypertension B)Headache and vision changes C) Confusion and lethargy D)Jaundice and elevated liver enzymes

C) Confusion and lethargy

A home care nurse performs the initial visit to a patient who is soon being discharged from a rehabilitation facility. This initial visit is to assess what the patient can do and to see what he will need when discharged home. What does this help ensure for the patient? A) Social relationships B) Family assistance C) Continuity of care D) Realistic expectations

C) Continuity of care

The nurse is preparing to discharge a patient after thoracotomy. The patient is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this patient? A) Safe technique for self-suctioning of secretions B) Technique for performing postural drainage C) Correct and safe use of oxygen therapy equipment D) How to provide safe and effective tracheostomy care

C) Correct and safe use of oxygen therapy equipment

The nurse is completing a patients health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases? A) Have you ever been employed in a factory, smelter, or mill? B) Does anyone in your family have any form of lung disease? C) Do you currently smoke, or have you ever smoked? D) Have you ever lived in an area that has high levels of air pollution?

C) Do you currently smoke, or have you ever smoked?

A patient will be undergoing a total hip arthroplasty later in the day and it is anticipated that the patient may require blood transfusion during surgery. How can the nurse best ensure the patients safety if a blood transfusion is required? A) Prime IV tubing with a unit of blood and keep it on hold. B) Check that the patients electrolyte levels have been assessed preoperatively. C) Ensure that the patient has had a current cross-match. D) Keep the blood on standby and warmed to body temperature.

C) Ensure that the patient has had a current cross-match.

The nurse is working with a rehabilitation patient who has a deficit in mobility following a skiing accident. The nurse knows that preparation for ambulation is extremely important. What nursing action will best provide the foundation of preparation for ambulation? A) Stimulating the patients desire to ambulate B) Assessing the patients understanding of ambulation C) Helping the patient perform frequent exercise D) Setting realistic expectations

C) Helping the patient perform frequent exercise

You are caring for a 71-year-old patient who is 4 days postoperative for bilateral inguinal hernias. The patient has a history of congestive heart failure and peptic ulcer disease. The patient is highly reluctant to ambulate and will not drink fluids except for hot tea with her meals. The nurses aide reports to you that this patients vital signs are slightly elevated and that she has a nonproductive cough. When you assess the patient, you auscultate crackles at the base of the lungs. What would you suspect is wrong with your patient? A) Pulmonary embolism B) Hypervolemia C) Hypostatic pulmonary congestion D) Malignant hyperthermia

C) Hypostatic pulmonary congestion

As an intraoperative nurse, you know that the patients emotional state can influence the outcome of his or her surgical procedure. How would you best reinforce the patients ability to influence outcome? A) Teach the patient strategies for distraction. B) Pair the patient with another patient who has better coping strategies. C) Incorporate cultural and religious considerations, as appropriate. D) Give the patient antianxiety medication.

C) Incorporate cultural and religious considerations, as appropriate.

A medical nurse has admitted a patient to the unit with a diagnosis of failure to thrive. The patient has developed a fever and cough, so a sputum specimen has been obtained. The nurse notes that the sputum is greenish and that there is a large quantity of it. The nurse notifies the patients physician because these symptoms are suggestive of what? A) Pneumothorax B) Lung tumors C) Infection D) Pulmonary edema

C) Infection

The intraoperative nurse is transferring a patient from the OR to the PACU after replacement of the right knee. The patient is a 73-year-old woman. The nurse should prioritize which of the following actions? A) Keeping the patient sterile B) Keeping the patient restrained C) Keeping the patient warm D) Keeping the patient hydrated

C) Keeping the patient warm

A patient is undergoing testing to see if he has a pleural effusion. Which of the nurses respiratory assessment findings would be most consistent with this diagnosis? A) Increased tactile fremitus, egophony, and a dull sound upon percussion of the chest wall B) Decreased tactile fremitus, wheezing, and a hyperresonant sound upon percussion of the chest wall C) Lung fields dull to percussion, absent breath sounds, and a pleural friction rub D) Normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion of the chest wall

C) Lung fields dull to percussion, absent breath sounds, and a pleural friction rub

The nurse is caring for a young adult male with a traumatic brain injury and severe disabilities caused by a motor vehicle accident when he was an adolescent. Where does the nurse often provide care for patients like this young adult? A) Adult day-care facilities B) Step-down units C) Medical-surgical units D) Pediatric units

C) Medical-surgical units

The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff? A) Deflate the cuff overnight to prevent tracheal tissue trauma. B) Inflate the cuff to the highest possible pressure in order to prevent aspiration. C) Monitor the pressure in the cuff at least every 8 hours D) Keep the tracheostomy tube plugged at all times.

C) Monitor the pressure in the cuff at least every 8 hours

A female patient, 47 years old, visits the clinic because she has been experiencing stress incontinence when she sneezes or exercises vigorously. What is the best instruction the nurse can give the patient? A) Keep a record of when the incontinence occurs. B) Perform clean intermittent self-catheterization. C) Perform Kegel exercises four to six times per day. D) Wear a protective undergarment to address this age-related change.

C) Perform Kegel exercises four to six times per day.

You are the nurse caring for an elderly adult who is bedridden. What intervention would you include in the care plan that would most effectively prevent pressure ulcers? A) Turn and reposition the patient a minimum of every 8 hours. B) Vigorously massage lotion into bony prominences. C) Post a turning schedule at the patients bedside and ensure staff adherence. D) Slide, rather than lift, the patient when turning.

C) Post a turning schedule at the patients bedside and ensure staff adherence.

The circulating nurse will be participating in a 78-year-old patients total hip replacement. Which of the following considerations should the nurse prioritize during the preparation of the patient in the OR? A) The patient should be placed in Trendelenburg position. B) The patient must be firmly restrained at all times. C) Pressure points should be assessed and well padded. D) The preoperative shave should be done by the circulating nurse.

C) Pressure points should be assessed and well padded.

The rehabilitation team has reaffirmed the need to maximize the independence of a patient in rehabilitation. When working toward this goal, what action should the nurse prioritize? A) Encourage families to become paraprofessionals in rehabilitation. B) Delegate care planning to the patient and family. C) Recognize the importance of informal caregivers. D) Make patients and families to work together.

C) Recognize the importance of informal caregivers.

The nurse is caring for a patient on the medicalsurgical unit postoperative day 5. During each patient assessment, the nurse evaluates the patient for infection. Which of the following would be most indicative of infection? A) Presence of an indwelling urinary catheter B) Rectal temperature of 99.5F (37.5C) C) Red, warm, tender incision D) White blood cell (WBC) count of 8,000/mL

C) Red, warm, tender incision

The nurse is caring for a 78-year-old man who has had an outpatient cholecystectomy. The nurse is getting him up for his first walk postoperatively. To decrease the potential for orthostatic hypotension and consequent falls, what should the nurse have the patient do? A) Sit in a chair for 10 minutes prior to ambulating. B) Drink plenty of fluids to increase circulating blood volume. C) Stand upright for 2 to 3 minutes prior to ambulating. D) Perform range-of-motion exercises for each joint.

C) Stand upright for 2 to 3 minutes prior to ambulating.

You have been referred to the care of an extended care resident who has been diagnosed with a stage III pressure ulcer. You are teaching staff at the facility about the role of nutrition in wound healing. What would be the best meal choice for this patient? A) Whole wheat macaroni with cheese B) Skim milk, oatmeal, and whole wheat toast C) Steak, baked potato, spinach and strawberry salad D) Eggs, hash browns, coffee, and an apple

C) Steak, baked potato, spinach and strawberry salad

The home care nurse is assessing a patient who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the patient in the home environment? A) The patient desires a low-maintenance oxygen delivery system that delivers oxygen flow rates up to 6 L/min. B) The patient requires a high-flow system for use with a tracheostomy collar. C) The patient desires a portable oxygen delivery system that can deliver 2 L/min. D) The patients respiratory status requires a system that provides an FiO2 of 65%.

C) The patient desires a portable oxygen delivery system that can deliver 2 L/min.

You are the nurse caring for a young mother who has a longstanding diagnosis of multiple sclerosis (MS). She was admitted to your unit with a postpartum infection 3 days ago. You are planning to discharge her home when she has finished 5 days of IV antibiotic therapy. With what information would it be most important for you to provide this patient? A) A succinct overview of postpartum infections B) How the response to infection differs in patients with multiple sclerosis C) The same information you would provide to a patient without a chronic condition D) Information on effective management of multiple sclerosis in the home setting

C) The same information you would provide to a patient without a chronic condition

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of the patients closed chest-drainage system. What should the nurse conclude? A) The system is functioning normally. B) The patient has a pneumothorax. C) The system has an air leak. D) The chest tube is obstructed.

C) The system has an air leak.

You are presenting patient teaching to a 48-year-old man who was just diagnosed with type 2 diabetes. The patient has a BMI of 35 and leads a sedentary lifestyle. You give the patient information on the risk factors for his diagnosis and begin talking with him about changing behaviors around diet and exercise. You know that further patient teaching is necessary when your patient tells you what? A) I need to start slow on an exercise program approved by my doctor. B) I know theres a chance I could have avoided this if Id always eaten better and exercised more. C) There is nothing that can be done anyway, because chronic diseases like diabetes cannot be prevented. D) I want to have a plan in place before I start making a lot of changes to my lifestyle.

C) There is nothing that can be done anyway, because chronic diseases like diabetes cannot be prevented.

The patient has just had an MRI ordered because a routine chest x-ray showed suspicious areas in the right lung. The physician suspects bronchogenic carcinoma. An MRI would most likely be order to assess for what in this patient? A) Alveolar dysfunction B) Forced vital capacity C) Tidal volume D) Chest wall invasion

C) Tidal volume

A patient in the ICU has had an endotracheal tube in place for 3 weeks. The physician has ordered that a tracheostomy tube be placed. The patients family wants to know why the endotracheal tube cannot be left in place. What would be the nurses best response? A) The physician may feel that mechanical ventilation will have to be used long-term. B) Long-term use of an endotracheal tube diminishes the normal breathing reflex. C) When an endotracheal tube is left in too long it can damage the lining of the windpipe. D) It is much harder to breathe through an endotracheal tube than a tracheostomy.

C) When an endotracheal tube is left in too long it can damage the lining of the windpipe.

You are the nurse caring for a patient who has paraplegia following a hunting accident. You know to assess regularly for the development of pressure ulcers on this patient. What rationale would you cite for this nursing action? A) You know that this patient will have a decreased level of consciousness. B) You know that this patient may not be motivated to prevent pressure ulcers. C) You know that the risk for pressure ulcers is directly related to the duration of immobility. D) You know that the risk for pressure ulcers is related to what caused the immobility.

C) You know that the risk for pressure ulcers is directly related to the duration of immobility.

The nurse is caring for a patient admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the patient is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the patients blood? A) A capillary blood sample B) Pulse oximetry C) an arterial blood gas (ABG) study D) a complete blood count (CBC)

C) an arterial blood gas (ABG) study

The OR nurse is providing care for a 25-year-old major trauma patient who has been involved in a motorcycle accident. The nurse should know that the patient is at increased risk for what complication of surgery? A) Respiratory depression B) Hypothermia C) Anesthesia awareness D) Moderate sedation

C) anesthesia awareness

The nurse is caring for a 79-year-old man who has returned to the postsurgical unit following abdominal surgery. The patient is unable to ambulate and is now refusing to wear an external pneumatic compression stocking. The nurse should explain that refusing to wear external pneumatic compression stockings increases his risk of what postsurgical complication? A) Sepsis B) infection C) pulmonary embolism D) hematoma

C) pulmonary embolism

The ED nurse is assessing the respiratory function of a teenage girl who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive what? A)Pleurisy B)Emphysema C)Asthma D)Pneumonia

C)Asthma

The nurse is assessing the respiratory status of a patient who is experiencing an exacerbation of her emphysema symptoms. When preparing to auscultate, what breath sounds should the nurse anticipate? A) Absence of breath sounds B)Wheezing with discontinuous breath sounds C)Faint breath sounds with prolonged expiration D)Faint breath sounds with fine crackles

C)Faint breath sounds with prolonged expiration

The nurse is caring for an 82-year-old female patient in the PACU. The woman begins to awaken and responds to her name, but is confused, restless, and agitated. What principle should guide the nurses subsequent assessment? A)Postoperative confusion in older adults is an indication of impaired oxygenation or possibly a stroke during surgery. B)Confusion, restlessness, and agitation are expected postoperative findings in older adults and they will diminish in time. C)Postoperative confusion is common in the older adult patent, but it could also indicate a significant blood loss. D)Confusion, restlessness, and agitation indicate an underlying cognitive deficit such as dementia.

C)Postoperative confusion is common in the older adult patent, but it could also indicate a significant blood loss.

You are caring for a male patient who has had spinal anesthesia. The patient is under a physicians order to lie flat postoperatively. When the patient asks to go to the bathroom, you encourage him to adhere to the physicians order. What rationale for complying with this order should the nurse explain to the patient? A) Preventing the risk of hypotension B)Preventing respiratory depression C)Preventing the onset of a headache D)Preventing pain at the lumbar injection site

C)Preventing the onset of a headache

The nurse is caring for a patient after abdominal surgery in the PACU. The patients blood pressure has increased and the patient is restless. The patients oxygen saturation is 97%. What cause for this change in status should the nurse first suspect? A)The patient is hypothermic. B)The patient is in shock. C)The patient is in pain. D)The patient is hypoxic.

C)The patient is in pain.

The nurse in the ED is caring for a man who has returned to the ED 4 days after receiving stitches for a knife wound on his hand. The wound is now infected, so the stitches were removed, and the wound is cleaned and packed with gauze. The ED doctor plans to have the man return tomorrow to remove the packing and resuture the wound. You are aware that the wound will now heal by what means? A)Late intention B)Second intention C)Third intention D)First intention

C)Third intention

The dressing surrounding a mastectomy patients Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion? A)Describe the appearance of the dressing in the electronic health record. B)Photograph the patients abdomen for later comparison using a smartphone. C)Trace the outline of the drainage on the dressing for future comparison. D)Remove and weigh the dressing, reapply it, and then repeat in 8 hours.

C)Trace the outline of the drainage on the dressing for future comparison.

A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order? A)Non-rebreather air mask B)Tracheostomy collar C)Venturi mask D)Face tent

C)Venturi mask

A patient is being treated for a pulmonary embolism and the medical nurse is aware that the patient suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology? A) Maintenance of constant osmotic pressure in the alveoli B)Maintenance of muscle tone in the diaphragm C) pH balance in the pulmonary veins and arteries D) Adequate flow of blood through the pulmonary circulation.

D) Adequate flow of blood through the pulmonary circulation.

A female patient has been achieving significant improvements in her ADLs since beginning rehabilitation from the effects of a brain hemorrhage. The nurse must observe and assess the patients ability to perform ADLs to determine the patients level of independence in self-care and her need for nursing intervention. Which of the following additional considerations should the nurse prioritize? A) Liaising with the patients insurer to describe the patients successes. B) Teaching the patient about the pathophysiology of her functional deficits. C) Eliciting ways to get the patient to express a positive attitude. D) Appraising the familys involvement in the patients ADLs.

D) Appraising the familys involvement in the patients ADLs.

A patients plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy? A) Administer the treatment with the patient in a high Fowlers or semi-Fowlers position. B) Perform the procedure immediately following the patients meals. C) Apply percussion firmly to bare skin to facilitate drainage. D) Assist the patient into a position that will allow gravity to move secretions.

D) Assist the patient into a position that will allow gravity to move secretions.

The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the patient has what diagnosis? A) Asthma B) Pneumonia C) Lung cancer D) COPD

D) COPD

A patient has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation? A) Expiratory wheezes B) Inspiratory wheezes C) Rhonchi D) Crackles

D) Crackles

A major cause of health-related problems is the increase in the incidence of chronic conditions. This is the case not only in developed countries like the United States but also in developing countries. What factor has contributed to the increased incidence of chronic diseases in developing countries? A) Developing countries are experiencing an increase in average life span. B) Increasing amounts of health research are taking place in developing countries. C) Developing countries lack the health infrastructure to manage illness. D) Developing countries are simultaneously coping with emerging infectious diseases.

D) Developing countries are simultaneously coping with emerging infectious diseases.

The nurse is packing a patients abdominal wound with sterile, half-inch Iodoform gauze. During the procedure, the nurse drops some of the gauze onto the patients abdomen 2 inches (5 cm) away from the wound. What should the nurse do? A)Apply povidone-iodine (Betadine) to that section of the gauze and continue packing the wound. B)Pick up the gauze and continue packing the wound after irrigating the abdominal wound with Betadine solution. C) Continue packing the wound and inform the physician that an antibiotic is needed. D) Discard the gauze packing and repack the wound with new Iodoform gauze.

D) Discard the gauze packing and repack the wound with new Iodoform gauze.

The nurse is admitting a patient to the medical surgical unit from the PACU. What should the nurse do to help the patient clear secretions and help prevent pneumonia? A) Encourage the patient to eat a balanced diet that is high in protein. B) Encourage the patient to limit his activity for the first 72 hours. C) Encourage the patient to take his medications as ordered. D) Encourage the patient to use the incentive spirometer every 2 hours.

D) Encourage the patient to use the incentive spirometer every 2 hours.

Prior to a patients scheduled surgery, the nurse has described the way that members of diverse health disciplines will collaborate in the patients care. What is the main rationale for organizing perioperative care in this collaborative manner? A) Historical precedence B) Patient requests C) Physicians needs D) Evidence-based practice

D) Evidence-based practice

A patient recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the patient? A) Assure the patient that everything will be all right and that remaining calm is the best strategy. B) Ask a family member to interpret what the patient is trying to communicate. C) Ask the physician to wean the patient off the mechanical ventilator to allow the patient to speak freely. D) Express empathy and then encourage the patient to write, use a picture board, or spell words with an alphabet board.

D) Express empathy and then encourage the patient to write, use a picture board, or spell words with an alphabet board.

The nurses aide notifies the nurse that a patient has decreased oxygen saturation levels. The nurse assesses the patient and finds that he is tachypnic, has crackles on auscultation, and his sputum is frothy and pink. The nurse should suspect what complication? A) Pulmonary embolism B) Atelectasis C) Laryngospasm D) Flash pulmonary edema

D) Flash pulmonary edema

You are caring for a young woman who has Down syndrome and who has just been diagnosed with type 2 diabetes. What consideration should you prioritize when planning this patients nursing care? A) How her new diagnosis affects her health attitudes B) How her diabetes affects the course of her Down syndrome C) How her chromosomal disorder affects her glucose metabolism D) How her developmental disability influences her health management

D) How her developmental disability influences her health management

The nurse is performing patient education for a patient who is being discharged on mini-nebulizer treatments. What information should the nurse prioritize in the patients discharge teaching? A) How to count her respirations accurately B) How to collect serial sputum samples C) How to independently wean herself from treatment D) How to perform diaphragmatic breathing

D) How to perform diaphragmatic breathing

An elderly female patient who is bedridden is admitted to the unit because of a pressure ulcer that can no longer be treated in a community setting. During your assessment of the patient, you find that the ulcer extends into the muscle and bone. At what stage would document this ulcer? A) I B) II C) III D) IV

D) IV

The nurse is providing teaching about tissue repair and wound healing to a patient who has a leg ulcer. Which of the following statements by the patient indicates that teaching has been effective? A)Ill make sure to limit my intake of protein. B) Ill make sure that the bandage is wrapped tightly. C) My foot should feel cool or cold while my legs healing. D) Ill eat plenty of fruits and vegetables.

D) Ill eat plenty of fruits and vegetables.

A nurse is aware that the number of people in the United States who are living with disabilities is expected to continue increasing. What is considered to be one of the factors contributing to this increase? A) The decrease in the number of people with early-onset disabilities B) The increased inability to cure chronic disorders C) Changes in infection patterns resulting from antibiotic resistance D) Increased survival rates among people who experience trauma

D) Increased survival rates among people who experience trauma

A patient is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The patient inquires about the normal function of pleural fluid. What should the nurse describe? A) It allows for full expansion of the lungs within the thoracic cavity. B) It prevents the lungs from collapsing within the thoracic cavity. C) It limits lung expansion within the thoracic cavity. D) It lubricates the movement of the thorax and lungs.

D) It lubricates the movement of the thorax and lungs.

A nurse is caring for a patient following knee surgery that was performed under a spinal anesthetic. What intervention should the nurse implement to prevent a spinal headache? A) Have the patient sit in a chair and perform deep breathing exercises. B) Ambulate the patient as early as possible. C) Limit the patients fluid intake for the first 24 hours postoperatively. D) Keep the patient positioned supine.

D) Keep the patient positioned supine.

A 59-year-old male patient is scheduled for a hemorrhoidectomy. The OR nurse should anticipate assisting the other team members with positioning the patient in what manner? A) Dorsal recumbent position B) Trendelenburg position C) Sims position D) Lithotomy position

D) Lithotomy position

The medical nurse is creating the care plan of an adult patient requiring mechanical ventilation. What nursing action is most appropriate? A) Keep the patient in a low Fowlers position. B) Perform tracheostomy care at least once per day. C) Maintain continuous bedrest. D) Monitor cuff pressure every 8 hours.

D) Monitor cuff pressure every 8 hours.

A patient is undergoing rehabilitation following a stroke that left him with severe motor and sensory deficits. The patient has been unable to ambulate since his accident, but has recently achieved the goals of sitting and standing balance. What is the patient now able to use? A) A cane B) Crutches C) A two-wheeled walker D) Parallel bars

D) Parallel bars

The nurse is caring for a patient who is scheduled to have a needle biopsy of the pleura. The patient has had a consultation with the anesthesiologist and a conduction block will be used. Which local conduction block can be used to block the nerves leading to the chest? A) Transsacral block B) Brachial plexus block C) Peudental block D) Paravertebral block

D) Paravertebral block

During their prime employable years between ages 21 and 64, 77% of those with a nonsevere disability are employed. What has research shown about this employed population? A) Their salaries are commensurate with their experience. B) They enjoy their jobs more than people who do not have disabilities. C) Employment rates are higher among people with a disability than those without. D) People with disabilities earn less money than people without disabilities.

D) People with disabilities earn less money than people without disabilities.

In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a patients arterial oxygen saturation (SaO2). What procedure will best accomplish this? A) Incentive spirometry B) Arterial blood gas (ABG) measurement C) Peak flow measurement D) Pulse oximetry

D) Pulse oximetry

As a perioperative nurse, you know that the National Patient Safety Goals have the potential to improve patient outcomes in a wide variety of health care settings. Which of these Goals has the most direct relevance to the OR? A) Improve safety related to medication use B) Reduce the risk of patient harm resulting from falls C) Reduce the incidence of health care-associated infections D) Reduce the risk of fires

D) Reduce the risk of fires

A community health nurse has drafted a program that will address the health promotion needs of members of the community who live with one or more disabilities. Which of the following areas of health promotion education is known to be neglected among adults with disabilities? A) Blood pressure screening B) Diabetes testing C) Nutrition D) Sexual health

D) Sexual health

The nurse is caring for a patient who has just returned to the unit after a colon resection. The patient is showing signs of hypoxia. The nurse knows that this is probably caused by what? A) Nitrogen narcosis B) Infection C) Impaired diffusion D) Shunting

D) Shunting

The home care nurse is visiting a patient newly discharged home after a lobectomy. What would be most important for the home care nurse to assess? A) Resumption of the patients ADLs B) The familys willingness to care for the patient C) Nutritional status and fluid balance D) Signs and symptoms of respiratory complications

D) Signs and symptoms of respiratory complications

The nurse caring for a patient with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes? A) Cognition is decreased. B) Daily arterial blood gases (ABGs) are necessary. C) Slight tracheal bleeding is anticipated. D) The cough reflex is depressed.

D) The cough reflex is depressed.

A patient has a diagnosis of multiple sclerosis. The nurse is aware that neuromuscular disorders such as multiple sclerosis may lead to a decreased vital capacity. What does vital capacity measure? A) The volume of air inhaled and exhaled with each breath B) The volume of air in the lungs after a maximal inspiration C) The maximal volume of air inhaled after normal expiration D) The maximal volume of air exhaled from the point of maximal inspiration

D) The maximal volume of air exhaled from the point of maximal inspiration

An adult patient is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The patients vital signs and level of consciousness stabilized, but the patient then complains of severe nausea and begins to retch. What should the nurse do next? A) Administer a dose of IV analgesic. B) Apply a cool cloth to the patients forehead. C) Offer the patient a small amount of ice chips. D) Turn the patient completely to one side.

D) Turn the patient completely to one side.

You have admitted a new patient to your unit with a diagnosis of stage IV breast cancer. This woman has a comorbidity of myasthenia gravis. While you are doing the initial assessment, the patient tells you that she felt the lump in her breast about 9 months ago. You ask the patient why she did not see her health care provider when she first found the lump in her breast. What would be a factor that is known to influence the patient in seeking health care services? A) Lack of insight due to the success of self-managing a chronic condition B) Lack of knowledge about treatment options C) Overly sensitive patient reactions to health care services D) Unfavorable interactions with health care providers

D) Unfavorable interactions with health care providers

The circulating nurse is admitting a patient prior to surgery and proceeds to greet the patient and discuss what the patient can expect in surgery. What aspect of therapeutic communication should the nurse implement? A) Wait for the patient to initiate dialogue. B) Use medically acceptable terms. C) Give preoperative medications prior to discussion. D) Use a tone that decreases the patients anxiety.

D) Use a tone that decreases the patients anxiety.

The nurse is caring for a patient who has been scheduled for a bronchoscopy. How should the nurse prepare the patient for this procedure? A) Administer a bolus of IV fluids. B) Arrange for the insertion of a peripherally inserted central catheter. C) Administer nebulized bronchodilators every 2 hours until the test. D) Withhold food and fluids for several hours before the test.

D) Withhold food and fluids for several hours before the test.

The recovery room nurse is admitting a patient from the OR following the patients successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted patient? A) Heart rate and rhythm B) Skin integrity C) Core body temperature D) Airway patency

D) airway patency

You are the nurse providing care for a patient who has limited mobility after a stroke. What would you do to assess the patient for contractures? A) Assess the patients deep tendon reflexes (DTRs). B) Assess the patients muscle size. C) Assess the patient for joint pain. D) Assess the patients range of motion.

D) assess the patients range of motion

A 21-year-old patient is positioned on the OR bed prior to knee surgery to correct a sports-related injury. The anesthesiologist administers the appropriate anesthetic. The OR nurse should anticipate which of the following events as the teams next step in the care of this patient? A) Grounding B) Making the first incision C) Giving blood D) Intubating

D) intubating

The PACU nurse is caring for a male patient who had a hernia repair. The patients blood pressure is now 164/92 mm Hg; he has no history of hypertension prior to surgery and his preoperative blood pressure was 112/68 mm Hg. The nurse should assess for what potential causes of hypertension following surgery? A)Dysrhythmias, blood loss, and hyperthermia B)Electrolyte imbalances and neurologic changes C) a parasympathetic reaction and low blood volumes D) pain, hypoxia, or bladder distention

D) pain, hypoxia or bladder distention

The nursing instructor is talking with a group of medicalsurgical students about deep vein thrombosis (DVT). A student asks what factors contribute to the formation of a DVT. What would be the instructors best response? A)There is a genetic link in the formation of deep vein thrombi. B) Hypervolemia is often present in patients who go on to develop deep vein thrombi. C) No known factors contribute to the formation of deep vein thrombi; they just occur. D)Dehydration is a contributory factor to the formation of deep vein thrombi.

D)Dehydration is a contributory factor to the formation of deep vein thrombi.

The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give to the patient regarding activity immediately following discharge? A) Walk 1 mile 3 to 4 times a week. B) Use weights daily to increase arm strength. C)Walk on a treadmill 30 minutes daily. D)Perform shoulder exercises five times daily.

D)Perform shoulder exercises five times daily.

A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for? A)Maintaining positive chest-wall pressure B)Monitoring pleural fluid osmolarity C)Providing positive intrathoracic pressure D)Removing excess air and fluid

D)Removing excess air and fluid

The decision has been made to discharge a ventilator-dependent patient home. The nurse is developing a teaching plan for this patient and his family. What would be most important to include in this teaching plan? A)Administration of inhaled corticosteroids B) Assessment of neurologic status C)Turning and coughing D)Signs of pulmonary infection

D)Signs of pulmonary infection

a man with a physical disability uses a wheelchair. the individual wants to attend a support group for the parents of autistic children, which is being held in the basement of a church. when the individual arrives at the church, he realizes there are no ramps or elevators to the basement so he will not be able to attend the support group. what time of barrier did the patient encounter? a. a structural barrier b. a barrier to health care c. an institutional barrier d. a transportation barrier

a. a structural barrier

a patient who is legally blind is being admitted to the hospital. the patient informs the nurse that she needs to have her guide dog present during her hospitalization. what is the nurses best response to the patient? a. arrangements can be made for your guide dog to be at the hospital with you during your stay b. i will need to check with the care plan team before that decision can be made c. because of infection control, your guide dog will likely not be allowed to stay in your room during your hospitalization d. your guide dog can stay with you during your hospitalization, but he will need to stay in a crate that you will need to provide

a. arrangements can be made for your guide dog to be at the hospital with you during your stay

a patient tells the nurse that her doctor just told her that her new diagnosis of rheumatoid arthritis is considered to be a chronic condition. she asks the nurse what chronic condition means. what would be the nurses best response? a. chronic conditions are defined as health problems that require management of several months or longer b. chronic conditions are diseases that come and go in a relatively predictable cycle c. chronic conditions are medical conditions that culminate in disabilities that require hospitalization d. chronic conditions are those that require short-term managament in extended care facilities

a. chronic conditions are defined as health problems that require management of several months or longer

an international nurse has noted that a trend in developing countries is a decrease in mortality from some acute conditions. this has corresponded with an increase in the incidence and prevalence of chronic diseases. what has contributed to his decrease in mortality from some acute conditions? a. improved nutrition b. integration of alternative health practices c. stronger international security measures d. decrease in obesity

a. improved nutrition

a home care nurse is making an initial visit to a 68 year old man. the nurse finds the man tearful and emotionally withdrawn. even though the man lives alone and has no family, he has been managing well at home until now. what would be the appropriate action for the nurse to take? a. reassess the patients psychosocial status and make the necessary referrals b. have the patient volunteer in the community for social contact c. arrange for the patient to be reassessed by his social worker d. encourage the patient to focus on the positive aspects of his lfie

a. reassess the patients psychosocial status and make the necessary referrals

A patient who is receiving rehabilitation following a spinal cord injury has been diagnosed with reflex incontinence. The nurse caring for the patient should include which intervention in this patients plan of care? A) Regular perineal care to prevent skin breakdown B) Kegel exercises to strengthen the pelvic floor C) Administration of hypotonic IV fluid D) Limited fluid intake to prevent incontinence

a. regular perineal care to prevent skin breakdown

you are caring for a patient with a history of chronic angina. the patient tells you that after breakfast he usually takes a shower and shaves. it is at this time, the patient says, that he tends to experience chest pain. what might you counsel the patient to do to decrease the likelihood of angina in the morning? a. shower in the evening and shave before breakfast b. skip breakfast and eat an early lunch c. take a nitro tab prior to breakfast d. shower once a week and shave prior to breakfast

a. shower in the evening and shave before breakfast

A school nurse is providing health promotion teaching to a group of high school seniors. The nurse should highlight what salient risk factor for traumatic brain injury? A) Substance abuse B) Sports participation C) Anger mismanagement D) Lack of community resources

a. substance abuse

You are the nurse caring for an elderly patient who has been on a bowel training program due to the neurologic effects of a stroke. In the past several days, the patient has begun exhibiting normal bowel patterns. Once a bowel routine has been well established, you should avoid which of the following? A) Use of a bedpan B)Use of a padded or raised commode C)Massage of the patients abdomen D)Use of a bedside toilet

a. use of a bedpan

an elderly patient has presented to a clinic with a new diagnosis of osteoarthritis. the patient's daughter is accompanying him and you have explained why the incidence of chronic diseases increase with age. what rationale for this phenomenon should you describe? a. with age, biologic changes reduce the efficiency of body systems b. older adults often have less support and care from their family, resulting in illness c. there is an increased morbidity of peers in this age group, and this leads to the older adults desire to also assume the sick role d. chronic illnesses are diagnosed more often in older adults because they have more contact with the healthcare system

a. with age, biologic changes reduce the efficiency of body system

The nurse is providing care for an older adult man whose diagnosis of dementia has recently led to urinary incontinence. When planning this patients care, what intervention should the nurse avoid? A) Scheduled toileting B) Indwelling catheter C) External condom catheter D) Incontinence pads

b) indwelling catheter

Research has corroborated an experienced nurses observation that the incidence and prevalence of chronic conditions is increasing in the United States. What health promotion initiative most directly addresses the factor that has been shown to contribute to this increase? a. A program to link residents with primary care providers b. A community-based weight-loss program c. A stress management workshop d. A cancer screening campaign

b. a community-based weight-loss program

a 19 yr old patient with a diagnosis of down syndrome is being admitted on your unit for the treatment of community-acquired pneumonia. when planning this patients care, the nurse recognizes that this patient's disability is categorized as what? a. a sensory disability b. a developmental disability c. an acquired disability d. an age-associated disability

b. a developmental disability

A nurse knows that patients with invisible disabilities like chronic pain often feel that their chronic conditions are more challenging to deal with than more visible disabilities. Why would they feel this way? a. Invisible disabilities create negative attitudes in the health care community. b. Despite appearances, invisible disabilities can be as disabling as visible disabilities. c. Disabilities, such as chronic pain, are apparent to the general population. d.Disabilities. Such as chronic pain, may not be curable, unlike visible disabilities.

b. despite appearances. invisible disabilities can be as disabling as visible disabilities

A nurse is planning the care of a patient who has been diagnosed with renal failure, which the nurse recognizes as being a chronic condition. Which of the following descriptors apply to chronic conditions? Select all that apply. a. Diseases that resolve slowly b. Diseases where complete cures are rare c. Diseases that have a short, unpredictable course d. Diseases that do not resolve spontaneously e. Diseases that have a prolonged course

b. diseases where complete cures are rare d. disease that do not resolve spontaneously e. diseases that have a prolonged course

a patient with end-stage lung cancer has been admitted to hospice care. the hospice team is meeting with the patient and her family to establish goals for care. what is likely to be a first priority in goal setting for the patient? a. maintenance of activities of daily living b. pain control c. social interaction d. promotion of spirituality

b. pain control

an interdisciplinary team has been working collaboratively to improve the health outcomes of an adult who suffered a spinal cord injury in a workplace accident. which member of the rehabilitation team is the one who determines the final outcome of the process? a. most-responsible nurse b. patient c. patients family d. primary care physician

b. patient

a medical-surgical nurse is teaching a patient about the health implications of her recently diagnosed type 2 diabetes. the nurse should teach the patient to be proactive with her glycemic control in order to reduce her risk of what health problem? a. arthritis b. renal failure c. pancreatic cancer d. asthma

b. renal failure

the staff development nurse is presenting a class on the importance of incorporating people-first language into daily practice as well as documentation. what is an example of the use of people-first language when giving a verbal report? a. the schizophrenic b. the patient with schizophrenia c. the schizophrenic patient d. the schizophrenic client

b. the patient with schizophrenia

A man and woman are in their early eighties and have provided constant care for their 44-year-old son who has Down syndrome. When planning this family's care, the nurse should be aware that the parents most likely have what concerns around what question? a. What could we have done better for our son? b. Why was our son born with Down syndrome while our other children are healthy? c. Who will care for our son once were unable? d. Will we experience the effects of developmental disabilities late in life?

c. Who will care for our son once were unable?

A patient who has recently been diagnosed with chronic heart failure is being taught by the nurse how to live successfully with her chronic condition. Her ability to meet this goal will primarily depend on her ability to do which of the following? A) Lower her expectations for quality of life and level of function. B) Access community services to eventually cure her disease. C) Adapt her lifestyle to accommodate her symptoms. D) Establish good rapport with her primary care provider.

c. adapt her lifestyle to accommodate her symptoms

An elderly patient is brought to the emergency department with a fractured tibia. The patient appears malnourished, and the nurse is concerned about the patients healing process related to insufficient protein levels. What laboratory finding would the floor nurse prioritize when assessing for protein deficiency? A) Hemoglobin B) Bilirubin C) Albumin D) Cortisol

c. albumin

A 52-year-old married man with two adolescent children is beginning rehabilitation following a motor vehicle accident. You are the nurse planning the patients care. Who will the patients condition affect? A) Himself B) His wife and any children that still live at home C) Him and his entire family D) No one, provided he has a complete recovery

c. him and his entire family

the nurse is reviewing the importance of preventative health care with a patient who has a disability. the patient states that she will not have money to pay for her annual gynecologic exams or mammograms due to the cost of this hospitalizations. what information would be appropriate for the nurse to share with the patient? a. Limited finances are a common problem for patients with a disability. Since you were hospitalized this year, you can likely forego the gynecologic exam and mammogram. b. These are very important health preventative measures, so you will need to borrow the money to pay for the exam and mammogram c. ill look into federal assistance programs that provide financial assistance for health-related expenses for people with disabling conditions d. these preventative measures should likely be tax deductible, so you should consult with your accountant and then make your appointments.

c. ill look into federal assistance programs that provide financial assistance for health-related expenses for people with disabling conditions

You are the case manager who oversees the multidisciplinary care of several patients living with chronic conditions. Two of your patients are living with spina bifida. You recognize that the center of care for these two patients typically exists where? A) In the hospital B) In the physicians office C) In the home D) In the rehabilitation facility

c. in the home

The nurse is caring for a patient diagnosed with cancer of the liver who has chosen to remain in his home as long as he is able. The nurse reviews the care plan for the patient and notes that it focuses on palliative measures. The nurse also notes that over the last 3 weeks, the patients condition has continued to deteriorate. What is the nurses best response to this clinical information? A) Recognize that death will most likely occur in the next week. B) Recognize that the patient is in the trajectory phase of chronic illness and should be kept pain-free. c. recognize that the patient is in the downward phase of chronic illness and should be reassessed d. recognize that the patient should immediately be admitted into the hospital

c. recognize that the patient is int he downward phase of chronic illness and should be reassessed

the patient has been transferred to a rehabilitative setting from an acute care unit. what is the most important reason for the nurse to begin a program for ADLs as soon as the patient is admitted to the rehabilitation facility? a. the ability to perform ADLs may be the key to dependence b. the ability to perform ADLs is essential to living in a group home c. the ability to perform ADLs may be the key to reentry into the community d. the ability to perform ADLs is necessary to function in an assisted-living situation

c. the ability to perform ADLs may be the key to reentry into the community

The nurse is providing care for a 90-year-old patient whose severe cognitive and mobility deficits result in the nursing diagnosis of risk for impaired skin integrity due to lack of mobility. When planning relevant assessments, the nurse should prioritize inspection of what area? a. The patients elbows b. The soles of the patients feet c. The patients heels d. The patients knees

c. the patients heels

A 93-year-old male patient with failure to thrive has begun exhibiting urinary incontinence. When choosing appropriate interventions, you know that various age-related factors can alter urinary elimination patterns in elderly patients. What is an example of these factors? A) Decreased residual volume B) Urethral stenosis C) Increased bladder capacity D)Decreased muscle tone

d) decreased muscle tone

You are caring for a 35-year-old man whose severe workplace injuries necessitate bilateral below-the- knee amputations. How can you anticipate that the patient will respond to this news? A)The patient will go through the stages of grief over the next week to 10 days. B) The patient will progress sequentially through five stages of the grief process. C) The patient will require psychotherapy to process his grief. D) the patient will experience grief in an individualized manner

d) the patient will experience grief in an individualized manner

a 37 year old woman with multiple sclerosis is married and has 3 children. the nurse has worked extensively with the woman and her family to plan appropriate care. what is the nurses most important role with this patient? a. ensure the patient adheres to all treatments b. provide the patient with advice on alternative treatment options c. provide a detailed plan of activities of daily living (ADLs) for the patient d. help the patient develop strategies to implement treatment regimens

d. help the patient develop strategies to implement treatment regimens

a patient has recently been diagnosed with type 2 diabetes. the patient is clinically obese and has a sedentary lifestyle. how can the nurse best begin to help the patient increase his activity level? a. set up appointment times at a local fitness center for the patient to attend b. have a family member ensure the patient follows a suggested exercise plan c. construct an exercise program and have the patient follow it d. identify the barriers with the patient that inhibit his lifestyle change

d. identify the barriers with the patient that inhibit his lifestyle changes

The interface model of disability is being used to plan the care of a patient who is living with the effects of a stroke. Why should the nurse prioritize this model? a. It fosters dependency and rapport between the caregiver and the patient. b. It encourages the provision of care that is based specifically on the disability. c. It promotes interactions with patients focused on the root cause of the disability. d. It promotes the idea that patients are capable and responsible.

d. it promotes the idea that patients are capable and responsible

You are planning rehabilitation activities for a patient who is working toward discharge back into the community. During a care conference, the team has identified a need to focus on the patients instrumental activities of daily living (IADLs). When planning the patients subsequent care, you should focus particularly on which of the following? A) Dressing B)Bathing c) Feeding d) Meal preparation

d. meal preparation

a patient who undergoes hemodialysis three times weekly is on fluid restriction of 1000 mL/day. the nurse sees the patient drinking a 355-mL (12 ounce) soft drink after the patient has already reached the maximum intake of fluid for the day. what action should the nurse take? a. take the soft drink away from the patient and inform the dialysis nurse to remove extra fluid from the patient during the next dialysis treatment b. document the patients behavior as noncompliant and notify the physician c. further restrict the patients fluid for the following day and communicate this information to the charge nurse d. reinforce the importance of the fluid restriction and document the teaching and the intake of extra fluid

d. reinforce the importance of the fluid restriction and document the teaching and the intake of extra fluid