Surgical First Assist Test 5
Q. Information in nursing care plans is regulated by _______.
A. The Joint Commission The Joint Commission determines the guidelines of nursing care plans. It is established that they must include specific interventions that meet patient needs.
Q. If one kilogram is converted to grams, which of the following would be considered correct?
A. 1000 The metric system is considered the International System for weights and measures. If one kilogram is converted to grams, it would equal 1000 grams.
Q.If the concentration of bupicacaine is 0.25%, which of the following would be considered the maximum dose for a patient that weighs 192 pounds?
A. 174.55 mg First convert the pounds to kg. 192 divided by 2.2 = 87.27 kg. The maximum dose for bupivacaine is up to 2 mg/kg. Then multiply the 87.27 kg x 2= 174.55 mg. The maximum dose for this particular patient would be 174.55 mg.
Q. The HCO3 values for respiratory alkalosis will be:
A. 22 - 26 mEq/L. The HCO3 results for both respiratory alkalosis and acidosis will be within normal range. The normal range for this electrolyte is 22 - 26 mEq/L.
Q.The humidity in the storage room in the surgical suite should be kept which of the following?
A. 30-60% The humidity in these sections should be kept 30-60%: Class A OR Class B and C OR Cesarean Delivery Room Storage room PACU
Q. Which of the following PaCO2 readings is normal?
A. 34 - 44 mm Hg PaCO2, or the partial pressure of carbon dioxide in arterial blood, is the best measure of adequate alveolar ventilation. A PaCO2 of 34 - 44 mm Hg is normal.
Q. The number 15 scalpel has which of the following?
A. A short rounded edge for shallow short controlled incisions. A number 15 scalpel has a short rounded edge for shallow short controlled incisions. A number 11 blade has a linear edge with a sharp tip. A number 10 blade is rounded toward the tip and are often used for opening the skin.
Q. The ability to answer for one's actions is known as which of the following?
A. Accountability Accountability is the ability to answer for or take responsibility for one's actions. Nurses must be accountable to patients, families, and the larger healthcare institutions in which they work in order to provide quality care.
Q. ATLS stands for which of the following?
A. Advanced Trauma Life Support ATLS stands for Advanced Trauma Life Support. The American College of Surgeons established protocols and training in trauma medicine.
Q.After all the instruments, supplies, and contaminated equipment are removed from the surgical suite, which of the following interventions could be correct during terminal decontamination?
A. All the surfaces of the operating table and pads are cleaned, paying special attention to the hinges, castors and pivotal joints and the operating table is moved to the side so that it can be cleaned underneath. The surgical suite including the walls, floors, fixtures, and furniture must be cleaned between cases. After this decontamination is completed, the furniture is then repositioned and fresh linen put on the operating bed.
Q. What precaution should be taken when using alcohol-based prep solutions?
A. Allowing solutions to dry before using electrical equipment Alcohol solutions used to prep are at high concentrations (60-90%) and very volatile. A spark from electrical equipment could ignite undried solution.
Q. Often patients use over-the-counter medications to treat themselves. Which over-the-counter medication might indicate a sensivity to streptomycin?
A. Antibiotic ointments A patient may not identify drug sensitivity to over-the-counter medications. A patient who is sensitive to antibiotic ointments such as Neosporin may also be sensitive to streptomycin or other drugs antibiotics used in a procedure.
Q. A patient has not listed any allergies in medical history. How would you confirm this before surgery?
A. Ask the patient directly to confirm history and allergies. Ask the patient directly to confirm history and allergies. The patient may have forgotten a past incident. The patient may also have forgotten to fill out the form
Q. Which local anesthetic is applied to the skin?
A. Benzocaine Benzocaine is a common local anesthetic. It is a topical that can be applied to skin, throat or mouth.
Q. The adrenal medulla secretes epinephrine and norepinephrine, which help regulate what?
A. Blood pressure The adrenal medulla secretes hormones that regulate the blood pressure. Epinephrine and norepinephrine are vasopressors (drugs that regulate vascular pressure).
Q. The first tier in Maslow's hierarchy of needs are physiological needs, which include which of the following?
A. Breathing Maslow's first hierarchy of needs include physiological needs, such as breathing, food, and shelter. These are needs that a person must have in order to survive.
Q. The following terms are associated with professional patient care. Which of the following is a professional method used for evaluating and recognizing INDIVIDUALS to ensure they meet education, practice, and national standard guidelines?
A. Certification Certification is a professional method used for evaluating and recognizing INDIVIDUALS to ensure they meet education, practice, and national standard guidelines. Nurses can obtain certification in a variety of specialties, such as perioperative patient care. The other answer choices are also related to healthcare practice and professionalism but have different meanings.
Q. All of the following would be considered a type of urologic surgery except?
A. Cholecystectomy Cholecystectomy would be removal of the gallbladder. Types of urologic surgery could include: Urethroplasty Nephrectomy Cystectomy Prostatectomy Circumcision
Q.Which class of operating room would more than likely be correct for a patient having a limited regional block procedure?
A. Class A The class A operating room is a smaller room. It is commonly used for smaller procedures that are performed with local, topical or limited regional blocks with a minimal need for equipment
Q. A patient under anesthesia is in the supine position develops breathing problems. What intervention should be done first?
A. Clear airway A patient's extreme physical needs must be addressed first. The ABCs are airway, breathing and cardiovascular needs require immediate attention. The first step in a patient with breathing difficulty is to clear the airway.
Q. The part of the inner ear that transforms sound into nerve impulses that travel to the brain is known as which of the following?
A. Cochlea The cochlea is a spiral-shaped part of the inner ear that translates sound into nerve impulses that travel to the brain. Attached to the cochlea are fluid-filled semicircular canals which sends the information on balance and the head position to the brain.
Q. The method of patient placement in which patients are grouped by the pathogen that they are colonized or infected by would be considered which of the following?
A. Cohorting Cohorting would be considered the patient placement method of grouping patients who are colonized or infected with the same pathogen. This is a particularly effective method in long-term care settings.
Q.The nursing interventions should be chosen based on _____.
A. Condition and needs of the patient The NIC is used to assist in interventions. The interventions, however, will vary with condition of each patient. For example, not all patient at risk of aspiration have artificial airways. The individual conditions and needs must be considered
Q. Which of the following jaws has crisscrossed serrations on the inside surface rather than grooved ones?
A. Crosshatched jaws The crosshatched jaws has crisscrossed serrations on the inside surfaces. This crisscross pattern helps provide a smoother surface which helps prevent damage to the needle.
Q. The rate of electrical flow would be considered the ________?
A. Current The rate of electrical flow would be the current. The direct current is a low voltage and typically originates from a battery. The alternating current is transmitted by a 110 or 220-V line
Q. Choose the diagnosis that belongs under safety and security in Maslow's hierarchy.
A. Death anxiety Safety and security include both physical and psychological problems. Death anxiety is a psychological problem that needs to be addressed as the patient's safety and security needs.
Q.Surgical team members should be aware of anesthetic side effects and how patients may re-act when recovering from certain anesthetics. For instance, which measure should circulating nurses take for patients regaining consciousness who have received the anesthetic ketamine during a procedure?
A. Dim the lights in the room The anesthetic ketamine can cause hallucinations and nightmares. The nurse can ease the process of regaining consciousness and minimize startling the patient by dimming the lights in the room.
Q. Dehiscence or evisceration often occur as a result of what?
A. Distention Dehiscence or evisceration often occur because of excessive vomiting, excessive coughing, dehydration, infection and distention. Distention can particularly lead to evisceration due to the location.
Q. During the sociocultural assessment, your patient tells you that she basically works 10 hours per day, then comes home to care for her family. She does not see friends or have any outside activities. She expresses that she is often tired and lonely. Which of the following is an appropriate nursing diagnosis for this patient?
A. Diversional activity deficit This patient's lack of outside activities constitutes a diversional activity deficit. This deficit can potentially have adverse effects on her overall well being and sh ould be noted.
Q. Which of the following statements about evidence-based nursing practice (EBNP) is least accurate?
A. EBNP relies solely on randomized control trials. This is the least accurate statement. EBNP differs from evidence-based medicine because it does not rely solely on randomized control trials.
Q. A fine rasp might be used for which of the following procedures?
A. Ear, throat, nose. The fine rasp is used on delicate bones and also surfaces of the nasal sinuses and ears. A fine rasp might be used for: Ear procedures Throat procedures Nose procedures
Q. __________ is the process of tissue surface destruction which is used in electrosurgery?
A. Fulguration Frequency in electricity is the periodicity of electromagnetic waves. Ablation is the complete destruction of tissue. Current is the flow of electricity. Fulguration is the process of a tissue surface destruction used in electrosurgery.
Q. A patient asks you for information on the benefits of a vegetarian diet. What nursing diagnosis would you give this patient?
A. Health seeking behaviors This patient is demonstrating a health seeking behavior by asking about the health benefits of a vegetarian diet. In addition to the general diagnosis, specify in the assessment notes that the patient has asked about vegetarian diet and health.
Q. What are common areas for pressure ulcers to form?
A. Heels, elbows The most common areas for pressure ulcers to form are bony prominences where the tissue tends to be thin. The heels, elbows, scapula, sacrum, and coccyx are at high risks for forming a pressure ulcer.
Q. A ____________ would be considered an abnormal flow of blood or bleeding from the surgical wound?
A. Hemorrhage When a hematoma occurs, it is a collection of blood in the body tissue. An abnormal flow of blood or bleeding from the surgical wound could be considered a hemorrhage. Bleeding is considered a major surgical complication.
Q. A nursing theory that asserts that health has a spiritual dimension is known as which of the following?
A. Human becoming theory Human becoming theory holds that health has a spiritual dimension. It is key to learn about the patient's spiritual needs and to help him or her meet those needs as part of overall health promotion.
Q. Ellen is establishing milestones and patient goals with a patient who is being treated for chronic foot pain. What is a reasonable goal Ellen can set for the patient to reach after leaving the hospital?
A. Improve endurance while walking An attainable goal for a person with foot pain is to build endurance over time. Many nurses may set a designated time or just monitor progress. It would be unreasonable for the nurse to expect the patient eliminate all pain or refrain from daily activities
Q. How can the Trendelenburg position impact the patient?
A. Increase the volume of blood to (engorge) the lungs The Trendelenburg position can cause the lungs to become engorged because the head and upper body are positioned lower than the feet. The patient can also experience diminished ability of the thoracic cage to expand and muscle fatigue. Additionally, because the increased blood volume decreases the space for alveolar expansion, the patient experiences a reduction in oxygenated blood.
Q. Which of the following statements about psoriasis is least accurate?
A. It is an acute, infectious inflammatory skin disease. This is the least accurate statement. Psoriasis is a chronic, noninfectious inflammatory skin disease. It occurs in up to 2% of the population. It seems to have a genetic basis.
Q.During a hysterectomy procedure, which of the following scissors are most often used?
A. Jorgenson The scissors that are most often preferred for use in a hysterectomy procedure would be Jorgenson. Some types of scissors are: Metzenbaum Mayo Stevens Castroviejo
Q. Which of the following would be considered a regulatory organ which could maintain the volume and composition of body fluid by filtration of the blood? `
A. Kidneys Kidneys maintain the composition and volume of body fluid by filtration of the blood. The kidneys also do this by selective reabsorption or secretion of filtered solutes.
Q. Which other patient outcome is most related to fear?
A. Knowledge deficit With a knowledge deficit, the patient is unaware and lacks knowledge about the procedures and treatment. Fear is often based on a lack of knowledge.
Q. Knowledge deficits can occur due to cognitive limitations or learning disabilities. The perioperative nurse should be aware of the Three Levels of Learning, which are:
A. Knowledge, attitude, skills The three levels of learning are Knowledge, Attitude, and Skills. These are the three primary factors which affect cognition.
Q.The hepatic portal vein is used by the stomach and intestines to carry blood to the which part of the body?
A. Liver The stomach and intestines send the blood to the liver through the hepatic portal to help process the nutrients and chemicals absorbed from food. The liver then removes the toxins, stores the sugars and processes the products from digestion. The blood then returns to the heart.
Q. Patients who have had multiple transfusions may experience what outcome?
A. Lowered immunity. Nurses must be aware of all the factors affecting a patient's recovery. Patients who receive multiple blood transfusions have a lower immunity.
Q. ________ would be considered the study of metals?
A. Metalurgy Metalurgy would be considered the study of metals. The vast majority of instruments are made of stainless steel, but some are made of such things as titanium or cobalt-based alloys.
Q. Of the following, which is considered the most commonly scissors used in general surgical procedures?
A. Metzenbaum The Metzenbaum scissors as used for dissecting normal peritoneal tissue. These scissors are the ones that are most commonly used
Q. Potential adverse outcomes related to transferring patients include what?
A. Moaning and discomfort The patient who is being moved to and from the operative suite is at risk of adverse outcomes in the transferring process. The patient is at risk for injury, altered body temperature, ineffective breathing patterns, altered tissue perfusion, and pain or discomfort.
Q.Failure of a caregiver to maintain accountability can constitute which of the following actions?
A. Negligence Failure to a caregiver to maintain accountability can result in negligence. Negligence can incur legal action, such as a malpractice claim. Malpractice is negligence cause by the reasonable actions or inactions of a professional. Nurses as well as physicians can be charged with negligence.
Q. An anesthesia provider asks a circulating nurse to add a certain anesthesia medication to an intravenous (IV) line. She indicates she has not received adequate training for the task and refuses the request. This refusal is an example of which of the following?
A. Nurses' right to refuse an assignment Nurses have a right to refuse an assignment or task for which they have not received proper training to perform. An act of refusal can be deemed as an aspect of the nurse's advocacy role. Patients entrust their health to nurses when undergoing perioperative procedures and expect nurses to promote their well-being
Q.What is the organizational system for determining patient care which involves assessment, diagnosing, planning, implementation, and evaluation?
A. Nursing process. The nursing process is the organizational process for determining patient care, which involves assessment, diagnosing, planning, implementation, and evaluation. The three phases of perioperative nursing care are integrated into these components.
Q. When is the flash sterilizer typically used?
A. Only when there is no other alternative is available These sterilizers are typically located just outside the operating suite. They are typically used only when there is no other alternative. Unwrapped items coming from the immediate-use sterilizers will be wet because there is no drying cycle for unwrapped items. The term flash sterilizer has been replaced with the term immediate-use sterilizer.
Q.What is common difference in patient reaction to epidural blocks and spinal anesthesia?
A. Patients lose less motor function with a epidural block than spinal block Epidural and spinal blocks are both injected into the spine. Epidural blocks can be a single dose or given in repeated doses. Epidural blocks produce fewer headaches than spinal blocks. Patients lose less motor function with an epidural block than the spinal block.
Q. Also known as the "master gland," the ________ gland exerts control over all of the other glands in the endocrine system?
A. Pituitary The pituitary gland is the controller of all the glands in the endocrine system. It is made up of the anterior and posterior lobe and is composed of an outgrowth of the brain.
Q. What antibiotic is a commonly used to soak prosthetic devices?
A. Polymyxin B Prostheses such as breast and orthopedic implants must be soaked in antibiotics before they are implanted. A nurse will prepare a soaking medication and deliver it to the sterile field. Polymyxin B, gentamicin, and bacitracin are commonly added to an isotonic solution to soak prosthetic devices.
Q.The operating room should be vented with ________ pressure?
A. Positive The operating room should be vented with positive pressure. Sliding doors are used instead of swinging doors because they eliminate the air currents that the swinging doors cause.
Q. The stage of health promotion that occurs when a person still denies having a problem, but may see others as having a problem and thus wants to change his or her behavior, is known as which of the following?
A. Precontemplation stage The precontemplation stage occurs early in the health education or promotion process. In this stage, a person may not see him or herself as having a problem or risk. However, the person sees that problem or risk in others, and thus wants to change his or her own behavior.
Q. When mounting suture on a French eye suture needle, which of the following would be considered correct?
A. Press the suture down over the top of the spring causing it to snap into the eye of the needle. The scrub technician should press the suture down over the top of the spring causing it to snap into the eye of the needle. After the suturing is in the eye it shouldn't be pulled through the eye because it can strip the suture and could break it.
Q. Segmental atelectasis is caused by what?
A. Prolonged bed rest Segmental atelectasis is lack of expansion of the alveoli. When a large enough area (or segment) is affected, the person stops breathing. Prolonged bed rest can restrict the person's ability to expand their chest and breathe properly.
Q. A communication technique which encourages the patient to expand on his or her remarks is known as which of the following?
A. Reflecting Reflecting encourages the patient to reflect on and expand upon his or her remarks. This can be used to encourage the patient to further explore his or her feelings or reactions about a diagnosis, family situation, or other factor influencing his or her health.
Q. Pharmacies are an integral part of facilities and pharmacists support nurses and surgeons by preparing all admixtures and conveying information. Who is usually responsible for mixing medications in the pre-operative holding area, OR, PACU, or SICU?
A. Registered nurses While the pharmacist prepares all admixtures, it is typically the nurse who mixes medications in the pre-operative holding area, OR, PACU, or SICU. The pharmacy technician usually is not part of the perioperative team. Nursing attendants do not administer or mix medications.
Q. The stages of death and dying would include all of the following except?
A. Rejection Rejection would not be one of these stages. In the 1960's. Elisabeth Kubler-Ross developed the stages of death and dying which include: Denial Anger Bargaining Depression Acceptance
Q. A deep, loud sound that results from percussion is known as which of the following?
A. Resonance Resonance is a deep, loud sound produced by percussion. It is the normal finding for lungs.
Q. Why should someone stand in front of the patient receiving a spinal block?
A. Safety purposes. A nurse or assistant should stand in front of the patient receiving an epidural or spinal block to prevent the patient from falling off the bed. Also, this person can provide the patient further instructions as needed.
Q. Which of the following is NOT a guideline for determining priorities?
A. Self-actualization. Self-actualization is included in Maslow's hierarchy of needs. The other answers are guidelines that need to be used by nurses when determining their priorities.
Q. How many liters of fluids does the digestive system secrete per day?
A. Seven The digestive system secretes around 7 liters of fluids a day. These fluids can consist of: Mucus Saliva Bile Enzymes Hydrochloric acid
Q. Which patient is at the most risk for developing a pulmonary complication after an operation?
A. Smoker The smoker is at most risk for developing pulmonary complications. Smoking not only affects the respiratory functions, but it also impairs the immune system making the patient more prone to developing an infection.
Q. All of the following would be correct for the reason that the furniture in the operating room is made of stainless steel except?
A. Stainless steel is cheaper. Stainless steel is not considered cheaper. Stainless steel furniture is considered: Plain Easier to clean More durable
Q. Which of the following statements would be considered correct regarding sterility in surgery?
A. Sterility is absolute. The medical devices, instruments, supplies, and materials that are used in surgery must be sterile. Sterility is absolute, there is no partial sterility. Something is either sterile or nonsterile.
Q. A patient has just relocated and started a new job. The patient is mildly hypertensive. What is the probable cause?
A. Stress Emotional stress can cause physical symptoms. A patient who has emotional stress is likely to have elevated heart rate and blood pressure. This is why the psychosocial assessment is so important
Q. A person who makes a decision on behalf of an incapacitated patient is known as which of the following?
A. Substitutionary decision maker A person authorized to make a decision for an incapacitated patient is known as a substitutionary decision maker. This authorization can be made through healthcare proxy or power of attorney.
Q.There are two main circulatory loops in the human body known as the pulmonary circulation loop and which of the following?
A. Systemic circulation loop The second circulatory loop is the systemic circulation loop which carries highly oxygenated blood from the left side of the heart to all of the tissues of the body (excluding the heart and lungs). This removes wastes from the body tissues and returns deoxygenated blood to the right side of the heart.
Q. What is the definition of polypharmacy?
A. The use of multiple medications at once Polypharmacy is a common term used to simply describe the use of multiple medications by the same person. Many people are considered polypharmacy, especially those with chronic conditions that may require help in multiple areas.
Q. Civil wrongs committed against a person or property are known as which of the following?
A. Torts Torts are civil, rather than criminal, wrongs committed against another person or his or her property. They may be intentional or unintentional. Malpractice is an unintentional tort that results from negligence by a professional
Q. Which of the following could be defined as displacement of a structure by pulling the tissue in an opposing direction to facilitate sharp or blunt dissection of the tissue planes?
A. Traction-countertraction Traction-countertraction could be considered the pulling of a tissue in an opposing direction to facilitate dissection of tissue planes. Examples would be pulling the skin away from the scalpel during incisions or pushing the skin towards the sutures when closing the wound.
Q. Which of the following pieces of special equipment might be needed during a gastrointestinal surgery?
A. Ultrasound scalpel and bowel bag Some of this equipment could include: Ultrasound scalpel Bowel bag-to enclose the bowel during open surgery High-frequency vessel-sealing system Vessel loops for large vessel dissection Ultrasound probe Temporary ostomy bag
Q.For surgical or invasive procedures, when should the nurse confirm informed consent?
A. Well in advance of the procedure if possible The process of informed consent should allow the patient sufficient time to ask questions and understand the procedures. When informed consent is obtained immediately before a procedure, the patient has to deal the pressures of time and interference from medication. Of course in some instances, it is not possible to obtain informed consent well in advance of procedures, such as the case with emergency procedures.
Q. Signs and symptoms of anaphylaxis could include which of the following?
A. Wheezing and a Rash The signs and symptoms could include: Wheezing Rash Abnormal lung sounds detected during auscultation Difficulty breathing
Q. All of the following might be considered correct for helping keep a sterile person in the operating room sterile?
A. When a sterile person passes an unsterile person, they should turn their backs to the unsterile person and when a sterile person is passing a sterile area, they should face the sterile area. When a sterile person is passing an unsterile area or person, care should be taken. The following would be observed: When a sterile person passes an unsterile person, they should turn their backs to the unsterile person. When a sterile person is passing a sterile area, they should face the sterile area. When the sterile person is draping the patient in the operating room, they should stand back at a safe distance. When two sterile personnel are passing each other, they should do a back-to-back at a 360 degree turn. The sterile personnel should stay in the sterile field, not walking around or especially going outside of the operating room.
Q. The nurse would document which of the following about teaching a patient how to care for his wound after discharge?
A. When the patient isn't ready to learn because of difficulty with pain, the actual teaching activity used, the data on which the patient's educational assessment is based. Documentation of the educational process for a patient would include all of the items listed in the first three choices. The documentation would also include the action taken after the patient assessment of learning, if any.
Q. You have a patient who is being treated for an exacerbation of systemic lupus erythematosus (SLE). This patient begins to experience hallucinations. You understand that this psychosis may indicate which of the following?
A. central nervous system disease In a patient with an exacerbation of SLE psychosis may indicate central nervous system disease. It may also be the effect of corticosteroid therapy
Q. When taking the health history of a patient, which of the following items would NOT be included in the personal history?
A. chief complaint The nurse would begin the patient health history with biographic data such as name, address, and age. Then the nurse determines the patient's chief complaint, and a history of current illnesses. The personal history comes next and includes a host of information such as tobacco use, allergies, immunizations, work history, lifestyle habits, sexual orientation and much more. This would be followed by a family history and then a review of the patient's physical status.
Q. When faced with an ethical dilemma, the nurse should do all of the following EXCEPT:
A. consult the patient as to his or her preferences This is not one of the steps in solving an ethical dilemma. An ethical dilemma arises when a nurse must choose between competing claims or select from equally undesirable alternatives. When faced with an ethical dilemma, the nurse should apply a rational decision-making process by gathering all the facts, identifying the problem or dilemma, listing possible actions, choosing the most appropriate action, and evaluating the results of the action.
Q. The nurse's ability to work and interact effectively with people of all cultures is known as which of the following?
A. cultural competency Cultural competency is the ability to work and interact effectively with people of other cultures. Culture is not limited to a specific ethnic background or racial heritage, but rather is an adapted way of life that is learned from families and other social interactions.
Q. In terms of the principles of wound care, which of the following is the term for the separation of the layers of a surgical wound?
A. dehiscence Dehiscence is the separation of the layers of a surgical wound. In other words, it is the separation of a surgical incision or rupture of a wound closure, typically an abdominal incision.
Q. In terms of ethical theories, the theory which holds that an act's moral rightness is determined by the inherent duty one has to act in accordance with rules and principles is which of the following?
A. deontology Deontology holds that that an act's moral rightness is determined by the inherent duty one has to act in accordance with rules and principles. It presumes that the rightness of an act is determined by the intent to conform with a moral rule, not by the consequences of the act.
Q. For which of the following reasons might a bronchoscopy be used?
A. detecting tumors, obtaining sputum culture, removing foreign bodies A bronchoscopy involves visualization of the trachea and bronchi. It has many uses, including the first three answer choices. It is also used for biopsying accessible lesions, removing excessive secretions, and locating bleeding sites in the tracheobronchial tree.
Q. Your patient has a spinal cord injury. His patellar reflex is 1+. This indicates that it is which of the following?
A. diminished Deep tendon reflexes include the biceps reflex, triceps reflex, brachoradialis reflex, patellar reflex, and Achilles tendon reflex. They are graded as 0 (absent), 1+ (diminished), 2+ (normal), 3+ (increased), and 4+ (hyperactive). A patellar reflex of 1+ is therefore considered diminished.
Q. Your patient has just had gallbladder surgery. You would monitor this patient's vital signs on which of the following schedules?
A. every 1 to 2 hours for 4 to 8 hours and then every 4 hours to detect fluid imbalances, hemorrhage, or shock You would monitor vital signs every 1 to 2 hours for 4 to 8 hours and then every 4 hours to detect fluid imbalances, hemorrhage, or shock. You would monitor bowel sounds every 4 hours and bowel output to determine return of GI functions.
Q. The first stage of the progress of disease is which of the following?
A. exposure Disease occurs or progresses through stages. The initial stage is exposure or injury when target tissue is exposed to a causative agent. This is followed in order by: latency or incubation period; prodromal period; acute phase; remission; convalescence; and recovery.
Q. A burn that is dry, leathery, and possibly edematous is which of the following?
A. full thickness burn A full-thickness burn (third-degree burn) has a dry, leathery, and possibly edematous appearance. Its color is white to charred and there is little or no pain. The depth of the burn is to subcutaneous tissue and possible fascia, muscle, and bone.
Q. A nurse should be familiar with terminology involved in quantitative and qualitative research. A formal statement of the expected relationships between two or more variables in research is known as which of the following?
A. hypothesis A hypothesis is the formal statement of the expected relationships between two or more variables. Sampling is the selecting of subjects representative of the population being studied. Intuiting and reflecting refer to focused awareness on the phenomena under study. Control involves the use of design techniques to decrease the possibility of error, thereby increasing the potential for findings that accurately reflect reality.
Q. A private duty nurse hired by the hospital on a per diem basis would be which of the following?
A. independent contractor An independent contractor is a person who contracts with another to do a specific job. In nursing, the private duty nurse who is used by an agency on a per diem basis is the most common example of an independent contractor.
Q. Nursing implications for a patient who has undergone a bone marrow transplantation include all of the following EXCEPT:
A. preventing dislodgment of implanted radiation devices This is not a part of the nursing implications for patients who have undergone a bone marrow transplantation. All of the other choices are. The nurse must also recognize the need for patient and family emotional support during the transplantation process.
Q. Three approaches are used to evaluate the quality of care for performance improvement. When the professional examines the activities and behaviors of the health care provider such as the nurse this is which type of evaluation?
A. process evaluation The three approaches to evaluating the quality of care include: structure evaluation, process evaluation, and outcome evaluation. Process evaluation examines the activities and behaviors of the health care provider such as the nurse.
Q. Your patient has developed a dependency on you that seems to relate to the fact that he lost his mother recently. These feelings are classified as which of the following?
A. transference Transference occurs when the patient transfers feelings from the past to the nurse. Counter-transference takes place when the nurse responds to the patient on a personal level.
Q. What information should the patient slip for transport to operative procedures include?
A.Patient name, hospital number, location , date, time of departure The patient name must be on any transport documentation to ensure the correct person is taken to the procedure. The pickup slip will also have additional information (such as locations, date and time of transport) as required by the facility
Q. After a minimally-invasive procedure, a patient feels fatigue, the need to urinate often, and some discomfort. He asks if his experience is typical. How should the nurse respond?
A.Re-assure the patient that his experiences are normal while attending to post-procedure care In this case, part of educating the patient is re-assurance and feedback. The nurse should explain that what the patient is experiencing is normal after minimally-invasive procedures.
Q.The stage of shock in which compensatory mechanisms are ineffective and coronary and cerebral perfusion decline, and organ systems fail is which of the following?
A.irreversible stage The stages of shock progress from the initial stage to the compensatory stage, then to the progressive stage and finally to the irreversible stage. In this last stage lactic acid continues to accumulate, and capillary permeability dilation increases, resulting in loss of intravascular volume and tachycardia. This further aggravates falling blood pressure and cardiac output.
Q. When assessing a patient with a wound, the nurse will want to make sure that the patient's laboratory values fall within the normal range. Which of the following values would NOT be in the normal range?
A.thyroxine-binding prealbumin level: 12.9 mg/dL This is not a value in the normal range. The normal range of thyroxine-binding prealbumin level is 15.7 to 29.6 mg/dL.