Ch. 41- Study Guide

Question 1

4. The patient reports, “I ran into the coffee table and bruised my shin.” Which sample of documentation best reflects the nurse’s knowledge of anatomy and medical terminology?

a. “Skin damage noted on the right lower leg in the shin area.”
b. “Patient reports running into coffee table and bruising shin.”
c. “Moderate bruising noted on the patient’s right leg just below knee.
d. “4-cm ecchymosis on mid-anterior of right tibia-fibula.”

Answer 1

d. “4-cm ecchymosis on mid anterior of right tibia fibula.”

Question 2

5. Which transport process allows water and solutes to move through the kidney to form urine?

a. Diffusion
b. Filtration
c. Osmosis
d. lon pump

Answer 2

b. Filtration

Question 3

6. A neglected infant sustained a superficial sunburn on the dorsal body surface. Which instructions would the nurse give to the unlicensed assistive personnel (UAP)?

a. “You will see a thin film of cream on the baby’s perineal area.”
b. “If you see peeling or blistering on the front of the chest, let me know.”
c. “Use tepid water and gently wash the baby’s back and pat dry.”
d. “The baby’s face and the top of his head may appear red and flaky.”

Answer 3

c. “Use tepid water and gently wash the baby’s back and pat dry.”

Question 4

7. The nurse is checking a patient’s peripheral pulses. Which pulse is the most distal in the lower extremities?

a. Dorsalis pedis
b. Popliteal
c. Posterior tibial
d. Femoral

Answer 4

a. Dorsalis pedis

Question 5

8. Which anatomic structure is in the medial portion of the chest?

a. Lungs
b. Heart
c. Sternum
d. Clavicles

Answer 5

c. Sternum

Question 6

9. Which part of the cell has distinct surface proteins that play an important role in tissue typing to determine compatibility for organ transplant?

a. Protoplasm
b. Nucleus
c. Cytoplasm
d. Plasma membrane

Answer 6

d. Plasma membrane

Question 7

10. One type of cell in the body relies on the action of the ion pump to move nearly all calcium ions to special compartments or out of the cell. Which body function is most affected by this process?

a. Muscle contraction
b. Digestion of food
c. Infection control measures
d. Secretion of hormones

Answer 7

a. Muscle contraction

Question 8

11. The health care provider (HCP) tells the nurse that the patient has a hematopoietic disorder. Which laboratory result would the nurse expect to see?

a. Decreased potassium
b. Decreased red blood cell count
c. Increased glucose
d. Increased blood urea nitrogen

Answer 8

b. Decreased red blood cell count

Question 9

12. For a patient with a history of splenectomy, which topic is the nurse most likely to review to ensure that the patient has a good understanding of the self-care related to loss of the spleen?

a. Blood glucose monitoring
b. Dietary sources of fiber
c. Protection against infection
d. Fall prevention

Answer 9

c. Protection against infection

Question 10

13. The patient reports pain in the right upper abdomen just inferior to the ribs. Based on the nurse’s knowledge of anatomy, which organ is most likely to be contributing to the patient’s discomfort?

a. Small intestine
b. Spleen
c. Gallbladder
d. Cecum

Answer 10

c. Gallbladder

Question 11

14. The nurse suspects that the patient has urinary retention and must assess for bladder distention. Which region of the patient’s abdomen will the nurse palpate?

a. Umbilical region
b. Hypogastric region
c. Right hypochondriac region
d. Left iliac region

Answer 11

b. Hypogastric region

Question 12

15. The patient has a stomach ulcer. Based on knowledge of anatomy, the nurse recognizes that the patient is likely to report pain or discomfort in which region of the abdomen?

a. Epigastric region
b. Right iliac region
c. Left lumbar region
d. Hypogastric region

Answer 12

a. Epigastric region

Question 13

16. The patient is diagnosed with appendicitis. The HCP orders ice to the abdomen pending emergency surgery. Where will the nurse place the prepared ice bag?

a. Left lower quadrant
b. Right lower quadrant
c. Left upper quadrant
d. Right upper quadrant

Answer 13

b. Right lower quadrant

Question 14

17. In the case of bowel obstruction, which condition is most likely to cause the first episodes of vomiting if the patient is consuming solid foods?

a. Distal large intestine obstruction
b. Proximal large intestine obstruction
c. Distal small intestine obstruction
d. Proximal small intestine obstruction

Answer 14

d. Proximal small intestine obstruction

Question 15

18. The patient sustains injury to the epidermis. Which problem will the nurse anticipate and try to prevent?

a. Risk for infection
b. Loss of strength
c. Decreased secretion of mucus
d. Loss of insulation

Answer 15

a. Risk for infection

Question 16

19. The patient who is comatose displays continuous open-mouthed breathing, which causes drying of the mucous membranes. What is the most important rationale for ensuring good oral hygiene for this patient?

a. Preserve patient’s dignity.
b. Lubricate food for digestion.
c. Prevent respiratory infection.
d. Maintain condition of teeth.

Answer 16

c. Prevent respiratory infection.

Question 17

20. The patient tells the nurse that he has a history of bursitis. Which focused assessment is the nurse most likely to perform that relates to this information?

a. Auscultate the bowel sounds and palpate the abdomen.
b. Auscultate the lung sounds and watch respiratory effort.
c. Put joints through range of motion and ask about discomfort.
d. Ask patient to balance on right leg and then on left leg.

Answer 17

c. Put joints through range of motion and ask about discomfort.

Question 18

21. The cell structures known as flagella are important for which body function?

a. Digestion
b. Circulation
c. Reproduction
d. Respiration

Answer 18

c. Reproduction

Question 19

22. Which patient is most likely to benefit from biofeedback as a self-care management technique?

a. Has difficulty communicating needs because of brain damage
b. Has an elevated temperature secondary to an infection
c. Has pain in the right lateral ankle during weight- bearing
d. Has occasional asthma attacks with labored respiration

Answer 19

d. Has occasional asthma attacks with labored respiration

Question 20

23. A frail older patient had a prolonged illness and now has minimal adipose tissue. Which member of the health care team would be best to help restore the reserve tissue?

a. Dietitian
b. Physical therapist
c. Nurse practitioner
d. Blood bank technician

Answer 20

a. Dietitian

Question 21

24. The patient is bedridden and needs assistance. Documentation with date and nurse’s signature includes: 10:00 Assisted into a right lateral side-lying position; 12:00 Assisted into supine position; 14:00 Assisted into left lateral side-lying position. What is the best rationale for this type of documentation?

a. Documentation shows that needs were met and the goal was achieved.
b. Documentation reflects actions taken to prevent complications of immobility.
c. Nurse is following standard documentation guidelines.
d. Nurse is demonstrating a professional knowledge of terminology.

Answer 21

b. Documentation reflects actions taken to prevent complications of immobility.