Asbury's Medical Surgical Midterm Master Bank Chapters 17, 18, 19, 23, 24, 41, 61, 62, 63, 64 (from 10th Edition)

Question 1

1. A 66-yr-old man with type 2 diabetes mellitus and atrial fibrillation has begun taking glucosamine and chondroitin for osteoarthritis. Which question is most important for the nurse to ask?
   a. “Did you have any hypoglycemic reactions?”
   b. “Have you noticed any bruising or bleeding?”
   c. “Have you had any dizzy spells when standing up?”
   d. “Do you have any numbness or tingling in your feet?”

Answer 1

b. “Have you noticed any bruising or bleeding?”

Glucosamine and chondroitin are dietary supplements commonly used to treat osteoarthritis. Both may increase the risk of bleeding. Patients with atrial fibrillation routinely take an anticoagulant to reduce the risk of venous thromboembolism and stroke. Use of glucosamine and chondroitin along with an anticoagulant may precipitate excessive bleeding. Glucosamine may decrease the effectiveness of insulin or other drugs used to control blood glucose, and hyperglycemia may occur.

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Question 2

2. The nurse obtains a history from a 46-yr-old woman with rheumatoid arthritis. The nurse should follow up on which patient statement?
   a. “I perform range of motion exercises at least twice a day.”
   b. “I use a heating pad for 20 minutes to reduce morning stiffness.”
   c. “I take a 20-minute nap in the afternoon even if I sleep 9 hours at night.”
   d. “I restrict fluids to prevent edema when taking methotrexate (Rheumatrex).”

Answer 2

d. “I restrict fluids to prevent edema when taking methotrexate (Rheumatrex).”

Methotrexate can affect renal function. Patients should be well hydrated to prevent nephropathy. Heat application, range of motion, and rest are appropriate interventions to manage rheumatoid arthritis.

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Question 3

3. The nurse teaches a 64-yr-old man with gouty arthritis about food that may be consumed on a low-purine diet. The patient’s choice of which food item would indicate an understanding of the instructions?
   a. Eggs
   b. Liver
   c. Salmon
   d. Chicken

Answer 3

a. Eggs

Gout is caused by an increase in uric acid production, underexcretion of uric acid by the kidneys, or increased intake of foods containing purines, which are metabolized to uric acid by the body. Liver is high in purine, and chicken and salmon are moderately high in purine.

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Question 4

4. A 24-yr-old female patient with systemic lupus erythematosus (SLE) tells the nurse she wants to have a baby and is considering getting pregnant. Which response by the nurse is most appropriate?
   a. “Infertility can result from some medications used to control your disease.”
   b. “Temporary remission of your signs and symptoms is common during pregnancy.”
   c. “Autoantibodies transferred to the baby during pregnancy will cause heart defects.”
   d. “The baby is at high risk for neonatal lupus erythematosus being diagnosed at birth.”

Answer 4

a. “Infertility can result from some medications used to control your disease.”

Infertility may be caused by renal involvement and the previous use of high-dose corticosteroid and chemotherapy drugs. Neonatal lupus erythematosus rarely occurs in infants born to women with SLE. Exacerbation is common after pregnancy during the postpartum period. Spontaneous abortion, stillbirth, and intrauterine growth retardation are common problems with pregnancy-related to deposits of immune complexes in the placenta and because of inflammatory responses in the placental blood vessels. There is not an increased risk of heart defects.

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Question 5

5. Which nursing intervention would be most appropriate for a patient with Sjögren’s syndrome?
   a. Ambulate with assistive devices
   b. Use lubricating eye drops frequently
   c. Administer acetaminophen as needed
   d. Apply ice or heat compresses to affected areas

Answer 5

b. Use lubricating eye drops frequently

Sjögren’s syndrome is an autoimmune disorder in which lymphocytes attack moisture-producing glands. Treatment is symptomatic, including adding moisture to eyes and increasing intake of fluids, especially with meals.

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Question 6

6. A nurse is working with a 73-yr-old patient with osteoarthritis. Which description of the disorder should be included in the teaching plan?
   a. Joint destruction caused by an autoimmune process
   b. Degeneration of articular cartilage in synovial joints
   c. Overproduction of synovial fluid resulting in joint destruction
   d. Breakdown of tissue in non–weight-bearing joints by enzymes

Answer 6

b. Degeneration of articular cartilage in synovial joints

OA is a degeneration of the articular cartilage in diarthrodial (synovial) joints from damage to the cartilage. The condition has also been referred to as degenerative joint disease. OA is not an autoimmune disease. There is no overproduction of synovial fluid causing destruction or breakdown of tissue by enzymes.

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Question 7

7. A nurse is assessing the recent health history of a 63-yr-old patient with osteoarthritis. Which activity pattern will the nurse recommend?
   a. Bed rest with bathroom privileges
   b. Daily high-impact aerobic exercise
   c. Regular exercise program of walking
   d. Frequent rest periods with minimal exercise

Answer 7

c. Regular exercise program of walking

A regular low-impact exercise, such as walking, is important in helping to maintain joint mobility in patients with osteoarthritis. A balance of rest and activity is needed. High-impact aerobic exercises would cause stress to affected joints and further damage.

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Question 8

8. The nurse is admitting a patient who is scheduled for knee arthroscopy related to osteoarthritis. Which finding should the nurse expect when examining the patient’s knees?
   a. Ulnar drift
   b. Pain with joint movement
   c. Reddened, swollen affected joints
   d. Stiffness that increases with movement

Answer 8

b. Pain with joint movement

Osteoarthritis is characterized predominantly by joint pain upon movement and is a classic feature of the disease. Ulnar drift occurs with rheumatoid arthritis, not osteoarthritis. Local inflammation (red, swollen joints) is unlikely with osteoarthritis. Stiffness decreases with movement.

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Question 9

9. The nurse is caring for a patient with bilateral knee osteoarthritis. Which measure will the nurse recommend to slow progression of the disease?
   a. Use a wheelchair to avoid walking as much as possible.
   b. Sit in chairs that cause the hips to be lower than the knees.
   c. Eat a well-balanced diet to maintain a healthy body weight.
   d. Use a walker for ambulation to relieve the pressure on the hips.

Answer 9

c. Eat a well-balanced diet to maintain a healthy body weight.

Because maintaining an appropriate load on the joints is essential to the preservation of articular cartilage integrity, the patient should maintain an optimal overall body weight or lose weight if overweight. Walking is encouraged. The best chairs for this patient have a higher seat and armrests to facilitate sitting and rising from the chair. Relieving pressure on the hips is not important for knee disease.

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Question 10

10. When reinforcing health teaching on the management of osteoarthritis (OA), which patient statement indicates additional instruction is needed?
    a. “I can use a cane to relieve the pressure on my back and hip.”
    b. “I should take the Naprosyn as prescribed to help control the pain.”
    c. “I should try to stay standing all day to keep my joints from becoming stiff.”
    d. “A warm shower in the morning will help relieve the stiffness I have when I get up.”

Answer 10

c. “I should try to stay standing all day to keep my joints from becoming stiff.”

Maintaining a balance between rest and activity is important to prevent overstressing joints affected by OA. Naproxen may be used for moderate to severe OA pain. Using a cane and warm shower to help relieve pain and morning stiffness are helpful.

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Question 11

11. Which patient statement suggests a need to assess the patient for ankylosing spondylitis (AS)?
    a. “My right elbow has become red and swollen over the last few days.”
    b. “I wake up stiff every morning, and my knees just don’t want to bend.”
    c. “My husband tells me that my posture has become so stooped this winter.”
    d. “My lower back pain seems to be getting worse and nothing seems to help.”

Answer 11

d. “My lower back pain seems to be getting worse and nothing seems to help.”

AS primarily affects the axial skeleton. Based on this, symptoms of inflammatory spine pain are often the first clues to a diagnosis of AS. Knee or elbow involvement is not consistent with the typical course of AS. Back pain is likely to precede the development of kyphosis.

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Question 12

12. A female patient’s complex symptomatology over the past year has led to a diagnosis of systemic lupus erythematosus (SLE). Which statement demonstrates the patient’s need for further teaching about the disease?
    a. “I’ll try my best to stay out of the sun this summer.”
    b. “I know that I have a high chance of getting arthritis.”
    c. “I’m hoping surgery will be an option for me in the future.”
    d. “I understand I’m going to be vulnerable to getting infections.”

Answer 12

c. “I’m hoping surgery will be an option for me in the future.”

Surgery is not a key treatment modality for SLE, so this indicates a need for further teaching. SLE carries an increased risk of infection, sun damage, and arthritis.

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Question 13

13. The patient developed gout while hospitalized for a heart attack. Because the patient takes aspirin for its antiplatelet effect, what should the nurse recommend in preventing future attacks of gout?
    a. Limited fluid intake.
    b. Administration of probenecid
    c. Administration of allopurinol
    d. Administration of nonsteroidal anti-inflammatory drugs (NSAIDs)

Answer 13

c. Administration of allopurinol

To prevent future attacks of gout, the urate-lowering drug allopurinol may be administered. Increased fluid will be encouraged to prevent precipitation of uric acid in the renal tubules. This patient will not be able to take the uricosuric drug probenecid because the patient’s aspirin will inactivate its effect, resulting in urate retention. NSAIDs for pain management will not be used, related to the aspirin, because of the potential for increased side effects.

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Question 14

14. The public health nurse is providing community education to increase the number of people who seek care after a tick bite. What priority information should the nurse provide to people at risk for tick bites?
    a. The best therapy for the acute illness is an IV antibiotic.
    b. Check for an enlarging reddened area with a clear center.
    c. Surveillance is necessary during the summer months only.
    d. Antibiotics will prevent Lyme disease if taken for 10 days.

Answer 14

b. Check for an enlarging reddened area with a clear center.

After a tick bite, the expanding “bull’s eye rash” is the most characteristic symptom that usually occurs in 3 to 30 days. Flu-like symptoms and migrating joint and muscle pain also may be present. Active lesions are treated with oral antibiotics for 2 to 3 weeks; doxycycline is effective in preventing Lyme disease when given within 3 days after the bite of a deer tick. IV therapy is used with neurologic or cardiac complications. Although ticks are most prevalent during summer months, residents of high-risk areas should check for ticks whenever they are outdoors. No vaccine is available.

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Question 15

15. Four patients have been newly diagnosed with connective tissue disorders. The nurse should be aware of safety issues and interstitial lung involvement for the patient with which diagnosis?
    a. Polymyositis
    b. Reactive arthritis
    c. Sjögren’s syndrome
    d. Systemic lupus erythematosus (SLE)

Answer 15

a. Polymyositis

Polymyositis is an inflammatory disease affecting striated muscle and resulting in muscle weakness that increases the patient’s risk of falls and injury. Weakened pharyngeal muscles also increase the risk for aspiration, with interstitial lung disease in up to 65% of patients. Safety concerns and interstitial lung involvement are not associated with reactive arthritis (Reiter’s syndrome) or Sjögren’s syndrome. Safety may be an issue later in disease progression of SLE.

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Question 16

16. A nurse assesses a 38-yr-old patient with joint pain and stiffness who was diagnosed with stage III rheumatoid arthritis (RA). Which additional characteristics should the nurse expect (select all that apply.)?
    a. Presence of nodules
    b. Consistent muscle strength
    c. Localized disease symptoms
    d. No destructive changes on x-ray
    e. Subluxation of joints without fibrous ankyloses
    f. Joint space narrowing and formation of osteophytes

Answer 16

a. Presence of nodules
e. Subluxation of joints without fibrous ankyloses

In stage III severe RA, extraarticular soft tissue lesions or nodules may be present along with subluxation without fibrous or bony ankylosis. Muscle strength is decreased because of extensive muscle atrophy. Manifestations are systemic rather than localized. There is x-ray evidence of cartilage and bone destruction in addition to osteoporosis. Joint space narrowing with osteophytes is consistent with osteoarthritis.

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Question 17

17. A 40-yr-old African American woman has longstanding Raynaud’s phenomenon. Currently, she reports red spots on her hands, forearms, palms, face, and lips. Which additional findings will the nurse expect (select all that apply.)?
    a. Calcinosis
    b. Weight loss
    c. Sclerodactyly
    d. Difficulty swallowing
    e. Weakened leg muscles
    f. Skin thickening below the elbow and knee

Answer 17

a. Calcinosis
c. Sclerodactyly
d. Difficulty swallowing
f. Skin thickening below the elbow and knee

This patient is at risk for scleroderma. The acronym CREST represents the clinical manifestations. C: calcinosis, painful calcium deposits in the skin; R: Raynaud’s phenomenon; E: esophageal dysfunction, difficulty swallowing; S: sclerodactyly, tightening of the skin on fingers and toes; and T: telangiectasia. Weight loss and weakened leg muscles are associated with polymyositis and dermatomyositis, not scleroderma.

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Question 18

18. A patient with fibromyalgia has pain at 12 of the 18 identified tender sites, including the neck, upper back, and knees. The patient also reports nonrefreshing sleep, depression, and anxiety when dealing with multiple tasks. Which treatments will be included in the plan of care (select all that apply.)?
    a. Massage therapy
    b. Low-impact aerobic exercise
    c. Relaxation strategy (biofeedback)
    d. Antiseizure drug pregabalin (Lyrica)
    e. Morphine sulfate extended-release tablets
    f. Serotonin reuptake inhibitor (e.g., sertraline [Zoloft])

Answer 18

a. Massage therapy
b. Low-impact aerobic exercise
c. Relaxation strategy (biofeedback)
d. Antiseizure drug pregabalin (Lyrica)
f. Serotonin reuptake inhibitor (e.g., sertraline [Zoloft])

Massage will improve blood flow and relaxation. Low-impact aerobic exercise will prevent muscle atrophy without increasing pain in the knees. Relaxation using biofeedback may decrease the patient’s stress and anxiety. Because the treatment of fibromyalgia is symptomatic, this patient will preferably be prescribed a nonopioid pain medication, an antiseizure medication such as pregabalin to help with widespread pain, and a serotonin reuptake inhibitor for depression. Long-acting opioids such as morphine are generally avoided unless pain cannot be relieved by other medications.

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Question 19

1. In assessing the joints of a patient with osteoarthritis, the nurse understands that Heberden’s nodes
   a. are often red, swollen, and tender.
   b. indicate osteophyte formation at the DIP joints.
   c. are the result of pannus formation at the PIP joints.
   d. occur from deterioration of cartilage by proteolytic enzymes.

Answer 19

b. indicate osteophyte formation at the DIP joints.

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Question 20

2. A patient with rheumatoid arthritis is experiencing articular involvement of the joints. The nurse recognizes that these characteristic changes include(select all that apply)
   a. bamboo-shaped fingers.
   b. metatarsal head dislocation in feet.
   c. noninflammatory pain in large joints.
   d. asymmetric involvement of small joints.
   e. morning stiffness lasting 60 minutes or more.

Answer 20

b. metatarsal head dislocation in feet.
e. morning stiffness lasting 60 minutes or more.

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Question 21

3. When administering medications to the patient with gout, the nurse would recognize that which drug is used as a treatment for this disease?
   a. Colchicine
   b. Febuxostat
   c. Sulfasalazine
   d. Cyclosporine

Answer 21

b. Febuxostat

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Question 22

4. The nurse should teach the patient with ankylosing spondylitis the importance of
   a. regularly exercising and maintaining proper posture.
   b. avoiding extremes in environmental temperatures.
   c. maintaining usual physical activity during flare-ups.
   d. applying hot and cool compresses for the relief of local symptoms.

Answer 22

a. regularly exercising and maintaining proper posture.

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Question 23

5. In teaching a patient with SLE about the disorder, the nurse knows that the pathophysiology of SLE includes
   a. circulating immune complexes formed from IgG autoantibodies reacting with IgG.
   b. an autoimmune T-cell reaction that results in the destruction of the deep dermal skin layer.
   c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles.
   d. the production of a variety of autoantibodies directed against components of the cell nucleus.

Answer 23

d. the production of a variety of autoantibodies directed against components of the cell nucleus.

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Question 24

6. In teaching a patient with Sjögren’s syndrome about drug therapy for this disorder, the nurse includes instruction on the use of which drug?
   a. Pregabalin (Lyrica)
   b. Etanercept (Enbrel)
   c. Cyclosporine (Restasis)
   d. Cyclobenzaprine (Flexeril)

Answer 24

c. Cyclosporine (Restasis)

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Question 25

7. Teach the patient with fibromyalgia the importance of limiting intake of which foods(select all that apply)?
   a. Sugar
   b. Alcohol
   c. Caffeine
   d. Red meat
   e. Root vegetables

Answer 25

a. Sugar
b. Alcohol
c. Caffeine

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Question 26

1. A 66-year-old man with type 2 diabetes mellitus and atrial fibrillation has begun taking glucosamine and chondroitin for osteoarthritis. Which question is most important for the nurse to ask?

A. “Did you have any hypoglycemic reactions?”

B. “Have you noticed any bruising or bleeding?”

C. “Have you had any dizzy spells when standing up?”

D. “Do you have any numbness or tingling in your feet?”

Answer 26

B. “Have you noticed any bruising or bleeding?”

Glucosamine and chondroitin are dietary supplements commonly used to treat osteoarthritis. Both glucosamine and chondroitin may increase the risk of bleeding. Anticoagulant therapy is indicated for patients with atrial fibrillation to reduce the risk of a thromboembolism and a stroke. Use of glucosamine and chondroitin along with an anticoagulant may precipitate excessive bleeding. Glucosamine may decrease the effectiveness of insulin or other drugs used to control blood glucose levels, and hyperglycemia may occur. Peripheral neuropathy symptoms that can develop with prolonged hyperglycemia include numbness and tingling in the feet.

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Question 27

2. The nurse obtains a history from a 46-year-old woman with rheumatoid arthritis. It is most important for the nurse to follow up on which patient statement?

A. “I perform range of motion exercises at least twice a day.”

B. “I use a heating pad for 20 minutes to reduce morning stiffness.”

C. “I take a 20-minute nap in the afternoon even if I sleep 9 hours at night.”

D. “I restrict fluids to prevent edema when taking methotrexate (Rheumatrex).”

Answer 27

D. “I restrict fluids to prevent edema when taking methotrexate (Rheumatrex).”

Methotrexate can affect renal function. Patients should be well hydrated to prevent nephropathy. Heat application, range of motion, and rest are appropriate interventions to manage rheumatoid arthritis.

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Question 28

3. The nurse teaches a 64-year-old man with gouty arthritis about food that may be consumed on a low-purine diet. Which food item, if selected by the patient, would indicate an understanding of the instructions?

A. Eggs

B. Liver

C. Salmon

D. Chicken

Answer 28

A. Eggs

Gout is caused by an increase in uric acid production, underexcretion of uric acid by the kidneys, or increased intake of foods containing purines, which are metabolized to uric acid by the body. Liver is high in purine, and chicken and salmon are moderately high in purine.

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Question 29

4. A 24-year-old female patient with systemic lupus erythematosus (SLE) tells the nurse she wants to have a baby and is considering getting pregnant. Which response by the nurse is most appropriate?

A. “Infertility can result from the medications used to control your disease.”

B. “Pregnancy will result in a temporary remission of your signs and symptoms.”

C. “Autoantibodies transferred to the baby during pregnancy will cause heart defects.”

D. “The baby is at high risk for neonatal lupus erythematosus being diagnosed at birth.”

Answer 29

A. “Infertility can result from the medications used to control your disease.”

Infertility may be caused by renal involvement and the previous use of high-dose corticosteroid and chemotherapy drugs. Neonatal lupus erythematosus rarely occurs in infants born to women with SLE. Exacerbation is common following pregnancy during the postpartum period. Spontaneous abortion, stillbirth, and intrauterine growth retardation are common problems with pregnancy related to deposits of immune complexes in the placenta and because of inflammatory responses in the placental blood vessels. There is not an increased risk for heart defects.

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Question 30

5. A 62-year-old woman diagnosed with fibromyalgia syndrome (FMS) reports difficulty sleeping at night. Which suggestion should the nurse give to the patient?

A. “Drinking a glass of red wine 30 minutes before bedtime will reduce anxiety and help you fall asleep.”

B. “Evening primrose oil is an herbal supplement that can be used as a sleep aid and to relieve anxiety.”

C. “Melatonin is a hormone that is often used in supplements to improve sleep and ease fibromyalgia pain.”

D. “Diphenhydramine (Benadryl) is a nonprescription sleep aid that is effective and does not cause tolerance.”

Answer 30

C. “Melatonin is a hormone that is often used in supplements to improve sleep and ease fibromyalgia pain.”

Melatonin is a hormone prepared as a supplement. Scientific evidence suggests that melatonin decreases sleep latency and may increase the duration of sleep. In addition, melatonin may decrease fatigue and pain in individuals with fibromyalgia. Alcohol should not be consumed 4 to 6 hours before bedtime. Evening primrose oil is an herbal product used for breast pain (oral form) and skin disorders (topical form). Long-term use of diphenhydramine for sleep causes tolerance.

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Question 31

1. The nurse is caring for patients in a primary care clinic. Which individual is most at risk to develop osteomyelitis caused by Staphylococcus aureus?
   a. 22-yr-old female patient with gonorrhea who is an IV drug user
   b. 48-yr-old male patient with muscular dystrophy and acute bronchitis
   c. 32-yr-old male patient with type 1 diabetes mellitus and stage IV pressure ulcer
   d. 68-yr-old female patient with hypertension who had a knee arthroplasty 3 years ago

Answer 31

c. 32-yr-old male patient with type 1 diabetes mellitus and stage IV pressure ulcer

Osteomyelitis caused by Staphylococcus aureus is usually associated with a pressure ulcer or vascular insufficiency related to diabetes mellitus. Osteomyelitis caused by Staphylococcus epidermidis is usually associated with indwelling prosthetic devices from joint arthroplasty. Osteomyelitis caused by Neisseria gonorrhoeae is usually associated with gonorrhea. Osteomyelitis caused by Pseudomonas is usually associated with IV drug use. Muscular dystrophy is not associated with osteomyelitis.

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Question 32

2. A 58-yr-old woman with breast cancer is admitted for severe back pain related to a vertebral compression fracture. The patient’s laboratory values include serum potassium of 4.5 mEq/L, serum sodium of 144 mEq/L, and serum calcium of 14.3 mg/dL. Which signs and symptoms will the nurse expect the patient to exhibit?
   a. Anxiety, irregular pulse, and weakness
   b. Muscle stiffness, dysphagia, and dyspnea
   c. Hyperactive reflexes, tremors, and seizures
   d. Nausea, vomiting, and altered mental status

Answer 32

d. Nausea, vomiting, and altered mental status

Breast cancer can metastasize to the bone, with vertebrae as a common site. Pathologic fractures at the site of metastasis are common because of a weakening of the involved bone. High serum calcium results as calcium is released from damaged bones. Normal serum calcium is 8.6 to 10.2 mg/dL. Clinical manifestations of hypercalcemia include nausea, vomiting, and altered mental status (e.g., lethargy, decreased memory, confusion, personality changes, psychosis, stupor, coma). Other manifestations include weakness, depressed reflexes, anorexia, bone pain, fractures, polyuria, dehydration, and nephrolithiasis. Manifestations of hypomagnesemia include hyperactive reflexes, tremors, and seizures. Symptoms of hyperkalemia include anxiety, irregular pulse, and weakness. Symptoms of hypocalcemia include muscle stiffness, dysphagia, and dyspnea.

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Question 33

3. The nurse provides instructions to a 30-yr-old female office worker who has low back pain. Which statement indicates additional patient teaching is required?
   a. “Switching between hot and cold packs may relieve pain and stiffness.”
   b. “Acupuncture to the lower back would cause irreparable nerve damage.”
   c. “Smoking may aggravate back pain by decreasing blood flow to the spine.”
   d. “Sleeping on my side with knees and hips bent reduces stress on my back.”

Answer 33

b. “Acupuncture to the lower back would cause irreparable nerve damage.”

Acupuncture is a safe therapy when the practitioner has been appropriately trained. Very fine needles are inserted into the skin to stimulate specific anatomic points in the body for therapeutic purposes.

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Question 34

4. The nurse receives report from the licensed practical nurse about care provided to patients on the orthopedic surgical unit. It is most important for the nurse to follow up on which statement?
   a. “The patient who had a spinal fusion 12 hours ago has hypoactive bowel sounds and is not passing flatus.”
   b. “The patient who had cervical spine surgery 2 days ago wants to wear her soft cervical collar when out of bed.”
   c. “The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing.”
   d. “The patient who had a laminectomy 24 hours ago is using patient-controlled analgesia with morphine for pain management.”

Answer 34

c. “The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing.”

After spinal surgery there is potential for cerebrospinal fluid (CSF) leakage. Severe headache or leakage of CSF (clear or slightly yellow) on the dressing should be reported immediately. The drainage is CSF if a dipstick test is positive for glucose. Patients after spinal surgery may experience interference with bowel function for several days. Postoperatively most patients require opioids such as morphine IV for 24 to 48 hours. Patient-controlled analgesia is the preferred method for pain management during this time. After cervical spine surgery, patients often wear a soft or hard cervical collar to immobilize the neck.

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Question 35

5. An older adult is diagnosed with Paget’s disease. Which finding would indicate improvement in the condition?
   a. Waddling gait
   b. Curvature in affected bones
   c. Lower serum alkaline phosphatase
   d. Uptake of radiolabeled bisphosphonate in affected bones

Answer 35

c. Lower serum alkaline phosphatase

Paget’s disease is characterized by excessive bone resorption and replacement of normal marrow with vascular, fibrous connective tissue. A normalizing alkaline phosphatase indicates bone resorption has slowed or stopped. Additional characteristics of the disease include bone pain, a waddling gait, loss of stature, and curved bones. Uptake of radiolabeled bisphosphonate indicates a bone is affected. Treatment of the disease includes administration of calcium, vitamin D, calcitonin, and bisphosphonates. Additional recommendations would include creating a safe environment, using firm mattress, wearing a corset, and using appropriate body mechanics and assistive devices.

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Question 36

6. During a health screening event, which assessment finding in a white, 61-yr-old woman would alert the nurse to the possible presence of osteoporosis?
   a. Presence of bowed legs
   b. Measurable loss of height
   c. Poor appetite and aversion to dairy products
   d. Development of unstable, wide-gait ambulation

Answer 36

b. Measurable loss of height

A gradual but measurable loss of height and the development of kyphosis (“dowager’s hump”) are indicative of the presence of osteoporosis. Bowed legs may be caused by abnormal bone development or rickets but are not indicative of osteoporosis. Lack of calcium and Vitamin D intake may cause osteoporosis but are not indicative of its presence. A wide gait is used to support balance and does not indicate osteoporosis.

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Question 37

7. The nurse is reinforcing health teaching about osteoporosis with a 72-yr-old patient admitted to the hospital. What should the nurse explain to the patient?
   a. With a family history of osteoporosis, you cannot prevent or slow bone resorption.
   b. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis.
   c. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis.
   d. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

Answer 37

d. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

The rate of progression of osteoporosis can be slowed if the patient takes calcium supplements or foods high in calcium and engages in regular weight-bearing exercise. Corticosteroids interfere with bone metabolism. Estrogen therapy is no longer used to prevent osteoporosis because of the associated increased risk of heart disease and breast and uterine cancer.

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Question 38

8. The nurse determines dietary teaching for a 75-yr-old patient with osteoporosis has been successful when the patient selects which meal as highest in calcium?
   a. Chicken stir fry with 1 cup each onions and green peas, and 1 cup of steamed rice
   b. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple
   c. Sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk
   d. A two-egg omelet with 2 oz of American cheese, one slice of whole wheat toast, and a half grapefruit

Answer 38

c. Sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk

The highest calcium content is present in the lunch containing milk and milk products (yogurt) and small fish with bones (sardines). Chicken, onions, green peas, rice, ham, whole wheat bread, broccoli, apple, eggs, and grapefruit each have less than 75 mg of calcium per 100 g of food. Swiss cheese and American cheese have more calcium but not as much as the sardines, yogurt, and milk.

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Question 39

9. The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. When completing a focused assessment, which symptom will the nurse expect?
   a. Nausea and vomiting
   b. Localized pain and warmth
   c. Paresthesia in the affected extremity
   d. Generalized bone pain throughout the leg

Answer 39

b. Localized pain and warmth

Osteomyelitis is an infection of bone and bone marrow that can occur with trauma, surgery, or spread from another part of the body. Because it is an infection, the patient will exhibit typical signs of inflammation and infection, including localized pain and warmth. Nausea and vomiting and paresthesia of the extremity are not expected to occur. Pain occurs, but it is localized rather than generalized throughout the leg.

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Question 40

10. A 54-yr-old patient with acute osteomyelitis asks the nurse how this problem will be treated initially. Which response by the nurse is most appropriate?
    a. “IV antibiotics are usually required for several weeks.”
    b. “Oral antibiotics are often required for several months.”
    c. “Surgery is almost always necessary to remove the dead tissue that present.”
    d. “Drainage of the foot and instillation of antibiotics into the affected area are the usual therapy.”

Answer 40

a. “IV antibiotics are usually required for several weeks.”

The standard treatment for acute osteomyelitis consists of several weeks of IV antibiotic therapy. However, as many as 3 to 6 months may be required. Bone is denser and less vascular than other tissues, and it takes time for the antibiotic therapy to eradicate all microorganisms. Surgery may be used for chronic osteomyelitis, to include debridement of the devitalized, infected tissue and irrigation of the affected bone with antibiotics.

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Question 41

11. A 67-yr-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges and elevation of the affected foot on two pillows. The nurse would place the highest priority on which intervention?
    a. Ambulate the patient to the bathroom every 2 hours.
    b. Ask the patient about preferred activities to relieve boredom.
    c. Allow the patient to dangle legs at the bedside every 2 to 4 hours.
    d. Perform frequent position changes and range-of-motion exercises.

Answer 41

d. Perform frequent position changes and range-of-motion exercises.

The patient is at risk for atelectasis of the lungs and contractures because of prescribed bed rest. For this reason, the nurse should place the priority on changing the patient’s position frequently to promote lung expansion and performing range-of-motion exercises to prevent contractures. Assisting the patient to the bathroom will keep the patient safe as the patient is in pain, but it may not be needed every 2 hours. Providing activities to relieve boredom will assist the patient to cope with the bed rest. Dangling the legs every 2 to 4 hours may be too painful.

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Question 42

12. The nurse identifies a nursing diagnosis of pain related to muscle spasms for a 45-yr-old patient who has low back pain from a herniated lumbar disc. Which nursing intervention would be most appropriate?
    a. Provide gentle ROM to the lower extremities.
    b. Elevate the head of the bed 20 degrees and flex the knees.
    c. Place a small pillow under the patient’s upper back to gently flex the lumbar spine.
    d. Place the bed in reverse Trendelenburg with the patient’s feet firmly against the footboard.

Answer 42

b. Elevate the head of the bed 20 degrees and flex the knees.

To reduce pain, the nurse should elevate the head of the bed 20 degrees and have the patient flex the knees to avoid extension of the spine. The slight flexion provided by this position often is comfortable for a patient with a herniated lumbar disc. ROM to the lower extremities will be limited to prevent extremes of spinal movement. Reverse Trendelenburg and a pillow under the patient’s upper back will more likely increase pain.

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Question 43

13. The nurse is admitting a patient who complains of new onset of lower back pain. To differentiate between the pain of a lumbar herniated disc from other causes, what is the best question for the nurse to ask the patient?
    a. “Is the pain worse in the morning or in the evening?”
    b. “Is the pain sharp and stabbing or burning and aching?”
    c. “Does the pain radiate down the buttock or into the leg?”
    d. “Is the pain totally relieved by acetaminophen (Tylenol)?”

Answer 43

c. “Does the pain radiate down the buttock or into the leg?”

Lower back pain associated with a herniated lumbar disc is accompanied by radiation along the sciatic nerve and can be commonly described as traveling through the buttock to the posterior thigh or down the leg. This is because the herniated disc causes compression on spinal nerves as they exit the spinal column. Time of occurrence, type of pain, and pain relief questions do not elicit differentiating data.

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Question 44

14. The nurse is admitting a patient with a history of a herniated lumbar disc and low back pain. Which action would most likely aggravate the pain?
    a. Bending or lifting
    b. Application of warm moist heat
    c. Sleeping in a side-lying position
    d. Sitting in a fully extended recliner

Answer 44

a. Bending or lifting

Back pain related to a herniated lumbar disc is aggravated by events and activities that increase stress and strain on the spine, such as bending or lifting, coughing, sneezing, and lifting the leg with the knee straight (straight leg-raising test). Moist heat, sleeping position, and ability to sit in a fully extended recliner do not aggravate the pain of a herniated lumbar disc.

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Question 45

15. The nurse has reviewed proper body mechanics with a patient who has a history of low back pain caused by a herniated lumbar disc. Which patient statement indicates a need for further teaching?
    a. “I should sleep on my side or back with my hips and knees bent.”
    b. “I should exercise at least 15 minutes every morning and evening.”
    c. “I should pick up items by leaning forward without bending my knees.”
    d. “I should try to keep one foot on a stool whenever I have to stand for a period of time.”

Answer 45

c. “I should pick up items by leaning forward without bending my knees.”

The patient should avoid leaning forward without bending the knees. Bending the knees helps to prevent lower back strain and is part of proper body mechanics for lifting. Sleeping on the side or back with hips and knees bent and standing with a foot on a stool will decrease lower back strain. Back strengthening exercises are done twice a day once symptoms subside.

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Question 46

16. Which nursing intervention is most appropriate when turning a patient after spinal surgery?
    a. Having the patient turn to the side by grasping the side rails to help turn
    b. Placing a pillow between the patient’s legs and turning the body as a unit
    c. Elevating the head of bed 30 degrees and having the patient extend the legs while turning
    d. Turning the patient’s head and shoulders and then the hips, keeping the patient’s body centered in the bed

Answer 46

b. Placing a pillow between the patient’s legs and turning the body as a unit

Placing a pillow between the legs and turning the patient as a unit (logrolling) helps to keep the spine in good alignment and reduces pain and discomfort after spinal surgery. The other interventions will not maintain proper spine alignment and may cause spinal damage.

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Question 47

17. The nurse is planning health promotion teaching for a 45-yr-old patient with asthma who is experiencing low back pain from herniated lumbar disc. What activity will the nurse include in an individualized exercise plan for the patient?
    a. Yoga
    b. Walking
    c. Calisthenics
    d. Weight lifting

Answer 47

b. Walking

The patient would benefit from an aerobic exercise that considers the patient’s health status and fits the patient’s lifestyle. The best exercise is walking, which builds strength in the back and leg muscles without putting undue pressure or strain on the spine. If the patient has exercise-induced asthma, the nurse would recommend use of a rescue inhaler prior to exercise. Yoga, calisthenics, and weight lifting would all put pressure on or strain the spine.

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Question 48

18. The nurse is caring for a patient hospitalized with a herniated lumbar disc and an exacerbation of chronic bronchitis. Which breakfast choice would be most appropriate for the patient to select from the breakfast menu?
    a. Bran muffin
    b. Scrambled eggs
    c. Puffed rice cereal
    d. Buttered white toast

Answer 48

a. Bran muffin

Each meal should contain one or more sources of fiber to reduce the risk of constipation and straining with defecation, which increases back pain. A patient with chronic breathing difficulties also will benefit from regularity and ease of bowel evacuation. In addition, if lumbar nerve compression is present, bowel and bladder function may be impaired. Bran is a typical high-fiber food choice and is an appropriate selection from the menu. Scrambled eggs, puffed rice cereal, and buttered white toast do not have as much fiber.

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Question 49

19. A 24-yr-old male patient has come to the clinic with a gradual onset of pain and swelling in the left knee. The patient is diagnosed with osteosarcoma without metastasis. Chemotherapy is ordered before surgery. How will the nurse explain the reason for preoperative chemotherapy?
    a. “The chemotherapy is being used to save your left leg.”
    b. “Chemotherapy will increase your 5-year survival rate.”
    c. “Chemotherapy is being used to decrease the tumor size.”
    d. “Chemotherapy will help decrease the pain before and after surgery.”

Answer 49

c. “Chemotherapy is being used to decrease the tumor size.”

Preoperative chemotherapy is used to decrease the tumor size before surgery. The chemotherapy will not save his leg if the lesion is too big or there is neurovascular or muscle involvement. Adjunct chemotherapy after amputation or limb salvage has increased 5-year survival rates in people without metastasis. Chemotherapy is not used to decrease pain before or after surgery.

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Question 50

20. When the patient is diagnosed with muscular dystrophy, what information should the nurse include in the teaching plan?
    a. Use prolonged bed rest to decrease fatigue.
    b. Continuous positive airway pressure will facilitate sleeping.
    c. An orthotic jacket will limit mobility and may contribute to deformity.
    d. Remain active to prevent skin breakdown and respiratory complications.

Answer 50

d. Remain active to prevent skin breakdown and respiratory complications.

With muscular dystrophy, the patient must remain active for as long as possible. Prolonged bed rest should be avoided because immobility leads to further muscle wasting. An orthotic jacket may be used to provide stability and prevent further deformity. Continuous positive airway pressure (CPAP) may be used as respiratory function decreases before mechanical ventilation is needed to sustain respiratory function.

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Question 51

1. A patient with osteomyelitis is treated with surgical debridement with implantation of antibiotic beads. When the patient asks why the beads are used, the nurse answers(select all that apply)
   a. “The beads are used to directly deliver antibiotics to the site of the infection.”
   b. “There are no effective oral or IV antibiotics to treat most cases of bone infection.”
   c. “This is the safest method of delivering long-term antibiotic therapy for a bone infection.”
   d. “The beads are an adjunct to debridement and oral and IV antibiotics for deep infections.”
   e. “The ischemia and bone death that occur with osteomyelitis are impenetrable to IV antibiotics.”

Answer 51

a. “The beads are used to directly deliver antibiotics to the site of the infection.”
d. “The beads are an adjunct to debridement and oral and IV antibiotics for deep infections.”

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Question 52

2. A patient has been diagnosed with osteosarcoma of the humerus. He shows an understanding of his treatment options when he states
   a. “I accept that I have to lose my arm with surgery.”
   b. “The chemotherapy before surgery will shrink the tumor.”
   c. “This tumor is related to the melanoma I had 3 years ago.”
   d. “I’m glad they can take out the cancer with such a small scar.”

Answer 52

b. “The chemotherapy before surgery will shrink the tumor.”

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Question 53

3. Which individuals would be at high risk for low back pain(select all that apply)?
   a. A 63-year-old man who is a long-distance truck driver
   b. A 36-year-old 6 ft, 2 in construction worker who weighs 260 lb
   c. A 28-year-old female yoga instructor who is 5 ft, 6 in and weighs 130 lb
   d. A 30-year-old male nurse who works on an orthopedic unit and smokes
   e. A 44-year-old female chef with prior compression fracture of the spine

Answer 53

a. A 63-year-old man who is a long-distance truck driver
b. A 36-year-old 6 ft, 2 in construction worker who weighs 260 lb
d. A 30-year-old male nurse who works on an orthopedic unit and smokes
e. A 44-year-old female chef with prior compression fracture of the spine

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Question 54

4. The nurse’s responsibility for a patient with a suspected disc herniation who is experiencing acute pain and muscle spasms is
   a. encouraging total bed rest for several days.
   b. teaching the principles of back strengthening exercises.
   c. stressing the importance of straight-leg raises to decrease pain.
   d. promoting the use of cold and hot compresses and pain medication.

Answer 54

d. promoting the use of cold and hot compresses and pain medication.

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Question 55

5. In caring for a patient after a spinal fusion, the nurse would immediately report to the physician which patient symptom?
   a. The patient experiences a single episode of emesis.
   b. The patient is unable to move the lower extremities.
   c. The patient is nauseated and has not voided in 4 hours.
   d. The patient complains of pain at the bone graft donor site.

Answer 55

b. The patient is unable to move the lower extremities.

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Question 56

6. Before discharge from the same-day surgery unit, instruct the patient who has had a surgical correction of bilateral hallux valgus to
   a. rest frequently with the feet elevated.
   b. soak the feet in warm water several times a day.
   c. expect the feet to be numb for the next few days.
   d. expect continued pain in the feet, since this is not uncommon.

Answer 56

a. rest frequently with the feet elevated

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Question 57

7. You are teaching a patient with osteopenia. What is important to include in the teaching plan?
   a. Lose weight.
   b. Stop smoking.
   c. Eat a high-protein diet.
   d. Start swimming for exercise.

Answer 57

b. Stop smoking.

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Question 58

1. The nurse is caring for patients in a primary care clinic. Which individual is most at risk to develop osteomyelitis caused by Staphylococcus aureus?

A. 22-year-old female with gonorrhea who is an IV drug user

B. 48-year-old male with muscular dystrophy and acute bronchitis

C. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer

D. 68-year-old female with hypertension who had a knee arthroplasty 3 years ago

Answer 58

C. 32-year-old male with type 1 diabetes mellitus and a stage IV pressure ulcer

Osteomyelitis caused by Staphylococcus aureus is usually associated with a pressure ulcer or vascular insufficiency related to diabetes mellitus. Osteomyelitis caused by Staphylococcus epidermidis is usually associated with indwelling prosthetic devices such as joint replacements. Osteomyelitis caused by Neisseria gonorrhoeae is usually associated with gonorrhea. Osteomyelitis caused by Pseudomonas is usually associated with IV drug use. Muscular dystrophy is not associated with osteomyelitis.

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Question 59

2. The nurse cares for a 58-year-old woman with breast cancer who is admitted for severe back pain related to a compression fracture. The patient’s laboratory values include serum potassium of 4.5 mEq/L, serum sodium of 144 mEq/L, and serum calcium of 14.3 mg/dL. Which signs and symptoms will the nurse expect the patient to exhibit?

A. Anxiety, irregular pulse, and weakness

B. Muscle stiffness, dysphagia, and dyspnea

C. Hyperactive reflexes, tremors, and seizures

D. Nausea, vomiting, and altered mental status

Answer 59

D. Nausea, vomiting, and altered mental status

Breast cancer can metastasize to the bone. Vertebrae are a common site. Pathologic fractures at the site of metastasis are common because of a weakening of the involved bone. High serum calcium levels result as calcium is released from damaged bones. Normal serum calcium is between 8.6 to 10.2 mg/dL. Clinical manifestations of hypercalcemia include nausea, vomiting, and altered mental status (e.g., lethargy, decreased memory, confusion, personality changes, psychosis, stupor, coma). Other manifestations include weakness, depressed reflexes, anorexia, bone pain, fractures, polyuria, dehydration, and nephrolithiasis. Manifestations of hypomagnesemia include hyperactive reflexes, tremors, and seizures. Symptoms of hyperkalemia include anxiety, irregular pulse, and weakness. Symptoms of hypocalcemia include muscle stiffness, dysphagia, and dyspnea.

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Question 60

3. The nurse provides instructions to a 30-year-old female office worker who has low back pain. Which statement by the patient requires an intervention by the nurse?

A. “Acupuncture to the lower back would cause irreparable nerve damage.”

B. “Smoking may aggravate back pain by decreasing blood flow to the spine.”

C. “Sleeping on my side with knees and hips bent reduces stress on my back.”

D. “Switching between hot and cold packs provides relief of pain and stiffness.”

Answer 60

A. “Acupuncture to the lower back would cause irreparable nerve damage.”

Acupuncture is a safe therapy when the practitioner has been appropriately trained. Very fine needles are inserted into the skin to stimulate specific anatomic points in the body for therapeutic purposes.

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Question 61

4. The nurse receives report from the licensed practical nurse about care provided to patients on the orthopedic surgical unit. It is most important for the nurse to follow up on which statement?

A. “The patient who had a spinal fusion 12 hours ago has hypoactive bowel sounds and is not passing flatus.”

B. “The patient who had cervical spine surgery 2 days ago wants to wear her soft cervical collar when out of bed.”

C. “The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing.”

D. “The patient who had a laminectomy 24 hours ago is using patient-controlled analgesia with morphine for pain management.”

Answer 61

C. “The patient who had spinal surgery 3 hours ago is complaining of a headache and has clear drainage on the dressing.”

After spinal surgery there is potential for cerebrospinal fluid (CSF) leakage. Severe headache or leakage of CSF (clear or slightly yellow) on the dressing should be reported immediately. The drainage is CSF if a dipstick test is positive for glucose. Patients after spinal surgery may experience paralytic ileus and interference with bowel function for several days. Postoperatively most patients require opioids such as morphine IV for 24 to 48 hours. Patient-controlled analgesia is the preferred method for pain management during this time. After cervical spine surgery patients often wear a soft or hard cervical collar to immobilize the neck.

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Question 62

5. The nurse prepares to administer IV ibandronate (Boniva) to a 67-year-old woman with osteoporosis. What is a priority laboratory assessment to make before the administration of ibandronate?

A. Serum calcium

B. Serum creatinine

C. Serum phosphate

D. Serum alkaline phosphatase

Answer 62

B. Serum creatinine

Ibandronate is a bisphosphonate that is administered IV every 3 months and is administered slowly over 15 to 30 seconds to prevent renal damage. Ibandronate should not be used by patients taking other nephrotoxic drugs or by those with severe renal impairment (defined as serum creatinine above 2.3 mg/dL or creatinine clearance less than 30 mL/min).

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Question 63

1. A 19-yr-old male patient has a plaster cast applied to the right arm for a Colles’ fracture after a skateboarding accident. Which nursing action is most appropriate?
   a. Elevate the right arm on two pillows for 24 hours.
   b. Apply heating pad to reduce muscle spasms and pain.
   c. Limit movement of the thumb and fingers on the right hand.
   d. Place arm in a sling to prevent movement of the right shoulder.

Answer 63

a. Elevate the right arm on two pillows for 24 hours.

The casted extremity should be elevated at or above heart level for 24 hours to reduce swelling or inflammation. The cast should be supported on pillows during the drying period to prevent denting and flattening of the cast. Ice (not heat) should be applied for the first 24 to 36 hours to reduce swelling or inflammation. Active movement of the thumb and fingers should be encouraged to reduce edema and increase venous return. A sling may be used to support and protect the extremity after the cast is completely dry, but the patient should perform active movements of the shoulder to prevent stiffness or contracture.

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Question 64

2. The home care nurse visits a 74-yr-old man diagnosed with Parkinson’s disease who fell while walking this morning. What observation is of most concern to the nurse?
   a. 2 × 6 cm right calf abrasion with sanguineous drainage
   b. Left leg externally rotated and shorter than the right leg
   c. Stooped posture with a shuffling gait and slow movements
   d. Mild pain and minimal swelling of the right ankle and foot

Answer 64

b. Left leg externally rotated and shorter than the right leg

Clinical manifestations of hip fracture include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Expected clinical manifestations of Parkinson’s disease include a stooped posture, shuffling gait, and slow movements. An abrasion is a soft tissue injury. Mild pain and minimal swelling may occur with a sprain or strain.

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Question 65

3. A 28-yr-old woman with a fracture of the proximal left tibia in a long leg cast and complains of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which nursing action is a priority?
   a. Notify the health care provider immediately.
   b. Elevate the left leg above the level of the heart.
   c. Administer prescribed morphine sulfate intravenously.
   d. Apply ice packs to the left proximal tibia over the cast.

Answer 65

a. Notify the health care provider immediately.

Notify the health care provider immediately of this change in patient’s condition, which suggest development of compartment syndrome. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Changes in sensation (tingling) also suggest compartment syndrome. Because elevation of the extremity may lower venous pressure and slow arterial perfusion, the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. Administration of morphine may be warranted, but it is not the first priority.

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Question 66

4. A 42-yr-old man underwent amputation below the knee on the left leg after a recent heavy farm machinery accident. Which intervention should the nurse include in the plan of care?
   a. Sit in a chair for 1 to 2 hours three times each day.
   b. Dangle the residual limb for 20 to 30 minutes every 6 hours.
   c. Lie prone with hip extended for 30 minutes four times per day.
   d. Elevate the residual limb on a pillow for 4 to 5 days after surgery.

Answer 66

c. Lie prone with hip extended for 30 minutes four times per day.

To prevent hip flexion contractures, the patient should lie on the abdomen for 30 minutes three or four times each day and position the hip in extension while prone. The patient should avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. The patient should avoid dangling the residual limb over the bedside to minimize edema.

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Question 67

5. A nurse performs discharge teaching for a 58-yr-old woman after a left hip arthroplasty using the posterior approach. Which statement by the patient indicates teaching is successful?
   a. “Leg-raising exercises are necessary for several months.”
   b. “I should not try to drive a motor vehicle for 2 to 3 weeks.”
   c. “I will not have any restrictions now on hip and leg movements.”
   d. “Blood tests will be done weekly while taking enoxaparin (Lovenox).”

Answer 67

a. “Leg-raising exercises are necessary for several months.”

Exercises designed to restore strength and muscle tone will be done for months after surgery. The exercises include leg raises in supine and prone positions. Driving a car is not allowed for 4 to 6 weeks. In the posterior approach hip arthroplasties, extremes of internal rotation and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively. The knees must be kept apart. The patient should never cross the legs or twist to reach behind. To prevent thromboembolism, enoxaparin is administered subcutaneously and can be given at home. Enoxaparin does not require monitoring of the patient’s coagulation status.

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Question 68

6. The nurse completes an admission history for a 73-yr-old man with osteoarthritis scheduled for total knee arthroplasty. Which response is expected when asking the patient the reason for admission?
   a. Recent knee trauma
   b. Debilitating joint pain
   c. Repeated knee infections
   d. Onset of frozen knee joint

Answer 68

b. Debilitating joint pain

The most common reason for knee arthroplasty is debilitating joint pain despite exercise, weight management, and drug therapy. Recent knee trauma, repeated knee infections, and onset of frozen knee joint are not primary indicators for a knee arthroplasty.

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Question 69

7. The nurse is caring for a patient with osteoarthritis scheduled for total left knee arthroplasty. Preoperatively, the nurse assesses for which contraindication to surgery?
   a. Pain
   b. Left knee stiffness
   c. Left knee infection
   d. Left knee instability

Answer 69

c. Left knee infection

The patient must be free of infection before total knee arthroplasty. An infection in the joint could lead to even greater pain and joint instability, requiring more extensive surgery. The nurse must assess the patient for signs of infection, such as redness, swelling, fever, and elevated white blood cell count. Pain, knee stiffness, or instability are typical of osteoarthritis.

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Question 70

8. The nurse formulates a nursing diagnosis of Impaired physical mobility related to decreased muscle strength for an older adult patient recovering from left total knee arthroplasty. What nursing intervention is appropriate?
   a. Promote vitamin C and calcium intake in the diet.
   b. Provide passive range of motion to all of the joints q4hr.
   c. Keep the left leg in extension and abduction to prevent contractures.
   d. Encourage isometric quadriceps-setting exercises at least four times a day.

Answer 70

d. Encourage isometric quadriceps-setting exercises at least four times a day.

Emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery. Vitamin C and calcium do not improve muscle strength, but they will facilitate healing. The patient should be able to perform active range of motion to all joints. Keeping the leg in one position (extension and abduction) may contribute to contractures.

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Question 71

9. The nurse is caring for a 76-yr-old man who has undergone left total knee arthroplasty to relieve the pain of severe osteoarthritis. What care would be expected postoperatively?
   a. Progressive leg exercises to obtain 90-degree flexion
   b. Early ambulation with full weight bearing on the left leg
   c. Bed rest for 3 days with the left leg immobilized in extension
   d. Immobilization of the left knee in 30-degree flexion to prevent dislocation

Answer 71

a. Progressive leg exercises to obtain 90-degree flexion

The patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible; continuous passive motion also may be used based on surgeon preference. Early ambulation is implemented, sometimes the day of surgery, but orders are likely to indicate weight bearing as tolerated rather than full weight bearing. Immobilization and bed rest are not indicated. The patient’s knee is unlikely to dislocate.

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Question 72

10. The nurse is completing discharge teaching with an 80-yr-old male patient who is recovering from a right total hip arthroplasty by posterior approach. Which patient action indicates further instruction is needed?
    a. Uses an elevated toilet seat
    b. Sits with feet flat on the floor
    c. Maintains hip in adduction and internal rotation
    d. Verifies need to notify future caregivers about the prosthesis

Answer 72

c. Maintains hip in adduction and internal rotation

The patient should not force hip into adduction or internal rotation because these movements could dislocate the hip prosthesis. Sitting with feet flat on the floor (avoiding crossing the legs), using an elevated toilet seat, and notifying future caregivers about the prosthesis indicate understanding of discharge teaching.

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Question 73

11. The patient has frostbite on the distal toes of both feet. The patient is scheduled for amputation of damaged tissue. Which assessment finding or diagnostic study is most objective in determining tissue viability?
    a. Arteriogram showing blood vessels
    b. Peripheral pulse palpation bilaterally
    c. Patches of black, indurated, cold tissue
    d. Bilateral pale, cool skin below the ankles

Answer 73

a. Arteriogram showing blood vessels

Arteriography determines viable tissue for salvage based on blood flow observed in real time and is considered the gold standard for evaluating arterial perfusion. Only arteriography determines where tissue perfusion stops and amputation needs to occur. Bilateral peripheral pulse assessment and areas of black, indurated, cold, and pale skin indicate ischemia.

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Question 74

12. This morning a 21-yr-old male patient had a long leg cast applied, and he asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient’s request?
    a. “No one is available to assist and accompany the patient.”
    b. “The cast is not dry yet, and it may be damaged while using crutches.”
    c. “Rest, ice, compression, and elevation are in process to decrease pain.”
    d. “Excess edema and complications are prevented when the leg is elevated for 24 hours.”

Answer 74

d. “Excess edema and complications are prevented when the leg is elevated for 24 hours.”

For the first 24 hours after a lower extremity cast is applied, the leg should be elevated on pillows above heart level to avoid excessive edema and compartment syndrome. A plaster cast will also be drying during this 24-hour period. RICE is used for soft tissue injuries, not with long leg casts.

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Question 75

13. A 21-yr-old soccer player has injured the anterior crucial ligament (ACL) and is having reconstructive surgery. Which patient statement indicates more teaching is required?
    a. “I probably won’t be able to play soccer for 6 to 8 months.”
    b. “They will have me do range of motion with my knee soon after surgery.”
    c. “I can’t wait to get this done now so I can play soccer for the next tournament.”
    d. “I will need to wear an immobilizer and progressively bear weight on my knee.”

Answer 75

c. “I can’t wait to get this done now so I can play soccer for the next tournament.”

The patient does not understand the severity of ACL reconstructive surgery if planning to resume playing soccer soon; safe return will not occur for 6 to 8 months. Initial range of motion, immobilization, and progressive weight bearing will be overseen by a physical therapist.

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Question 76

14. The nurse is caring for a patient placed in Buck’s traction before open reduction and internal fixation of a left hip fracture. Which care can be delegated to the LPN/LVN?
    a. Assess skin integrity around the traction boot.
    b. Determine correct body alignment to enhance traction.
    c. Remove weights from traction when turning the patient.
    d. Monitor pain intensity and administer prescribed analgesics.

Answer 76

d. Monitor pain intensity and administer prescribed analgesics.

The LPN/LVN can monitor pain intensity and administer analgesics. Assessment of skin integrity and determining correct alignment to enhance traction are within the RN scope of practice. Removing weights from the traction should not be delegated or done. Removal of weights can cause muscle spasms and bone misalignment, and should not be delegated or done.

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Question 77

15. An injured soldier underwent left leg amputation 2 weeks ago, but now reports shooting pain and heaviness in the left leg. What action by the nurse is supported by research findings?
    a. Use mirror therapy.
    b. Give opioid analgesics.
    c. Rebandage the residual limb.
    d. Show the patient the leg is gone.

Answer 77

a. Use mirror therapy.

Mirror therapy has been shown to reduce phantom limb pain in some patients. Opioid analgesics, rebandaging the residual limb, and showing the patient that the leg is gone may not decrease phantom limb pain.

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Question 78

16. The patient is brought to the emergency department after a car accident and is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus?
    a. Administer enoxaparin (Lovenox).
    b. Provide range-of-motion exercises.
    c. Apply sequential compression boots.
    d. Immobilize the fracture preoperatively.

Answer 78

d. Immobilize the fracture preoperatively.

The nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus development before surgical reduction. Enoxaparin is used to prevent blood clots not fat emboli. Range of motion and compression boots will not prevent a fat embolus in this patient.

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Question 79

17. When entering the grocery store, a patient trips on the curb and sprains the right ankle. Which initial care is appropriate (select all that apply.)?
    a. Apply ice directly to the skin.
    b. Apply heat to the ankle every 2 hours.
    c. Administer antiinflammatory medication.
    d. Compress ankle using an elastic bandage.
    e. Rest and elevate the ankle above the heart.
    f. Perform passive and active range of motion.

Answer 79

c. Administer antiinflammatory medication.
d. Compress ankle using an elastic bandage.
e. Rest and elevate the ankle above the heart.

Appropriate care for a sprain is represented with the acronym RICE (rest, ice, compression, and elevation). Antiinflammatory medication should be used to decrease swelling if not contraindicated for the patient. After the injury, the ankle should be immobilized and rested. Prolonged immobilization is not required unless there is significant injury. Ice is indicated, but will cause tissue damage if applied directly to the skin. Apply ice to sprains as soon as possible and leave in place for 20 to 30 minutes at a time. Moist heat may be applied 24 to 48 hours after the injury.

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Question 80

1. The nurse suspects an ankle sprain when a patient at the urgent care center relates
   a. being hit by another soccer player during a game.
   b. having ankle pain after sprinting around the track.
   c. dropping a 10-lb weight on his lower leg at the health club.
   d. twisting his ankle while running bases during a baseball game.

Answer 80

d. twisting his ankle while running bases during a baseball game.

Chapter 63 Musculoskeletal Tramua and Orthopedic Surgery (9th Edition)
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Question 81

2. The nurse explains to a patient with a fracture of the distal shaft of the humerus who is returning for a 4-week checkup that healing is indicated by
   a. formation of callus.
   b. complete bony union.
   c. hematoma at fracture site.
   d. presence of granulation tissue.

Answer 81

a. formation of callus.

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Question 82

3. A patient with a comminuted fracture of the tibia is to have an open reduction with internal fixation (ORIF) of the fracture. The nurse explains that ORIF is indicated when
   a. the patient is unable to tolerate prolonged immobilization.
   b. the patient cannot tolerate the surgery of a closed reduction.
   c. a temporary cast would be too unstable to provide normal mobility.
   d. adequate alignment cannot be obtained by other nonsurgical methods.

Answer 82

d. adequate alignment cannot be obtained by other nonsurgical methods.

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Question 83

4. An indication of a neurovascular problem noted during assessment of the patient with a fracture is
   a. exaggeration of strength with movement.
   b. increased redness and heat below the injury.
   c. decreased sensation distal to the fracture site.
   d. purulent drainage at the site of an open fracture.

Answer 83

c. decreased sensation distal to the fracture site.

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Question 84

5. A patient with a stable, closed fracture of the humerus caused by trauma to the arm has a temporary splint with bulky padding applied with an elastic bandage. The nurse suspects compartment syndrome and notifies the physician when the patient experiences
   a. increasing edema of the limb.
   b. muscle spasms of the lower arm.
   c. rebounding pulse at the fracture site.
   d. pain when passively extending the fingers.

Answer 84

d. pain when passively extending the fingers.

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Question 85

6. A patient with a fracture of the pelvis should be monitored for
   a. changes in urine output.
   b. petechiae on the abdomen.
   c. a palpable lump in the buttock.
   d. sudden increase in blood pressure.

Answer 85

a. changes in urine output.

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Question 86

7. During the postoperative period, the nurse instructs the patient with an above-the-knee amputation that the residual limb should not be routinely elevated because this position promotes
   a. hip flexion contractures.
   b. skin irritation and breakdown.
   c. clot formation at the incision site.
   d. increased risk of wound dehiscence.

Answer 86

a. hip flexion contractures.

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Question 87

8. A patient with osteoarthritis is scheduled for a total hip arthroplasty. The nurse explains that the purpose of this procedure is to (select all that apply)
   a. fuse the joint.
   b. replace the joint.
   c. prevent further damage.
   d. improve or maintain ROM.
   e. decrease the amount of destruction in the joint.

Answer 87

b. replace the joint.
d. improve or maintain ROM.

Chapter 63 Musculoskeletal Tramua and Orthopedic Surgery (9th Edition)
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Question 88

9. In teaching a patient scheduled for a total ankle replacement, it is important to tell the patient that after surgery he should avoid
   a. lifting heavy objects.
   b. sleeping on the back.
   c. abduction exercises of the affected ankle.
   d. bearing weight on the affected leg for 6 weeks.

Answer 88

d. bearing weight on the affected leg for 6 weeks.

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Question 89

1. A 19-year-old male patient has a plaster cast applied to the right upper extremity for a Colles’ fracture after a skateboarding accident. Which action, if taken by the nurse, is the most appropriate?

A. Elevate the right arm on two pillows for 24 hours.

B. Apply heating pad to reduce muscle spasms and pain.

C. Limit movement of the thumb and fingers on the right hand.

D. Place arm in a sling to prevent movement of the right shoulder.

Answer 89

A. Elevate the right arm on two pillows for 24 hours.

The cast should be supported on pillows during the drying period to prevent denting and flattening of the cast. The casted extremity should be elevated at or above the heart level to reduce swelling or inflammation. Ice should be applied for the first 24 to 36 hours to reduce swelling or inflammation. Active movement of the thumb and fingers should be encouraged to reduce edema and increase venous return. A sling may be used to support and protect the extremity after the cast is completely dry but the patient should perform active movements of the shoulder to prevent stiffness or contracture.

Chapter 63 Musculoskeletal Tramua and Orthopedic Surgery (9th Edition)
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Question 90

2. The home care nurse visits a 74-year-old man diagnosed with Parkinson’s disease who fell while walking this morning. What observation is of most concern to the nurse?

A. 2 × 6 cm right calf abrasion with sanguineous drainage

B. Left leg externally rotated and shorter than the right leg

C. Stooped posture with a shuffling gait and slow movements

D. Mild pain and minimal swelling of the right ankle and foot

Answer 90

B. Left leg externally rotated and shorter than the right leg

Clinical manifestations of a hip fracture include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Expected clinical manifestations of Parkinson’s disease include a stooped posture, shuffling gait, and slow movements. An abrasion is a soft tissue injury. Mild pain and minimal swelling may occur with a sprain or strain.

Chapter 63 Musculoskeletal Tramua and Orthopedic Surgery (9th Edition)
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Question 91

3. A 28-year-old woman with a fracture of the proximal left tibia in a long leg cast complains of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which action should the nurse take?

A. Notify the health care provider immediately.

B. Elevate the left leg above the level of the heart.

C. Administer prescribed morphine sulfate intravenously.

D. Apply ice packs to the left proximal tibia over the cast.

Answer 91

A. Notify the health care provider immediately.

Clinical manifestations of compartment syndrome include (1) paresthesia, (2) pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through the compartment, (3) pressure increases in the compartment, (4) pallor, coolness, and loss of normal color of the extremity, (5) paralysis or loss of function, and (6) pulselessness or diminished/absent peripheral pulses. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Pulselessness and paralysis (in particular) are later signs of compartment syndrome. Notify the health care provider immediately of a patient’s changing condition. Because elevation of the extremity may lower venous pressure and slow arterial perfusion, the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome.

Chapter 63 Musculoskeletal Tramua and Orthopedic Surgery (9th Edition)
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Question 92

4. A 42-year-old man has a recent amputation of the left leg below the knee as a result of a heavy farm machinery accident. Which intervention should the nurse include in the plan of care for this patient?

A. Sit in a chair for 1 to 2 hours three times each day.

B. Dangle the residual limb for 20 to 30 minutes every 6 hours.

C. Lay prone with hip extended for 30 minutes four times per day.

D. Elevate the residual limb on a pillow for 4 to 5 days after surgery.

Answer 92

C. Lay prone with hip extended for 30 minutes four times per day.

To prevent hip flexion contractures, patients should lie on their abdomen for 30 minutes three or four times each day and position the hip in extension while prone. Patients should avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. The patient should avoid dangling the residual limb over the bedside to minimize edema.

Chapter 63 Musculoskeletal Tramua and Orthopedic Surgery (9th Edition)
Pre-Test

Question 93

5. A nurse performs discharge teaching for a 58-year-old woman after a left hip arthroplasty (posterior approach). Which statement, if made by the patient to the nurse, indicates teaching is successful?

A. “I should not try to drive a motor vehicle for 2 to 3 weeks.”

B. “Leg-raising exercises are necessary for several months.”

C. “I will not have any restrictions now on hip and leg movements.”

D. “Blood tests will be done weekly while taking enoxaparin (Lovenox).”

Answer 93

B. “Leg-raising exercises are necessary for several months.”

Exercises designed to restore strength and muscle tone will be done for months after surgery. The exercises include leg raises in supine and prone positions. Driving a car is not allowed for 4 to 6 weeks. In the posterior approach hip arthroplasties, extremes of internal rotation and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively. The knees must be kept apart. The patient should never cross the legs or twist to reach behind. To prevent thromboembolism, enoxaparin is administered subcutaneously and can be given at home. Enoxaparin does not require monitoring of the patient’s coagulation status.

Chapter 63 Musculoskeletal Tramua and Orthopedic Surgery (9th Edition)
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Question 94

1. A 63-yr-old woman with a kidney transplant has been taking prednisone (Deltasone) daily for several years to prevent organ rejection. What is the most important assessment for the nurse to perform?
   a. Staggering gait
   b. Ruptured tendon
   c. Back or neck pain
   d. Tardive dyskinesia

Answer 94

c. Back or neck pain

Osteoporosis with fractures is a serious complication of corticosteroid therapy. The ribs and vertebrae fractures cause back and neck pain. Ataxic (staggering) gait is an adverse effect of phenytoin, an antiseizure medication. A rare adverse effect of ciprofloxacin and other fluoroquinolones is tendon rupture, usually the Achilles tendon. Antipsychotics and antidepressants may cause tardive dyskinesia, characterized by involuntary movements of the tongue and face.

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Question 95

2. The home care nurse visits an 84-yr-old woman with pneumonia after her discharge from the hospital. Which age-related change in the musculoskeletal system is expected?
   a. Positive straight-leg-raising test
   b. Muscle strength is scale grade 3/5
   c. Lateral S-shaped curvature of the spine
   d. Fingers drift to the ulnar side of the forearm

Answer 95

b. Muscle strength is scale grade 3/5

Decreased muscle strength is an age-related change of the musculoskeletal system caused by decreased number and size of the muscle cells. The other assessment findings indicate musculoskeletal abnormalities. A positive straight-leg-raising test indicates nerve root irritation from intervertebral disk prolapse and herniation. An ulnar deviation or drift indicates rheumatoid arthritis due to tendon contracture. Scoliosis is a lateral curvature of the spine.

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Question 96

3. The nurse admits a 55-yr-old woman with multiple sclerosis to a long-term care facility. Which finding represents a safety concern?
   a. Ataxic gait
   b. Radicular pain
   c. Severe fatigue
   d. Urinary retention

Answer 96

a. Ataxic gait

An ataxic gait is a staggering, uncoordinated gait. Fall risk is the highest in individuals with gait instability and visual or cognitive impairments. The other signs and symptoms (e.g., fatigue, urinary retention, radicular pain) may also occur in the patient with multiple sclerosis.

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Question 97

4. A 57-yr-old postmenopausal woman is scheduled for dual-energy x-ray absorptiometry (DXA). Which statement by the patient indicates understanding of the procedure?
   a. “The bone density in my heel will be measured.”
   b. “This procedure will not cause any pain or discomfort.”
   c. “I will not be exposed to any radiation during the procedure.”
   d. “I will need to remove my hearing aids before the procedure.”

Answer 97

b. “This procedure will not cause any pain or discomfort.”

DXA is painless and measures the bone mass of spine, femur, forearm, and total body with minimal radiation exposure. A quantitative ultrasound evaluates bone density using ultrasound of the calcaneus (heel). MRI would require removal of objects such as hearing aids that have metal parts.

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Question 98

5. A 42-yr-old man who is scheduled for arthrocentesis arrives at the outpatient surgery unit and states, “I do not want this procedure done today.” Which response by the nurse is most appropriate?
   a. “When would you like to reschedule the procedure?”
   b. “Tell me what your concerns are about this procedure.”
   c. “The procedure is safe, so why should you be worried?”
   d. “The procedure is not painful because an anesthetic is used.”

Answer 98

b. “Tell me what your concerns are about this procedure.”

The nurse should use therapeutic communication to determine the patient’s concern about the procedure. The nurse should not provide false reassurance. It is not appropriate for the nurse to conclude the patient is concerned about pain or assume the patient is asking to reschedule the procedure.

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Question 99

6. A 54-yr-old patient admitted with cellulitis and probable osteomyelitis received an injection of radioisotope at 9:00 AM for a bone scan. Which statement by the nurse is correct?
   a. “Decreased isotope uptake is seen with osteomyelitis.”
   b. “Isotopes injected for the scan are not harmful to you.”
   c. “The scan will be performed in one hour at 10:00 AM.”
   d. “The procedure takes approximately 10 minutes to complete.”

Answer 99

b. “Isotopes injected for the scan are not harmful to you.”

The isotope does not harm the patient. A technician administers a calculated dose of a radioisotope 2 hours before a bone scan. If the patient was injected at 9:00 AM, the procedure should be done at 11:00 AM. Increased isotope uptake indicates osteomyelitis. Bone scans are completed in about 1 hour.

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Question 100

7. A 54-yr-old patient is about to have a bone scan. In teaching the patient about this procedure, the nurse should include what information?
   a. “Only mild pain is associated with the procedure.”
   b. “Two additional follow-up scans will be required.”
   c. “The procedure takes approximately 15 to 30 minutes.”
   d. “You will need to drink increased fluids after the procedure.”

Answer 100

d. “You will need to drink increased fluids after the procedure.”

Patients are asked to drink increased fluids after a bone scan to aid in excretion of the radioisotope, if not contraindicated by another condition. No follow-up scans are required. Only mild pain may be associated with bone scans related to 1 hour of lying supine.

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Question 101

8. When administered long-term, which medication requires ongoing musculoskeletal assessment?
   a. Corticosteroids
   b. β-Adrenergic blockers
   c. Antiplatelet aggregators
   d. Calcium-channel blockers

Answer 101

a. Corticosteroids

Corticosteroids are associated with avascular necrosis and decreased bone and muscle mass. β-Blockers, calcium-channel blockers, and antiplatelet aggregators are not commonly associated with damage to the musculoskeletal system.

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Question 102

9. A female patient with a history of rheumatoid arthritis complains of stiffness in her right knee and complete fixation of the joint. What problem does the nurse anticipate will be identified in the patient’s history and physical examination?
   a. Atrophy
   b. Ankylosis
   c. Crepitation
   d. Contracture

Answer 102

b. Ankylosis

Ankylosis is stiffness or fixation of a joint, and contracture is reduced movement as a consequence of fibrosis of soft tissue (muscles, ligaments, or tendons). Atrophy is a wasting of muscle leading to decreased function and tone. Crepitation is a grating or crackling sound that accompanies joint movement. Problem identification leads to determination of an appropriate treatment.

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Question 103

10. The nurse is performing a musculoskeletal assessment on an 81-yr-old patient whose mobility has been progressively declining. How should the nurse safely assess range of motion (ROM) in the affected leg?
    a. Observe the patient’s unassisted ROM in the affected leg.
    b. Perform passive ROM, asking the patient to report any pain.
    c. Ask the patient to lift progressive weights with the affected leg.
    d. Move both the patient’s legs from a supine position to full flexion.

Answer 103

a. Observe the patient’s unassisted ROM in the affected leg.

Observing the patient’s active ROM is more accurate and safe than lifting weights. Passive ROM should be performed with extreme caution; it may cause harm when performed on older patients.

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Question 104

11. What should the nurse explain to the student regarding normal bone remodeling?
    a. Osteoclasts add canaliculi.
    b. Osteoblasts deposit new bone.
    c. Osteocytes are immature bone cells.
    d. Osteons synthesize organic bone matrix.

Answer 104

b. Osteoblasts deposit new bone.

Bone remodeling is achieved when osteoclasts remove old bone and osteoblasts deposit new bone. Osteocytes are mature bone cells, and osteons or Haversian systems create a dense bone structure; however, they are not involved with bone remodeling.

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Question 105

12. An 82-yr-old patient is frustrated by loose abdominal tissue and rigid hips. How should the nurse respond?
    a. “You should go on a diet and exercise more to feel better about yourself.”
    b. “Something must be wrong with you because you should not have these problems.”
    c. “You have arthritis and need to take nonsteroidal antiinflammatory drugs (NSAIDs).”
    d. “Decreased muscle mass and strength and increased hip rigidity are expected with aging.”

Answer 105

d. “Decreased muscle mass and strength and increased hip rigidity are expected with aging.”

The musculoskeletal system’s normal changes of aging include decreased muscle mass and strength; increased rigidity in the hips, neck, shoulders, back, and knees; decreased fine motor dexterity; and slowed reaction times. Going on a diet and exercising will help but not stop these changes. Telling the patient “Something must be wrong with you…” is untrue and will not be helpful to the patient’s frustrations.

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Question 106

13. A 50-yr-old patient reports shoulder discomfort after raking the yard. Which problem should the nurse suspect?
    a. Bursitis
    b. Fasciitis
    c. Sprained ligament
    d. Achilles tendonitis

Answer 106

a. Bursitis

Bursitis is common in adults older than age 40 years and with repetitive motion, such as raking. Plantar fasciitis occurs as a stabbing pain at the heel caused by straining the ligament that supports the arch. Achilles tendonitis is an inflammation of the tendon that attaches the calf muscle to the heel bone and causes pain with walking or running. A sprained ligament occurs when a ligament is stretched or torn from a direct injury or sudden twisting of the joint, not from repetitive motion.

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Question 107

14. The nurse understands that patients have the most difficulties with diarthrodial joints. Which joints are included in this group (select all that apply.)?
    a. Hinge joint of the knee
    b. Ligaments joining the vertebrae
    c. Gliding joints of the wrist and hand
    d. Fibrous connective tissue of the skull
    e. Ball and socket joint of the shoulder or hip
    f. Cartilaginous connective tissue of the pubis joint

Answer 107

a. Hinge joint of the knee
c. Gliding joints of the wrist and hand
e. Ball and socket joint of the shoulder or hip

The diarthrodial joints include the hinge joint of the knee and elbow, ball and socket joint of the shoulder and hip, pivot joint of the radioulnar joint, and condyloid, saddle, and gliding joints of the wrist and hand. The ligaments and cartilaginous connective tissue joining the vertebrae and pubis joint and the fibrous connective tissue of the skull are synarthrotic joints.

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Question 108

1. The bone cells that function in the resorption of bone tissue are called
   a. osteoids.
   b. osteocytes.
   c. osteoclasts.
   d. osteoblasts.

Answer 108

c. osteoclasts.

Chapter 62 Musculoskeletal System
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Question 109

2. While performing passive range of motion for a patient, the nurse puts the ankle joint through the movements of (select all that apply)
   a. flexion and extension.
   b. inversion and eversion.
   c. pronation and supination
   d. flexion, extension, abduction, and adduction.
   e. pronation, supination, rotation, and circumduction.

Answer 109

a. flexion and extension.
b. inversion and eversion.

Chapter 62 Musculoskeletal System
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Question 110

3. To prevent muscle atrophy, the nurse teaches the patient with a leg immobilized in traction to perform (select all that apply)
   a. flexion contractions.
   b. tetanic contractions.
   c. isotonic contractions.
   d. isometric contractions.
   e. extension contractions.

Answer 110

d. isometric contractions.

Chapter 62 Musculoskeletal System
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Question 111

4. A patient with tendonitis asks what the tendon does. The nurse’s response is based on the knowledge that tendons
   a. connect bone to muscle.
   b. provide strength to muscle.
   c. lubricate joints with synovial fluid.
   d. relieve friction between moving parts.

Answer 111

a. connect bone to muscle.

Chapter 62 Musculoskeletal System
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Question 112

5. The increased risk for falls in the older adult is most likely due to
   a. changes in balance.
   b. decrease in bone mass.
   c. loss of ligament elasticity.
   d. erosion of articular cartilage.

Answer 112

a. changes in balance.

Chapter 62 Musculoskeletal System
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Question 113

6. While obtaining subjective assessment data related to the musculoskeletal system, it is particularly important to ask a patient about other medical problems such as
   a. hypertension.
   b. thyroid problems.
   c. diabetes mellitus.
   d. chronic bronchitis.

Answer 113

c. diabetes mellitus.

Chapter 62 Musculoskeletal System
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Question 114

7. When grading muscle strength, the nurse records a score of 3, which indicates
   a. no detection of muscular contraction.
   b. a barely detectable flicker of contraction.
   c. active movement against full resistance without fatigue.
   d. active movement against gravity but not against resistance.

Answer 114

d. active movement against gravity but not against resistance.

Chapter 62 Musculoskeletal System
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Question 115

8. A normal assessment finding of the musculoskeletal system is
   a. no deformity or crepitation.
   b. muscle and bone strength of 4.
   c. ulnar deviation and subluxation.
   d. angulation of bone toward midline.

Answer 115

a. no deformity or crepitation.

Chapter 62 Musculoskeletal System
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Question 116

9. A patient is scheduled for an electromyogram (EMG). The nurse explains that this diagnostic test involves
   a. incision or puncture of the joint capsule.
   b. insertion of small needles into certain muscles.
   c. administration of a radioisotope before the procedure.
   d. placement of skin electrodes to record muscle activity.

Answer 116

b. insertion of small needles into certain muscles.

Chapter 62 Musculoskeletal System
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Question 117

1. A 63-year-old woman has been taking prednisone (Deltasone) daily for several years after a kidney transplant to prevent organ rejection. What is most important for the nurse to assess?

A. Staggering gait

B. Ruptured tendon

C. Back or neck pain

D. Tardive dyskinesia

Answer 117

C. Back or neck pain

Osteoporosis with resultant fractures is a frequent and serious complication of systemic corticosteroid therapy. The ribs and vertebrae are affected the most, and patients should be observed for signs of compression fractures (back and neck pain). Phenytoin (Dilantin) is an antiseizure medication. An adverse effect of phenytoin is an ataxic (or staggering) gait. A rare adverse effect of ciprofloxacin (Cipro) and other fluoroquinolones is tendon rupture, usually of the Achilles tendon. The highest risk is in people age 60 and older and in people taking corticosteroids. Antipsychotics and antidepressants may cause tardive dyskinesia, which is characterized by involuntary movements of the tongue and face.

Chapter 62 Musculoskeletal System
Pre-Test

Question 118

2. The home care nurse visits an 84-year-old woman with pneumonia after her discharge from the hospital. Which assessment finding would the nurse expect because of age-related changes in the musculoskeletal system?

A. Positive straight-leg-raising test

B. Muscle strength is scale grade 3/5

C. Lateral S-shaped curvature of the spine

D. Fingers drift to the ulnar side of the forearm

Answer 118

B. Muscle strength is scale grade 3/5

Decreased muscle strength is an age-related change of the musculoskeletal system caused by decreased number and size of the muscle cells. The other assessment findings indicate musculoskeletal abnormalities. A positive straight-leg-raising test indicates nerve root irritation from intervertebral disk prolapse and herniation. An ulnar deviation or drift indicates rheumatoid arthritis due to tendon contracture. Scoliosis is a lateral curvature of the spine.

Chapter 62 Musculoskeletal System
Pre-Test

Question 119

3. The nurse admits a 55-year-old female with multiple sclerosis to a long-term care facility. Which finding is of most immediate concern to the nurse?

A. Ataxic gait

B. Radicular pain

C. Severe fatigue

D. Urinary retention

Answer 119

A. Ataxic gait

An ataxic gait is a staggering, uncoordinated gait. Fall risk is the highest in individuals with gait instability or visual or cognitive impairments. The other signs and symptoms (e.g., fatigue, urinary retention, radicular pain) may also occur in the patient with multiple sclerosis and need to be managed, but are not the priority.

Chapter 62 Musculoskeletal System
Pre-Test

Question 120

4. A 57-year-old postmenopausal woman is scheduled for dual-energy x-ray absorptiometry (DXA). Which statement, if made by the patient to the nurse, indicates understanding of the procedure?

A. “The bone density in my heel will be measured.”

B. “This procedure will not cause any pain or discomfort.”

C. “I will not be exposed to any radiation during the procedure.”

D. “I will need to remove my hearing aids before the procedure.”

Answer 120

B. “This procedure will not cause any pain or discomfort.”

Dual-energy x-ray absorptiometry (DXA) is painless and measures the bone mass of spine, femur, forearm, and total body with minimal radiation exposure. A quantitative ultrasound (QUS) evaluates density, elasticity, and strength of bone using ultrasound of the calcaneus (heel). Magnetic resonance imaging would require removal of objects such as hearing aids that have metal parts.

Chapter 62 Musculoskeletal System
Pre-Test

Question 121

5. A 42-year-old man who is scheduled for an arthrocentesis arrives at the outpatient surgery unit and states, “I do not want this procedure done today.” Which response by the nurse is most appropriate?

A. “When would you like to reschedule the procedure?”

B. “Tell me what your concerns are about this procedure.”

C. “The procedure is safe, so why should you be worried?”

D. “The procedure is not painful because an anesthetic is used.”

Answer 121

B. “Tell me what your concerns are about this procedure.”

The nurse should use therapeutic communication to determine the patient’s concern about the procedure. The nurse should not provide false reassurance. It is not appropriate for the nurse to assume the patient is concerned about pain or to assume the patient is asking to reschedule the procedure.

Chapter 62 Musculoskeletal System
Pre-Test

Question 122

1. The nurse is caring for a patient who complains of abdominal pain and hematemesis. Which new assessment finding(s) would indicate the patient is experiencing a decline in condition?
   a. Pallor and diaphoresis
   b. Ecchymotic peripheral IV site
   c. Guaiac-positive diarrhea stools
   d. Heart rate 90, respiratory rate 20, BP 110/60

Answer 122

a. Pallor and diaphoresis

A patient with hematemesis has some degree of bleeding from an unknown source. Guaiac-positive diarrhea stools would be an expected finding. When monitoring the patient for stability, the nurse observes for signs of hypovolemic shock such as tachycardia, tachypnea, hypotension, altered level of consciousness, pallor, and cool and clammy skin. An ecchymotic peripheral IV site will require assessment to determine the need for reinsertion. Access would be critical in the immediate treatment of shock, but the ecchymotic site does not represent a decline in condition.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 123

2. The nurse is caring for a postoperative patient who has just vomited yellow green liquid and reports nausea. Which action would be an appropriate nursing intervention?
   a. Offer the patient an herbal supplement such as ginseng.
   b. Apply a cool washcloth to the forehead and provide mouth care.
   c. Take the patient for a walk in the hallway to promote peristalsis.
   d. Discontinue any medications that may cause nausea or vomiting.

Answer 123

b. Apply a cool washcloth to the forehead and provide mouth care.

Cleansing the face and hands with a cool washcloth and providing mouth care are appropriate comfort interventions for nausea and vomiting. Ginseng is not used to treat postoperative nausea and vomiting. Unnecessary activity should be avoided. The patient should rest in a quiet environment. Medications may be temporarily withheld until the acute phase is over, but the medications should not be discontinued without consultation with the health care provider.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 124

3. Which patient would be at highest risk for developing oral candidiasis?
   a. A 74-yr-old patient who has vitamin B and C deficiencies
   b. A 22-yr-old patient who smokes 2 packs of cigarettes per day
   c. A 32-yr-old patient who is receiving ciprofloxacin for 3 weeks
   d. A 58-yr-old patient who is receiving amphotericin B for 2 days

Answer 124

c. A 32-yr-old patient who is receiving ciprofloxacin for 3 weeks

Oral candidiasis is caused by prolonged antibiotic treatment (e.g., ciprofloxacin) or high doses of corticosteroids. Amphotericin B is used to treat candidiasis. Vitamin B and C deficiencies may lead to Vincent’s infection. Use of tobacco products leads to stomatitis, not candidiasis.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 125

4. A 74-yr-old female patient with osteoporosis is diagnosed with gastroesophageal reflux disease (GERD). Which over-the-counter medication to treat GERD should be used with caution?
   a. Sucralfate
   b. Cimetidine
   c. Omeprazole
   d. Metoclopramide

Answer 125

c. Omeprazole

There is a potential link between proton pump inhibitors (PPIs) (e.g., omeprazole) use and bone metabolism. Long-term use or high doses of PPIs may increase the risk of fractures of the hip, wrist, and spine.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 126

5. The nurse teaches senior citizens at a community center how to prevent food poisoning at social events. Which community member statement reflects accurate understanding?
   a. “Pasteurized juices and milk are safe to drink.”
   b. “Alfalfa sprouts are safe if rinsed before eating.”
   c. “Fresh fruits do not need to be washed before eating.”
   d. “Ground beef is safe to eat if cooked until it is brown.”

Answer 126

a. “Pasteurized juices and milk are safe to drink.”

Drink only pasteurized milk, juice, or cider. Ground beef should be cooked thoroughly. Browned meat can still harbor live bacteria. Cook ground beef until a thermometer reads at least 160° F. If a thermometer is unavailable, decrease the risk of illness by cooking the ground beef until there is no pink color in the middle. Fruits and vegetables should be washed thoroughly, especially those that will not be cooked. Persons who are immunocompromised or older should avoid eating alfalfa sprouts until the safety of the sprouts can be ensured.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 127

6. After administration of a dose of metoclopramide, which patient assessment finding would show the medication was effective?
   a. Decreased blood pressure
   b. Absence of muscle tremors
   c. Relief of nausea and vomiting
   d. No further episodes of diarrhea

Answer 127

c. Relief of nausea and vomiting

Metoclopramide is classified as a prokinetic and antiemetic medication. If it is effective, the patient’s nausea and vomiting should resolve. Metoclopramide does not affect blood pressure, muscle tremors, or diarrhea.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 128

7. The patient receiving chemotherapy rings the call bell and reports the onset of nausea. The nurse should prepare an as-needed dose of which medication?
   a. Zolpidem
   b. Ondansetron
   c. Dexamethasone
   d. Morphine sulfate

Answer 128

b. Ondansetron
Ondansetron is a 5-HT3 receptor antagonist antiemetic that is especially effective in reducing cancer chemotherapy-induced nausea and vomiting. Morphine sulfate may cause nausea and vomiting. Zolpidem does not relieve nausea and vomiting. Dexamethasone is usually used in combination with ondansetron for acute and chemotherapy-induced emesis.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 129

8. The patient who is admitted with a diagnosis of diverticulitis and a history of irritable bowel disease and gastroesophageal reflux disease (GERD) has received a dose of Mylanta 30 mL PO. The nurse will determine the medication was effective when which symptom has been resolved?
   a. Diarrhea
   b. Heartburn
   c. Constipation
   d. Lower abdominal pain

Answer 129

b. Heartburn

Mylanta is an antacid that contains both aluminum and magnesium. It is indicated for the relief of gastrointestinal discomfort, such as heartburn associated with GERD. Mylanta can cause both diarrhea and constipation as a side effect. Mylanta does not affect lower abdominal pain.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 130

9. A patient complaining of nausea receives a dose of metoclopramide. Which potential adverse effect should the nurse tell the patient to report?
   a. Tremors
   b. Constipation
   c. Double vision
   d. Numbness in fingers and toes

Answer 130

a. Tremors

Extrapyramidal side effects, including tremors and tardive dyskinesias, may occur with metoclopramide administration. Constipation, double vision, and numbness in fingers and toes are not adverse effects of metoclopramide.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 131

10. After administering a dose of promethazine to a patient with nausea and vomiting, what medication side effect does the nurse explain is common and expected?
    a. Tinnitus
    b. Drowsiness
    c. Reduced hearing
    d. Sensation of falling

Answer 131

b. Drowsiness

Although being given to this patient as an antiemetic, promethazine also has sedative and amnesic properties. For this reason, the patient is likely to experience drowsiness as an adverse effect of the medication. Tinnitus, reduced hearing, and loss of balance are not side effects of promethazine.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 132

11. The nurse is caring for a patient treated with IV fluid therapy for severe vomiting. As the patient recovers and begins to tolerate oral intake, which food choice would be most appropriate?
    a. Iced tea
    b. Dry toast
    c. Hot coffee
    d. Plain yogurt

Answer 132

b. Dry toast

Dry toast or crackers may alleviate the feeling of nausea and prevent further vomiting. Water is the initial fluid of choice. Extremely hot or cold liquids and fatty foods are generally not well tolerated.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 133

12. The nurse determines a patient has experienced the beneficial effects of therapy with famotidine when which symptom is relieved?
    a. Nausea
    b. Belching
    c. Epigastric pain
    d. Difficulty swallowing

Answer 133

c. Epigastric pain

Famotidine is an H2-receptor antagonist that inhibits parietal cell output of HCl acid and minimizes damage to gastric mucosa related to hyperacidity, thus relieving epigastric pain. It is not indicated for nausea, belching, and dysphagia.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 134

13. A patient with oral cancer is not eating. A small-bore feeding tube was inserted and the patient started on enteral feedings. Which patient goal would indicate improvement?
    a. Weight gain of 1 kg in 1 week
    b. Administer tube feeding at 25 mL/hr.
    c. Consume 50% of clear liquid tray this shift.
    d. Monitor for tube for placement and gastrointestinal residual.

Answer 134

a. Weight gain of 1 kg in 1 week

The goal for a patient with oral cancer that is not eating would be to note weight gain rather than loss. Consuming 50% of the clear liquid tray is not a realistic goal. Administering feedings, monitoring tube placement, and tolerance are interventions used to achieve the goal.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 135

14. A patient with a history of peptic ulcer disease has presented to the emergency department with severe abdominal pain and a rigid, boardlike abdomen. The health care provider suspects a perforated ulcer. Which interventions should the nurse anticipate?
    a. Providing IV fluids and inserting a nasogastric (NG) tube
    b. Administering oral bicarbonate and testing the patient’s gastric pH level
    c. Performing a fecal occult blood test and administering IV calcium gluconate
    d. Starting parenteral nutrition and placing the patient in a high-Fowler’s position

Answer 135

a. Providing IV fluids and inserting a nasogastric (NG) tube

A perforated peptic ulcer requires IV replacement of fluid losses and continued gastric aspiration by NG tube. Nothing is given by mouth, and gastric pH testing is not a priority. Calcium gluconate is not a medication directly relevant to the patient’s suspected diagnosis, and parenteral nutrition is not a priority in the short term.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 136

15. The results of a patient’s recent endoscopy indicate the presence of peptic ulcer disease (PUD). Which teaching point should the nurse provide to the patient based on this new diagnosis?
    a. “It would be beneficial for you to eliminate drinking alcohol.”
    b. “You’ll need to drink at least two to three glasses of milk daily.”
    c. “Many people find that a minced or pureed diet eases their symptoms of PUD.”
    d. “Taking medication will allow you to keep your present diet while minimizing symptoms.”

Answer 136

a. “It would be beneficial for you to eliminate drinking alcohol.”

Alcohol increases the amount of stomach acid produced. so it should be avoided. Although there is no specific recommended dietary modification for PUD, most patients find it necessary to make some sort of dietary modifications to minimize symptoms. Milk may exacerbate PUD.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 137

16. A patient has a sliding hiatal hernia. What nursing intervention will reduce the symptoms of heartburn and dyspepsia?
    a. Keeping the patient NPO
    b. Putting the bed in the Trendelenburg position
    c. Having the patient eat 4 to 6 smaller meals each day
    d. Giving various antacids to determine which one works for the patient

Answer 137

c. Having the patient eat 4 to 6 smaller meals each day

Eating smaller meals during the day will decrease the gastric pressure and symptoms of hiatal hernia. Keeping the patient NPO or in a Trendelenburg position is not safe or realistic for a long period of time for any patient. Varying antacids will only be done with the health care provider’s prescription, so this is not a nursing intervention.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 138

17. A patient is seeking emergency care after choking on a piece of steak. The nursing assessment reveals a history of alcoholism, cigarette smoking, and hemoptysis. Which diagnostic study is most likely to be performed on this patient?
    a. Barium swallow
    b. Endoscopic biopsy
    c. Capsule endoscopy
    d. Endoscopic ultrasonography

Answer 138

b. Endoscopic biopsy

Because of this patient’s history of excessive alcohol intake, smoking, and hemoptysis and the current choking episode, cancer may be present. A biopsy is necessary to make a definitive diagnosis of carcinoma, so an endoscope will be used to obtain a biopsy and observe other abnormalities as well. A barium swallow may show narrowing of the esophagus, but it is more diagnostic for achalasia. An endoscopic ultrasonography may be used to stage esophageal cancer. Capsule endoscopy can show alterations in the esophagus but is more often used for small intestine problems. A barium swallow, capsule endoscopy, and endoscopic ultrasonography cannot provide a definitive diagnosis for cancer.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 139

18. A patient was admitted with epigastric pain because of a gastric ulcer. Which patient assessment warrants an urgent change in the nursing plan of care?
    a. Back pain 3 or 4 hours after eating a meal
    b. Chest pain relieved with eating or drinking water
    c. Burning epigastric pain 90 minutes after breakfast
    d. Rigid abdomen and vomiting following indigestion

Answer 139

d. Rigid abdomen and vomiting following indigestion

A rigid abdomen with vomiting in a patient who has a gastric ulcer indicates a perforation of the ulcer, especially if the manifestations of perforation appear suddenly. Midepigastric pain is relieved by eating, drinking water, or antacids with duodenal ulcers, not gastric ulcers. Back pain 3 to 4 hours after a meal is more likely to occur with a duodenal ulcer. Burning epigastric pain 1 to 2 hours after a meal is an expected manifestation of a gastric ulcer related to increased gastric secretions and does not cause an urgent change in the nursing plan of care.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 140

19. The patient with chronic gastritis is being put on a combination of medications to eradicate Helicobacter pylori. Which drugs does the nurse know will probably be used?
    a. Antibiotic(s), antacid, and corticosteroid
    b. Antibiotic(s), aspirin, and antiulcer/protectant
    c. Antibiotic(s), proton pump inhibitor, and bismuth
    d. Antibiotic(s) and nonsteroidal antiinflammatory drugs (NSAIDs)

Answer 140

c. Antibiotic(s), proton pump inhibitor, and bismuth

To eradicate H. pylori, a combination of antibiotics, a proton pump inhibitor, and possibly bismuth (for quadruple therapy) will be used. Corticosteroids, aspirin, and NSAIDs are drugs that can cause gastritis and do not affect H. pylori.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 141

20. The patient is having an esophagoenterostomy with anastomosis of a segment of the colon to replace the resected portion. What initial postoperative care should the nurse expect when this patient returns to the nursing unit?
    a. Turn, deep breathe, cough, and use spirometer every 4 hours.
    b. Maintain an upright position for at least 2 hours after eating.
    c. NG will have bloody drainage and it should not be repositioned.
    d. Keep in a supine position to prevent movement of the anastomosis.

Answer 141

c. NG will have bloody drainage and it should not be repositioned.

The patient will have bloody drainage from the nasogastric (NG) tube for 8 to 12 hours, and it should not be repositioned or reinserted without contacting the surgeon. Turning and deep breathing will be done every 2 hours, and the spirometer will be used more often than every 4 hours. Coughing would put too much pressure in the area and should not be done. Because the patient will have the NG tube, the patient will not be eating yet. The patient should be kept in a semi-Fowler’s or Fowler’s position, not supine, to prevent reflux and aspiration of secretions.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 142

21. A patient who had a gastroduodenostomy (Billroth I operation) for stomach cancer reports generalized weakness, sweating, palpitations, and dizziness 15 to 30 minutes after eating. What long-term complication does the nurse suspect is occurring?
    a. Malnutrition
    b. Bile reflux gastritis
    c. Dumping syndrome
    d. Postprandial hypoglycemia

Answer 142

c. Dumping syndrome

After a Billroth I operation, dumping syndrome may occur 15 to 30 minutes after eating because of the hypertonic fluid going to the intestine and additional fluid being drawn into the bowel. Malnutrition may occur but does not cause these symptoms. Bile reflux gastritis cannot happen when the stomach has been removed. Postprandial hypoglycemia occurs with similar symptoms, but 2 hours after eating.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 143

22. The nurse is teaching a group of college students how to prevent food poisoning. Which comment shows an understanding of foodborne illness protection?
    a. “Eating raw cookie dough from the package is a great snack when you do not have time to bake.”
    b. “Since we only have one cutting board, we can cut up chicken and salad vegetables at the same time.”
    c. “To save refrigerator space, leftover food can be kept on the counter if it is in sealed containers.”
    d. “When the cafeteria gave me a pink hamburger, I sent it back and asked for a new bun and clean plate.”

Answer 143

d. “When the cafeteria gave me a pink hamburger, I sent it back and asked for a new bun and clean plate.”

The student who did not accept the pink hamburger and asked for a new bun and clean plate understood that the pink meat may not have reached 160°F and could be contaminated with bacteria. Improperly storing cooked foods, eating raw cookie dough from a refrigerated package, and only using one cutting board without washing it with hot soapy water between the chicken and salad vegetables could all lead to food poisoning from contamination.

Chapter 41 Upper Gastrointestinal Problems (10th Edition)
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Question 144

1. M.J. calls to tell the nurse that her 85-year-old mother has been nauseated all day and has vomited twice. Before the nurse hangs up and calls the health care provider, she should instruct M.J. to
   a. administer antispasmodic drugs and observe skin turgor.
   b. give her mother sips of water and elevate the head of her bed to prevent aspiration.
   c. offer her mother a high-protein liquid supplement to drink to maintain her nutritional needs.
   d. offer her mother large quantities of Gatorade to drink because older adults are at risk for sodium depletion.

Answer 144

b. give her mother sips of water and elevate the head of her bed to prevent aspiration.

Chapter 42 Upper Gastrointestinal Problems (9th Edition)
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Question 145

2. The nurse explains to the patient with Vincent’s infection that treatment will include
   a. smallpox vaccinations.
   b. viscous lidocaine rinses.
   c. amphotericin B suspension.
   d. topical application of antibiotics.

Answer 145

d. topical application of antibiotics.

Chapter 42 Upper Gastrointestinal Problems (9th Edition)
Bridge to NCLEX Examination

Question 146

3. The nurse teaching young adults about behaviors that put them at risk for oral cancer includes
   a. discouraging use of chewing gum.
   b. avoiding use of perfumed lip gloss.
   c. avoiding use of smokeless tobacco.
   d. discouraging drinking of carbonated beverages.

Answer 146

c. avoiding use of smokeless tobacco.

Chapter 42 Upper Gastrointestinal Problems (9th Edition)
Bridge to NCLEX Examination

Question 147

4. The nurse explains to the patient with gastroesophageal reflux disease (GERD) that this disorder
   a. results in acid erosion of the esophagus from frequent vomiting.
   b. will require surgical wrapping or repair of the pyloric sphincter to control the symptoms.
   c. is the protrusion of a portion of the stomach into the esophagus through an opening in the diaphragm.
   d. often involves relaxation of the lower esophageal sphincter, allowing stomach contents to back up into the esophagus.

Answer 147

d. often involves relaxation of the lower esophageal sphincter, allowing stomach contents to back up into the esophagus.

Chapter 42 Upper Gastrointestinal Problems (9th Edition)
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Question 148

5. A patient who has undergone an esophagectomy for esophageal cancer develops increasing pain, fever, and dyspnea when a full liquid diet is started postoperatively. The nurse recognizes that these symptoms are most indicative of
   a. an intolerance to the feedings.
   b. extension of the tumor into the aorta.
   c. leakage of fluid or foods into the mediastinum.
   d. esophageal perforation with fistula formation into the lung.

Answer 148

c. leakage of fluid or foods into the mediastinum.

Chapter 42 Upper Gastrointestinal Problems (9th Edition)
Bridge to NCLEX Examination

Question 149

6. The pernicious anemia that may accompany gastritis is due to
   a. chronic autoimmune destruction of cobalamin stores in the body.
   b. progressive gastric atrophy from chronic breakage in the mucosal barrier and blood loss.
   c. a lack of intrinsic factor normally produced by acid-secreting cells of the gastric mucosa.
   d. hyperchlorhydria resulting from an increase in acid-secreting parietal cells and degradation of RBCs.

Answer 149

c. a lack of intrinsic factor normally produced by acid-secreting cells of the gastric mucosa.

Chapter 42 Upper Gastrointestinal Problems (9th Edition)
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Question 150

7. The nurse is teaching the patient and family that peptic ulcers are
   a. caused by a stressful lifestyle and other acid-producing factors such as H. pylori.
   b. inherited within families and reinforced by bacterial spread of Staphylococcus aureus in childhood.
   c. promoted by factors that tend to cause oversecretion of acid, such as excess dietary fats, smoking, and H. pylori.
   d. promoted by a combination of factors that may result in erosion of the gastric mucosa, including certain drugs and alcohol.

Answer 150

d. promoted by a combination of factors that may result in erosion of the gastric mucosa, including certain drugs and alcohol.

Chapter 42 Upper Gastrointestinal Problems (9th Edition)
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Question 151

8. An optimal teaching plan for an outpatient with stomach cancer receiving radiation therapy should include information about
   a. cancer support groups, alopecia, and stomatitis.
   b. avitaminosis, ostomy care, and community resources.
   c. prosthetic devices, skin conductance, and grief counseling.
   d. wound and skin care, nutrition, drugs, and community resources.

Answer 151

d. wound and skin care, nutrition, drugs, and community resources.

Chapter 42 Upper Gastrointestinal Problems (9th Edition)
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Question 152

9. The teaching plan for the patient being discharged after an acute episode of upper GI bleeding includes information concerning the importance of (select all that apply)
   a. only taking aspirin with milk or bread products.
   b. avoiding taking aspirin and drugs containing aspirin.
   c. only taking drugs prescribed by the health care provider.
   d. taking all drugs 1 hour before mealtime to prevent further bleeding.
   e. reading all OTC drug labels to avoid those containing stearic acid and calcium.

Answer 152

b. avoiding taking aspirin and drugs containing aspirin.
c. only taking drugs prescribed by the health care provider.

Chapter 42 Upper Gastrointestinal Problems (9th Edition)
Bridge to NCLEX Examination

Question 153

10. Several patients are seen at an urgent care center with symptoms of nausea, vomiting, and diarrhea that began 2 hours ago while attending a large family reunion potluck dinner. You question the patients specifically about foods they ingested containing
    a. beef.
    b. meat and milk.
    c. poultry and eggs.
    d. home-preserved vegetables.

Answer 153

b. meat and milk.

Chapter 42 Upper Gastrointestinal Problems (9th Edition)
Bridge to NCLEX Examination

Question 154

1. The nurse receives an order for a parenteral dose of promethazine (Phenergan) and prepares to administer the medication to a 38-year-old male patient with nausea and repeated vomiting. Which action is most important for the nurse to take?

A. Administer the medication subcutaneously for fast absorption.

B. Administer the medication into an arterial line to prevent extravasation.

C. Administer the medication deep into the muscle to prevent tissue damage.

D. Administer the medication with 0.5 mL of lidocaine to decrease injection pain.

Answer 154

C. Administer the medication deep into the muscle to prevent tissue damage.

Promethazine (Phenergan) is an antihistamine administered to relieve nausea and vomiting. Deep muscle injection is the preferred route of injection administration. This medication should not be administered into an artery or under the skin because of the risk of severe tissue injury, including gangrene. When administered IV, a risk factor is that it can leach out from the vein and cause serious damage to surrounding tissue.

Chapter 42 Upper Gastrointestinal Problems (9th Edition)
Pre-Test

Question 155

2. The nurse cares for a postoperative patient who has just vomited yellow green liquid and reports nausea. Which action would be an appropriate nursing intervention?

A. Offer the patient a herbal supplement such as ginseng.

B. Apply a cool washcloth to the forehead and provide mouth care.

C. Take the patient for a walk in the hallway to promote peristalsis.

D. Discontinue any medications that may cause nausea or vomiting.

Answer 155

B. Apply a cool washcloth to the forehead and provide mouth care.

Cleansing the face and hands with a cool washcloth and providing mouth care are appropriate comfort interventions for nausea and vomiting. Ginseng is not used to treat postoperative nausea and vomiting. Unnecessary activity should be avoided. The patient should rest in a quiet environment. Medications may be temporarily withheld until the acute phase is over, but the medications should not be discontinued without consultation with the health care provider.

Chapter 42 Upper Gastrointestinal Problems (9th Edition)
Pre-Test

Question 156

3. Which patients would be at highest risk for developing oral candidiasis?

A. A 74-year-old patient who has vitamin B and C deficiencies

B. A 22-year-old patient who smokes 2 packs of cigarettes per day

C. A 58-year-old patient who is receiving amphotericin B for 2 days

D. A 32-year-old patient who is receiving ciprofloxacin (Cipro) for 3 weeks

Answer 156

D. A 32-year-old patient who is receiving ciprofloxacin (Cipro) for 3 weeks

Oral candidiasis is caused by prolonged antibiotic treatment (e.g., ciprofloxacin) or high doses of corticosteroids. Amphotericin B is used to treat candidiasis. Vitamin B and C deficiencies are rare but may lead to Vincent’s infection. Use of tobacco products leads to stomatitis.

Chapter 42 Upper Gastrointestinal Problems (9th Edition)
Pre-Test

Question 157

4. A 74-year-old female patient with gastroesophageal reflux disease (GERD) takes over-the-counter medications. For which medication, if taken long-term, should the nurse teach about an increased risk of fractures?

A. Sucralfate (Carafate)

B. Cimetidine (Tagamet)

C. Omeprazole (Prilosec)

D. Metoclopramide (Reglan)

Answer 157

C. Omeprazole (Prilosec)

There is a potential link between proton pump inhibitors (PPIs) (e.g., omeprazole) use and bone metabolism. Long-term use or high doses of PPIs may increase the risk of fractures of the hip, wrist, and spine. Lower doses or shorter duration of therapy should be considered.

Chapter 42 Upper Gastrointestinal Problems (9th Edition)
Pre-Test

Question 158

5. The nurse teaches senior citizens at a community center how to prevent food poisoning at their informal social events. The nurse determines that teaching is successful if a community member makes which statement?

A. “Pasteurized juices and milk are safe to drink.”

B. “Alfalfa sprouts are safe if rinsed before eating.”

C. “Fresh fruits do not need to be washed before eating.”

D. “Ground beef is safe to eat if cooked until it is brown.”

Answer 158

A. “Pasteurized juices and milk are safe to drink.”

Drink only pasteurized milk, juice, or cider. Ground beef should be cooked thoroughly. Browned meat can still harbor live bacteria. Cook ground beef until a thermometer reads at least 160° F. If a thermometer is unavailable, decrease risk of illness by cooking the ground beef until there is no pink color in the middle. Fruits and vegetables should be washed thoroughly, especially those that will not be cooked. Persons who are immunocompromised or older should avoid eating alfalfa sprouts until the safety of the sprouts can be ensured.

Chapter 42 Upper Gastrointestinal Problems (9th Edition)
Pre-Test

Question 159

1. In a patient admitted with cellulitis of the left foot, which clinical manifestation would the nurse expect to find on assessment of the left foot?
   a. Redness and swelling
   b. Pallor and poor turgor
   c. Cyanosis and coolness
   d. Edema and brown skin discoloration

Answer 159

a. Redness and swelling

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

Chapter 23 Integumentary Problems (10th Edition)
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Question 160

2. The nurse would assess a patient admitted with cellulitis for what localized manifestation?
   a. Pain
   b. Fever
   c. Chills
   d. Malaise

Answer 160

a. Pain

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

Chapter 23 Integumentary Problems (10th Edition)
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Question 161

3. Which nursing intervention would be most helpful in managing a patient newly admitted with cellulitis of the right foot?
   a. Applying warm, moist heat
   b. Wrapping the foot snugly in blankets
   c. Keeping the foot at or below heart level
   d. Limiting ambulation to three times daily

Answer 161

a. Applying warm, moist heat

The application of warm, moist heat speeds the resolution of inflammation and infection when accompanied by appropriate antibiotic therapy. It does this by increasing local circulation to the affected area to bring macrophages to the area and carry off cellular debris. Immobilization and elevation is also used. Snug blankets would not be helpful and could decrease circulation to this sensitive tissue.

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Question 162

4. A patient is admitted with a diagnosis of cellulitis of the left leg and has been placed on antibiotics. Which laboratory result is the best indicator that the treatment is having a positive outcome for the patient?
   a. WBC of 2900/μL
   b. WBC of 8200/μL
   c. WBC of 12,700/μL
   d. WBC of 16,300/μL

Answer 162

b. WBC of 8200/μL

The normal white blood cell count is generally 4000 to 11,000/μL. For this reason, the patient’s level would be returning to normal if it was 8200/μL, indicating recovery from cellulitis. The 2900/µL is too low and indicates another problem is occurring. The 12,700/µL and 16,300/µL are evidence of continuing infection.

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Question 163

5. The nurse is performing a skin assessment for an older adult patient. What finding should the nurse immediately report to the health care provider?
   a. The presence of wrinkles on the face and hands
   b. The patient’s report of dry skin that is frequently itchy
   c. The presence of an irregularly shaped mole that the patient states is new
   d. The presence of veins on the back of the patient’s leg that are blue and tortuous

Answer 163

c. The presence of an irregularly shaped mole that the patient states is new

The presence of an irregular mole that is new is suggestive of a neoplasm and warrants immediate reporting and follow-up. Age-related changes may occur that involve the decrease in skin oils that may cause dry skin that itches. Blue and tortuous veins may be unsightly for the patient but are a normal age-related change. Wrinkles are a normal age related change.

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Question 164

6. Which patient has the highest risk of developing malignant melanoma?
   a. A fair-skinned woman who uses a tanning booth regularly
   b. An African American patient with a family history of cancer
   c. An adult who required phototherapy as an infant for the treatment of hyperbilirubinemia
   d. A Hispanic man with a history of psoriasis and eczema that responded poorly to treatment

Answer 164

a. A fair-skinned woman who uses a tanning booth regularly

Risk factors for malignant melanoma include a fair complexion and exposure to ultraviolet light. Psoriasis, eczema, short-duration phototherapy, and a family history of other cancers are less likely to be linked to malignant melanoma.

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Question 165

7. The nurse is teaching a patient regarding her medications. With which mediation should the nurse be sure to inform the patient to avoid prolonged sun exposure?
   a. Tetracycline
   b. Ipratropium
   c. Morphine sulfate
   d. Oral contraceptives

Answer 165

a. Tetracycline

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

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Question 166

8. The nurse should recognize that which patient is likely to have the poorest prognosis?
   a. A patient who is being treated for stage IV malignant melanoma
   b. A patient diagnosed with nodular ulcerative basal cell carcinoma
   c. A patient who has been diagnosed with late squamous cell carcinoma
   d. A patient whose biopsy has revealed superficial squamous cell carcinoma

Answer 166

a. A patient who is being treated for stage IV malignant melanoma

Late detection of malignant melanoma is associated with a poor outcome. Basal cell carcinomas often have very effective treatment success rates. Although late squamous cell carcinoma (SCC) has worse outcomes than superficial SCC, these are both exceeded in mortality rates by late-stage malignant melanoma.

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Question 167

9. The nurse is teaching a patient about the application of a topical medication. What should the nurse include in the instruction for the patient?
   a. Avoid applying medications directly onto dressings.
   b. Use a tongue blade whenever the patient’s skin integrity allows.
   c. Avoid covering skin areas where a topical medication has been applied.
   d. Apply a layer of medication that is just thick enough to ensure coverage.

Answer 167

d. Apply a layer of medication that is just thick enough to ensure coverage.

Topical medication should be applied in a thin film to clean skin and spread evenly in a downward motion in the direction of hair growth. Medications may be applied directly on to secondary dressings, and regions with medications may be covered. A tongue blade is not normally used for the application of a thin coat.

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Question 168

10. The patient has bleeding gums and purpura. What vitamin in which foods should be encouraged as a nutritional aid to these problems?
    a. Vitamin B7 in liver, cauliflower, salmon, carrots
    b. Vitamin A in sweet potatoes, carrots, dark leafy greens
    c. Vitamin C in peppers, dark leafy greens, broccoli, and kiwi
    d. Vitamin D in canned salmon, sardines, fortified dairy, and eggs

Answer 168

d. Vitamin D in canned salmon, sardines, fortified dairy, and eggs

An absence of vitamin C causes symptoms of scurvy, including petechiae, bleeding gums, and purpura. A deficiency of vitamin B7 (biotin) may result in rashes and alopecia. Vitamins A is needed for wound healing. Vitamin D is needed for bone and body health.

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Question 169

11. A patient presents with a flat, dry, scaly area on the eyebrows that is treated with a chemical peel. What should the nurse include in the discharge teaching?
    a. Metastasis of this type of lesion is rare.
    b. The patient has an increased risk for melanoma.
    c. Recurrence of the premalignant lesion is possible.
    d. Untreated lesions may metastasize to regional lymph nodes.

Answer 169

c. Recurrence of the premalignant lesion is possible.

The flat or elevated dry scaly area is actinic keratosis from sun damage and is a premalignant skin lesion common in older whites with possible recurrence even with adequate treatment. Metastasis of basal cell carcinoma is rare; it is a small slowly enlarging papule. There is an increased risk for melanoma with atypical or dysplastic nevi. With squamous cell carcinoma, untreated lesions may metastasize to regional lymph nodes and distant organs, but it has a high cure rate with early detection and treatment.

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Question 170

12. The nurse is teaching the residents of an independent living facility about preventing skin infections and infestations. What should be included in the teaching?
    a. Use cool compresses if an infection occurs.
    b. Oral antibiotics will be needed for any skin changes.
    c. Antiviral agents will be needed to prevent outbreaks.
    d. Inspect skin for changes when bathing with mild soap.

Answer 170

d. Inspect skin for changes when bathing with mild soap.

Persons living in independent living facilities are usually older, which means their skin does not need cleaning with hot water and vigorous scrubbing or as often as a younger person. Mild soap (e.g., Ivory) should be used to avoid loss of protection from neutralization of the skin’s surface. The skin should be inspected for changes with bathing. Cool compresses are used with ringworm or stings for the antiinflammatory effect. Oral antibiotics are used for Lyme disease from ticks. Antiviral agents are used for viral infections but not to prevent outbreaks.

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Question 171

13. The nurse is providing preoperative teaching for the patient having a facelift (rhytidectomy) surgery. Which patient response indicates the patient understands the teaching?
    a. “I am afraid of the pain afterwards, while it is healing.”
    b. “I can’t wait to have my forehead and lip wrinkles eliminated.”
    c. “I have some time off work so I will not look so bad when I go back.”
    d. “Now I can be excited to go to my 50th high school reunion this week.”

Answer 171

c. “I have some time off work so I will not look so bad when I go back.”

A rhytidectomy or face-lift surgery will not have immediate results and will take time to heal, so taking time off from work will allow more healing to be accomplished before returning to work. There is not much pain with most cosmetic surgeries. A rhytidectomy will not eliminate forehead lines and vertical lip wrinkles.

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Question 172

14. The patient with a stage IV pressure ulcer on the coccyx will need a skin graft to close the wound. Which postoperative care should the nurse expect to use to facilitate healing?
    a. No straining of the grafted site
    b. The wound will be exposed to air.
    c. Soft tissue expansion will be done daily.
    d. The pressure dressing will not be removed.

Answer 172

a. No straining of the grafted site

Straining or stretching of the grafted site must be avoided to allow the graft to be vascularized and fixed to the new site for healing. The wound may or may not be exposed to air depending on the type of graft, and the donor site will be covered with a protective dressing to prevent further damage. Soft tissue expansion and pressure dressings will not be used after this wound’s skin graft.

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Question 173

15. A patient informs the nurse that they are afraid to use the treatment recommended for psoriasis. What is the best response by the nurse?
    a. “You will only know if you try it and see.”
    b. “You may need to get counseling to help you cope.”
    c. “No treatment is medically necessary, but it can be removed.”
    d. “Topical, light therapy, and systemic medications are now available.”

Answer 173

d. “Topical, light therapy, and systemic medications are now available.”

Treatment of psoriasis usually involves a combination of strategies, including topical treatments; phototherapy; and/or systemic medications, including biologic drugs. Telling her that she will only know if she tries or that she may need counseling is denying the patient’s concern. Psoriasis is treated to manage the disease as the patient may have a weakened immune system and be at risk for cardiovascular disease.

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Question 174

16. A patient has been diagnosed with tinea unguium (onychomycosis) under the nails but does not like the oral antifungal medication. What is the best alternate treatment the nurse should describe for her?
    a. Nail avulsion
    b. Antifungal cream
    c. Thinning of fingernails
    d. Soaking nails in salt water

Answer 174

a. Nail avulsion

Nail avulsion is the best alternate treatment to the oral antifungal medication. Antifungal cream is minimally effective. Thinning fingernails is not needed if the tinea unguium is under her toenails. Soaking the nails will not be helpful.

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Question 175

17. The nurse assesses small, firm, reddened raised lesions with flat, rough patches on a patient that are causing intense pruritus. What question should the nurse next ask the patient?
    a. “Have you started any new medications?”
    b. “Do you have a history of seasonal allergies?”
    c. “Have you had any lesions such as this before?”
    d. “Tell me about your activities the past 2 to 7 days.”

Answer 175

d. “Tell me about your activities the past 2 to 7 days.”

The patient’s lesions are papules and plaques characteristic of contact dermatitis. The nurse should ask the patient about activities over the past 2 to 7 days to identify potential allergens because contact dermatitis has a delayed onset. Even if an offending agent is not identified, the nurse can provide patient teaching about managing the pruritus and preventing infection by decreasing scratching. Seasonal allergies and new medications are more likely to cause urticaria than papules and plaque. The nurse should also ask about pruritic rashes in the past to determine potential illnesses that can cause dermatologic manifestations.

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Question 176

18. The nurse is caring for a patient admitted for uncontrolled seizures who is also diagnosed with impetigo on the face and neck. Which action is appropriate for the nurse to take?
    a. Put on a protective gown before entering the room.
    b. Wash hands for 1 to 2 minutes when leaving the room.
    c. Wear gloves to leave a diet menu on the patient’s table.
    d. Wear a particulate mask when within 3 feet of the patient.

Answer 176

b. Wash hands for 1 to 2 minutes when leaving the room.

Impetigo is a bacterial skin infection with group A β-hemolytic streptococci or staphylococci. Meticulous hygiene (including hand washing) is essential to prevent the spread of infection. A particulate mask or a gown would not be necessary to prevent the spread of impetigo. Gloves would not be needed to make a delivery to the room.

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Question 177

19. A patient admitted with heart failure is also diagnosed with herpes zoster and draining vesicles. Which action, if observed by the nurse, would require additional teaching for that individual?
    a. The dietitian wears a mask when entering the patient’s room.
    b. The patient keeps the draining vesicles covered with a dressing.
    c. The student nurse who takes prednisone requests a different patient assignment.
    d. The nursing assistant washes hands frequently and wears gloves when in the room.

Answer 177

a. The dietitian wears a mask when entering the patient’s room.

Herpes zoster, commonly known as shingles, is spread by contact with fluid draining from the vesicles (not by coughing, sneezing, or casual contact). Shingles is not contagious before the vesicles appear or after the vesicles have crusted over. The risk of a person with shingles spreading the virus is low if the rash is covered. Wearing a mask would not prevent the spread of infection. Until the rash develops crusts, the patient should not have contact with an immunocompromised person (e.g., a person taking prednisone). Frequent hand washing helps to prevent the spread of varicella zoster virus.

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Question 178

20. The nurse is teaching about skin cancer prevention at the community center. Which person is most at risk for developing skin cancer?
    a. A 67-yr-old bald-headed man with psoriasis and type 2 diabetes mellitus
    b. A 76-yr-old Hispanic man who has a latex allergy and numerous acrochordons
    c. A 55-yr-old woman with fair skin and red hair who has a family history of skin cancer
    d. A 62-yr-old woman with chronic kidney disease who has blond hair with dry, pale skin

Answer 178

c. A 55-yr-old woman with fair skin and red hair who has a family history of skin cancer

Risk factors for skin cancer include having fair skin (with red hair) and a family history of skin cancer. Allergies, acrochordons (skin tags), psoriasis, type 2 diabetes mellitus, and chronic kidney disease are not risk factors associated with the development of skin cancer.

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Question 179

21. A patient reports to the clinic nurse a ring-like itchy rash on the upper leg, low-grade fever, nausea, and joint pain for the past 3 weeks. What question is important for the nurse to ask the patient?
    a. “Is the itching worse at night?”
    b. “Have you had a tick bite recently?”
    c. “Have you been exposed to pubic lice?”
    d. “Have you had unprotected sexual contact?”

Answer 179

b. “Have you had a tick bite recently?”

Symptoms are consistent with Lyme disease caused by the organism Borrelia burgdorferi, which is transmitted by a tick bite. The itching would not necessarily be worse at night. Exposure to pubic lice would cause itching in the genital area and not fever, nausea, and joint pain. Unprotected sexual contact would not cause an isolated itchy rash on the upper leg.

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Question 180

22. The nurse educates a patient with chronic kidney disease about several interventions to reduce pruritus associated with dry skin and uremia. Which statement, if made by the patient to the nurse, indicates further teaching is required?
    a. “I will avoid taking hot showers.”
    b. “I can rub my skin instead of scratching.”
    c. “Menthol can be used to numb the itch sensation.”
    d. “A lubricating lotion right after bathing will help.”

Answer 180

b. “I can rub my skin instead of scratching.”

Any activity that causes vasodilation, such as rubbing or bathing and showering in hot water, should be avoided because vasodilation leads to increased itching. Menthol in skin products provides a sensation that may distract the patient from the sensation of itchiness. Applying lotion right after bathing helps retain moisture in the skin.

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Question 181

23. The postoperative patient has dry skin and complains of pruritus on both legs. What nursing actions can help stop the itch–scratch cycle (select all that apply.)?
    a. Moisturize the skin on the legs.
    b. Provide a warm blanket and room.
    c. Administer antihistamines at bedtime.
    d. Vigorously rub the patient’s legs after bathing.
    e. Cleanse the legs with a saline solution twice daily.

Answer 181

a. Moisturize the skin on the legs.
c. Administer antihistamines at bedtime.

Moisturizing the skin to decrease the dryness and the itch sensation and bedtime antihistamines to decrease a potential allergic reaction and provide some sedation will help the patient sleep since pruritus is often worse at night and the patient needs sleep for healing. Using nonallergic sheets may also help. Anything causing vasodilation, such as warmth or rubbing, should be avoided. Saline solution would only further dry the skin, so it should not be used on the patient’s legs.

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Question 182

1. Which safe sun practices would the nurse include in the teaching care plan for a patient who has photosensitivity (select all that apply)?
   a. Wear protective clothing.
   b. Apply sunscreen liberally and often.
   c. Emphasize the short-term use of a tanning booth.
   d. Avoid exposure to the sun, especially during midday.
   e. Wear any sunscreen as long as it is purchased at a drugstore.

Answer 182

a. Wear protective clothing.
b. Apply sunscreen liberally and often.
d. Avoid exposure to the sun, especially during midday.

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Question 183

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

Answer 183

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

Chapter 24 Integumentary Problems (9th Edition)
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Question 184

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

Answer 184

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

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Question 185

4. In teaching a patient with malignant melanoma about this disorder, the nurse recognizes that the patient’s prognosis is most dependent on
   a. the thickness of the lesion.
   b. the degree of asymmetry in the lesion.
   c. the amount of ulceration in the lesion.
   d. how much the lesion has spread superficially.

Answer 185

a. the thickness of the lesion.

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Question 186

5. The nurse determines that a patient with a diagnosis of which disorder is most at risk for spreading the disease?
   a. Tinea pedis
   b. Impetigo on the face
   c. Candidiasis of the nails
   d. Psoriasis on the palms and soles

Answer 186

b. Impetigo on the face

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Question 187

6. A mother and her two children have been diagnosed with pediculosis corporis at a health care center. An appropriate measure in treating this condition is
   a. applying pyrethrins to the body.
   b. topical application of griseofulvin.
   c. moist compresses applied frequently.
   d. administration of systemic antibiotics.

Answer 187

a. applying pyrethrins to the body.

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Question 188

7. A common site for the lesions associated with atopic dermatitis is the
   a. buttocks.
   b. temporal area.
   c. antecubital space.
   d. plantar surface of the feet.

Answer 188

c. antecubital space.

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Question 189

8. During the assessment of a patient, you note an area of red, sharply defined plaques covered with silvery scales that are mildly itchy on the patient’s knees and elbows. You recognize this finding as
   a. lentigo.
   b. psoriasis.
   c. actinic keratosis.
   d. seborrheic keratosis.

Answer 189

b. psoriasis.

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Question 190

9. Dermatologic manifestation(s) of Addison’s disease can include (select all that apply)
   a. urticaria.
   b. loss of body hair.
   c. increased sweating.
   d. generalized hyperpigmentation.
   e. hypopigmentation in the legs and trunk.

Answer 190

b. loss of body hair.
d. generalized hyperpigmentation.

Chapter 24 Integumentary Problems (9th Edition)
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Question 191

10. Important patient teaching after a chemical peel includes
    a. avoidance of sun exposure.
    b. application of firm bandages.
    c. limitation of vigorous exercise.
    d. use of moist heat to relieve discomfort.

Answer 191

a. avoidance of sun exposure.

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Question 192

1. The nurse cares for a 41-year-old male patient admitted for uncontrolled seizures who is also diagnosed with impetigo on the face and neck. Which action is appropriate for the nurse to take?

A. Put on a protective gown before entering the room.

B. Wash hands for 1 to 2 minutes when leaving the room.

C. Wear gloves to leave a diet menu on the patient’s table.

D. Wear a particulate mask when within 3 feet of the patient.

Answer 192

B. Wash hands for 1 to 2 minutes when leaving the room.

Impetigo is a bacterial skin infection with group A ß-hemolytic streptococci or staphylococci. Meticulous hygiene (including hand washing) is essential to prevent the spread of infection. A particulate mask or a gown would not be necessary to prevent the spread of impetigo. Gloves would not be needed to make a delivery to the room.

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Question 193

2. A 67-year-old woman admitted with heart failure is also diagnosed with herpes zoster (shingles) and draining vesicles. Which action, if observed by the nurse, would require additional teaching for that individual?

A. The dietitian wears a mask when entering the patient’s room.

B. The patient keeps the draining vesicles covered with a dressing.

C. The student nurse who takes prednisone requests a different patient assignment.

D. The nursing assistant washes hands frequently and wears gloves when in the room.

Answer 193

A. The dietitian wears a mask when entering the patient’s room.

Herpes zoster (shingles) is spread by contact with fluid draining from the vesicles (not by coughing, sneezing, or casual contact). Shingles is not contagious before the vesicles appear or after the vesicles have crusted over. The risk of a person with shingles spreading the virus is low if the rash is covered. Wearing a mask would not prevent the spread of infection. Until the rash develops crusts, the patient should not have contact with an immunocompromised person (e.g., a person taking prednisone). Frequent hand washing helps to prevent the spread of varicella zoster virus.

Chapter 24 Integumentary Problems (9th Edition)
Pre-Test

Question 194

3. The nurse is teaching about skin cancer prevention at the community center. Which individual is most at risk for developing skin cancer?

A. A 67-year-old bald-headed man with psoriasis and type 2 diabetes mellitus

B. A 76-year-old Hispanic man who has a latex allergy and numerous acrochordons

C. A 55-year-old woman with fair skin and red hair who has a family history of skin cancer

D. A 62-year-old woman with chronic kidney disease who has blond hair with dry, pale skin and pruritus

Answer 194

C. A 55-year-old woman with fair skin and red hair who has a family history of skin cancer

Risk factors for skin cancer include having fair skin (with red hair) and a family history of skin cancer. Allergies, acrochordons (skin tags), psoriasis, type 2 diabetes mellitus, and chronic kidney disease are not risk factors associated with the development of skin cancer.

Chapter 24 Integumentary Problems (9th Edition)
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Question 195

4. A 19-year-old patient reports to the clinic nurse the following symptoms: a ring-like itchy rash on the upper leg, low-grade fever, nausea, and joint pain for the past 3 weeks. What question is important for the nurse to ask the patient?

A. “Is the itching worse at night?”

B. “Have you had a tick bite recently?”

C. “Have you been exposed to pubic lice?”

D. “Have you had unprotected sexual contact?”

Answer 195

B. “Have you had a tick bite recently?”

Symptoms are consistent with Lyme disease caused by the organism Borrelia burgdorferi, which is transmitted by a tick bite.

Chapter 24 Integumentary Problems (9th Edition)
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Question 196

5. The nurse teaches a 50-year-old woman with chronic kidney disease several interventions to reduce pruritus associated with dry skin and uremia. Which statement, if made by the patient to the nurse, indicates further teaching is required?

A. “I will avoid taking hot showers.”

B. “I can rub my skin instead of scratching.”

C. “Menthol can be used to numb the itch sensation.”

D. “A lubricating lotion right after bathing will help.”

Answer 196

B. “I can rub my skin instead of scratching.”

Any activity that causes vasodilation, such as rubbing or bathing and showering in hot water should be avoided as vasodilation leads to increased itching. Menthol in skin products provides a sensation that may distract the patient from the sensation of itchiness. Applying lotion right after bathing helps retain moisture in the skin.

Chapter 24 Integumentary Problems (9th Edition)
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Question 197

1. The nurse is preparing to perform an assessment for a newly admitted patient with a potential hematologic disorder and petechiae. What does the nurse anticipate finding when assessing this patient?
   a. Tiny purple spots on the skin
   b. Large ecchymotic areas on the skin
   c. Hyperkeratotic papules and plaques
   d. Small, raised red areas on the soles of the feet

Answer 197

a. Tiny purple spots on the skin

Petechiae present as tiny purple spots on the skin. Large ecchymotic areas are purpura. Hyperkeratotic papules and plaques characterize actinic keratosis. Small, raised red areas on the soles of the feet signify Osler’s nodes.

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Question 198

2. A patient is admitted to the acute care facility with purpura. Which laboratory test would be most important to check in the patient?
   a. Urinalysis
   b. Serum electrolytes
   c. Coagulation studies
   d. White blood cell count

Answer 198

c. Coagulation studies

Purpura are areas of ecchymoses that may signify a bleeding disorder. Therefore, it is most important for the nurse to assess the patient’s coagulation studies.

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Question 199

3. The nurse is administering medications to a patient. What medication taken by the patient is most likely to have an effect on the integumentary system?
   a. Diuretic
   b. Corticosteroid
   c. Benzodiazepine
   d. Calcium channel blocker

Answer 199

b. Corticosteroid

Corticosteroids can have unwanted integumentary side effects such as telangiectasia. Integumentary effects are less likely to occur with benzodiazepines, calcium channel blockers, and diuretics.

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Question 200

4. An adolescent is brought to the clinic by a parent for treatment of acne. What should the nurse assess the patient for to support the existence of acne?
   a. Ulcers
   b. Wheals
   c. Vesicles
   d. Pustules

Answer 200

d. Pustules

Pustules are elevated, superficial lesions filled with purulent fluid, such as those commonly associated with acne. Wheals, ulcers, and vesicles are not common manifestations of acne.

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Question 201

5. The nurse is performing an assessment of a patient with obesity. Inspection reveals the presence of a foul odor that emanates from the patient’s abdominal skin folds. What is most likely causing the odor?
   a. Ecchymosis
   b. Colonization by yeast or bacteria
   c. Age-related integumentary changes
   d. Atrophy of the skin under the abdominal folds

Answer 201

b. Colonization by yeast or bacteria

Unusual foul odors, especially those found in intertriginous areas, are often the result of colonization by yeast or bacteria. Ecchymosis is the presence of bruising. An unusual odor would not normally be attributed to age-related changes or skin atrophy.

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Question 202

6. The nurse is assessing a white patient’s skin color for cyanosis. The best place for the nurse to assess this is the
   a. lips.
   b. legs.
   c. wrists.
   d. sclera.

Answer 202

a. lips.

On light-skinned individuals, cyanosis or a grayish blue tone initially appears on the lips, nail beds, earlobes, mucous membranes, palms of the hands, and soles of the feet.

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Question 203

7. A patient with hypothyroidism has developed carotenemia. The nurse should assess for improvement of this condition on which part of the patient’s body?
   a. Face
   b. Chest
   c. Sclera
   d. Palms of hands

Answer 203

d. Palms of hands

Carotenemia or carotenosis is yellow discoloration of the skin without yellowing sclera. It is most noticeable on the palms of the hands and the soles of the feet.

Chapter 22 Integumentary System (10th Edition)
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Question 204

8. On assessment, a linear crack from the epidermis to the dermis is noted at the corner of the patient’s mouth. The nurse would document this finding as a(n)
   a. scar.
   b. fissure.
   c. atrophy.
   d. excoriation.

Answer 204

b. fissure.

A fissure is a linear crack or break from the epidermis to the dermis. It can be dry as in athlete’s foot or moist as in cracks at the corner of the mouth. A scar is abnormal formation of connective tissue that replaces normal skin when a wound heals. Atrophy is a depression in skin resulting from thinning of the epidermis or dermis. Excoriation is an area where epidermis is missing which exposes dermis (e.g., abrasion, scratch).

Chapter 22 Integumentary System (10th Edition)
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Question 205

9. The nurse is assessing a patient’s skin temperature, turgor, moisture, and texture. What is the best technique for the nurse to use to obtain the data?
   a. Inspection of skin color
   b. Examination for vascularity
   c. Palpation of skin with the hand
   d. Percussion of the skin on the back

Answer 205

c. Palpation of skin with the hand

Palpation of the skin with the back of the hand will assess temperature. Turgor is assessed by gently pinching the skin on the back of the hand and observing its return to original position when released. Moisture and texture of skin is assessed by touching it to assess it. Percussion does not assess the skin, but the organs beneath the skin.

Chapter 22 Integumentary System (10th Edition)
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Question 206

10. The patient has diffuse distribution of moles on the body and the nurse is preparing the patient for a punch biopsy of one of the moles. What is the benefit of doing a punch biopsy for this patient?
    a. It is used for a superficial lesion.
    b. It provides a full-thickness of skin.
    c. It is used for good cosmetic results.
    d. It is used because the lesion is too large to remove.

Answer 206

b. It provides a full-thickness of skin.

The punch biopsy provides full-thickness skin for diagnostic purposes. A shave biopsy is used for a superficial lesion or when only a small sample is needed for diagnostic purposes. An excisional biopsy is used when a good cosmetic result is desired. An incisional biopsy is a wedge-shaped incision made in a lesion that is too large for an excisional biopsy. It is useful when a larger specimen is needed than a shave or punch biopsy can provide.

Chapter 22 Integumentary System (10th Edition)
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Question 207

11. A patient has been diagnosed with hypothyroidism. What should the nurse expect to assess in this patient’s integumentary system?
    a. Warm, flushed skin; alopecia; thin nails
    b. General hyperpigmentation and loss of body hair
    c. Pale skin; pale mucous membranes; hair loss; nail dystrophy
    d. Cold, dry, pale skin; dry, coarse hair; brittle, slow-growing nails

Answer 207

d. Cold, dry, pale skin; dry, coarse hair; brittle, slow-growing nails

With hypothyroidism, the patient will manifest with cold, dry, pale skin; dry, coarse, brittle hair; and brittle, slow-growing nails. With hyperthyroidism, the patient will have warm, flushed skin; alopecia with fine soft hair; and thin nails. With Addison’s disease, the patient will have loss of body hair and generalized hyperpigmentation, especially in folds. With anemia, the patient will display pallor, pale mucous membranes, hair loss, and nail dystrophy.

Chapter 22 Integumentary System (10th Edition)
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Question 208

12. When assessing an older adult patient, the nurse observed general wrinkles, sagging breasts, and tenting of the skin; gray hair; and thick brittle toenails. What age-related changes can cause these changes in the integumentary system?
    a. Decreased activity of apocrine and sebaceous glands, decreased density of hair, and increased keratin in nails
    b. Decreased extracellular water, surface lipids, and sebaceous gland activity; decreased scalp oil; and decreased circulation
    c. Muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply
    d. Increased capillary fragility and permeability, cumulative androgen effect and decreasing estrogen levels, and decreased circulation

Answer 208

c. Muscle laxity, degeneration of elastic fibers, collagen stiffening, decreased melanin, and decreased peripheral blood supply

The normal changes of aging include muscle laxity, degeneration of elastic fibers, and collagen stiffening that contribute to the wrinkles, sagging breasts, and tenting of the skin. Decreased melanin and melanocytes in the hair lead to gray hair, and decreased peripheral blood supply leads to thick brittle nails with diminished growth. Decreased apocrine and sebaceous glands would lead to dry skin with minimal to no perspiration and uneven skin color. Decreased density of hair leads to thinning and loss of hair. Increased keratin in nails leads to longitudinal ridging of the nails. The decreased extracellular water, surface lipids, and sebaceous gland activity lead to dry flaking skin. Decreased scalp oil leads to dry coarse hair and a scaly scalp, and decreased circulation leads to prolonged return of blood to nails on blanching. Increased capillary fragility and permeability in aging leads to bruising. A cumulative androgen effect and decreased estrogen levels lead to facial hirsutism in women and baldness in men. Decreased circulation leads to prolonged return of blood to nails on blanching.

Chapter 22 Integumentary System (10th Edition)
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Question 209

13. A nurse is obtaining a health history from a patient with a new diagnosis of type 2 diabetes mellitus. What question related to the skin would be most important for the nurse to ask this patient?
    a. “Is your sleep interrupted by severe episodes of itching at night?”
    b. “Have you noticed any changes in the way sores or wounds heal?”
    c. “Do you have any skin lesions that have changed in size or shape?”
    d. “What changes if any have you noticed in your skin, hair, and nails?”

Answer 209

b. “Have you noticed any changes in the way sores or wounds heal?”

A patient with diabetes is more susceptible to poor wound healing because of the macrovascular and microvascular changes that occur in diabetes. Poor circulation, especially in the lower extremities, increases the risk for poor wound healing. A patient with diabetes is at increased risk for infection because of a defect in the mobilization of inflammatory cells and an impairment of phagocytosis by neutrophils and monocytes.

Chapter 22 Integumentary System (10th Edition)
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Question 210

14. An older adult patient is admitted to the hospital with dehydration resulting from prolonged vomiting. Which assessment finding by the nurse is most consistent with severe dehydration?
    a. The skin color over the nose and ears has a blue tint.
    b. The skin of the extremities is warm and dry to touch.
    c. Pressing the skin over the ankles causes pitting for 10 seconds.
    d. Pinching the skin under the clavicle causes tenting for 10 seconds.

Answer 210

d. Pinching the skin under the clavicle causes tenting for 10 seconds.

Skin turgor is good when skin moves easily when lifted and immediately returns to its original position when released (no tenting). A loss of skin turgor occurs with dehydration and aging that will result in tenting. With hypovolemia, expected skin changes are cool without edema or central cyanosis.

Chapter 22 Integumentary System (10th Edition)
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Question 211

15. A patient with thrombocytopenia secondary to sepsis has small, pinpoint deposits of blood visible through the skin on the anterior and posterior chest. The nurse will document this skin abnormality as
    a. petechiae.
    b. erythema.
    c. ecchymosis.
    d. telangiectasia.

Answer 211

a. petechiae.

Petechiae are pinpoint, discrete deposits of blood less than 1 to 2 mm in the extravascular tissues and visible through the skin or mucous membranes. Erythema is redness occurring in patches of variable size and shape. Telangiectasia is visibly dilated, superficial, cutaneous small blood vessels. Ecchymosis is a large, bruise-like lesion caused by a collection of extravascular blood in the dermis and subcutaneous tissue.

Chapter 22 Integumentary System (10th Edition)
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Question 212

16. The nurse performs a physical assessment on a dark-skinned African American patient who reports difficulty breathing. What is the best location for the nurse to assess for cyanosis in this patient?
    a. Lips
    b. Earlobe
    c. Conjunctiva
    d. Palm of hand

Answer 212

c. Conjunctiva

Cyanosis will appear ashen or gray color and is most easily seen in the conjunctiva of the eye, mucous membranes, and nail beds of dark-skinned individuals. The nail beds, earlobes, lips, mucous membranes, and palms and soles of feet would be appropriate locations to assess for cyanosis in a light-skinned individual.

Chapter 22 Integumentary System (10th Edition)
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Question 213

17. The nurse is teaching a patient about diagnostic testing for allergic dermatitis. Which statement by the patient demonstrates a correct understanding of the teaching?
    a. “A blood test will confirm the presence of abnormal antibodies.”
    b. “My skin cells will be stained and examined under the microscope.”
    c. “The rash will be scraped with a razor blade and the flakes cultured.”
    d. “I will return to have the substances removed and the areas evaluated.”

Answer 213

d. “I will return to have the substances removed and the areas evaluated.”

A patch test is used to determine skin reactions to certain allergens applied to the skin. The patient will return in 48 to 72 hours for allergen removal and return again in 96 hours for evaluation.

Chapter 22 Integumentary System (10th Edition)
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Question 214

18. A patient with diabetes mellitus has been diagnosed with peripheral vascular disease. Which dermatologic manifestations should the nurse assess?
    a. Redness of exposed areas of the skin on the hand, foot, face, or neck
    b. Leathery, brownish skin on lower leg, pruritus, concave lesions with edema, scar tissue with healing
    c. Loss of hair in periphery, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing
    d. Atrophy, epidermal thinning, increased vascular fragility, impaired wound healing, thin loose dermis, and excess fat at the back of the neck

Answer 214

c. Loss of hair in periphery, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing

A patient with diabetes mellitus and peripheral vascular disease is likely to have loss of peripheral hair, delayed capillary filling, dependent rubor, neuropathy, and delayed wound healing. A patient with a nicotinic acid (niacin) deficiency manifests redness of exposed areas of the skin on the hand or foot, face, or neck and infected dermatitis. A patient with venous ulcers will have leathery, brownish skin on the lower leg, pruritus, concave lesions with edema, and scar tissue with healing. A patient with glucocorticoid excess (Cushing syndrome) may have atrophy, epidermal thinning, increased vascular fragility, impaired wound healing, thin loose dermis, and excess fat at the back of the neck, clavicles, abdomen, and face.

Chapter 22 Integumentary System (10th Edition)
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Question 215

19. The nurse is conducting an integumentary assessment of an African American patient who has darkly pigmented skin and a history of chronic obstructive pulmonary disease (COPD). Which locations should the nurse inspect for cyanosis (select all that apply.)?
    a. Patient’s sclera
    b. Patient’s nail beds
    c. Soles of the patient’s feet
    d. Palms of the patient’s hands
    e. Conjunctiva of the patient’s eyes

Answer 215

b. Patient’s nail beds
e. Conjunctiva of the patient’s eyes

In patients with darkly pigmented skin, the conjunctiva and nail beds are often examined to assess for cyanosis. The palms of the hands, soles of the feet, and the sclera are not the focus when assessing for cyanosis.

Chapter 22 Integumentary System (10th Edition)
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Question 216

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

Answer 216

b. protection.

Chapter 23 Integumentary System (9th Edition)
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Question 217

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

Answer 217

b. scaly scalp.
d. thicker, brittle nails.
e. longitudinal nail ridging.

Chapter 23 Integumentary System (9th Edition)
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Question 218

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

Answer 218

c. recent changes in wound healing.

Chapter 23 Integumentary System (9th Edition)
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Question 219

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

Answer 219

c. pinch up a fold of skin to assess for turgor.

Chapter 23 Integumentary System (9th Edition)
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Question 220

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

Answer 220

a. wheals.

Chapter 23 Integumentary System (9th Edition)
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Question 221

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

Answer 221

a. palpation.

Chapter 23 Integumentary System (9th Edition)
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Question 222

7. Individuals with dark skin are more likely to develop
   a. keloids.
   b. wrinkles.
   c. skin rashes.
   d. skin cancer.

Answer 222

a. keloids.

Chapter 23 Integumentary System (9th Edition)
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Question 223

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

Answer 223

d. Nevus of Ota.

Chapter 23 Integumentary System (9th Edition)
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Question 224

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

Answer 224

b. a more definitive diagnosis is needed.

Chapter 23 Integumentary System (9th Edition)
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Question 225

1. A nurse is obtaining a health history from a 56-year-old man who has a new diagnosis of type 2 diabetes mellitus. What question related to the skin would be most important for the nurse to ask this patient?

A. “Is your sleep interrupted by severe episodes of itching at night?”

B. “Have you noticed any changes in the way sores or wounds heal?”

C. “Do you have any skin lesions that have changed in size or shape?”

D. “What changes if any have you noticed in your skin, hair, and nails?”

Answer 225

B. “Have you noticed any changes in the way sores or wounds heal?”

A patient with diabetes is more susceptible to poor wound healing because of the macrovascular and microvascular changes that occur in diabetes. Poor circulation, especially in the lower extremities, increases the risk for poor wound healing. A patient with diabetes is at increased risk for infection because of a defect in the mobilization of inflammatory cells and an impairment of phagocytosis by neutrophils and monocytes.

Chapter 23 Integumentary System (9th Edition)
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Question 226

2. A 78-year-old woman is admitted to the hospital with dehydration resulting from prolonged vomiting. Which assessment finding by the nurse is most consistent with severe dehydration?

A. The skin color over the nose and ears has a blue tint.

B. The skin of the extremities is warm and dry to touch.

C. Pressing the skin over the ankles causes pitting for 10 seconds.

D. Pinching the skin under the clavicle causes tenting for 10 seconds.

Answer 226

D. Pinching the skin under the clavicle causes tenting for 10 seconds.

Skin turgor is good when skin moves easily when lifted and immediately returns to its original position when released (no tenting). A loss of skin turgor occurs with dehydration and aging that will result in tenting. With hypovolemia, expected skin changes are cool, without edema or central cyanosis.

Chapter 23 Integumentary System (9th Edition)
Pre-Test

Question 227

3. A patient with thrombocytopenia secondary to sepsis has small, pinpoint deposits of blood visible through the skin on the anterior and posterior chest. What term will the nurse use to describe this skin abnormality?

A. Petechiae

B. Erythema

C. Ecchymosis

D. Telangiectasia

Answer 227

A. Petechiae

Petechiae are pinpoint, discrete deposits of blood less than 1 to 2 mm in the extravascular tissues and visible through the skin or mucous membranes. Erythema is redness occurring in patches of variable size and shape. Telangiectasia is visibly dilated, superficial, cutaneous small blood vessels. Ecchymosis is a large, bruise-like lesion caused by a collection of extravascular blood in the dermis and subcutaneous tissue.

Chapter 23 Integumentary System (9th Edition)
Pre-Test

Question 228

4. The nurse performs a physical assessment on a dark-skinned African American man who reports difficulty breathing. What is the best location for the nurse to assess for cyanosis in this patient?

A. Lips

B. Earlobe

C. Conjunctiva

D. Palm of hand

Answer 228

C. Conjunctiva

Cyanosis will appear ashen or gray color and is most easily seen in the conjunctiva of the eye, mucous membranes, and nail beds of dark-skinned individuals. The nail beds, earlobes, lips, mucous membranes, and palms and soles of feet would be appropriate locations to assess for cyanosis in a light-skinned individual.

Chapter 23 Integumentary System (9th Edition)
Pre-Test

Question 229

5. The nurse is teaching a patient about diagnostic testing for allergic dermatitis. Which statement by the patient demonstrates a correct understanding of the teaching?

A. “A blood test will confirm the presence of abnormal antibodies.”

B. “My skin cells will be stained and examined under the microscope.”

C. “The rash will be scraped with a razor blade and the flakes cultured.”

D. “I will return to have the substances removed and the areas evaluated.”

Answer 229

D. “I will return to have the substances removed and the areas evaluated.”

A patch test is used to determine skin reactions to certain allergens applied to the skin. The patient will return in 48 to 72 hours for allergen removal and return again in 96 hours for evaluation.

Chapter 23 Integumentary System (9th Edition)
Pre-Test

Question 230

1. The nurse is positioning a patient after a surgical procedure. What is the best position unless contraindicated, for this patient to be placed in to prevent respiratory complications?
   a. Supine
   b. Lateral
   c. Semi-Fowler’s
   d. High-Fowler’s

Answer 230

b. Lateral

Unless contraindicated by the surgical procedure, an unconscious patient is positioned in a lateral “recovery” position. This recovery position keeps the airway open and reduces the risk of aspiration if the patient vomits. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated.

Chapter 19 Postoperative Care (10th Edition)
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Question 231

2. The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse’s initial action be upon the patient’s arrival?
   a. Assess the patient’s pain.
   b. Assess the patient’s vital signs.
   c. Check the rate of the IV infusion.
   d. Check the physician’s postoperative orders.

Answer 231

b. Assess the patient’s vital signs.

The highest priority action by the nurse is to assess the physiologic stability of the patient. This is accomplished in part by taking the patient’s vital signs. The other actions can then take place in rapid sequence.

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Question 232

3. When assessing a patient’s surgical dressing on the first postoperative day, the nurse notes new, bright-red drainage about 5 cm in diameter. What is the priority action by the nurse?
   a. Recheck in 1 hour for increased drainage.
   b. Notify the surgeon of a potential hemorrhage.
   c. Assess the patient’s blood pressure and heart rate.
   d. Remove the dressing and assess the surgical incision.

Answer 232

c. Assess the patient’s blood pressure and heart rate.

The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report all of the findings. Continued reassessment will be done. Agency policy determines whether the nurse may change the dressing for the first time or simply reinforce it.

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Question 233

4. In planning postoperative interventions to promote repositioning, ambulation, coughing, and deep breathing, which action should the nurse recognize will best enable the patient to achieve the desired outcomes?
   a. Administering adequate analgesics to promote relief or control of pain
   b. Asking the patient to demonstrate the postoperative exercises every 1 hour
   c. Giving the patient positive feedback when the activities are performed correctly
   d. Warning the patient about possible complications if the activities are not performed

Answer 233

a. Administering adequate analgesics to promote relief or control of pain

Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.

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Question 234

5. A postoperative patient has a bronchial obstruction resulting from retained secretions and an oxygen saturation of 87%. What condition does the nurse suspect is occurring?
   a. Atelectasis
   b. Bronchospasm
   c. Hypoventilation
   d. Pulmonary embolism

Answer 234

a. Atelectasis

The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate or depth. Pulmonary emboli do not involve blockage by retained secretions.

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Question 235

6. In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can the nurse delegate to the unlicensed assistive personnel (UAP)?
   a. Monitor the patient’s pain.
   b. Do the admission vital signs.
   c. Assist the patient to take deep breaths and cough.
   d. Change the dressing when there is excess drainage.

Answer 235

c. Assist the patient to take deep breaths and cough.

The UAP can encourage and assist the patient to do deep breathing and coughing exercises and report complaints of pain to the nurse caring for the patient. The RN should do the admission vital signs for the patient transferring to the clinical unit from the PACU. The LPN or RN will monitor and treat the patient’s pain and change the dressings.

Chapter 19 Postoperative Care (10th Edition)
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Question 236

7. A patient having abdominal surgery had an estimated blood loss of 400 mL and received 300 mL of 0.9% normal saline. Postoperatively, the patient’s blood pressure is 70/48 mm Hg. What treatment does the nurse anticipate administering?
   a. Blood administration
   b. IV fluid administration
   c. An ECG to check circulatory status
   d. Return to surgery to check for internal bleeding

Answer 236

b. IV fluid administration

The nurse should anticipate restoring circulating volume with IV infusion. Although blood could be used to restore circulating volume, there are no manifestations in this patient indicating a need for blood administration. An ECG may be done if there is no response to the fluid administration, there is a past history of cardiac disease, or cardiac problems were noted during surgery. Returning to surgery to check for internal bleeding would only be done if patient’s level of consciousness changes or the abdomen becomes firm and distended.

Chapter 19 Postoperative Care (10th Edition)
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Question 237

8. The patient donated a kidney, and early ambulation is included in the plan of care, but the patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation?
   a. “Early walking keeps your legs limber and strong.”
   b. “Early ambulation will help you be ready to go home.”
   c. “Early ambulation will help you get rid of your syncope and pain.”
   d. “Early walking is the best way to prevent postoperative complications.”

Answer 237

d. “Early walking is the best way to prevent postoperative complications.”

The best rationale is that early ambulation will prevent postoperative complications that can then be discussed. Ambulating increases muscle tone, stimulates circulation that prevents venous stasis and venous thromboembolism, speeds wound healing, and increases vital capacity and maintains normal respiratory function. These things help the patient be ready for discharge, but early ambulation does not eliminate syncope and pain. Pain management should always occur before walking.

Chapter 19 Postoperative Care (10th Edition)
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Question 238

9. An older adult patient who had surgery is displaying manifestations of delirium. What priority action would benefit this patient?
   a. Check the chart for intraoperative complications.
   b. Check which medications were used for anesthesia.
   c. Check the effectiveness of the analgesics received.
   d. Check the preoperative assessment for previous delirium or dementia.

Answer 238

d. Check the preoperative assessment for previous delirium or dementia.

If the patient’s ABCs are okay, it is important to first know if the patient was mentally alert without cognitive impairments before surgery. Then intraoperative complications, anesthesia medications and pain will be assessed as these can all contribute to delirium.

Chapter 19 Postoperative Care (10th Edition)
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Question 239

10. A patient is having elective cosmetic surgery performed on the face and will be staying in the facility for 24 hours after surgery. What is the nurse’s postoperative priority for this patient?
    a. Manage patient pain.
    b. Control the bleeding.
    c. Maintain fluid balance.
    d. Manage oxygenation status.

Answer 239

d. Manage oxygenation status.

The nurse’s priority is to manage the patient’s oxygenation status by maintaining an airway and ventilation. With surgery on the face, there may be swelling that could compromise her ability to breathe. Pain, bleeding, and fluid imbalance from the surgery may increase her risk for upper airway edema causing airway obstruction and respiratory suppression, which also indicate managing oxygenation status as the priority.

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Question 240

11. A patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression?
    a. Increased respiratory rate
    b. Decreased oxygen saturation
    c. Increased carbon dioxide pressure
    d. Frequent premature ventricular contractions (PVCs)

Answer 240

c. Increased carbon dioxide pressure

Transcutaneous carbon dioxide pressure (PtcCO2) monitoring is a sensitive indicator of respiratory depression. Increased CO2 pressures would indicate respiratory depression. Clinical manifestations of inadequate oxygenation include increased respiratory rate, dysrhythmias (e.g., premature ventricular contractions), and decreased oxygen saturation.

Chapter 19 Postoperative Care (10th Edition)
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Question 241

12. A nurse is caring for an unconscious patient who has just been admitted to the postanesthesia care unit after abdominal hysterectomy. How should the nurse position the patient?
    a. Left lateral position with head supported on a pillow
    b. Prone position with a pillow supporting the abdomen
    c. Supine position with head of bed elevated 30 degrees
    d. Semi-Fowler’s position with the head turned to the right

Answer 241

a. Left lateral position with head supported on a pillow

An unconscious patient should be placed in the lateral “recovery” position to keep the airway open and reduce the risk of aspiration. When conscious, the patient is usually returned to a supine position with the head of the bed elevated to maximize expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.

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Question 242

13. Which patient would be at highest risk for hypothermia after surgery?
    a. A 42-yr-old patient who had a laparoscopic appendectomy
    b. A 38-yr-old patient who had a lumpectomy for breast cancer
    c. A 20-yr-old patient with an open reduction of a fractured radius
    d. A 75-yr-old patient with repair of a femoral neck fracture after a fall

Answer 242

d. A 75-yr-old patient with repair of a femoral neck fracture after a fall

Patients at highest risk for hypothermia are those who are older, debilitated, or intoxicated. Also, long surgical procedures and prolonged anesthetic administration increase the patient’s risk for hypothermia.

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Question 243

14. The nurse is providing discharge teaching to a patient who has had a laparoscopic cholecystectomy at an ambulatory surgery center. Which statement, if made by the patient, indicates an understanding of the discharge instructions?
    a. “I will have someone stay with me for 24 hours in case I feel dizzy.”
    b. “I should wait for the pain to be severe before taking the medication.”
    c. “Because I did not have general anesthesia, I will be able to drive home.”
    d. “It is expected after this surgery to have a temperature up to 102.4º F.”

Answer 243

a. “I will have someone stay with me for 24 hours in case I feel dizzy.”

The nurse must assess understanding of discharge instructions and the ability of the patient and caregiver to provide for home care needs. A responsible adult caregiver must accompany the patient. The patient may not drive after receiving anesthetics or sedatives. The patient should understand how to manage pain, and pain medication should be taken before the pain becomes severe. The patient should understand symptoms to be reported, such as a fever.

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Question 244

15. The nurse is caring for a Native American patient 2 days after a thoracotomy for tumor resection. What would be the most appropriate action if the patient does not report any pain?
    a. Contact the health care provider.
    b. Identify possible reasons for denial of pain.
    c. Administer the prescribed pain medication.
    d. Assess the renal and liver function test results.

Answer 244

b. Identify possible reasons for denial of pain.

Encourage older adults to report pain, especially those who are reluctant to discuss pain or deny pain when it is likely present, such as after surgery. Older patients may be hesitant to request pain medication, believe pain is an inevitable consequence of surgery, and may not understand how to use patient-controlled machines. Some cultures discourage the expression of pain. The nurse should encourage the use of analgesics, explaining to the patient that untreated pain has a negative effect on recovery. Assessment of pain and administration of medications are within the scope of practice of a nurse. An older patient may have decreased renal and liver function that may lead to drug toxicity. However, this would not be a reason for denial of pain. Administration of pain medication must be based on the patient assessment.

Chapter 19 Postoperative Care (10th Edition)
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Question 245

16. A patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply.)?
    a. Vital signs baseline or stable
    b. Minimal nausea and vomiting
    c. Wants to go to the bathroom at home
    d. Responsible adult taking patient home
    e. Comfortable after IV opioid 15 minutes ago

Answer 245

a. Vital signs baseline or stable
b. Minimal nausea and vomiting
d. Responsible adult taking patient home

Ambulatory surgery discharge criteria includes meeting phase I PACU discharge criteria that includes vital signs baseline or stable and minimal nausea and vomiting. Phase II criteria include a responsible adult driving patient, no IV opioid drugs for the past 30 minutes, able to void, able to ambulate if not contraindicated, and received written discharge instruction with patient understanding confirmed.

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Question 246

17. A postoperative patient is transferred from the postanesthesia unit to the medical-surgical nursing floor. The nurse notes that the patient has an order for D5 ½NS to infuse at 125 mL/hr. Until an IV pump is available, the nurse regulates the IV at what flow rate in drops (gtt)/min, noting that the tubing has a drop factor of 10 drops/mL?
    a. 20 gtt/min
    b. 21. gtt/min
    c. 22 gtt/min
    d. 23 gtt/min

Answer 246

b. 21. gtt/min

125 mL/hr × 10 gtt/mL = 1250 gtt/hr
1250 gtt ÷ 60 min = 20.83 gtt/min

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Question 247

18. The nurse is preparing to administer cefazolin (Ancef) 2 g in 100 mL of normal saline to a postoperative patient. What infusion rate on the infusion pump will infuse this medication over 20 minutes?
    a. 3 mL/hr
    b. 4 mL/hr
    c. 5 mL/hr
    d. 6 mL/hr

Answer 247

c. 5 mL/hr

Volume ÷ Time in hours = Rate in mL/hr.
Therefore 100 mL ÷ 0.33 hr (20 min) = 300 mL/hr.

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Question 248

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

Answer 248

c. Assess for airway patency and quality of respirations, and obtain vital signs.

Assessment in the postanesthesia care unit (PACU) begins with evaluation of the airway, breathing, and circulation (ABC) status of the patient. Identification of inadequate oxygenation and ventilation or respiratory compromise necessitates prompt intervention.

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Question 249

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

Answer 249

c. position patient in lateral recovery position.

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

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Question 250

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

Answer 250

a. Oxygen saturation of 85%

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

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Question 251

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

Answer 251

d. evaluate the patient’s fluid volume status since surgery and obtain a bladder ultrasound.

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

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Question 252

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

Answer 252

c. no respiratory depression.
d. written discharge instructions understood.
e. opioid pain medication given 45 minutes ago.

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

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Question 253

1. A 67-year-old male patient is admitted to the postanesthesia care unit (PACU) after abdominal surgery. Which assessment, if made by the nurse, is the best indicator of respiratory depression?

A. Increased respiratory rate

B. Decreased oxygen saturation

C. Increased carbon dioxide pressure

D. Frequent premature ventricular contractions (PVCs)

Answer 253

C. Increased carbon dioxide pressure

Transcutaneous carbon dioxide pressure (PtcCO2) monitoring is a sensitive indicator of respiratory depression. Increased CO2 pressures would indicate respiratory depression. Clinical manifestations of inadequate oxygenation include increased respiratory rate, dysrhythmias (e.g., premature ventricular contractions), and decreased oxygen saturation.

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Question 254

2. The nurse is caring for a 54-year-old unconscious female patient who has just been admitted to the postanesthesia care unit after abdominal hysterectomy. How should the nurse position the patient?

A. Left lateral position with head supported on a pillow

B. Prone position with a pillow supporting the abdomen

C. Supine position with head of bed elevated 30 degrees

D. Semi-Fowler’s position with the head turned to the right

Answer 254

A. Left lateral position with head supported on a pillow

The unconscious patient should be placed in the lateral “recovery” position to keep the airway open and reduce the risk of aspiration. Once conscious, the patient is usually returned to a supine position with the head of the bed elevated to maximize expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm.

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Question 255

3. Which patient would be at highest risk for hypothermia after surgery?

A. A 42-year-old patient who had a laparoscopic appendectomy

B. A 38-year-old patient who had a lumpectomy for breast cancer

C. A 20-year-old patient with an open reduction of a fractured radius

D. A 75-year-old patient with repair of a femoral neck fracture after a fall

Answer 255

D. A 75-year-old patient with repair of a femoral neck fracture after a fall

Patients at highest risk for hypothermia are those who are older, debilitated, or intoxicated. Also, long surgical procedures and prolonged anesthetic administration place the patient at increased risk for hypothermia.

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Question 256

4. The nurse is providing discharge teaching to a 51-year-old female patient who has had a laparoscopic cholecystectomy at an ambulatory surgery center. Which statement, if made by the patient, indicates an understanding of the discharge instructions?

A. “I will have someone stay with me for 24 hours in case I feel dizzy.”

B. “I should wait for the pain to be severe before taking the medication.”

C. “Because I did not have general anesthesia, I will be able to drive home.”

D. “It is expected after this surgery to have a temperature up to 102.4° F.”

Answer 256

A. “I will have someone stay with me for 24 hours in case I feel dizzy.”

The nurse must assess understanding of discharge instructions and the ability of the patient and caregiver to provide for home care needs. The patient must be accompanied by a responsible adult caregiver. The patient may not drive after receiving anesthetics or sedatives. The patient should understand how to manage pain, and pain medication should be taken before the pain becomes severe. The patient should understand symptoms to be reported, such as a fever.

Chapter 20 Postoperative Care (9th Edition)
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Question 257

5. The nurse cares for a 72-year-old Native American male patient 2 days after a thoracotomy for tumor resection. What would be the most appropriate action if the patient does not report any pain?

A. Contact the health care provider.

B. Identify possible reasons for denial of pain.

C. Administer the prescribed pain medication.

D. Assess the renal and liver function test results.

Answer 257

B. Identify possible reasons for denial of pain.

Encourage the older adult to report pain, especially those who are reluctant to discuss pain or deny pain when it is likely present, such as after surgery. Older patients may be hesitant to request pain medication, believe pain is an inevitable consequence of surgery, and may not understand how to use patient-controlled machines. Some cultures discourage the expression of pain. The nurse should encourage the use of analgesics, explaining to the patient that untreated pain has a negative effect on recovery. Assessment of pain and administration of medications are within the scope of practice of a nurse. An older patient may have decreased renal and liver function that may lead to drug toxicity. However, this would not be a reason for denial of pain. Administration of pain medication must be based on the patient assessment.

Chapter 20 Postoperative Care (9th Edition)
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Question 258

1. The nurse is circulating for a surgical procedure. What clinical manifestation would indicate to the nurse that the patient may be experiencing malignant hyperthermia?
   a. Hypocapnia
   b. Muscle rigidity
   c. Decreased body temperature
   d. Confusion upon arousal from anesthesia

Answer 258

b. Muscle rigidity

Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles from altered control of intracellular calcium occurring as a result of exposure to certain anesthetic agents in susceptible patients. Hypoxemia, hypercapnia, and ventricular dysrhythmias may also be seen with this disorder.

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Question 259

2. The circulating nurse is caring for a patient during a colon resection. What observation made by the nurse is immediately recognized as a violation of aseptic technique?
   a. A glove contacts the leg of the table that supports the sterile field.
   b. The cuff of the scrub nurse’s sterile gown contacts the sterile field.
   c. The sterile field was established at 0650, and the current time is 0900.
   d. Bacteria are present in the nares and upper respiratory passages of the nurse.

Answer 259

a. A glove contacts the leg of the table that supports the sterile field.

Tables are sterile only at tabletop level. Areas below this are considered contaminated. The sterile gown below the point 2 inches above the elbow is considered sterile. The passage of time in and of itself does not necessarily render a field contaminated. Bacteria are inevitable in the respiratory passages of team members, but they present a threat to sterility only if they are not confined by attire.

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Question 260

3. The perioperative nurse would recognize the need to monitor the patient for hallucinations and agitation when which anesthetic agent is administered?
   a. Ketamine
   b. Halothane
   c. Thiopental
   d. Nitrous oxide

Answer 260

a. Ketamine

A disadvantage of ketamine is the associated risk of agitation, hallucinations, and nightmares. Ketamine is considered dissociative anesthesia. These unwanted effects are not associated with the use of thiopental, halothane, or nitrous oxide.

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Question 261

4. An older adult patient is undergoing coronary artery bypass graft (CABG) surgery and has just experienced intraoperative vomiting. The nurse should consequently anticipate the use of which drug?
   a. Fentanyl
   b. Midazolam
   c. Meperidine
   d. Ondansetron

Answer 261

d. Ondansetron

Ondansetron is an antiemetic, midazolam is a benzodiazepine, and fentanyl and meperidine are opioid analgesics

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Question 262

5. A surgical patient’s premedication regimen includes midazolam. What are the most likely desired effects of this medication that the nurse should recognize?
   a. Monitored anesthesia care and amnesia
   b. Potentiates volatile agents to speed induction
   c. Analgesia and prevention of intraoperative vomiting
   d. Relaxation of skeletal muscles and facilitation of endotracheal intubation

Answer 262

a. Monitored anesthesia care and amnesia

Midazolam is a benzodiazepine that is widely used for its ability to induce amnesia and provide moderate sedation (conscious sedation). Nitrous oxide is a gaseous agent that potentiates volatile agents to speed induction and reduce total dosage and side effects. Antiemetics prevent intraoperative vomiting. Neuromuscular blocking agents facilitate endotracheal intubation.

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Question 263

6. A patient asks a student nurse if his family member may accompany him to the surgical area. What is the best response by the nurse?
   a. “Your family member may not enter the surgical area”
   b. “Your family can be with you in the preoperative holding area.
   c. “Your family can’t be with you until the postanesthesia care unit.
   d. “Your family is only allowed in the conference room for preoperative teaching.”

Answer 263

b. “Your family can be with you in the preoperative holding area.

The perioperative nurse should explain to the student nurse that the family can be in the preoperative holding area before the patient goes to surgery, but this includes talking to the nurse at the nursing station. They are also taken to the conference room for preoperative and postoperative meetings with staff, including teaching.

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Question 264

7. A patient is being prepared for a surgical procedure. What is the priority intervention by the nurse prior to the start of the procedure according to the National Patient Safety Goal (NPSG)?
   a. Prevention of infection
   b. Improved staff communication
   c. Identify patients at risk for suicide.
   d. Patient, surgical procedure, and site are checked.

Answer 264

d. Patient, surgical procedure, and site are checked.

During the surgical time-out, the Universal Protocol is used to verify the patient’s identity, surgical procedure, and site to prevent mistakes in surgery. Prevention of infection is to be done at all times. Improved staff communication relates to getting important test results to the right staff on time. Identifying patient’s safety risks for suicide is not usually vital before surgery and does not occur during the time-out.

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Question 265

8. A patient having an open reduction internal fixation (ORIF) of a left lower leg fracture will receive regional anesthesia during the procedure. As the patient is prepared in the operating room, what should the nurse implement to maintain patient safety during surgery that is directly related to the type of anesthesia being used?
   a. Apply grounding pad to unaffected leg.
   b. Assess peripheral pulses and skin color.
   c. Verify the last oral intake before surgery.
   d. Ensure a smooth surface under the patient.

Answer 265

d. Ensure a smooth surface under the patient.

Regional anesthesia decreases sensation to the anesthetized area without impairing level of consciousness, which means the affected leg will be without sensation while the anesthetic is effective. A double tourniquet on the affected leg is used to restrict blood flow. This increases the patient’s risk of impaired skin integrity because the patient does not have sensation and cannot identify discomfort or foreign objects and will not be moving during surgery. The nurse’s role includes positioning the patient for correct alignment, exposure of the surgical site, and preventing injury. The other options will be occurring but are not directly related to the regional anesthesia.

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Question 266

9. An older adult patient is having surgery. What risk areas will the nurse need to be especially aware of for this patient during surgery?
   a. Sterility
   b. Paralysis
   c. Urine output
   d. Skin integrity

Answer 266

d. Skin integrity

Skin of older adults has lost elasticity and is at increased risk for injury from tape, electrodes, warming or cooling blankets, and dressings. Pooling cleansing solution may create skin burns or abrasions. The nurse is responsible for monitoring patient safety and adjusting patient position as necessary to prevent pressure or misalignment. Sterility and urine output would be monitored for all patients. Paralysis would not be unusual during some types of surgery but would have an impact on any patient’s skin integrity.

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Question 267

10. The patient is going to have a colonoscopy. Which type of anesthesia should the nurse expect to be used?
    a. Local anesthesia
    b. Moderate sedation
    c. General anesthesia
    d. Monitored anesthesia care (MAC)

Answer 267

d. Monitored anesthesia care (MAC)

The nurse should expect MAC to be used for the patient having a colonoscopy because it can match the sedation level to the patient needs and procedural requirements. Local anesthesia would not be used because the area affected by a colonoscopy is larger than loss of sensation could be provided for with topical, intracutaneous, or subcutaneous application. Moderate sedation is used for procedures performed outside the operating room, and the patient remains responsive. General anesthesia is not needed for a colonoscopy, and it requires advanced airway management.

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Question 268

11. In which surgical area will the patient’s surgical skin scrub prep be performed for surgery, and what clothing is appropriate for the nurse performing the scrub to wear?
    a. Surgical suite wearing a lab coat
    b. Preoperative holding area wearing street clothes
    c. Postanesthesia care unit (PACU) wearing scrubs
    d. Operating room wearing surgical attire and masks

Answer 268

d. Operating room wearing surgical attire and masks

Surgical attire includes pants and shirts (or scrubs), a cap or hood, masks, and protective eyewear. All surgical attire is worn when the patient’s skin is being prepped in the operating room to avoid contamination of the site. The surgical suite includes all unrestricted, semirestricted, and restricted areas of the controlled surgical environment. The staff usually wears a lab coat over their scrubs when they leave the surgical area. The staff will not wear street clothes in the preoperative holding area, although the family may. The holding area and PACU will not include prepping the patient for surgery.

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Question 269

12. While the perioperative nurse is transporting a patient to the operating room for general surgery, the patient states, “I am a Jehovah’s Witness, and I am worried about blood transfusions.” What would be the best response by the nurse to this patient’s statement?
    a. “I will make sure that you do not receive a blood transfusion during this surgery.”
    b. “Would you like to sign the consent form just in case you need blood during surgery?”
    c. “Do you have someone I can contact in an emergency if you need a blood transfusion?”
    d. “Tell me what you would like done if it is determined that you need blood replacement during surgery.”

Answer 269

d. “Tell me what you would like done if it is determined that you need blood replacement during surgery.”

The perioperative nurse should identify what the patient’s concern is related to a blood transfusion. In addition, the nurse should clarify whether the patient wants a blood transfusion. The Jehovah’s Witness community member may refuse blood transfusions, but each patient should be consulted to determine an individualized plan related to receiving or refusing blood transfusions.

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Question 270

13. The perioperative nurse is supervising the surgical technologist before the arrival of the patient in the operating room for an exploratory laparotomy. Which action, if taken by the surgical technologist, would require the nurse to intervene?
    a. The surgical technologist holds hands away from the body and above the elbows at all times.
    b. The surgical technologist scrubs the fingers and hands first followed by the forearms and elbows.
    c. After a surgical scrub, the surgical technologist puts on a sterile gown and one pair of sterile gloves.
    d. When wearing a sterile gown and gloves, the surgical technologist is able to organize the equipment on the sterile field.

Answer 270

c. After a surgical scrub, the surgical technologist puts on a sterile gown and one pair of sterile gloves.

After a surgical hand scrub is completed, the surgical technologist should put on a sterile surgical gown and two pairs of gloves to prevent the transmission of microorganisms. Surgical hand antisepsis is completed by scrubbing fingers and hands first followed by progression to forearms and elbows. The hands should be held away from surgical attire and higher than the elbows at all times to prevent contamination. After performing a surgical hand scrub and applying a sterile gown and two pairs of sterile gloves, the person may manipulate and organize all sterile items for use during the procedure.

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Question 271

14. The surgical team in the operating room performs a surgical time-out just before starting hip replacement surgery. Which action would be part of the surgical time-out?
    a. Assess the patient’s vital signs and oxygen saturation level.
    b. Check the chart for a signed consent form for the procedure.
    c. Determine if the patient has any questions about the procedure.
    d. Have the patient verify the procedure and the location of the surgery.

Answer 271

d. Have the patient verify the procedure and the location of the surgery.

During a surgical time-out, the surgery team will stop all activities right before the procedure to verify the patient identification, surgical procedure, and surgical site. Proper identification will be accomplished by asking the patient to state name, birth date, and operative procedure and location. In addition, the surgical team will compare the hospital ID number with the patient’s own ID band and chart.

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Question 272

15. The nurse administered midazolam to a patient during a colonoscopy. What nursing action is appropriate if the patient’s respiratory rate changes from 14 breaths/min to 3 breaths/min?
    a. Administer flumazenil
    b. Give a dose of naloxone.
    c. Initiate oxygen at 4 L/min per nasal cannula.
    d. Reposition the patient with the head of bed up.

Answer 272

a. Administer flumazenil

Midazolam is a benzodiazepine administered during monitored anesthesia care to patients having procedures such as a colonoscopy. The nurse should monitor the level of consciousness and assess for respiratory depression, hypotension, and tachycardia. To reverse severe benzodiazepine-induced respiratory depression, the nurse would administer flumazenil. Naloxone would reverse opioid-induced respiratory depression. Oxygen should be initiated based on pulse oximetry but at a higher concentration than what is provided with a nasal cannula at 4 L/min. The patient with severe respiratory depression should receive 100% oxygen with a non-rebreather mask. Repositioning the patient will not reverse the effects of sedation and may interfere with the procedure in progress.

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Question 273

16. The perioperative nurse is reviewing the chart of a patient who is being admitted into the operating room for a laminectomy. What information obtained from the chart review should the nurse discuss with the anesthesiologist?
    a. The patient’s grandmother developed hypothermia during a craniotomy.
    b. The patient’s mother developed contact dermatitis related to a latex allergy.
    c. The patient’s brother developed nausea after surgery with general anesthesia.
    d. The patient’s father developed an elevated temperature during a recent surgery.

Answer 273

d. The patient’s father developed an elevated temperature during a recent surgery.

Malignant hyperthermia (MH) is an autosomal dominant disorder characterized by hyperthermia with rigidity of skeletal muscles that can result in death. It may occur if an affected individual is exposed to certain general anesthetic agents. To prevent MH, it is important for the nurse to obtain a careful family history. The patient known or suspected to be at risk for MH can be anesthetized with minimal risks if appropriate precautions are taken.

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Question 274

17. The nurse is preparing a patient for a surgical procedure. Before admitting the patient into the perioperative suite, what documents must the nurse make sure are in the chart of the patient?
    Select all that apply.

a. Electrocardiogram
b. Signed consent form
c. Functional status evaluation
d. Renal and liver function tests
e. A history and physical examination report

Answer 274

b. Signed consent form
e. A history and physical examination report

The National Patient Safety Goals (NPSG) require documentation of a history and physical, signed consent form, and nursing and preanesthesia assessment in the chart of a patient going for surgery. The physical examination explains in detail the overall status of the patient before surgery for the surgeon and other members of the surgical team.

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Question 275

18. Which intraoperative nursing responsibilities should be performed by the scrub nurse?
    Select all that apply.

a. Documenting intraoperative care
b. Keeping track of irrigation solutions for monitoring of blood loss
c. Passing instruments and supplies to the surgeon by anticipating his or her needs
d. Coordinating the flow and activities of members of the surgical team in the surgical suite
e. Performing the count of sponges, needles, and instruments used during the surgical procedure

Answer 275

b. Keeping track of irrigation solutions for monitoring of blood loss
c. Passing instruments and supplies to the surgeon by anticipating his or her needs
e. Performing the count of sponges, needles, and instruments used during the surgical procedure

Both the scrub nurse and circulating nurse participate in the counting of surgical sponges, needles, and instruments. Passing instruments to the surgeon and other sterile activities are the exclusive responsibility of the scrub nurse. The circulating nurse takes primary responsibility for the coordination of the surgical suite and documentation.

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Question 276

1. Proper attire for the semirestricted area of the surgery department is
   a. street clothing.
   b. surgical attire and head cover.
   c. surgical attire, head cover, and mask.
   d. street clothing with the addition of shoe covers.

Answer 276

b. surgical attire and head cover.

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

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Question 277

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

Answer 277

b. preparing the instrument table.
c. passing instruments to the surgeon and assistants.
e. maintaining accurate counts of sponges, needles, and instruments.

Maintaining accurate counts of sponges, needles, and instruments is a shared responsibility of the scrub nurse and circulating nurse. (Note: It is listed as an activity for both in Table 18-1.)

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Question 278

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

Answer 278

a. Universal protocol is followed.
e. The patient’s allergies are conveyed to the surgical team.

Intraoperative nursing care includes determining the patient’s allergy status in response to food, drugs, and latex. Preventing use of the wrong site, wrong procedure, and wrong surgery has become known as the Universal Protocol. The Universal Protocol is part of a global patient safety initiative.

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Question 279

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

Answer 279

a. developing an individualized plan of nursing care for the patient.

A primary role of the nurse is to assess the patient to develop an individual plan of care.

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Question 280

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

Answer 280

d. hold the hands higher than the elbows.

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

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Question 281

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

Answer 281

a. incorrect musculoskeletal alignment.

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

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Question 282

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

Answer 282

c. induction is rapid and pleasant.

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

Chapter 19 Intraoperative Care (9th Edition)
Bridge to NCLEX Examination

Question 283

1. While the perioperative nurse is transporting a 34-year-old female patient to the operating room for general surgery, the patient states, “I am a Jehovah’s Witness and I am worried about blood transfusions.” What would be the best response by the nurse to this patient’s statement?

A. “I will make sure that you do not receive a blood transfusion during this surgery.”

B. “Would you like to sign the consent form just in case you need blood during surgery?”

C. “Do you have someone I can contact in an emergency if you need a blood transfusion?”

D. “Tell me what you would like done if it is determined that you need blood replacement during surgery.”

Answer 283

D. “Tell me what you would like done if it is determined that you need blood replacement during surgery.”

The perioperative nurse should identify what the patient’s concern is related to a blood transfusion. In addition, the nurse should clarify whether the patient wants a blood transfusion. The Jehovah’s Witness community member may refuse blood transfusions, but each patient should be consulted to determine an individualized plan related to receiving or refusing blood transfusions.

Chapter 19 Intraoperative Care (9th Edition)
Pre-Test

Question 284

2. The perioperative nurse is supervising the surgical technologist before the arrival of the patient in the operating room for an exploratory laparotomy. Which action, if taken by the surgical technologist, would require the nurse to intervene?

A. The surgical technologist holds hands away from the body and above the elbows at all times.

B. The surgical technologist scrubs the fingers and hands first followed by the forearms and elbows.

C. After a surgical scrub, the surgical technologist puts on a sterile gown and a pair of sterile gloves.

D. Once wearing a sterile gown and gloves, the surgical technologist is able to organize the equipment on the sterile field.

Answer 284

C. After a surgical scrub, the surgical technologist puts on a sterile gown and a pair of sterile gloves.

Once a surgical hand scrub is completed, the surgical technologist should put on a sterile surgical gown and two pairs of gloves to prevent the transmission of microorganisms. Surgical hand antisepsis is completed by scrubbing fingers and hands first followed by progression to forearms and elbows. The hands should be held away from surgical attire and higher than the elbows at all times to prevent contamination. After performing a surgical hand scrub and applying a sterile gown and two pairs of sterile gloves, the person may manipulate and organize all sterile items for use during the procedure.

Chapter 19 Intraoperative Care (9th Edition)
Pre-Test

Question 285

3. The surgical team in the operating room performs a surgical time-out just before starting hip replacement surgery for a 62-year-old woman. Which action would be part of the surgical time-out?

A. Assess the patient’s vital signs and oxygen saturation level.

B. Check the chart for a signed consent form for the procedure.

C. Determine if the patient has any questions about the procedure.

D. Have the patient verify the procedure and the location of the surgery.

Answer 285

D. Have the patient verify the procedure and the location of the surgery.

During a surgical time-out, the surgery team will stop all activities right before the procedure to verify the patient identification, surgical procedure, and surgical site. Proper identification will be accomplished by asking the patient to state name, birth date, and operative procedure and location. In addition, the surgical team will compare the hospital ID number with the patient’s own ID band and chart.

Chapter 19 Intraoperative Care (9th Edition)
Pre-Test

Question 286

4. The nurse administered midazolam (Versed) to a 58-year-old male patient during a colonoscopy. What nursing action is appropriate if the patient’s respiratory rate changes from 14 breaths/minute to 3 breaths/minute?

A. Give a dose of naloxone (Narcan).

B. Administer flumazenil (Romazicon).

C. Initiate oxygen at 4 L/min per nasal cannula.

D. Reposition the patient with the head of bed up.

Answer 286

B. Administer flumazenil (Romazicon).

Midazolam is a benzodiazepine administered during monitored anesthesia care to patients having procedures such as a colonoscopy. The nurse should monitor the level of consciousness and assess for respiratory depression, hypotension, and tachycardia. To reverse severe benzodiazepine-induced respiratory depression, the nurse would administer flumazenil. Naloxone would reverse opioid-induced respiratory depression. Oxygen should be initiated based on pulse oximetry but at a higher concentration than what is provided with a nasal cannula at 4 L/min. The patient with severe respiratory depression should receive 100% oxygen with a non-rebreather mask. Repositioning the patient will not reverse the effects of sedation and may interfere with the procedure in progress.

Chapter 19 Intraoperative Care (9th Edition)
Pre-Test

Question 287

5. The perioperative nurse is reviewing the chart of a 48-year-old male patient who is being admitted into the operating room for a laminectomy. What information obtained from the chart review should be immediately discussed with the anesthesiologist?

A. The patient’s grandmother developed hypothermia during a craniotomy.

B. The patient’s mother developed contact dermatitis related to a latex allergy.

C. The patient’s brother developed nausea after surgery with general anesthesia.

D. The patient’s father developed an elevated temperature during a recent surgery.

Answer 287

D. The patient’s father developed an elevated temperature during a recent surgery.

Malignant hyperthermia (MH) is an autosomal dominant disorder characterized by hyperthermia with rigidity of skeletal muscles that can result in death. It may occur if an affected individual is exposed to certain general anesthetic agents. To prevent MH, it is important for the nurse to obtain a careful family history. The patient known or suspected to be at risk for MH can be anesthetized with minimal risks if appropriate precautions are taken.

Chapter 19 Intraoperative Care (9th Edition)
Pre-Test

Question 288

1. Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks to get up to go to the bathroom to urinate. What is the most appropriate action for the nurse to take?
   a. Offer the patient to use a urinal or bedpan after explaining the need to maintain safety.
   b. Assist the patient to the bathroom and stay next to the door to assist patient back to bed when done.
   c. Allow the patient to go to the bathroom since the onset of the medication will be more than 5 minutes.
   d. Ask the patient to hold the urine for a short period since a urinary catheter will be placed in the operating room.

Answer 288

a. Offer the patient to use a urinal or bedpan after explaining the need to maintain safety.

The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance. The other options would not be safe for the patient.

Chapter 17 Preoperative Care (10th Edition)
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Question 289

2. The nurse is performing a preoperative assessment for a patient scheduled for a surgical procedure. What is the rationale for the nurse’s careful documentation of the patient’s current medication list?
   a. Some medications may alter the patient’s perceptions about surgery.
   b. Many anesthetics alter renal and hepatic function, causing toxicity of other drugs.
   c. Some medications may interact with anesthetics, altering the potency and effect of the drugs.
   d. Routine medications are withheld the day of surgery, requiring dosage and schedule adjustments after surgery.

Answer 289

c. Some medications may interact with anesthetics, altering the potency and effect of the drugs.

Drug interactions may occur between prescribed medications and anesthetic agents used during surgery. For this reason, it is important to take a careful medication history and check that it has been communicated to the anesthesia care provider. Routine medications may or may not be prescribed for use the day of surgery.

Chapter 17 Preoperative Care (10th Edition)
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Question 290

3. While performing preoperative teaching, the patient asks when he is no longer able to eat or drink. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, what is the best response by the nurse?
   a. “Stay NPO after midnight.”
   b. “Maintain NPO status until after breakfast.”
   c. “You may drink clear liquids up to 2 hours before surgery.”
   d. “You may drink clear liquids up until she is moved to the OR.”

Answer 290

c. “You may drink clear liquids up to 2 hours before surgery.”

Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidence-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight.

Chapter 17 Preoperative Care (10th Edition)
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Question 291

4. The nurse is admitting a patient to the same-day surgery unit and the patient informs the nurse they took kava last evening to sleep. Which nursing action would be most appropriate?
   a. Tell the patient that using kava to help sleep is often helpful.
   b. Inform the anesthesiologist of the patient’s recent use of kava.
   c. Tell the patient that the kava should continue to help him relax before surgery.
   d. Inform the patient about the dangers of taking herbal medicines without consulting his health care provider.

Answer 291

b. Inform the anesthesiologist of the patient’s recent use of kava.

Kava may prolong the effects of certain anesthetics. Thus, the anesthesiologist needs to be informed of recent ingestion of this herbal supplement. Patients should not take anything before surgery without the health care provider’s knowledge.

Chapter 17 Preoperative Care (10th Edition)
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Question 292

5. Which preoperative patient has the greatest risk of bleeding as a result of prescribed medication?
   a. A woman who takes metoprolol for the treatment of hypertension
   b. A man who is taking clopidogrel after the placement of a coronary artery stent
   c. A man whose type 1 diabetes is controlled with insulin injections four times daily
   d. A man who recently started taking finasteride for the treatment of benign prostatic hyperplasia

Answer 292

b. A man who is taking clopidogrel after the placement of a coronary artery stent

Any drug that inhibits platelet aggregation, such as clopidogrel, represents a bleeding risk. Insulin, metoprolol, and finasteride are less likely to contribute to a risk for bleeding.

Chapter 17 Preoperative Care (10th Edition)
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Question 293

6. The patient is having a mole removed that has changed appearance. What does the nurse teach the patient about the rationale for this surgical procedure?
   a. It is to prevent malignancy.
   b. It is to alleviate symptoms.
   c. It is to cure the malignancy.
   d. It is to provide cosmetic improvement.

Answer 293

a. It is to prevent malignancy.

Removing a mole that is changing is to prevent as well as diagnose malignancy. There are no symptoms to alleviate mentioned or cosmetic problems for this patient.

Chapter 17 Preoperative Care (10th Edition)
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Question 294

7. A patient informs the nurse prior to the surgical procedure that she is so nervous about the procedure and had to take a Xanax last night, but it did not relieve the anxiety. What is the priority action by the nurse?
   a. Review the surgery with the patient.
   b. Notify the anesthesia care provider (ACP).
   c. Administer another dose of alprazolam (Xanax).
   d. Tell the patient that everything will be okay with the surgery.

Answer 294

b. Notify the anesthesia care provider (ACP).

In determining the psychologic status of the patient, the nurse notes the patient’s anxiety. The nurse should notify the ACP after assessing the cause of the anxiety or fear the patient is experiencing. The patient may only need to talk about the surgery related to the situation, concerns with the unknown or body image, or past experiences to relieve the anxiety, but the nurse cannot assume that lack of knowledge is the cause of the anxiety. Medication administration will be prescribed by the ACP if needed, but medications can also be administered during surgery. Reassuring the patient is not taking the patient’s needs into account.

Chapter 17 Preoperative Care (10th Edition)
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Question 295

8. An older adult female patient has come to the ambulatory surgery center for surgery. When reviewing the assessment record, what test should the nurse seek an order for before this patient has surgery?

Tab 1: Past Health History:
Smoker for past 25 years; last cigarette yesterday; Has hypertension

Tab 2: Laboratory and Diagnostic Results:
CBC within normal limits; Chest x-ray clear; UA within normal limits; No other lab work drawn

Tab 3: Medications:
Takes hydrochlorothiazide 50 mg every morning

a. Blood glucose
b. Pregnancy test
c. Serum albumin
d. Serum potassium

Answer 295

d. Serum potassium

The nurse should seek a serum potassium level because the patient takes hydrochlorothiazide. An ECG would also be appropriate to seek with the history of hypertension and cigarette smoking. There are not indications for the need of a blood glucose, pregnancy, or serum albumin test.

Chapter 17 Preoperative Care (10th Edition)
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Question 296

9. When reviewing the preoperative forms, the nurse notices that the informed consent form is not present or signed. What is the best action for the nurse to take?
   a. Have the patient sign the consent form.
   b. Have the family sign the form for the patient.
   c. Call the surgeon to obtain consent for surgery.
   d. Teach the patient about the surgery and get verbal permission.

Answer 296

c. Call the surgeon to obtain consent for surgery.

The informed consent for the surgery must be obtained by the physician. The nurse can witness the signature on the consent form and verify that the patient (or caregiver if patient is a minor, unconscious, or mentally incompetent to sign) understands the informed consent. Verbal consents are not enough. The state’s nurse practice act and agency policies must be followed.

Chapter 17 Preoperative Care (10th Edition)
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Question 297

10. A patient requests that the nurse give his hearing aid to a family member so it will not be lost in surgery. What is the appropriate action by the nurse?
    a. Give the hearing aid to the wife as he wishes.
    b. Tape the hearing aid to his ear to prevent loss.
    c. Encourage the patient to wear it for the surgery.
    d. Tell the surgery nurse that he has his hearing aid out.

Answer 297

c. Encourage the patient to wear it for the surgery.

Although jewelry is removed before surgery, hearing aids should be left in place to allow the patient to better follow instructions given in the surgical suite and the postanesthesia care unit (PACU), as well as the dismissal instructions that will be given before he returns home for recovery.

Chapter 17 Preoperative Care (10th Edition)
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Question 298

11. At 0600, the anesthesiologist prescribes preoperative medications for a patient who is scheduled for surgery at 0730: cefazolin IV to be infused 30 minutes before surgery; midazolam before surgery, and scopolamine patch behind the ear. Which medication should the nurse administer first?
    a. Cefazolin
    b. Fentanyl
    c. Midazolam
    d. Scopolamine

Answer 298

d. Scopolamine

The scopolamine patch will be administered first to allow enough time for the serum level to become therapeutic. The cefazolin will be given at 0700 to allow infusion 30 minutes before surgery. Fentanyl is an opioid and was not ordered preoperatively. Midazolam, a short-acting benzodiazepine, is used as a sedative.

Chapter 17 Preoperative Care (10th Edition)
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Question 299

12. An alert patient does not want to have a tracheostomy inserted because of extended endotracheal intubation, although family members state that they want it done. What is the best action for the nurse to take?
    a. Advocate for the patient’s rights.
    b. Try to change the patient’s mind.
    c. Call surgery to cancel the procedure.
    d. Tell the family they cannot interfere.

Answer 299

a. Advocate for the patient’s rights.

The nurse must act as the patient’s advocate and assist the patient with fulfilling his wishes. However, as the patient’s advocate, the nurse must be sure he knows the risks and benefits of refusing a tracheostomy. Trying to change the patient’s mind is unethical because it is contrary to acting as an advocate. As long as the patient is lucid, he retains the right of self-determination. Canceling the procedure is not indicated until discussion with the patient and surgeon has occurred. Telling the family they cannot interfere can aggravate or escalate the situation.

Chapter 17 Preoperative Care (10th Edition)
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Question 300

13. The nurse is doing a preoperative assessment on a male patient who has type 2 diabetes mellitus; weighs 146 kg; and is 5 feet 8, inches tall. Which patient assessment is a priority related to anesthesia?
    a. Has hemoglobin A1C of 8.5%
    b. Has several seasonal allergies
    c. Has a body mass index of 48.8 kg/m2
    d. Has a history of postoperative vomiting

Answer 300

c. Has a body mass index of 48.8 kg/m2

The patient’s body mass index is the priority because it indicates the patient is severely obese. The patient’s size may impair the anesthesiologist’s ability to ventilate and medicate the patient properly, as well as the surgery room staff’s ability to position the patient safely. The other factors are not the priority.

Chapter 17 Preoperative Care (10th Edition)
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Question 301

14. The nurse is providing preoperative teaching to a group of patients. To which patient should the nurse plan to teach coughing and deep breathing exercises?
    a. A 20-yr-old man who is scheduled for a tonsillectomy
    b. A 40-yr-old woman who is scheduled for an open cholecystectomy
    c. A 30-yr-old woman who is scheduled for a transsphenoidal hypophysectomy
    d. A 50-yr-old man who is scheduled for an evacuation of a subdural hematoma

Answer 301

b. A 40-yr-old woman who is scheduled for an open cholecystectomy

Patients with abdominal surgeries should be taught how to cough and deep breathe to prevent pulmonary complications such as atelectasis and pneumonia. Coughing and deep breathing is contraindicated in cranial surgeries (e.g., subdural hematoma evacuation or transsphenoidal hypophysectomy) and tonsillectomies.

Chapter 17 Preoperative Care (10th Edition)
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Question 302

15. A patient with a recent diagnosis of prostate cancer is scheduled for a radical prostatectomy. Before signing the consent, the patient tells the nurse, “I am not sure if this surgery is safe.” Which response by the nurse is the most appropriate?
    a. “Tell me what you know about your surgery and the risks involved.”
    b. “Any surgery has risks, but we will be here to take good care of you.”
    c. “You seem anxious. After you sign the consent, I can give you a sedative.”
    d. “You do not need to be concerned. Your surgeon has not had any complaints.”

Answer 302

a. “Tell me what you know about your surgery and the risks involved.”

The health care provider performing the surgery is responsible for obtaining the patient’s consent. The nurse may witness the patient’s signature on the consent form. As a patient advocate, the nurse should verify that the patient understands the surgery and the risks involved. If the nurse determines that the patient is unclear about operative plans, the nurse should contact the health care provider about the patient’s need for more information. The other options provide false reassurance or do not respond to the patient’s concern.

Chapter 17 Preoperative Care (10th Edition)
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Question 303

16. A nurse is assigned to provide preoperative teaching to a patient scheduled for coronary artery bypass surgery who only speaks Spanish. What is the best method for the nurse to teach the patient how to use an incentive spirometer?
    a. Give the patient a pamphlet written in Spanish with directions on the use of the incentive spirometer.
    b. Ask another Spanish-speaking patient in the preoperative area to translate as the nurse describes the procedure.
    c. Have the hospital interpreter available while the nurse demonstrates the procedure and the patient returns the demonstration.
    d. Notify the postoperative unit to have a Spanish-speaking nurse provide teaching on the incentive spirometer after surgery.

Answer 303

c. Have the hospital interpreter available while the nurse demonstrates the procedure and the patient returns the demonstration.

If the patient does not speak English, it is essential that the services of a competent interpreter be obtained. Hospitals are required to provide interpreters for common languages other than English. Demonstration and return demonstration is the most effective teaching method for use of equipment such as the incentive spirometer and should be done in the preoperative period if possible.

Chapter 17 Preoperative Care (10th Edition)
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Question 304

17. Lorazepam (Ativan) 1 mg IV is ordered for a patient before surgery. What is the most appropriate action for the nurse to take before the administration of this medication?
    a. Ask the patient about an allergy to iodine or shellfish.
    b. Encourage or assist the patient to the bathroom to void.
    c. Explain that the medication is used to prevent postoperative nausea.
    d. Check the laboratory results for the most recent serum potassium level.

Answer 304

b. Encourage or assist the patient to the bathroom to void.

The nurse should instruct the patient to void before administering preoperative medications that may interfere with balance and increase the fall risk when ambulating to the bathroom. Lorazepam is a benzodiazepine that may be used for sedation and amnesia before surgery. Lorazepam does not affect serum potassium, is not contraindicated in patients with allergies to iodine or shellfish, and is not indicated to prevent or treat nausea.

Chapter 17 Preoperative Care (10th Edition)
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Question 305

18. The nurse in an ambulatory surgery center has administered the following preoperative medications to a patient scheduled for general surgery: diazepam, cefazolin, and famotidine. What mode of transportation to the operating room (OR) would be the most appropriate for the nurse to arrange for this patient?
    a. Seated in a wheelchair accompanied by a responsible family member
    b. Ambulatory and accompanied by a hospital escort and a family member
    c. Stretcher with side rails up and accompanied by OR transportation personnel
    d. Ambulatory accompanied by an OR staff member or transportation personnel

Answer 305

c. Stretcher with side rails up and accompanied by OR transportation personnel

The patient has received a sedative (diazepam) and should be transported either by stretcher (with side rails raised) or wheelchair and accompanied by either OR staff, OR transport personnel, or the nurse.

Chapter 17 Preoperative Care (10th Edition)
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Question 306

19. An older adult patient has been admitted before having surgery for a bilateral mastectomy and breast reconstruction. What should the nurse include in the patient’s preoperative teaching (select all that apply.)?
    a. Information about various options for reconstructive surgery
    b. Information about the risks and benefits of her particular surgery
    c. Information about risk factors for breast cancer and the role of screening
    d. Information about where in the hospital she will be taken postoperatively
    e. Information about performing postoperative deep-breathing and coughing exercises

Answer 306

d. Information about where in the hospital she will be taken postoperatively
e. Information about performing postoperative deep-breathing and coughing exercises

During preoperative teaching, it is important to introduce the role of deep-breathing and coughing exercises and to inform the patient about the different locations involved in her hospital stay. The specific risks and benefits of her surgery and reconstruction options should be addressed by her surgeon. Teaching about breast cancer screening would be inappropriate, and likely insensitive, at this point in her disease trajectory.

Chapter 17 Preoperative Care (10th Edition)
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Question 307

20. An older adult patient is being prepared for surgery. What assessment data needs to be included for this patient (select all that apply.)?
    a. Fluid balance history
    b. Attitude about surgery
    c. Foods the patient dislikes
    d. Current mobility problems
    e. Current cognitive function
    f. Patient’s opinion about the surgeon

Answer 307

a. Fluid balance history
d. Current mobility problems
e. Current cognitive function

Preoperative fluid balance history is especially critical for older adults because they have reduced adaptive capacity that puts them at greater risk for over- and underhydration. Mobility problems must be assessed to assist with intraoperative and postoperative positioning and ambulation. Preoperative assessment of the older person’s baseline cognition function is especially crucial for intraoperative and postoperative evaluation because they are more prone to adverse outcomes during and after surgery from the stressors of the surgery, dehydration, hypothermia, and anesthesia. Attitude about surgery and opinion or faith in the surgeon are important for all patients. Foods the patient dislikes are not important unless the patient is allergic to them, but this is no more important for older patients than it is for all patients.

Chapter 17 Preoperative Care (10th Edition)
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Question 308

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

Answer 308

a. surgery will involve multiple small incisions.

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

Chapter 18 Preoperative Care (9th Edition)
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Question 309

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

Answer 309

b. Ask additional questions to assess for a possible latex allergy.

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

Chapter 18 Preoperative Care (9th Edition)
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Question 310

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

Answer 310

a. Inform the surgeon, since the procedure may need to be rescheduled.

Ginkgo can increase bleeding during and after surgery. The surgeon should determine how long it should be discontinued before surgery.

Chapter 18 Preoperative Care (9th Edition)
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Question 311

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

Answer 311

a. Witness the permit after consent is obtained by the surgeon.

An emancipated minor may sign his or her own permit. The nurse should be available to witness the signature, but no further action is required.

Chapter 18 Preoperative Care (9th Edition)
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Question 312

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

Answer 312

d. explain the pain management plan, including the use of a pain rating scale.

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

Chapter 18 Preoperative Care (9th Edition)
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Question 313

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

Answer 313

c. Notify the anesthesia care provider of when and what the patient last ate.

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

Chapter 18 Preoperative Care (9th Edition)
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Question 314

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

Answer 314

b. take her usual dose at bedtime and eat a light breakfast in the morning.

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

Chapter 18 Preoperative Care (9th Edition)
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Question 315

8. Preoperative considerations for older adults include:
   Select all that apply.

a. only using large-print educational materials.
b. speaking louder for patients with hearing aids.
c. recognizing that sensory deficits may be present.
d. providing warm blankets to prevent hypothermia.
e. teaching important information early in the morning.

Answer 315

c. recognizing that sensory deficits may be present.
d. providing warm blankets to prevent hypothermia.

Many older adults have sensory deficits. Preoperative and operating rooms are cool; warm blankets should be provided as needed.

Chapter 18 Preoperative Care (9th Edition)
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Question 316

1. The nurse is providing preoperative teaching to the following patients. To which patient should the nurse plan to teach coughing and deep breathing exercises?

A. A 20-year-old man who is scheduled for a tonsillectomy

B. A 40-year-old woman who is scheduled for an open cholecystectomy

C. A 30-year-old woman who is scheduled for a transsphenoidal hypophysectomy

D. A 50-year-old man who is scheduled for an evacuation of a subdural hematoma

Answer 316

B. A 40-year-old woman who is scheduled for an open cholecystectomy

Patients with abdominal surgeries should be taught how to cough and deep breathe to prevent pulmonary complications such as atelectasis and pneumonia. Coughing and deep breathing is contraindicated in cranial surgeries (e.g., subdural hematoma evacuation or transsphenoidal hypophysectomy) and tonsillectomies.

Chapter 18 Preoperative Care (9th Edition)
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Question 317

2. A 58-year-old man with a recent diagnosis of prostate cancer is scheduled for a radical prostatectomy. Before signing the consent, the patient tells the nurse, “I am not sure if this surgery is safe.” Which response by the nurse is the most appropriate?

A. “Tell me what you know about your surgery and the risks involved.”

B. “Any surgery has risks, but we will be here to take good care of you.”

C. “You seem anxious. Once you sign the consent, I can give you a sedative.”

D. “You do not need to be concerned. Your surgeon has not had any complaints.”

Answer 317

A. “Tell me what you know about your surgery and the risks involved.”

The health care provider performing the surgery is responsible for obtaining the patient’s consent. The nurse may witness the patient’s signature on the consent form. As a patient advocate, the nurse should verify that the patient understands the surgery and the risks involved. If the nurse determines that the patient is unclear about operative plans, the nurse should contact the health care provider about the patient’s need for more information. The other options provide false reassurance or do not respond to the patient’s concern.

Chapter 18 Preoperative Care (9th Edition)
Pre-Test

Question 318

3. The nurse is assigned to provide preoperative teaching to a 54-year-old man who is scheduled for coronary artery bypass surgery. The patient speaks only Spanish but the nurse only speaks English. What is the best method for the nurse to teach the patient how to use an incentive spirometer?

A. Give the patient a pamphlet written in Spanish with directions on the use of the incentive spirometer.

B. Ask another Spanish-speaking patient in the preoperative area to translate as the nurse describes the procedure.

C. Have the hospital translator available while the nurse demonstrates the procedure and the patient returns the demonstration.

D. Notify the postoperative unit to have a Spanish-speaking nurse provide education on the incentive spirometer after surgery.

Answer 318

C. Have the hospital translator available while the nurse demonstrates the procedure and the patient returns the demonstration.

If the patient does not speak English, it is essential that the services of a competent translator be obtained. Hospitals are required to provide translators for common languages other than English. Demonstration and return demonstration is the most effective teaching method for use of equipment such as the incentive spirometer and should be done in the preoperative period if possible.

Chapter 18 Preoperative Care (9th Edition)
Pre-Test

Question 319

4. Lorazepam (Ativan) 1 mg IV is ordered for a 45-year-old male patient before a scheduled surgery. Which of the following is the most appropriate action for the nurse to take before the administration of this medication?

A. Ask the patient about an allergy to iodine or shellfish.

B. Encourage or assist the patient to the bathroom to void.

C. Explain that the medication is used to prevent postoperative nausea.

D. Check the laboratory results for the most recent serum potassium level.

Answer 319

B. Encourage or assist the patient to the bathroom to void.

The nurse should instruct the patient to void before administering preoperative medications that may interfere with balance and increase the fall risk when ambulating to the bathroom. Lorazepam is a benzodiazepine that may be used for sedation and amnesia before surgery. Lorazepam does not affect serum potassium, is not contraindicated in patients with allergies to iodine or shellfish, and is not indicated to prevent or treat nausea.

Chapter 18 Preoperative Care (9th Edition)
Pre-Test

Question 320

5. The nurse in an ambulatory surgery center has administered the following preoperative medications to a 42-year-old female patient scheduled for general surgery: diazepam (Valium), cefazolin (Ancef), and famotidine (Pepcid). What mode of transportation to the operating room (OR) would be the most appropriate for the nurse to arrange for this patient?

A. Seated in a wheelchair accompanied by a responsible family member

B. Ambulatory and accompanied by a hospital escort and a family member

C. Stretcher with side rails up and accompanied by OR transportation personnel

D. Ambulatory accompanied by an OR staff member or transportation personnel

Answer 320

C. Stretcher with side rails up and accompanied by OR transportation personnel

The patient has received a sedative (diazepam) and should be transported either by stretcher (with side rails raised) or wheelchair and accompanied by either OR staff, OR transport personnel, or the nurse.

Chapter 18 Preoperative Care (9th Edition)
Pre-Test

Question 321

1. As the nurse, you are getting the patient ready for surgery. You are completing the preoperative checklist. Which of the following is not part of the:

A. Preoperative Checklist
B. Assess for allergies
C. Conducting the time out
D. Informed consent is signed.

Answer 321

C. Conducting the time out

Chapter 17 Preoperative Care (10th Edition)
Asbury’s PowerPoint Questions

Question 322

2. Which of the following patients most likely requires special preoperative assessment and treatment as a result of his or her existing medication regimen?

A. A woman who takes daily anticoagulants to treat atrial fibrillation.

B. A woman who takes a daily thyroid supplement to treat her longstanding hypothyroidism.

C. A man who regularly treats his rheumatoid arthritis with OTC NSAIDS.

D. A man who takes an angiotensin converting enzyme inhibitor because he has hypertension.

Answer 322

A. A woman who takes daily anticoagulants to treat atrial fibrillation.

Chapter 17 Preoperative Care (10th Edition)
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Question 323

3. THE NURSE IS PREPARING TO SEND A PATIENT TO THE OPERATING ROOM FOR AN EXPLORATORY LAPAROSCOPY. THE NURSE RECOGNIZES THAT THERE IS NO INFORMED CONSENT. THE NURSE INFORMS THE PHYSICIAN WHO IS PERFORMING THE PROCEDURE. THE PHYSICIAN ASKS THE NURSE TO OBTAIN THE INFORMED CONSENT SIGNATURE FROM THE PT. WHAT IS THE NURSES BEST ACTION TO THE REQUEST

A. INFORM THE PHYSICIAN THAT IT IS HIS OR HER RESPONSIBILITY TO OBTAIN THE SIGNATURE

B. INFORM THE PHYSICIAN THAT THE NURSE MANAGER WILL NEED TO OBTAIN THE SIGNATURE

C. CALL THE HOUSE OFFICER TO OBTAIN THE SIGNATURE

D. OBTAIN THE SIGNATURE AND ASK ANOTHER NURSE TO COSIGN THE SIGNATURE

Answer 323

A. INFORM THE PHYSICIAN THAT IT IS HIS OR HER RESPONSIBILITY TO OBTAIN THE SIGNATURE

Chapter 17 Preoperative Care (10th Edition)
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Question 324

1. The physical environment of a surgery suite is designed primarily to promote
   a. electrical safety
   b. medical and surgical asepsis
   c. comfort and privacy of the patient
   d. communication among the surgical team

Answer 324

b. medical and surgical asepsis

Although all the factors are important to the safety and well being of the patient, the first consideration in the physical environment of the surgical suite is prevention of transmission of infection to the patient

Chapter 18 Intraoperative Care (10th Edition)
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Question 325

2. The primary goal of the circulating nurse during preparation of the operating room, transferring and positioning the patient, and assisting the anesthesia team is
   a. avoiding any type of injury to the patient
   b. maintaining a clean environment for the patient
   c. providing for patient comfort and sense of well being
   d. preventing breaks in aseptic technique by the sterile members of the team

Answer 325

c. providing for patient comfort and sense of well being

The protection of the patient from injury in the operating room environment is maintained by the circulating nurse by ensuring functioning equipment, preventing falls and injury during transport and transfer, monitoring asepsis, and being with the patient during anesthesia induction

Chapter 18 Intraoperative Care (10th Edition)
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Question 326

3. Goals for patient safety in the operating room (OR) include the Universal Protocol, in which
   a. all surgical centers of any type must submit reports on patient safety infractions to the accreditation agencies
   b. the members of the surgical team stop whatever they are doing to check that all sterile items have been properly prepared
   c. a surgical timeout is performed just before the procedure is started to verify patient identity, surgical procedure, and surgical site
   d. all members of the surgical team pause right before surgery to meditate for 1 minute to decrease stress and possible errors

Answer 326

c. a surgical timeout is performed just before the procedure is started to verify patient identity, surgical procedure, and surgical site

The Universal Protocol supported by The Joint Commission is used to prevent wrong site, wrong procedure, and wrong surgery in view of a high rate of these problems nationally. It involves pausing just before the procedure starts to verify identity, site, and procedure.

Chapter 18 Intraoperative Care (10th Edition)
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Question 327

4. At the end of the surgical procedure, the perioperative nurse evaluates the patient’s response to the nursing care delivered during the perioperative period. Which of the following criteria reflects an outcome related to the patient’s physical status?
   a. the patient’s right to privacy is maintained
   b. the patient’s care is consistent with the perioperative plan of care
   c. the patient receives consistent and comparable care regardless of the setting
   d. the patient’s respiratory function is consistent with or improved from baseline levels established preoperatively.

Answer 327

d. the patient’s respiratory function is consistent with or improved from baseline levels established preoperatively.

The Perioperative Nursing Data Set includes outcome statements that reflect standards and recommended practices or perioperative nursing. Outcomes related to physiologic responses include those of physiologic function, such as respiratory function; perioperative safety includes the patient’s freedom from any type of injury; and behavioral responses include knowledge and actions of the patient and family, including the consistency of the patient’s care with the perioperative plan and the patient’s right to privacy.

Chapter 18 Intraoperative Care (10th Edition)
Asbury’s PowerPoint Questions

Question 328

1. If a 77-year-old patient who is NPO after surgery has dry oral mucous membranes, which of the following is the most appropriate nursing intervention?

A. Increase oral fluid intake.

B. Perform oral hygiene frequently.

C. Swab the inside of the mouth with petroleum.

D. Increase the rate of IV fluid administration.

Answer 328

B. Perform oral hygiene frequently.

Frequent oral hygiene will help alleviate discomfort for a patient who is NPO. IV fluid rate is prescribed by the physician. Petroleum is always inappropriate intraorally. Oral fluid intake is contraindicated in a patient who is NPO.

Chapter 19 Postoperative Care (10th Edition)
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Question 329

2. To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious, the nurse

A. encourages deep breathing.

B. elevates the head of the bed.

C. administers oxygen per mask.

D. positions the patient in a side-lying position.

Answer 329

D. positions the patient in a side-lying position.

An unconscious or semiconscious patient should be placed in a lateral position to protect the airway from obstruction by the tongue. Deep breathing and elevation of the head of the bed are implemented to facilitate gas exchange when the patient is responsive. Oxygen administration is often used, but the patient must first have a patent airway.

Chapter 19 Postoperative Care (10th Edition)
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Question 330

3. The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the postanesthesia care unit (PACU). What should the nurse’s initial action be upon the patient’s arrival?

A. Assess the patient’s pain.

B. Assess the patient’s vital signs.

C. Check the rate of the IV infusion.

D. Check the physician’s postoperative orders.

Answer 330

B. Assess the patient’s vital signs.

Chapter 19 Postoperative Care (10th Edition)
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Question 331

4. An older patient who had surgery is displaying manifestations of delirium. What should the nurse do first to provide the best care for this new patient?

A. Check his chart for intraoperative complications.

B. Check which medications were used for anesthesia.

C. Check the effectiveness of the analgesics he has received.

D. Check his preoperative assessment for previous delirium or dementia.

Answer 331

D. Check his preoperative assessment for previous delirium or dementia.

Chapter 19 Postoperative Care (10th Edition)
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Question 332

5. In caring for the postoperative patient on the clinical unit after transfer from the PACU, which care can be delegated to the unlicensed assistive personnel (UAP)?

A. Monitor the patient’s pain.

B. Do the admission vital signs.

C. Assist the patient to take deep breaths and cough.

D. Change the dressing when there is excess drainage.

Answer 332

C. Assist the patient to take deep breaths and cough.

Chapter 19 Postoperative Care (10th Edition)
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Question 333

1. A PATIENT WITH AN OPEN FRACTURE OF THE LEFT TIBIA AND SOFT TISSUE DAMAGE UNDERWENT A SURGICAL REDUCTION AND FIXATION OF THE TIBIA WITH DEBRIDEMENT OF NONVIABLE TISSUE AND DRAIN PLACEMENT. WHEN ASSESSING THE PATIENT DURING THE POSTOPERATIVE PERIOD, THE NURSE WILL BE MOST CONCERNED ABOUT

A. FEVER WITH CHILLS AND NIGHT SWEATS.

B. LIGHT YELLOW DRAINAGE FROM THE WOUND.

C. PAIN ON MOVEMENT OF THE AFFECTED LIMB.

D. MUSCLE SPASMS AROUND THE AFFECTED BONE.

Answer 333

A. FEVER WITH CHILLS AND NIGHT SWEATS.

Fever, chills, and night sweats are suggestive of osteomyelitis. The other clinical manifestations are typical after a fracture repair.

Chapter 63 Musculoskeletal Problems (10th Edition)
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Question 334

2. OSTEOARTHRITIS OCCURS AS A RESULT OF:

A. DEFICIENCY OF CALCIUM IN YOUNG PEOPLE.

B. GRADUAL DEGENERATION OF THE MOVABLE JOINTS,

C. DUE TO WEAR AND TEAR OF THE ARTICULAR CARTILAGE, WITH THE ADVANCING AGE.

D. LOW LEVELS OF ESTROGEN IN OLDER WOMEN.

Answer 334

D. LOW LEVELS OF ESTROGEN IN OLDER WOMEN.

Gradual degeneration of the movable joints, due to wear and tear of the articular cartilage, with the advancing age

Chapter 63 Musculoskeletal Problems (10th Edition)
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Question 335

3. A CLIENT WITH A TOTAL HIP REPLACEMENT REQUIRES SPECIAL EQUIPMENT. WHICH EQUIPMENT WOULD ASSIST THE CLIENT WITH A TOTAL HIP REPLACEMENT WITH ACTIVITIES OF DAILY LIVING?

A. HIGH-SEAT COMMODE

B. RECLINER

C. TENS UNIT

D. ABDUCTION PILLOW

Answer 335

A. HIGH-SEAT COMMODE

The equipment that can help with activities of daily living is the high-seat commode. The hip should be kept higher than the knee. Option B: The recliner is good because it prevents 90° flexion but not daily activities. Option C: A TENS (Transcutaneous Electrical Nerve Stimulation) unit helps with pain management. Option D: An abduction pillow is used to prevent adduction of the hip and possibly dislocation of the prosthesis.

Chapter 63 Musculoskeletal Problems (10th Edition)
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Question 336

4.WHAT ARE THE CLASSIFICATIONS OF OSTEOARTHRITIS?

A. IDIOPATHIC

B. PRIMARY

C. SECONDARY

D. ALL OF THE ABOVE

Answer 336

D. ALL OF THE ABOVE

The classifications of osteoarthritis include primary or idiopathic and secondary osteoarthritis. A: Idiopathic OA is also known as primary OA. B: Primary OA is also known as idiopathic OA. C: Secondary OA results from previous joint injury or inflammatory disease.

Chapter 63 Musculoskeletal Problems (10th Edition)
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Question 337

5. DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS) ARE USED TO TREAT RHEUMATOID ARTHRITIS. SELECT-ALL-THE DRUGS BELOW THAT ARE DMARDS:

A. DEXAMETHASONE (DECADRON)

B. HYDROXYCHLOROQUINE (PLAQUENIL)

C. TERIPARATIDE (FORTEO)

D. CALCITONIN

E. LEFLUNOMIDE (ARAVA)

F. METHOTREXATE (TREXALL)

Answer 337

B. HYDROXYCHLOROQUINE (PLAQUENIL)

E. LEFLUNOMIDE (ARAVA)

F. METHOTREXATE (TREXALL)

The answers are B, E, and F. These are DMARDs that can be prescribed for RA. Option A is a corticosteroid. Option C and D are sometimes prescribed in osteoporosis.

Chapter 63 Musculoskeletal Problems (10th Edition)
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Question 338

6. A PHYSICIAN SUSPECTS A PATIENT MAY HAVE RHEUMATOID ARTHRITIS DUE TO THE PATIENT’S PRESENTING SYMPTOMS. WHAT DIAGNOSTIC TESTING CAN BE ORDERED TO HELP A PHYSICIAN DIAGNOSE RHEUMATOID ARTHRITIS? SELECT ALL THAT APPLY:

A. RHEUMATOID FACTOR

B. URIC ACID LEVEL

C. ERYTHROCYTE SEDIMENTATION

D. DEXA-SCAN

E. X-RAY IMAGING

Answer 338

A. RHEUMATOID FACTOR

C. ERYTHROCYTE SEDIMENTATION

E. X-RAY IMAGING

The answers are A, C, and E. These are diagnostic tests to help diagnose RA. Option B is used in gout, and option D is used with osteoporosis.

Chapter 63 Musculoskeletal Problems (10th Edition)
Asbury’s PowerPoint Questions

Question 339

1. A client is 1 day postoperative after a total hip replacement. The client should be placed in which of the following position?

A. Supine

B. Semi Fowler’s

C. Orthopneic

D. Trendelenburg

Answer 339

B. Semi Fowler’s

Chapter 62 Musculoskeletal Trauma and Orthopedic Surgery (10th Edition)
Asbury’s PowerPoint Questions

Question 340

2. Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus?

A. Acute respiratory distress syndrome

B. Migraine like headaches

C. Numbness in the right leg

D. Muscle spasms in the right thigh

Answer 340

A. Acute respiratory distress syndrome

Chapter 62 Musculoskeletal Trauma and Orthopedic Surgery (10th Edition)
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Question 341

3. The client who had an open femoral fracture was discharged to her home, where she developed, fever, night sweats, chills, restlessness and restrictive movement of the fractured leg. The nurse interprets these finding as indicating which of the following?

A. Pulmonary emboli

B. Osteomyelitis

C. Fat emboli

D. Urinary tract infection

Answer 341

B. Osteomyelitis

Chapter 62 Musculoskeletal Trauma and Orthopedic Surgery (10th Edition)
Asbury’s PowerPoint Questions

Question 342

A client in the PACU with a left below the knee amputation complains of pain in her left big toe. Which of the following would the nurse do first?

A. Tell the client it is impossible to feel the pain

B. Show the client that the toes are not there

C. Explain to the client that the pain is real

D. Give the client the prescribed narcotic analgesic

Answer 342

D. Give the client the prescribed narcotic analgesic

Chapter 62 Musculoskeletal Trauma and Orthopedic Surgery (10th Edition)
Asbury’s PowerPoint Questions

Question 343

1. The nurse is caring for an older patient. What should the nurse realize is an expected age-related change in this patient’s musculoskeletal system?

A. Decreased bone mass and calcium absorption, which increase risk for fractures

B. Difficulty with dexterity after age 50

C. Vertebrae lengthening and thinning, which leads to increased bone production

D. Pain when ambulating due to increased bone mass and minerals

Answer 343

A. Decreased bone mass and calcium absorption, which increase risk for fractures

Normal aging is associated with a reduction in bone mass and calcium absorption. Bone production does not increase with aging. Pain with ambulation is not associated with increased bone mass. Difficulty with dexterity is not necessarily a usual occurrence after age 50.

Chapter 61 Musculoskeletal System (10th Edition)
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Question 344

2. A patient is scheduled for a bone scan. For which health problem should the nurse suspect this test is being used to diagnose?

A. A muscle mass near the bone

B. Bone cancer

C. Normal calcium level

D. New onset pain in the area of the bone

Answer 344

B. Bone cancer

Bone scans show increased uptake of the radioisotope in bone cancer. The bone scan would do little to provide a definite analysis of a muscle mass. New onset bone pain would require other initial evaluation studies. A bone scan is not indicated to diagnose a normal calcium level.

Chapter 61 Musculoskeletal System (10th Edition)
Asbury’s PowerPoint Questions

Question 345

3. The height of a female patient has decreased 1 inch over the last year. The patient is concerned and asks the nurse, “What is happening to me?” How should the nurse respond to the patient?

A. “There is no need to worry; you only lost 1 inch since last year. You probably won’t lose much more than that.”

B. “Everybody gets shorter as they get older.”

C. “There could be something wrong, so you should discuss it with your physician.”

D. “There can be several causes for the loss of height, but as we age, bone mass decreases and the spinal column shortens.”

Answer 345

C. “There could be something wrong, so you should discuss it with your physician.”

With aging, the spinal column shortens and height decreases. Telling the patient that everyone gets shorter as they get older is a nontherapeutic answer to the concern that the patient has and does not address the concern. The second answer dismisses the patient’s concern and predicts a height loss that may not be accurate. The fourth answer also dismisses the patient’s concern and does not give the nurse the opportunity to educate the patient.

Chapter 61 Musculoskeletal System (10th Edition)
Asbury’s PowerPoint Questions

Question 346

4. A 62-year-old female patient is scheduled to have a DEXA exam. What should the nurse consider as most likely the reason the test has been ordered for this patient?

A. to check for fractures

B. to screen for osteomyelitis

C. to check the degree of osteoporosis

D. to evaluate bone cancer

Answer 346

C. to check the degree of osteoporosis

The bone density exam (DEXA) evaluates bone mineral density and the degree of osteoporosis. X-rays would be used to assess for the presence of fractures. Bone scans would be used in the evaluation of osteomyelitis and potential bone cancer.

Chapter 61 Musculoskeletal System (10th Edition)
Asbury’s PowerPoint Questions

Question 347

1. The nurse is caring for a 74-year-old woman. What would be a normal age-related finding?
   a. Kyphosis
   b. Back pain
   c. Loss of height
   d. Spinal crepitation

Answer 347

Orthopedics

Asbury’s PowerPoint Questions

Question 348

2. Which patient would be at greatest risk for developing osteoporosis?
   a. A 73-year-old man who has five alcoholic drinks per week and limits sun exposure to prevent recurrence of skin cancer.
   b. An 84-year-old man who has recently been diagnosed with hypothyroidism and is prescribed levothyroxine (Synthroid).
   c. A 69-year-old woman who had a renal transplant 5 years ago and has been taking prednisone to prevent organ rejection.
   d. A 55-year-old woman who recently had a hysterectomy with bilateral salpingo-oophorectomy and refuses estrogen therapy.

Answer 348

Orthopedics

Asbury’s PowerPoint Questions

Question 349

1. THE NURSE IS CARING FOR A CLIENT FOLLOWING A BILLROTH II PROCEDURE. ON REVIEW OF THE POST-OPERATIVE ORDERS, WHICH OF THE FOLLOWING, IF PRESCRIBED, WOULD THE NURSE QUESTION AND VERIFY?

A. IRRIGATING THE NASOGASTRIC TUBE

B. COUGHING A DEEP BREATHING EXERCISES

C. LEG EXERCISES

D. EARLY AMBULATION

Answer 349

A. IRRIGATING THE NASOGASTRIC TUBE

In a Billroth II procedure the proximal remnant of the stomach is anastomased to the proximal jejunum. Patency of the NG tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically ordered by the physician. In this situation, the nurse would clarify the order.

Chapter 41 from PowerPoints: Esophageal Cancer and Peptic Ulcer Disease
Asbury’s PowerPoint Questions

Question 350

2. THE CLIENT WITH PEPTIC ULCER DISEASE IS SCHEDULED FOR A PYLOROPLASTY. THE CLIENT ASKS THE NURSE ABOUT THE PROCEDURE. THE NURSE PLANS TO RESPOND KNOWING THAT A PYLOROPLASTY INVOLVES:

A. CUTTING THE VAGUS NERVE

B. REMOVING THE DISTAL PORTION OF THE STOMACH

C. REMOVAL OF THE ULCER AND A LARGE PORTION OF THE CELLS THAT PRODUCE HYDROCHLORIC ACID

D. AN INCISION AND RE-SUTURING OF THE PYLORUS TO RELAX THE MUSCLE AND ENLARGE THE OPENING FROM THE STOMACH TO THE DUODENUM

Answer 350

D. AN INCISION AND RE-SUTURING OF THE PYLORUS TO RELAX THE MUSCLE AND ENLARGE THE OPENING FROM THE STOMACH TO THE DUODENUM

D describes the procedure for a pyloroplasty. A vagotomy involves cutting the vagus nerve. A subtotal gastrectomy involves removing the distal portion of the stomach. A Billroth II procedure involves removal of the ulcer and a large portion of the tissue that produces hydrochloric acid.

Chapter 41 from PowerPoints: Esophageal Cancer and Peptic Ulcer Disease
Asbury’s PowerPoint Questions

Question 351

3. WHILE CARING FOR A CLIENT WITH PEPTIC ULCER DISEASE, THE CLIENT REPORTS THAT HE HAS BEEN NAUSEATED MOST OF THE DAY AND IS NOW FEELING LIGHTHEADED AND DIZZY. BASED UPON THESE FINDINGS, WHICH NURSING ACTIONS WOULD BE MOST APPROPRIATE FOR THE NURSE TO TAKE? SELECT ALL THAT APPLY.

A. ADMINISTERING AN ANTACID HOURLY UNTIL NAUSEA SUBSIDES.

B. MONITORING THE CLIENT’S VITAL SIGNS

C. NOTIFYING THE PHYSICIAN OF THE CLIENT’S SYMPTOMS

D. INITIATING OXYGEN THERAPY

E. REASSESSING THE CLIENT ON AN HOUR

Answer 351

B. MONITORING THE CLIENT’S VITAL SIGNS

C. NOTIFYING THE PHYSICIAN OF THE CLIENT’S SYMPTOMS

D. INITIATING OXYGEN THERAPY

The symptoms of nausea and dizziness in a client with peptic ulcer disease may be indicative of hemorrhage and should not be ignored. The appropriate nursing actions at this time are for the nurse to monitor the client’s vital signs and notify the physician of the client’s symptoms. To administer an antacid hourly or to wait one hour to reassess the client would be inappropriate; prompt intervention is essential in a client who is potentially experiencing a gastrointestinal hemorrhage. The nurse would notify the physician of assessment findings and then initiate oxygen therapy if ordered by the physician.

Chapter 41 from PowerPoints: Esophageal Cancer and Peptic Ulcer Disease
Asbury’s PowerPoint Questions

Question 352

4. THE CLIENT BEING TREATED FOR ESOPHAGEAL VARICES HAS A SENGSTAKEN-BLAKEMORE TUBE INSERTED TO CONTROL THE BLEEDING. THE MOST IMPORTANT ASSESSMENT IS FOR THE NURSE TO:

A. CHECK THAT THE HEMOSTAT IS ON THE BEDSIDE

B. MONITOR IV FLUIDS FOR THE SHIFT

C. REGULARLY ASSESS RESPIRATORY STATUS

D. CHECK THAT THE BALLOON IS DEFLATED ON A REGULAR BASIS

Answer 352

D. CHECK THAT THE BALLOON IS DEFLATED ON A REGULAR BASIS

The respiratory system can become occluded if the balloon slips and moves up the esophagus, putting pressure on the trachea. This would result in respiratory distress and should be assessed frequently. Scissors should be kept at the bedside to cut the tube if distress occurs. This is a safety intervention.

Chapter 41 from PowerPoints: Esophageal Cancer and Peptic Ulcer Disease
Asbury’s PowerPoint Questions

Question 353

1. The nurse discovers scabies when assessing a client who has just been transferred to the medical-surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse should:

A. Wash hands, apply a pediculicide to the client’s scalp, and remove any observable mites.

B. Isolate the client’s bed linens until the client is no longer infectious.

C. Notify the nurse in the day surgery unit of a potential scabies outbreak.

D. Place the client on enteric precautions.

Answer 353

To prevent the spread of scabies in other hospitalized clients, the nurse should isolate the client’s bed linens until the client is no longer infectious — usually 24 hours after treatment begins. Other required precautions include using good hand-washing technique and wearing gloves when applying the pediculicide and during all contact with the client. Although the nurse should notify the nurse in the day surgery unit of the client’s condition, a scabies epidemic is unlikely because scabies is spread through skin or sexual contact. This client doesn’t require enteric precautions because the mites aren’t found on feces.

Ch 23 & 24 Integumentary System
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Question 354

2. The nurse prepares to care for a male client with acute cellulites of the lower leg. The nurse anticipates that which of the following will be prescribed for the client?

A. Cold compress to the affected area

B. Warm compress to the affected area

C. Intermittent heat lamp treatments four times daily

D. Alternating hot and cold compresses continuously

Answer 354

B. Warm compress to the affected area

Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and alternating cold and hot compresses are not the best measures.

Ch 23 & 24 Integumentary System
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Question 355

3. The nurse is reviewing the healthcare record of a male clients scheduled to be seen at the health care clinic. The nurse determines that which of the following individuals is at the greatest risk for development of an integumentary disorder?

A. An adolescent

B. An older female

C. A physical education teacher

D. An outdoor construction worker

Answer 355

D. An outdoor construction worker

Prolonged exposure to the sun, unusual cold, or other conditions can damage the skin. The outdoor construction worker would fit into a high-risk category for the development of an integumentary disorder. An adolescent may be prone to the development of acne, but this does not occur in all adolescents. Immobility and lack of nutrition would increase the older person’s risk but the older client is not at as high a risk as the outdoor construction worker. The physical education teacher is at low or no risk of developing an integumentary problem.

Ch 23 & 24 Integumentary System
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