CHAPTER REVIEW QUESTIONS

Question 1

1. Which of the following is an example of a nursing activity that reflects the Canadian Nurses Association’s definition of nursing?
   a. Establishing that the client with jaundice has hepatitis
   b. Determining the cause of hemorrhage in a postoperative client based on vital signs
   c. Identifying and treating dysrhythmias that occur in a client in the coronary care unit
   d. Diagnosing that a client with pneumonia cannot effect- ively cough up pulmonary secretions

Answer 1

d

Question 2

2. Which of the following is most appropriate to demonstrate the nurse’s implementation of evidence-informed practice?
   a. Requires the use of clinical practice guidelines developed
   by national health agencies
   b. Uses only findings from randomized clinical trials to plan
   care for all client problems
   c. Uses clinical decision making and judgement to determine
   what evidence is appropriate for a specific clinical situation
   d. Statistically analyzes the relationship of nursing interven- tions to client outcomes to establish evidence that inter-
   ventions are appropriate for the client

Answer 2

c

Question 3

3. How do standardized nursing care plans benefit client care?
   a. Client problems and nursing care are clearly defined
   b. Nurses use the same terminology as physicians in delivery
   of client care
   c. A consistent, universal format is used to assess client
   responses to health problems
   d. Established prescriptions for nursing care eliminate the
   need for time-consuming nursing care planning

Answer 3

a

Question 4

4. When the nurse determines that the client’s anxiety must be relieved before effective teaching can be implemented, which
   phase of the nursing process is being used?
   a. Assessment
   b. Diagnosis
   c. Planning
   d. Evaluation

Answer 4

c

Question 5

5. Which of the following is an example of an independent nursing intervention?
   a. Administering blood infusion
   b. Starting an intravenous fluid
   c. Teaching a client about the effects of prescribed drugs
   d. Administering emergency drugs according to institutional
   protocols

Answer 5

c

Question 6

6. What does the diagnostic process involve that is different from the process of making a nursing diagnosis?
   a. Stating what needs the client has
   b. Identifying factors related to the pathology of a disease
   process
   c. Identifying the diagnosis, related factors, and signs and
   symptoms
   d. Analyzing assessment data to identify responses to health
   problems

Answer 6

b

Question 7

7. The nurse identifies the nursing diagnosis of constipation relatedto laxative misuse for a client. What is the most appropriate expected client outcome related to this nursing diagnosis?
   a. Theclientwillstoptheuseoflaxatives.
   b. The client ingests adequate fluid and fibre.
   c. The client passes normal stools without aids.
   d. The client’s stool is free of blood and mucus.

Answer 7

c

Question 8

A client has a nursing diagnosis of stress urinary incontinence related to overdistension between voidings. Which of the fol- lowing is an appropriate nursing intervention for this client related to this nursing diagnosis?
a. Provide privacy for toileting.
b. Monitor colour, odour, and clarity of urine.
c. Teach the client to void at 2-hour intervals.
d. Provide the client with perineal pads to absorb urine
leakage.

Answer 8

c

Question 9

What is the primary purpose of the evaluation phase of the nursing process?

a. Assess the client’s strengths.
b. Describe new nursing diagnoses.
c. Implement new nursing strategies.
d. Identify client progress toward outcomes.

Answer 9

d

Question 10

1. What is the most common cause of death, both globally and in Canada?
   a. Cancer
   b. Cardiovascular disease
   c. Respiratory disease
   d. Community-acquired pneumonia

Answer 10

b

Question 11

2. The nurse is working with Brian, a 35-year-old with recently
   diagnosed type 2 diabetes. Which of the following statements by Brian would suggest to the nurse that he understands the nature of chronic illness?
   a. “It’s too bad I ate so many sweets as a kid. I wouldn’t have
   diabetes now if I didn’t have a sweet tooth.”
   b. “Once I start my medication, I won’t have to worry about my diabetes.”
   c. “I guess that I won’t be able to live the same way I used to.” d. “I know if I take care of myself, I won’t run into any com-
   plications from diabetes when I’m older.”

Answer 11

c

Question 12

3. Which of the following are modifiable risk factors for developing chronic illness?
   a. Activity level and sex
   b. Age and genetic background
   c. Air pollution and occupation
   d. Smoking and weight

Answer 12

d

Question 13

5. Marilee is a 47-year-old woman who has been living with COPD for 5 years. Which of the following statements reflects her efficacy expectancy?
   a. “I only have this disease because I worked in an autobody
   shop for years and was exposed to toxic fumes.”
   b. “I know I can’t quit smoking. I’ve tried too many times in
   the past 5 years.”
   c. “My mother quit smoking and she still died from lung
   disease.”
   d. “It’s too late to quit smoking now, so what’s the point of
   trying?”

Answer 13

b

Question 14

6. In which of the following situations might caregiver burden
   be most likely to occur?
   a. A husband who must administer medications to his cogni-
   tively impaired wife
   b. A daughter who must empty her mother’s drains following
   a mastectomy
   c. A wife with heart failure who must assist her husband to
   the toilet following a cerebrovascular accident
   d. A neighbour who prepares meals for a client recently dis-
   charged from hospital following cataract surgery

Answer 14

c

Question 15

7. Heather has had multiple sclerosis for the last 2 years and is admitted to hospital to manage symptoms of an exacerba- tion. According to the illness trajectory model, which phase of chronic illness would she be in?
   a. Trajectory onset
   b. Unstable
   c. Acute
   d. Crisis

Answer 15

c

Question 16

8. Genevieve, a 53-year-old woman with fibromyalgia, happily reports to the nurse that she has followed her prescribed exer- cise program for the past month. What would this behaviour be an example of?
   a. Compliance
   b. Adherence
   c. Self-management
   d. Chronic care

Answer 16

b

Question 17

1. Which of the following surgical procedures involves removal of a body organ?
   a. Colostomy
   b. Laparotomy
   c. Mammoplasty
   d. Cholecystectomy

Answer 17

d

Question 18

2. Which of the following is one of the most important goals of
   the preoperative assessment by the nurse?
   a. Determine if the client’s psychological stress is too high to undergo surgery.
   b. Identify what information the client needs to understand
   before surgery.
   c. Establish baseline data for comparison of the client’s status
   in the intraoperative and postoperative periods.
   d. Determine whether the client’s surgery should be done on an inpatient, an outpatient, or a same-day admission
   basis.

Answer 18

c

Question 19

3. A client who is scheduled for a hysterectomy reports using Ginkgo biloba to improve her memory. Which of the following questions is the most important for the perioperative nurse to ask the client?
   a. “How long have you used Ginkgobiloba?”
   b. “How have you been able to tell if this herb is effective?”
   c. “Have you been taking this herb during the last several weeks?”
   d. “Have you experienced any side effects of taking this herbal product?”

Answer 19

c

Question 20

4. What is the nurse’s role when assisting a client with informed consent prior to an operative procedure?
   a. Obtains the consent when a surgeon cannot
   b. Makes the client sign the consent form before the surgical procedure
   c. Explains all the risks of the surgical procedure
   d. Ensures that the client signs the consent form before preoperative sedation is given

Answer 20

b

Question 21

5. What is a priority nursing intervention that will assist a client about to undergo surgery in coping with fear of pain?
   a. Describe the degree of pain expected.
   b. Explain the availability of pain medication.
   c. Divert the client when talking about pain.
   d. Inform the client of the frequency of pain medication.

Answer 21

a

Question 22

6. What is the last nursing intervention that should be performed before a client is transported to the operating room?
   a. Ask client to void in the bathroom.
   b. Check chart for signed consent form.
   c. Administer preanaesthetic medications.
   d. Lock up the client’s jewellery and money.

Answer 22

a

Question 23

7. What should the nurse administering preoperative medications recognize before administering the medication?
   a. Preoperative medications may help reduce anaesthetic requirements.
   b. Intravenous medications can be administered only by an anaesthesiologist on the day of surgery.
   c. A preoperative diazepam (Valium) tablet should be administered within 15 minutes of scheduled surgery.
   d. An intramuscular injection of secobarbital (Seconal) should be administered 2 hours before the scheduled surgery.

Answer 23

d

Question 24

8. What is a primary consideration in the instruction of the older client about to undergo surgery?
   a. Using large-print material
   b. Teaching early in the morning
   c. Standing very close to aid communication
   d. Recognizing that cognitive function may be decreased

Answer 24

d

Question 25

1. What is the proper attire for the semirestricted area of the surgery department?
   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 25

b

Question 26

2. What is one characteristic of the operating room environment that facilitates the prevention of infection in the surgical client?
   a. Adjustable lighting
   b. Conductive furniture
   c. Filters in the ventilating system
   d. Explosion-proof electrical plugs

Answer 26

c

Question 27

3. What is one activity that is carried out by nurses performing both sterile and nonsterile activities in the operating room?
   a. Checking electrical equipment
   b. Passing instruments to the surgeon and assistants
   c. Coordinating activities occurring in the operating room
   d. Assisting anaesthesiologist with monitoring of client during surgery

Answer 27

c

Question 28

4. What is the most important intervention to perform when a client arrives to the OR with musculoskeletal impairments?
   a. Ensure proper preparation of the skin.
   b. Ensure the anaesthesiologist uses muscle relaxants.
   c. Ensure positioning on the operating room bed to prevent injury.
   d. Provide detailed explanations about the surgical activities.

Answer 28

c

Question 29

5. What is the perioperative nurse’s primary responsibility for the care of the client undergoing surgery?
   a. Developing an individualized plan of nursing care for the client
   b. Carrying out specific tasks related to surgical policies and procedures
   c. Ensuring that the client has been assessed for safe administration of anaesthesia
   d. Performing a preoperative history and physical assessment to identify client needs

Answer 29

a

Question 30

6. What should the members of the surgical team ensure when scrubbing at the scrub sink?
   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 30

d

Question 31

7. Which of the following is acceptable when positioning the surgical client?
   a. Provision of modesty for the client
   b. Avoiding compression of nerve tissue
   c. Provision of correct skeletal alignment
   d. Ensuring that students in the room can see the operative site

Answer 31

c

Question 32

8. Mrs. Jones is scheduled for an abdominal hysterectomy. She is extremely anxious and has a tendency to hyperventilate when upset. What is the most appropriate type of anaesthetic for Mrs. Jones?
   a. A spinal block
   b. An epidural block
   c. A general anaesthetic
   d. A dissociative anaesthetic

Answer 32

c

Question 33

9. Why is intravenous induction for general anaesthesia the method of choice for most clients?
   a. The client is not intubated.
   b. The agents are nonexplosive.
   c. Induction is rapid and pleasant.
   d. The odour of the agent is not offensive.

Answer 33

c

Question 34

10. What is the name for the injection of the local anaesthetic into the tissues through the surgical incision?
    a. Nerve block
    b. Local infiltration
    c. Topical application
    d. Regional application

Answer 34

b

Question 35

1. What is the priority assessment by the nurse as soon as the client enters the PACU?
   a. Urinary output
   b. ECG monitoring
   c. Level of consciousness
   d. Airway patency and respiratory status

Answer 35

d

Question 36

2. Which of the following nursing interventions is indicated
   during the client’s recovery from general anaesthesia in the PACU?
   a. Placingtheclientinaproneposition
   b. Encouraging deep breathing and coughing
   c. Restraining clients during episodes of emergence delirium
   d. Withholding analgesics until the client is discharged from
   PACU

Answer 36

b

Question 37

3. Which of the following clients is at greatest risk for postopera-
   tive nausea and vomiting?
   a. A 14-year-old, 40-kg boy following an orchiopexy under
   general anaesthesia
   b. An81-year-old,55-kg woman following a cystoscopy under local anaesthesia
   c. A 45-year-old, 70-kg man following an arthroscopy under
   epidural anaesthesia
   d. A 23-year-old, 125-kg woman following a diagnostic laparoscopy under general anaesthesia

Answer 37

d

Question 38

4. Following admission of the client to the clinical unit post- operatively, which of the following pieces of assessment data requires the most immediate attention?
   a. Oxygen saturation of 80%
   b. Respiratory rate of 13/min
   c. Blood pressure of 90/60 mm Hg
   d. Temperature of 94.3°F

Answer 38

a

Question 39

5. Which of the following urine outputs would be a concern for a nurse’s care for a client on his first postoperative day?
   a. 1500mL
   b. 1000 mL
   c. 500 mL
   d. 2000 mL

Answer 39

c

Question 40

6. What is the priority information the nurse should advise the
   client of in preparation for discharge after surgery?
   a. A time frame for when various physical activities can be
   resumed
   b. The rationale for abstinence from sexual intercourse for 4
   to 6 weeks
   c. The need to call hospital clinical unit to report any abnor-
   mal signs or symptoms
   d. The necessity of a referral to nutritional centre for management of dietary restrictions

Answer 40

c

Question 41

1. How is pain best described?
   a. A creation of a person’s imagination
   b. An unpleasant, subjective experience
   c. A maladaptive response to a stimulus
   d. A neurological event resulting from activation of nociceptors

Answer 41

b

Question 42

2. Which of the following inhibiting neurotransmitters is known for its involvement in pain modulation?
   a. Dopamine
   b. Acetylcholine
   c. Prostaglandin
   d. Norepinephrine

Answer 42

d

Question 43

3. Which of the folloing words is most likely to be used to describe neuropathic pain?
   a. Dull
   b. Mild
   c. Aching
   d. Burning

Answer 43

d

Question 44

4. Which of the following is true of unrelieved pain?
   a. It is to be expected after major surgery.
   b. It is to be expected in a person with cancer.
   c. It is dangerous and can lead to many physical and psychological complications.
   d. It is an annoying sensation, but it is not as important as other physical care needs.

Answer 44

c

Question 45

5. Which of the following is a critical step in the pain assessment process?
   a. Assessment of critical sensory components
   b. Teaching the client about pain therapies
   c. Conducting a comprehensive pain assessment
   d. Provision of appropriate treatment and evaluation of its effect

Answer 45

c

Question 46

6. Which of the following is an example of distraction to provide pain relief?
   a. TENS
   b. Music
   c. Exercise
   d. Biofeedback

Answer 46

b

Question 47

7. Which of the following is an appropriate nonopioid analgesic for mild pain?
   a. Oxycodone (Percocet)
   b. Ibuprofen (Advil)
   c. Lorazepam (Ativan)
   d. Cyclobenzaprine (Flexeril)

Answer 47

b

Question 48

8. Which of the following is an important nursing responsibility related to pain?
   a. Encourage the client to stay in bed.
   b. Help the client appear to not be in pain.
   c. Believe what the client says about the pain.
   d. Assume responsibility for eliminating the client’s pain.

Answer 48

c

Question 49

9. A nurse is administering a prescribed dose of an IV opioid titrated for a person with severe pain related to a terminal illness. Which of the following actions is reflective of this practice?
   a. Euthanasia
   b. Assisted suicide
   c. Enabling the client’s addiction
   d. Palliative pain management

Answer 49

d

Question 50

10. A nurse believes that clients with the same type of tissue injury should have the same amount of pain. Which of the following statements best describes this belief?
    a. It will contribute to appropriate pain management.
    b. It is an accurate statement about pain mechanisms and an expected goal of pain therapy.
    c. The nurse’s belief will have no effect on the type of care provided to people in pain.
    d. It is a common misconception about pain, and a major contributor to ineffective pain management.

Answer 50

d

Question 51

1. In which context is physiological hyperplasia commonly found?
   a. Adistendedurinarybladder
   b. The female breast during lactation
   c. The bronchi of a chronic cigarette smoker
   d. An enlarged myocardium in heart failure

Answer 51

b

Question 52

4. Which of the following will be experienced by a client with an impaired mononuclear phagocyte system?
   a. Increased circulation of histamine
   b. Decreased susceptibility to infection
   c. Decreased vascular response to cellinjury
   d. Decreased surveillance for damaged or mutated cells

Answer 52

d

Question 53

5. Which response of the inflammatory process is affected by the complement system during opsonization?
   a. Healing
   b. Cellular
   c. Vascular
   d. Formation of exudate

Answer 53

b

Question 54

6. Which of the following is the most likely cause of fever that
   accompanies inflammation?
   a. Activation of the complement system
   c. Increased production and activity of neutrophils d. Massive vasodilation during the vascular response

Answer 54

b

Question 55

7. A client has an open, infected surgical wound that is treated with irrigations and moist gauze dressings. Which of the fol- lowing should the nurse expect of this wound?
   a. Is classified as a black wound
   b. Has to heal by tertiary intention
   c. Heals by regeneration of epithelial cells
   d. Heals by the same processes as an uninfected deep wound

Answer 55

d

Question 56

8. Why do contractures frequently occur after burn healing?
   a. Secondary infection
   b. Lack of adequate blood supply
   c. Weakness of connective tissue
   d. Excess fibrous tissue formation

Answer 56

d

Question 57

9. Why are rest and immobilization important measures of acute
   care for wound healing?
   a. They decrease the inflammatory response.
   b. They increase the circulation to the affected area.
   c. Theyincreasethebody’sproductionofcorticosteroids.
   d. They are mechanisms known to increase cytokine
   production.

Answer 57

a

Question 58

10. An 85-year-old client is assessed to have a score of 15 on the Braden scale. What does this score suggest?
    a. The client has an existing stage I pressure ulcer.
    b. The client is at risk for developing a pressure ulcer.
    c. The client is in need of a daily pressure ulcer risk assessment.
    d. The client is not at risk for developing a pressure ulcer at
    this time.

Answer 58

b

Question 59

11. A 65-year-old client who had a stroke and is confined to bed is
    assessed to be at risk for the development of a pressure ulcer. Based on this information, which of the following should the nurse implement?
    a. Beginaq2hturningschedule.
    b. Have the client maintain a high-fat diet.

d. Vigorously massage reddened bony prominences daily.

Answer 59

a

Question 60

12. An 82-year-old man who is being cared for at home by his family has a pressure ulcer that is 1 cm wide by 2 cm long. The wound is shallow, measuring 0.5 cm in depth, and pink tis- sue is completely visible on the wound bed. What stage is this pressure ulcer?
    a. StageI b. Stage II c. StageIII d. Stage IV

Answer 60

b

Question 61

13. Which one of the following orders should a nurse question as part of the plan of care for a client with a stage III pressure ulcer?
    a. Pack the ulcer with foam dressing.
    b. Turn and position the client every 2 hours.
    c. Clean the ulcer every shift with Dakin’s solution.
    d. Assess for pain and medicate before dressing change.

Answer 61

c

Question 62

1. How is shock best defined?
   a. Cardiovascular collapse
   b. Loss of sympathetic tone
   c. Inadequate tissue perfusion
   d. Blood pressure less than 90 mm Hg systolic

Answer 62

c

Question 63

2. A client has a spinal cord injury at T4. Vital signs include a falling blood pressure with bradycardia. What type of shock is the client likely experiencing?
   a. A relative hypervolemia
   b. An absolute hypovolemia
   c. Neurogenic shock from low blood flow
   d. Neurogenic shock from a maldistribution of blood flow

Answer 63

d

Question 64

3. What early effect does shock have on the body?
   a. Sympathetic nervous system activation that results in stimulation of adrenergic receptors
   b. Massive vasoconstriction in the heart and brain that causes stimulation of the renin–angiotensin system
   c. Decreased tissue perfusion that results in aerobic metabolism, leading to the development of lactic acidosis
   d. Heart rate that is usually slow and irregular in the compensatory stage because of parasympathetic nervous stimulation

Answer 64

a

Question 65

4. A 78-year-old man has confusion and temperature of 40°C. He is a diabetic and has purulent drainage from his right great toe. His assessment findings are BP 84/40 mm Hg; heart rate 110; respiratory rate 42 and shallow; CO 8 L/min; and PAOP 4 mm Hg. What is this client likely experiencing?
   a. Sepsis
   b. Septic shock
   c. Multiple organ dysfunction syndrome
   d. Systemic inflammatory response syndrome

Answer 65

b

Question 66

5. What treatment modalities would be included in the management of cardiogenic shock?
   a. Dobutamine to increase myocardial contractility
   b. Vasopressors to increase systemic vascular resistance
   c. Corticosteroids to stabilize the cell wall in the infarcted myocardium
   d. Plasma volume expanders such as albumin to decrease an elevated preload

Answer 66

a

Question 67

6. What are the most accurate assessment parameters for the nurse to use to determine adequate tissue perfusion in the client with MODS?
   a. Blood pressure, pulse, and respirations
   b. Breath sounds, blood pressure, and body temperature
   c. Pulse pressure, level of consciousness, and pupillary response
   d. Level of consciousness, urine output, and skin colour and temperature

Answer 67

d

Question 68

When the nurse encourages a patient with heart failure to alternate rest and activity periods to reduce cardiac workload, the phase of the nursing process being used is

a) Planning.
b) Diagnosis.
c) Evaluation.
d) Implementation.

Answer 68

d

Carrying out the specific, individualized plan constitutes the implementation phase of the nursing process. The nurse’s action of encouragement and instruction to the patient is part of carrying out a plan of action.

Question 69

When planning care for a patient, the nurse may use a visual diagram of patient problems and interventions to illustrate the relationships among pertinent clinical data. This format is called a

a) Concept map.
b) Critical pathway.
c) Clinical pathway.
d) Nursing care plan.

Answer 69

a

A concept map is another method of recording a nursing care plan. In a concept map, the nursing process is recorded in a visual diagram of patient problems and interventions. A clinical (critical) pathway is a prewritten plan that directs the entire health care team in the daily care goals for select health care problems.

Question 70

A group of nurses have a vision to implement evidence-based practice (EBP) for care of patients with pressure ulcers. This change in practice will encompass which of the following (select all that apply)?

a) Consulting with the wound care and ostomy nurse
b) The preferences of patients and their particular circumstances
c) Nurses’ expertise and their bodies of experience and knowledge
d) The traditions that surround pressure ulcer practices on the unit
e) Journal articles that address the care of patients with pressure ulcers

Answer 70

all except d

Question 71

One of the key values underlying nursing practice is ________________ for the sanctity and dignity of human life. Nurses work in cooperative relationships with others, rather than from potions of authority or power.

Answer 71

respect

Question 72

The ability to engage in _________ __________ is a fundamental skill in nursing education and practice.

Answer 72

critical thinking

Question 73

the art of analyzing and evaluating thinking with a view to improving it.

Answer 73

critical thinking

Question 74

the integration of nursing science, computer science, and information technology to manage and communicate data, information, and knowledge in nursing practice.

Answer 74

Nursing informatics

Question 75

the conscientious use of the best evidence (e.g., findings from research) in combination with clinical expertise and client values to facilitate decision-making.

Answer 75

Evidence-based practice (EBP)

Question 76

Four primary elements contribute to the practice of evidence-based nursing:

Answer 76

(1) clinical state, setting, and circumstances;
(2) client preferences and actions;
(3) best research evidence;
and (4) health care resources.

Question 77

The five elements of the nursing process are:

Answer 77

assessment
diagnosis
planning
implementation
evaluation

Question 78

____________ ____________ describe health states that nurses can legally diagnose and treat.

Answer 78

Nursing diagnoses

Question 79

A three-part nursing diagnosis statement includes:

Answer 79

the problem, etiology, and signs and symptoms.

Question 80

any treatment based on clinical judgment and knowledge that a nurse performs to enhance client outcomes.

Answer 80

nursing intervention

Question 81

During the ______________ phase, the nurse determines whether the client outcomes and nursing interventions were realistic, measurable, and achievable.

Answer 81

evaluation

Question 82

_____________ _______________ is recognized as one of the major health challenges confronting citizens of developed countries.

Answer 82

Chronic illness

Question 83

Besides causing premature death, __________ ______________negatively impacts quality of life for affected individuals, their families, and their communities.

Answer 83

chronic illness

Question 84

health problems that persist over extended periods of time and that are usually (but not always) associated with disability.

Answer 84

Chronic illness

Question 85

the rates of disease in a population.

Answer 85

Morbidity

Question 86

the rates of deaths in a population.

Answer 86

Mortality

Question 87

___________ and __________ can be viewed along a continuum upon which individuals journey throughout life.

Answer 87

health and illness

Question 88

a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.

Answer 88

health

Question 89

The state of ______________ is dependent upon complex interactions between multiple social and economic factors, the physical environment, and individual behaviour. These factors are referred to as determinants of health.

Answer 89

health

Question 90

______________ illness is usually characterized by sudden onset, with signs and symptoms related to the disease process itself.

Answer 90

Acute

Question 91

__________ __________ ends in a relatively short time, sometimes in recovery and sometimes in death.

Answer 91

Acute illness

Question 92

Chronic illness often continues ______________.

Answer 92

indefinitely

Question 93

Reduced quality of life, depression, fatigue, and stigma, together with physical symptoms, may make living with a ___________ __________ a daily challenge for many individuals and their families.

Answer 93

chronic illness

Question 94

An ______________ _____________is anyone who provides care without pay and who usually has personal ties to the care recipient.

Answer 94

informal caregiver

Question 95

Five minutes after receiving a preoperative sedative medication by IV injection, a client asks the nurse if he get up to go to the washroom and urinate. Which of the following is the most appropriate action for the nurse to take?

a) Assist client to bathroom and stay next to the door to assist client back to bed when he is done.
b) Allow the client to go to the washroom, since the onset of the medication will be more than 5 minutes.
c) Offer the client the use of a urinal/bedpan after explaining the need to maintain safety.
d) Ask client to hold his urine for a short period of time, since a urinary catheter will be placed in the operating room.

Answer 95

c

The prime issue after administration of either sedative or opioid analgesic medications is safety. Because these medications affect the central nervous system, the client is at risk for falls and should not be allowed out of bed, even with assistance.

Question 96

During a preoperative assessment, which one of the following is the primary reason for making it a priority to determine which medications the client is currently using?

a) Routine medications are usually withheld the day of surgery, requiring dosage and schedule adjustments.
b) Some medications may alter the client’s perceptions about surgery.
c) Some medications may interact with anaesthetics, altering the potency and effect of the drugs.
d) Anaesthetics alter renal and hepatic function, causing toxicity by other drugs.

Answer 96

c

Drug interactions between prescribed medications and anaesthetic agents used during surgery may occur. For this reason, it is important to take a careful medication history and check that they have been communicated to the anaesthesiologist.

Question 97

As the nurse is preparing a client for surgery, the client refuses to remove her wedding ring. Which of the following is the most appropriate action by the nurse?

a) Note the presence of the ring in the nurse’s notes on the chart.
b) Insist the client remove the ring.
c) Explain that the hospital will not be responsible for the ring.
d) Tape the ring securely to the finger.

Answer 97

d

It is customary policy to tape a client’s wedding band to the finger, and to make a notation on the preoperative checklist that the ring has been taped in place.

Question 98

While the nurse is performing preoperative teaching, the client asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the Canadian Anesthesiologists’ Society, what should the nurse tell the client?

a) She must be NPO after breakfast.
b) She needs to be NPO after midnight.
c) She can drink clear liquids up to 2 hours before surgery.
d) She can drink clear liquids up until she is taken to the OR.

Answer 98

c

The Canadian Anesthesiologists’ Society practice guidelines for preoperative fasting state that the minimum fasting period for clear liquids is 2 hours. Evidenced-based practice no longer supports the longstanding practice of requiring clients to be NPO after midnight.

Question 99

The nurse is admitting a client to the same-day surgery unit. The client tells the nurse that he was so nervous he had to take kava the previous evening, to help him sleep. Which of the following nursing actions would be most appropriate in this instance?

a) Inform the anaesthesiologist of the client’s ingestion of kava.
b) Tell the client that using kava to help him sleep was a good idea.
c) Tell the client that the kava should continue to help him relax before surgery.
d) Inform the client about the dangers of taking herbal medicines without first consulting his health care provider.

Answer 99

a

Kava may prolong the effects of certain anaesthetics. Thus the anaesthesiologist needs to be informed of the client’s recent ingestion of this herbal supplement.

Question 100

The nurse would be alerted to the occurrence of malignant hyperthermia when the client demonstrates which of the following?

a) Hypocapnia
b) Muscle rigidity
c) Decreased body temperature
d) Confusion upon arousal from anaesthesia

Answer 100

c

Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles occurring secondary to exposure to certain anaesthetic agents in susceptible clients. Hypoxemia, hypercarbia, and dysrhythmias may also be seen with this disorder.

Question 101

Before admitting a client to the operating room, the nurse recognizes that which one of the following must be attached to the chart for all clients?

a) A functional status evaluation
b) Renal and liver function tests
c) A physical examination report
d) An electrocardiogram

Answer 101

c

It is essential to have a physical examination report attached to the chart of a client going for surgery. This document explains in detail the overall status of the client for the surgeon and other members of the surgical team.

Question 102

Unless contraindicated by the surgical procedure, which of the following positions is preferred for the unconscious client immediately postoperative?

a) Supine
b) Lateral
c) Semi-Fowler’s
d) High-Fowler’s

Answer 102

b

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

Question 103

A postoperative client is transferred from the postanaesthesia unit to the medical-surgical nursing floor. The nurse notes that the client has an order for D5 ½ NS to infuse at 125 mL/hr. Until an IV pump is available, the nurse regulates the IV flow rate at which of the following drops/min, noting that the tubing has a drop factor of 10 drops/mL?

a) 13 drops/min
b) 31 drops/min
c) 25 drops/min
d) 21 drops/min

Answer 103

d

Question 104

The nurse is preparing to administer cefazolin (Ancef) 2 g in 100 mL IVPB to a postoperative client. Which of the following IV rates will infuse this medication over 20 minutes?

a) 100 mL/hr
b) 150 mL/hr
c) 200 mL/hr
d) 300 mL/hr

Answer 104

d

Question 105

The nurse is working on a surgical floor and is preparing to receive a postoperative client from the postanaesthesia unit. Which of the following should be the nurse’s initial action upon the client’s arrival?

a) Check the physician’s postoperative orders.
b) Assess the client’s pain.
c) Check the rate of the IV infusion.
d) Assess the client’s vital signs.

Answer 105

d

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

Question 106

When assessing a client’s surgical dressing on the first postoperative day, the nurse notes new bright-red drainage about 5 cm in diameter. In response to this finding, the nurse should do which of the following?

a) Assess the client’s blood pressure and heart rate.
b) Remove the dressing and assess the surgical incision.
c) Recheck the dressing in 1 hour for increased drainage.
d) Notify the surgeon of a potential hemorrhage.

Answer 106

a

The first action by the nurse is to gather additional assessment data to form a more complete clinical picture. The nurse can then report the findings as a whole.

Question 107

In planning postoperative interventions to promote ambulation, coughing, deep breathing, and turning, the nurse recognizes that which of the following actions will best enable the client to achieve the desired outcomes?

a) Giving the client positive feedback when the activities are completed.
b) Administering adequate analgesics to promote relative freedom from pain.
c) Warning the client about possible complications if the activities are not performed.
d) Asking the client to verbalize understanding of and demonstrate performance of activity.

Answer 107

b

Even when a client understands the importance of postoperative activities, it is unlikely that the best outcome will occur unless the client has sufficient pain relief to cooperate.

Question 108

Which one of the following nursing interventions should receive highest priority when a client is admitted to the postanaesthesia care unit (PCU)?

a) 1. Positioning the client
b) 2. Observing the operative site
c) 3. Checking the postoperative orders
d) 4. Receiving report from operating room personnel

Answer 108

a

A client is received in the postanaesthesia care unit on a bed or stretcher. Proper positioning is necessary to ensure airway patency in a sedated, unconscious, or semiconscious client. Observation of the operative site, receiving report from operating room personnel, and checking postoperative orders are interventions made after proper positioning of the client.

Question 109

Which one of the following may be left in place when a client is sent to the operating room?

• 1. Wig
• 2. Hearing aid
• 3. Engagement ring
• 4. Well-fitting dentures

Answer 109

2

If a client is wearing a hearing aid, the perioperative nurse should be notified. Leaving the hearing aid in place enhances communication in the operating room. The nurse should make certain to record that the appliance is in place. Wigs, engagement rings, and dentures are not necessary items to facilitate quality client care in the operating room.

Question 110

When caring for a client receiving an opioid analgesic through an epidural catheter, which following nursing responsibility is of prime importance?

• 1. Assessing for respiratory depression
• 2. Establishing a baseline laboratory profile
• 3. Inspecting the catheter insertion site hourly
• 4. Ensuring that the client remains on strict bed rest

Answer 110

1

Possible side effects of epidural opioids are pruritus, urinary retention, and delayed respiratory depression, occurring 4 to 12 hours after a dose. Establishing a baseline laboratory profile is outside the scope of practice for a nurse. Hourly inspection of the catheter insertion site is an unnecessary nursing intervention. In general, the site is assessed once per shift unless unexpected complications occur. Strict bed rest is not necessary for the client with an epidural catheter; however, assistance with getting out of bed could be necessary related to effects of the opioid analgesic.

Question 111

Which following action is most appropriate after administration of preoperative medications?

• 1. Confirming that the client has voided
• 2. Monitoring vital signs every 15 minutes
• 3. Placing the client in bed with the rails up
• 4. Transporting the client immediately to the operating room

Answer 111

3

After administration of preoperative medications, a nurse should instruct a client not to get up without assistance because medications can cause drowsiness or dizziness. Confirming that the client has recently voided should be done before preoperative medications are administered. Monitoring vital signs every 15 minutes is not a necessary intervention unless prescribed by the physician. Transporting the client immediately to the operating room is not necessary unless the client is called for.

Question 112

Which of the following best describes the function of a consent form?

• 1. It protects the health care facility but not the physician.
• 2. It signifies that the client understands all aspects of the procedure.
• 3. It signifies that the client and family have been told about the procedure.
• 4. It must be signed by the client or responsible party at the health care facility. Consent may not be obtained by phone or fax.

Answer 112

2

A consent form may be signed by an emancipated minor, and consent may be obtained by fax or phone with appropriate witnesses. Only in the cases of underage children or unconscious or mentally incompetent people must a family member be aware of the procedure. The document protects the surgeon and the health care facility in that it indicates that the client knows and understands all aspects of the procedure.

Question 113

Which one of the following interventions should be included in the plan of care for a client who had spinal anaesthesia?

• 1. Elevating the head of the bed to decrease nausea
• 2. Elevating the client’s feet to increase blood pressure
• 3. Instructing the client to remain flat in bed for 6 hours
• 4. Administering oxygen to reduce hypoxia produced by spinal anaesthesia

Answer 113

3

In addition to interventions designed to replace fluids and indirectly replace lost spinal fluid after administration of spinal anaesthesia, the client is instructed to lie flat for 6 to 8 hours. Elevating the head of the bed after spinal anaesthesia can precipitate “spinal headache” or nausea related to losses of cerebrospinal fluid or changes in ICP. Elevating the client’s feet or administering oxygen are not necessary interventions unless the client becomes hypotensive or hypoxic.

Question 114

A nurse has requested and received permission to observe a surgical procedure of interest in the hospital in which the nurse is employed. While the client is being draped, the nurse notices that a break in sterile technique occurs. Which following action on the nurse’s part is most appropriate?

• 1. Tell the surgeon before an incision is made.
• 2. Tell the circulating nurse at the end of the surgery.
• 3. Say nothing because someone else is also likely to notice this problem.
• 4. Point out the observation immediately to the personnel involved.

Answer 114

4

Any break in sterile technique in the operating room should be immediately pointed out and remedied.

Question 115

In the operating room, a client tells a circulating nurse that he is going to have the cataract in his left eye removed. If the nurse notes that the consent form indicates that surgery is to be performed on the right eye, what should be the nurse’s first action?

• 1. Ask the client his name.
• 2. Notify the surgeon and anaesthesiologist.
• 3. Check to see whether the client has received any preoperative medications.
• 4. Assume that the client is a little confused because he is older and has received midazolam intramuscularly.

Answer 115

1

Ensuring proper identification of a client is a responsibility of all members of the surgical team. In a specialty surgical setting where many clients undergo the same type of surgery each day, such as cataract removal, it is possible that the client and the record do not match. Nurses do not make assumptions in the care of their clients. The priority is for the nurse to identify the client and the client’s consent form before the physicians are notified.

Question 116

What should the nurse do when administering low-molecular-weight heparin (LMWH) after an operation?

• 1. Explain that the drug will help prevent clot formation in the legs.
• 2. Check the results of the partial thromboplastin time before administration.
• 3. Administer the dose with meals to prevent GI irritation and bleeding.
• 4. Inform the client that blood will be drawn every 6 hours to monitor the prothrombin time.

Answer 116

1

Unfractionated heparin or LMWH is given as a prophylactic measure for venous thrombosis and pulmonary embolism. These anticoagulants work by inhibiting thrombin-mediated conversion of fibrinogen to fibrin. LMWH is injected subcutaneously with no relationship to meals. It has a more predictable dose response and less risk of bleeding complications. It does not require anticoagulant monitoring and dosage adjustments.

Question 117

A physician is performing a sterile procedure at a client’s bedside. What should the nurse do when, near the end of the procedure, the nurse thinks that the physician has contaminated a sterile glove and the sterile field?

• 1. Report the physician for violating surgical asepsis and endangering the client.
• 2. Not say anything, because the nurse is not sure that the gloves and field were contaminated.
• 3. Ask the physician whether the contaminated glove and the sterile field have been contaminated.
• 4. Point out the possible break in surgical asepsis and provide another set of sterile gloves and fresh sterile field.

Answer 117

4

It is the responsibility of the nurse to point out any possible break in surgical asepsis when others are unaware that they have contaminated the field. Reporting the physician is not indicated, nor does it protect the client. Asking the physician may lead to infection if the physician is unaware of the break in technique that the nurse believes may have happened. Saying nothing does not protect the client and is negligent on the part of the nurse.

Question 118

Which one of the following is an advantage of laser surgery?

• 1. Diminished bleeding
• 2. Increased swelling
• 3. Increased postoperative pain
• 4. Increased risk for postoperative infection

Answer 118

1

Laser surgery offers the benefits of diminished bleeding, swelling, tissue damage, and postoperative pain and infection.

Question 119

Which one of the following preoperative assessment findings should be reported to a surgeon for preoperative treatment?

• 1. Serum sodium level of 140 mmol/L
• 2. Serum potassium level of 3 mmol/L
• 3. Hb concentration of 9.5 mmol/L
• 4. Prothrombin time of 11.5 seconds

Answer 119

2

Electrolyte imbalances increase operative risk. Preoperative laboratory results should be checked to see whether they are within the normal range. The normal potassium level is 3.5 to 5.0 mmol/L. A low serum potassium level puts the client at risk for cardiac dysrhythmias. A serum sodium level of 140 mmol/L is considered a normal value. An Hb concentration of 7.4 to 9.9 mmol/L (female) and 8.7 to 11.2 mmol/L (male) are considered normal values by most laboratory standards and does not interfere with operative decisions. A normal prothrombin time is between 11 and 12.5 seconds so this is a normal value and conducive to proceeding with a surgical procedure.

Question 120

Which one of the following is most likely to be effective in meeting a client’s teaching/learning needs preoperatively?

• 1. Teaching only the client
• 2. Teaching the client and family
• 3. Using brief verbal instructions
• 4. Using only written instructions

Answer 120

2

A nurse should determine learning needs preoperatively and teach both the client and the family before surgery. Using only written instructions does not provide the opportunity for evaluation for learning. Brief verbal instructions are often forgotten. Teaching only the client limits learning preoperatively because the client can be anxious and not receptive to new information.

Question 121

Which one of the following preoperative assessment findings should be reported to a surgeon for preoperative treatment?

• 1. Excessive thirst
• 2. Gradual weight gain
• 3. Overwhelming fatigue
• 4. Recurrent blurred vision

Answer 121

1

The classic clinical manifestations of diabetes mellitus are increased frequency of urination (polyuria); increased thirst and fluid intake (polydipsia); and as the disease progresses, weight loss despite increased hunger and food intake (polyphagia). Weakness, fatigue, and recurrent blurred vision are associated with diabetes mellitus but are not considered priority manifestations because of the generalization of these complaints being applied to other disease processes. Weight loss is the cardinal sign related to the depletion of water, glycogen, and triglyceride stores.

Question 122

A nurse is caring for a surgical client in the preoperative area. The nurse obtains the client’s informed consent for the surgical procedure. Which following statement is true regarding informed consent?

• 1. Informed consent must be witnessed.
• 2. Informed consent may be withdrawn at any time.
• 3. Informed consent must be signed by clients age 16 and older.
• 4. Informed consent must be obtained from the family even in a life-threatening emergency.

Answer 122

1

An informed consent must be signed while the client is free from mind-altering medications and must be witnessed after it has been determined that the client has received all of the necessary information needed to make an informed decision. An informed consent may be withdrawn at any time before the procedure and must be signed by clients age 18 and older. A parent or guardian’s signature is required for minors. The informed consent may be obtained by the physician or the nurse and is not required in the event of a life-threatening emergency.

Question 123

A nurse is caring for clients on a medical-surgical unit. The nurse plans the clients’ care and instructs the nursing assistant to assist in repositioning clients every 2 hours. Which following client is at the greatest risk for complications if not repositioned properly?

• 1. A 20-year-old post-operative client
• 2. A 50-year-old hearing impaired client
• 3. A 65-year-old client who is visually impaired
• 4. A 40-year-old client who has paraplegia

Answer 123

4

Clients who are at the greatest risk for complications if not properly repositioned are those who are unconscious, frail, or paralyzed.

Question 124

What would be the most effective way for a nurse to validate “informed consent”?

• 1. Ask the family whether the client understands the procedure.
• 2. Check the chart for a completed and signed consent form.
• 3. Ask the client what he or she understands regarding the procedure.
• 4. Determine from the physician what was discussed with the client.

Answer 124

3

Informed consent in the health care setting is a process whereby a client is informed of the risks, benefits, and alternatives of a certain procedure, and then gives consent for it to be done. The signed piece of paper is simply evidence that the informed consent process has been completed.

Question 125

If a 77-year-old client who is NPO after surgery has dry oral mucous membranes, which following nursing intervention is most appropriate?

• 1. Increase oral fluid intake.
• 2. Perform oral hygiene frequently.
• 3. Swab the inside of the mouth with petroleum.
• 4. Increase the rate of IV fluid administration.

Answer 125

2

Frequent oral hygiene will help alleviate discomfort for a client who is NPO. IV fluid rate is prescribed by the physician. Petroleum is always inappropriate intraorally. Oral fluid intake is contraindicated in a client who is NPO.

Question 126

While a nurse is caring for a client who is scheduled to have surgery in 2 hours, the client states, “My doctor was here and told me a lot of stuff I didn’t understand and then I signed a paper for her.” To fulfill the role of advocate, what is the best nursing action?

• 1. Reassure the client that the surgery will go as planned.
• 2. Explain the surgery and possible outcomes to the client.
• 3. Complete the nurse’s original priority, which is the preoperative teaching plan.
• 4. Call the physician to return and clarify information for the client.

Answer 126

4

Examples of nursing advocacy include questioning doctors’ orders, promoting client comfort, and supporting client decisions regarding health care choices.

Question 127

A client is scheduled for a hemorrhoidectomy at an ambulatory day-surgery centre. An advantage of performing surgery at an ambulatory centre is a decreased need for which one of the following?

• 1. Laboratory tests and perioperative medications
• 2. Preoperative and postoperative teaching by the nurse
• 3. Psychological support to alleviate fears of pain and discomfort
• 4. Preoperative nursing assessment related to possible risks and complications

Answer 127

1

Ambulatory surgery is usually less expensive and more convenient, generally involving fewer laboratory tests, fewer preoperative and postoperative medications, less psychological stress, and less susceptibility to hospital-acquired infections. However, the nurse is still responsible for assessing, supporting, and teaching the client undergoing surgery, regardless of where the surgery is performed.

Question 128

A client has the following preoperative medication order: morphine 10 mg with atropine 0.4 mg IM. The nurse informs the client that this injection will do which one of the following?

• 1. Decrease nausea and vomiting during and after surgery
• 2. Decrease oral and respiratory secretions, thereby drying the mouth
• 3. Decrease anxiety and produce amnesia of the preoperative period
• 4. Induce sleep, so the client will not be aware during transport to the operating room

Answer 128

2

Atropine, an anticholinergic medication, is frequently used preoperatively to decrease oral and respiratory secretions during surgery, and the addition of morphine will help to relieve discomfort during the preoperative procedures. Antiemetics decrease nausea and vomiting during and after surgery, and scopolamine and some benzodiazepines induce amnesia. An actual sleep state is rarely induced by preoperative medications unless an anaesthetic agent is administered before the client is transported to the operating room.

Question 129

Which one of the following is the primary goal of the circulating nurse during preparation of the operating room, transferring and positioning the client, and assisting the anaesthesia team?

• 1. Avoid any type of injury to the client
• 2. Maintain a clean environment for the client
• 3. Provide for the client’s comfort and sense of well-being
• 4. Prevent breaks in aseptic technique by the sterile members of the team

Answer 129

1

The protection of the client 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 client during anaesthesia induction.

Question 130

Conscious sedation is being considered for a client undergoing a cervical dilation and endometrial biopsy in the health care provider’s office. The client asks the nurse, “What is this conscious sedation?” The nurse’s response is based on the knowledge that which following statement is true about conscious sedation?

• 1. It can be administered only by anaesthesiologists.
• 2. It enables the client to respond to commands and accept painful procedures.
• 3. It is so safe that it can be administered by nurses with direction from health care providers.
• 4. It should never be used outside of the operating room because of the risk of serious complications.

Answer 130

2

Conscious sedation is a moderate sedation that allows the client to manage his or her own airway and respond to commands, and yet the client can emotionally and physically accept painful procedures. Drugs are used to provide analgesia, relieve anxiety and/or provide amnesia. It can be administered by personnel other than anaesthesiologists, but nurses should be specially trained in the techniques of conscious sedation to carry out this procedure because of the high risk of complications resulting in clinical emergencies.

Question 131

What should the nurse do to prevent airway obstruction in the postoperative client who is unconscious or semiconscious?

• 1. Encourage deep breathing.
• 2. Elevate the head of the bed.
• 3. Administer oxygen per mask.
• 4. Position the client in a side-lying position.

Answer 131

4

An unconscious or semiconscious client 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 client is responsive. Oxygen administration is often used, but the client must first have a patent airway.

Question 132

In the absence of postoperative vomiting, GI suctioning, and wound drainage, the physiological responses to the stress of surgery are most likely to cause which one of the following?

• 1. Diuresis
• 2. Hyperkalemia
• 3. Fluid overload
• 4. Impaired blood coagulation

Answer 132

3

Secretion and release of aldosterone and cortisol from the adrenal gland and ADH from the posterior pituitary as a result of the stress response cause fluid retention during the first 2 to 5 days postoperatively, and fluid overload is possible during this time. Aldosterone causes renal potassium loss with possible hypokalemia, and blood coagulation is enhanced by cortisol.

Question 133

A client is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 39° C. Which of the following parameters would the nurse monitor, other than temperature, if the client requires this medication?

a) Oxygen saturation
b) Pain level
c) Intake and output
d) Level of consciousness

Answer 133

c

Because fever can lead to excessive perspiration and evaporation of body fluid via the skin, the nurse should monitor the client’s overall intake and output to be sure that the client remains in proper fluid balance.

Question 134

The nurse determines that the client may be suffering from an acute bacterial infection based upon which of the following laboratory test results?

a) Increased blood urea nitrogen
b) Increased platelet count
c) Increased number of band neutrophils
d) Increased number of segmented neutrophils

Answer 134

c

The finding of increased numbers of band neutrophils in circulation is called a shift to the left, which is commonly found in clients with acute bacteria infections.

Question 135

A pressure ulcer demonstrating full-thickness skin loss involving damage to subcutaneous tissue extending down to, but not through, the underlying fascia, would be classified as which of the following stages?

a) Stage I
b) Stage II
c) Stage III
d) Stage IV

Answer 135

c

Stage III pressure ulcers are defined as full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Stage IV ulcers involve extensive destruction of surrounding and supporting structures. Stage II ulcers are partial-thickness whereby stage I ulcers are defined by a change in skin temperature, tissue consistency, and/or sensation.

Question 136

Which of the following strategies by the nurse would be most helpful in treating a client who is experiencing chills because of an infection?

a) Turn up the thermostat in the client’s room
b) Encourage a hot shower
c) Provide a light blanket
d) Monitor temperature every hour

Answer 136

c

Chills often occur in cycles and last for 10 to 30 minutes at a time. They usually signal the onset of a rise in temperature. For this reason, the nurse should provide a light blanket for comfort but avoid overheating the client.

Question 137

When caring for a client with a known latex allergy, the nurse would monitor the client closely for a cross-sensitivity to which of the following foods?

a) Honeydew melons
b) Grapefruit
c) Oranges
d) Bananas

Answer 137

d

Because some proteins in rubber are similar to food proteins, some foods may cause an allergic reaction in people who are allergic to latex. The most common of these foods are bananas, avocados, chestnuts, kiwi fruit, tomatoes, water chestnuts, guava, hazelnuts, potatoes, peaches, grapes, and apricots.

Question 138

The nurse is caring for an elderly client who is receiving IV fluids postoperatively. During the 8 AM assessment of this client, the nurse notes that the litre bag of IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4 AM. Which of the following nursing interventions would be the priority action at this time?

a) Obtain a new bag of IV solution to maintain patency of the site.
b) Listen to the client’s lung sounds and assess respiratory status.
c) Slow the rate to keep vein open until next bag is due at noon.
d) Notify the physician and complete an incident report.

Answer 138

b

After 4 hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This client is at risk for fluid volume excess and the nurse should assess the client’s respiratory status and lung sounds as the priority action, and then notify the physician for further orders.

Question 139

When the nurse encourages a client with heart failure to alternate rest and activity periods to reduce cardiac workload, which of the following phases of the nursing process is being used?

A) Planning
B) Diagnosis
C) Implementation
D) Evaluation

Answer 139

C

Carrying out the specific, individualized plan constitutes the implementation phase of the nursing process. The nurse’s action of encouragement and instruction to the client is part of carrying out a plan of action.

Question 140

When planning care for a client, the nurse may use a visual diagram of client problems and interventions to illustrate the relationships among pertinent clinical data. What is this format called?

A) Concept map
B) Critical pathway
C) Clinical pathway
D) Nursing care plan

Answer 140

A

A concept map is another method of recording a nursing care plan. In a concept map, the nursing process is recorded in a visual diagram of client problems and interventions. A clinical (critical) pathway is a prewritten plan that directs the entire health care team in the daily care goals for select health care problems.

Question 141

During an admission history and physical, the client describes symptoms to the nurse. How would these descriptions be documented?

A) Objective data
B) Subjective data
C) Generalized data
D) Comprehensive data

Answer 141

B

Subjective data are collected by interviewing the client and includes information that can only be described or verified by the client.

Question 142

The nurse would place assessment findings related to vision and hearing under which of the following functional health patterns?

A) Activity
B) Cognitive
C) Self
D) Health perception

Answer 142

B

Assessment of the cognitive-perceptual pattern involves a description of all senses (vision, hearing, taste, touch, and smell) and the cognitive functions.

Question 143

Which of the following techniques would be appropriate to enhance client learning?

A) Give information without asking for feedback.
B) Explain information in great scientific detail regardless of level of education.
C) Involve the client and family in the process.
D) Do not relate the information to the client’s lifestyle.

Answer 143

C

Asking for frequent feedback, involving the client and family, and emphasizing relevancy of the information to the client’s lifestyle are all appropriate techniques. The nurse would want to avoid giving great scientific detail to clients unless they have the educational background to receive it; simple is best.

Question 144

Which of the following is a method of individualizing learning needs for a particular client?

A) Use prepackaged learning materials.
B) Only teach the client “need-to-know” information.
C) Have the client arrange topic cards in order of priority.
D) Have the client watch a video and then read a pamphlet.

Answer 144

C

By allowing a client to prioritize his or her own learning needs, the nurse can begin with the client’s most important needs and end with the least important. The other choices may be appropriate teaching strategies, but they do not individualize the learning needs.

Question 145

When interviewing an elderly client, which of the following actions would it be most appropriate for the nurse to take?

A) Assure all assistive devices are in place.
B) Interview the client and caregiver together.
C) Perform the interview before administering analgesics.
D) Move on to the next question if the client does not respond quickly.

Answer 145

A

All assistive devices, such as glasses and hearing aids, should be in place when interviewing an elderly client. It is best to interview the client and caregiver separately to assure a reliable assessment related to elder mistreatment. The client should be free from pain during the assessment and may need extra time to respond to questions.

Question 146

Which of the following assessment findings would alert the nurse to possible elder mistreatment?

A) Calm
B) Happy
C) Weight gain
D) Hypernatremia

Answer 146

C

Agitation and depression may be manifestations of psychological abuse or neglect. Hypernatremia may signify dehydration caused by physical neglect. A loss of body weight, rather than weight gain, is another clinical manifestation of physical neglect.

Question 147

On which area of practice would a community health nurse focus?

A) Illness-oriented care of families.
B) Improving the health of the population as a whole.
C) Instituting preventative measures for large groups of unrelated individuals.
D) Providing health education to large groups of people

Answer 147

A

Community health nursing differs from public health nursing in that it focuses on promoting and protecting the health of families, whereas the public health nurse seeks to promote disease prevention and health improvement through education and other measures to large populations.

Question 148

A nurse is caring for a young adult who sustained a severe traumatic brain injury following a motor vehicle accident. Once the client recovers from the acute aspects of this injury and is no longer ventilator dependent, discharge planning would anticipate that this client will be transferred to which of the following practice settings?

A) Subacute care
B) Acute rehabilitation
C) Long-term acute care
D) Skilled nursing facility

Answer 148

B

Acute rehabilitation practice settings provide a postacute level of care, specializing in therapies for clients with neurological or physical injuries, such as those with head trauma, spinal cord injury, or stroke.

Question 149

A client asks the nurse a question about the safety and efficacy of chondroitin sulphate for the treatment of osteoarthritis. Which of the following statements is true, and will help the nurse answer the question?

A) All dietary supplements are safe and effective.
B) There is good scientific evidence for the use of this supplement in the treatment of osteoarthritis.
C) There is strong scientific evidence for the use of this supplement in the treatment of osteoarthritis.
D) There is unclear scientific evidence for the use of this supplement in the treatment of osteoarthritis.

Answer 149

C

Strong scientific evidence exists for the effectiveness of chondroitin in the treatment of osteoarthritis. In Canada, dietary supplements cannot be marketed without having proven safety or efficacy to the Health Protection Branch (HPB) of Health Canada, which also oversees and regulates consistent manufacturing practices.

Question 150

Which of the following assessments is of highest priority for the nurse to complete before administration of morphine?

A) Level of consciousness
B) Respiratory rate
C) Blood pressure
D) Pain rating

Answer 150

B

Decreased respirations below a rate of 12 per minute are a sign of opioid toxicity. Using the ABC approach to prioritization of care, a patent airway is always the first priority and is important to assess as a baseline before and during the administration of morphine.

Question 151

The nurse should instruct a client receiving NSAIDs to report which of the following adverse effects?

A) Nasal stuffiness
B) Blurred vision
C) Urinary retention
D) Black or tarry stools

Answer 151

D

Black, tarry stools could indicate GI bleeding, which is a risk associated with NSAIDs. For this reason, the client should be taught to report this sign and other signs of bleeding immediately.

Question 152

To reduce the risk of adverse effects, the nurse should do which of the following when caring for a client receiving morphine sulphate via patient-controlled analgesia (PCA)?

A) Teach the family not to push the button for the client.
B) Instruct the client not to push the button too frequently.
C) Ask the client to do deep breathing exercises every hour.
D) Administer Lomotil to prevent the occurrence of diarrhea.

Answer 152

A

It is important to teach the family not to push the button for the client because it is only the client who can determine the need for the medication. If the family pushes the button, the client could receive more of a dose than is actually needed, and this increases the risk of adverse effects.

Question 153

When assessing a client receiving morphine sulphate 2 mg every 10 minutes via patient-controlled analgesia (PCA) pump, the nurse should take action as soon as the client’s respiratory rate drops down to or below which of the following parameters?

A) 16 breaths per minute
B) 14 breaths per minute
C) 12 breaths per minute
D) 10 breaths per minute

Answer 153

C

To protect the client from adverse effects of respiratory depression from this medication, the nurse should alert the physician as soon as the respiratory rate drops down to or below 12 breaths per minute.

Question 154

Which of the following clinical manifestations would the nurse attribute to adverse effects of morphine sulphate administered via patient-controlled analgesia?

A) Urinary incontinence
B) Increased blood pressure
C) Diarrhea
D) Nausea and vomiting

Answer 154

D

Morphine sulphate promotes nausea and vomiting by directly stimulating the chemoreceptor trigger zone in the medulla. Other common side effects include constipation, sedation, respiratory depression, and pruritus.

Question 155

A client admitted with metastatic lung cancer is ordered to receive morphine sulphate for pain. The nurse will assess for which of the following common adverse reactions to this medication?

A) Constipation
B) Agitation
C) Diarrhea
D) Urinary incontinence

Answer 155

A

Morphine sulphate is an opioid analgesic that can lead to constipation as a side effect. It is very important to use countermeasures, such as increased fibre and fluids in the diet, whenever possible, to prevent this side effect.

Question 156

The client is receiving fentanyl (Duragesic) for control of chronic cancer pain. Which of the following should the nurse observe for as a potential adverse effect of this medication?

A) Pupillary dilation
B) Hypertension
C) Urinary incontinence
D) Decreased respiratory rate

Answer 156

D

Respiratory depression is a potentially life-threatening adverse effect of fentanyl (Duragesic), which is an opioid analgesic.

Question 157

The nurse is caring for a client receiving morphine sulphate 10 mg IV push p.r.n. for pain. Upon assessment, the nurse finds the client obtunded with a respiratory rate of 8. Which of the following medications would this nurse prepare to administer to treat these symptoms?

A) Naloxone (Narcan)
B) Atropine sulphate
C) Protamine sulphate
D) Neostigmine bromide (Prostigmin)

Answer 157

A

Naloxone is the antidote or reversal agent for opioid analgesics, such as morphine. Excessive sedation and respiratory depression are symptoms of overdose and or severe adverse effects that must be reversed for client safety.

Question 158

During admission of a client diagnosed with metastatic lung cancer, the nurse would assess for which of the following as a key indicator of clinical depression related to terminal illness?

A) Frustration with pain
B) Anorexia and nausea
C) Feelings of hopelessness
D) Inability to carry out activities of daily living

Answer 158

C

Feelings of hopelessness are likely to be present in a client with a terminal illness who has clinical depression. This can be attributed to lack of control over the disease process or outcome. The nurse should assess for depression routinely when working with clients with a terminal illness.

Question 159

When admitting a client to the emergency room who complains of chest pain, which of the following assessment findings would alert the nurse to possible cocaine abuse?

A) Bradycardia
B) Somnolence
C) Hypothermia
D) Dilated pupils

Answer 159

D

The nurse should suspect stimulant drug abuse in any client seeking health care who has dilated pupils, tachycardia, hyperactivity, fever, or behavioural abnormalities.

Question 160

Which of the following most often characterizes a client with a chronic illness?

A) Medical disability
B) Social disability
C) Fatigue
D) Behavioural problems

Answer 160

C

Fatigue is the hallmark of chronic illness. Clients with a chronic illness may not always have a medical or a social disability, nor a behavioural problem.

Question 161

In Canada, what are the three most common chronic illnesses, in descending order of prevalence?

A) Cardiovascular disease, cancer, and respiratory disease
B) Cancer, cardiovascular disease, and HIV-AIDS
C) Diabetes, cancer, and cardiovascular disease
D) Alzheimer’s disease, cardiovascular disease, and cancer

Answer 161

A

According to Health Canada, cardiovascular disease has the highest prevalence in Canada, followed by cancer, with respiratory disease being third. Diabetes represents only 2% of chronic disease, while all others, including HIV-AIDS and Alzheimer’s disease, account for only 9%.

Question 162

What is the primary outcome measure in evaluating the treatment of a chronic illness?

A) Relief from pain
B) Relief from fatigue
C) Return to work
D) Quality of life

Answer 162

D

Quality of life is the most important outcome measure. Relief of pain or from fatigue may or may not affect the quality of life. Return to work, while important, may not be applicable because many clients who have chronic illnesses are retired.

Question 163

The preparation of a nursing care plan (NCP) for a resident in a long-term care facility should involve input from which of the following people?

• 1. A dietitian
• 2. The resident
• 3. The resident’s lawyer
• 4. Registered nurses only

Answer 163

2

Input into an NCP ideally comes from family members, the social worker, the resident, and all licensed staff (not just RNs). Nursing assistants and dietitians are made aware of the NCP.

Question 164

Which following symptom may indicate pain in a 76-year-old client with communication impairments?

• 1. Increased appetite
• 2. Drying of the eyes
• 3. Increased social isolation
• 4. Long periods of daytime sleep

Answer 164

3

Decreased appetite, tearing of the eyes, and increased social isolation may indicate pain in an older client with communication impairments.

Question 165

Which one of the following clients is at highest risk of developing dehydration?

• 1. A 78-year-old with dementia
• 2. A 47-year-old with hyperthyroidism
• 3. A 53-year-old with pulmonary embolism
• 4. A 32-year-old with a respiratory infection

Answer 165

1

Older clients are at risk for dehydration because of altered responses to illness related to age. In addition, persons with dementia might not recognize the urge to drink.

Question 166

Which one of the following is a physiological response to unrelieved pain?

• 1. Hypotension
• 2. Urinary retention
• 3. Increased tidal volume
• 4. Increased bowel motility

Answer 166

2
Unrelieved pain has many negative physiological effects, including decreased vital capacity and bowel and bladder tone; hypertension; and increased myocardial oxygen needs.

Question 167

When a client complains of nausea after receiving the first dose of morphine for pain, the nurse should take which following action?

• 1. Tell the client that with continued use, the nausea will lessen.
• 2. Give only half of the prescribed dose of morphine the next time.
• 3. Encourage the client to wait as long as possible for the next dose.
• 4. Withhold the next dose of morphine until the dosage has been re-evaluated by the physician.

Answer 167

1

Opioids can cause nausea and vomiting because of their action on the brainstem centres. This side effect decreases with repeated use, but until then, treatment for nausea should also be instituted.

Question 168

In palliative care, a client’s quality of life is improved because of which following reason?

• 1. It is recognized that dying is a normal process.
• 2. This process does not offer an affirmation of life.
• 3. Care is focused solely on the dying client’s needs and comfort.
• 4. Proactive pursuits are encouraged and anticipatory grieving is postponed.

Answer 168

1

Through the work of an interdisciplinary team, palliative care provides physical, psychosocial, and spiritual support, plus management of clinical manifestations.

Question 169

Because of the risk of worsening respiratory depression, a client starting opioids should avoid using which following type of medication?

• 1. Antacids
• 2. Benzodiazepines
• 3. Antihypertensives
• 4. Oral antidiabetics

Answer 169

2

Respiratory depression increases with concurrent use of drugs with central nervous system–depressant actions, such as alcohol, barbiturates, and benzodiazepines. Antihypertensive drugs and other drugs that lower blood pressure can exacerbate morphine-induced hypotension. Antacids do not interact with opioids to produce adverse effects. Classes of drugs that interact with opioids to produce various adverse reactions, excluding respiratory depression, include agonist-antagonist opioids, anticholinergics, hypotensives, opioid antagonists, and MAO inhibitors.

Question 170

Decreased percentage of lean body mass, which is common in older adults, is likely to affect which following process in relation to medications?

• 1. Absorption
• 2. Metabolism
• 3. Elimination
• 4. Distribution

Answer 170

4

Decreased lean body mass in older adults can affect the distribution of drugs. Absorption of drugs in the older adult population can be affected by gastric pH, decreased absorption surface areas, decreased splanchnic blood flow, decreased GI motility, and delayed gastric emptying. Metabolism of drugs in older adults can be affected by decreased hepatic blood flow, decreased hepatic mass, and decreased activity of hepatic enzymes. Elimination of drugs in older adults can be affected by decreased renal blood flow, decreased glomerular filtration rate, decreased tubular secretion, and decreased number of nephrons.

Question 171

Drug administration would be considered palliative in which following situation?

• 1. Thyroid hormone replacement
• 2. Pain management for a client with terminal cancer
• 3. Antibiotic therapy for a client with a bacterial infection
• 4. Iron supplements for the treatment of iron-deficiency anemia

Answer 171

2

To palliate means to alleviate without curing. Palliation therapy is typically used for clients with end-stage disease or illness to make clients as comfortable as possible. An example is pain management for the terminally ill. Hormone replacement, antibiotic therapy, and iron supplementation are not typically palliative therapies.

Question 172

Which of the following is the most effective way for a nurse to administer pain medication to a client who is experiencing severe pain related to metastatic liver cancer?

• 1. Give only IV pain medications.
• 2. Dispense pain medications on a regular basis.
• 3. Respond promptly to as-needed (prn) pain requests.
• 4. Administer only when other methods of pain relief are ineffective.

Answer 172

2

Clients experiencing pain caused by widespread cancer require pain-relieving medication, often in higher doses on a regular basis. Regular administration enhances the client’s ability to function.

Question 173

A nurse is planning care for clients in a long-term care facility. The nurse knows that aging clients are at additional risk for which one of the following diseases?

• 1. Obesity
• 2. Depression
• 3. Multiple sclerosis
• 4. Type 1 diabetes

Answer 173

2

The nurse knows that aging adults are at additional risk for anorexia, depression, coronary artery disease, and type 2 diabetes.

Question 174

A home health nurse is performing an initial assessment on an elderly client. Which physiological change should the nurse anticipate as being “normal” for an elderly client?

• 1. Increased saliva production
• 2. Disorientation
• 3. Loss of visual acuity
• 4. Elevated blood pressure

Answer 174

3

The nurse should anticipate decreased salivary production, delayed wound healing, and loss of visual acuity as normal physiological changes in the elderly.

Question 175

When providing care to a dying client, a nurse should remember that which one of the following is the longest-lasting sense?

• 1. Smell
• 2. Touch
• 3. Vision
• 4. Hearing

Answer 175

4

Question 176

If the family of a dying client is highly emotional and critical of the nursing care, which following nursing response is appropriate?

• 1. Listen to concerns and provide reassurance.
• 2. Explain all interventions in technical terms.
• 3. Request that the nursing supervisor talk to the family.
• 4. Avoid family members as much as possible, to reduce confrontations.

Answer 176

1

Question 177

If a 77-year-old client states, “My religion does not permit me to bathe today,” which following nursing action is most appropriate?

• 1. Reply that the physician has prescribed a bath for today.
• 2. Insist that a bath be taken because it is the client’s scheduled bath day.
• 3. Call an appropriate clergy person and ask whether the client is telling the truth.
• 4. Request a clarification of the client’s beliefs and arrange a plan for bathing.

Answer 177

4

A client’s religious and cultural preferences should be considered when providing hygiene. Facility schedules should not take priority over the client’s religious beliefs, nor should physician instructions. Verifying the client’s beliefs with clergy is inappropriate.

Question 178

Which one of the following is an appropriate nursing intervention when caring for an 83-year-old client as death nears?

• 1. Tell the client, “You’ll be going home soon.”
• 2. Encourage the client to interact with family members.
• 3. Hold the client’s hand and state, “You’re not alone.”
• 4. Discuss what to expect with the family members at the bedside.

Answer 178

3

Question 179

On initial assessment, a client reports “a cough for 3 days and it’s getting worse.” The nurse says, “Tell me more about your cough.” The client says, “I wish I could, but that is why I’m here. You tell me what’s wrong!” Which following response would be most appropriate for enhancing communication?

• 1. “I’ll examine you and figure out later what the problem is.”
• 2. “I don’t know what’s wrong. You could have almost any disease.”
• 3. “After 3 days, you’re tired of coughing. Have you had a fever?”
• 4. “I’d like to hear more about your experiences. Where were you born?”

Answer 179

3

The nurse has validated the client’s information, relayed empathy, and sought further knowledge. Asking where the client was born is pertinent. Saying that the client “could have almost any disease” might exacerbate the client’s anxiety. Telling the client that the problem will be figured out later relays a negative message to the client.