Comprehensive Final

Question 1

The nurse is attempting to provide comfort measure for the patient experiencing pain. When assessing the patient, the nurse must remember pain is:

Answer 1

Subjective for the patient.

Question 2

Which of the following useful tool for assessing the intensity of pain is easy to use?

Answer 2

Numeric pain scale.

Question 3

Mr. Levy, a 45 year old man, has experienced chronic low back pain since a fall 8 years ago. He describes his pain as a “gnawing, constant dull pain” that makes him feel tired. The nurse caring for him recognizes that one of the differences between acute and chronic pain is:

Answer 3

chronic pain is often described as dull and lasting for a long period of time.

Question 4

One of the general principles of pain management is:

Answer 4

anticipated or mild pain is easier to relieve than severe pain.

Question 5

A nurse attending a conference asks if anyone can give a definition of drug tolerance. The correct response is:

Answer 5

a potentially serious condition may go unnoticed.

Question 6

The term intractable pain means:

Answer 6

unrelieved, persistent pain.

Question 7

When administering a narcotic medication, the most important vital sign to assess first is:

Answer 7

respiration.

Question 8

The most common adverse reaction to NSAIDS is:

Answer 8

GI distress including nausea, vomiting and pain.

Question 9

Which of the following descriptions best defines the gate control theory?

Answer 9

only one impulse is transmitted at a time.

Question 10

Mary Dolan, age 50, has gallbladder disease. She is complaining of right shoulder pain. What type of pain is she experiencing?

Answer 10

referred.

Question 11

A 55 year old patient has diabetes. He has just had a below the knee amputation of his left leg. He is complaining of pain in his left leg. What term describes this pain?

Answer 11

phantom limb.

Question 12

Certain types of drugs act on higher centers of the brain to modify perception and reaction to pain. They are the cornerstone of managing moderate to severe acute pain. They are:

Answer 12

opioid analgesics.

Question 13

Identifying that pain may be intensified when combined with fatigue, sleep disturbances and depression, the nurse understands this relationship is termed:

Answer 13

synergistic.

Question 14

Regarding the pain, the nurse identifies onset, duration, and severity. These steps are which part of the nursing process with regard to pain management?

Answer 14

Assessment.

Question 15

When the nurse is assessing the patient for objective signs of pain, one might observe:

Answer 15

restless.
increased blood pressure.
moaning.

Question 16

Morphine like substances found in the pituitary of the brain is activated in times of stress and pain, and produce analgesic effects. These substances are called:

Answer 16

endorphins.

Question 17

The nurse can assist the patient in pain relief and should begin pain intervention as soon as the:

Answer 17

the patient states he/she is in pain.

Question 18

A non-narcotic analgesic used to treat mild pain might be:

Answer 18

Tylenol.

Question 19

A commonly prescribed over the counter NSAID used to treat pain is:

Answer 19

Ibuprofen.

Question 20

The rational for making pain the 5th vital sign is:

Answer 20

it makes pain visible and raises awareness.

Question 21

You are examining a patient’s lower leg and see a draining ulceration. Which one of the following actions is most appropriate in this situation?

Answer 21

Wash your hands, proceed with the rest of the physical examination, and then continue with the examination of the leg ulceration.

Question 22

You are bathing an 80-year-old man and you notice that his skin is wrinkled, thin, lax, and dry. Which on of the following would be related to these findings?

Answer 22

an increased loss of elastin and a decrease in subcutaneous fat occurs in the elderly.

Question 23

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. You will encourage her to stop trying to remove the corn with her scissors because of which one of the following?

Answer 23

she could be at risk for infection and lesions that are slow to heal because of her chronic disease.

Question 24

During a skin assessment, you notice that a Mexican-American patient has skin that is yellowish-brown in color. However, the skin on the hard/soft palate is also yellow in color. Which of the following conditions is most likely the cause of these assessment findings?

Answer 24

jaundice.

Question 25

A 65-year-old male with chronic obstructive pulmonary disease (COPD) has come to your clinic for a skin assessment. Which one of the following might you expect to find?

Answer 25

clubbing of the nails.

Question 26

You notice that Mr. W. has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. In your charting, which one of the following is the appropriate term for this lesion?

Answer 26

papule.

Question 27

Your patient’s mother has noticed that her son, who has been to a new babysitter, has some blisters and yellow-colored crusts on his face and buttocks. On examination, you notice moist, thin-roofed vesicles with an erythematous base. Which one of the following would you suspect?

Answer 27

impetigo contagiosa.

Question 28

Your patient has AIDS, and you are assessing his skin. You notice widely disseminated, violet-colored tumors covering the skin and mucous membranes. Which one of the following is the most appropriate conclusion?

Answer 28

he is in the advanced state of AIDS.

Question 29

A 45-tear-old farmer comes in for a skin evaluation and complains of hair loss on his head. He has noticed that his hair seems to be breaking off in patches and that he has some scaling on his head. Which one of the following would you suspect?

Answer 29

tinea capitis.

Question 30

A 40-year-old female reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. Which one of the following would be the most appropriate response?

Answer 30

report her symptoms to the physician due to the suspicion of melanoma.

Question 31

Decreased skin turgor or tenting is an expected finding in which one of the following conditions?

Answer 31

severe dehydration.

Question 32

A 52-year-old woman has a papule on her nose that has rounded pearly borders and a central red ulcer. She said she has noticed it for several months and it has slowly grown larger. What condition do you suspect?

Answer 32

basal cell carcinoma.

Question 33

Your patient, age 14, has been walking in the woods. He complains of severe pruritus. The nurse notes an erythematous area on his lower legs. Which one of the following interventions should the nurse do first?

Answer 33

wash area with copious amounts of water.

Question 34

Your patient, age 29, is diagnosed with genital herpes. She is receiving acyclovir (Zovirax). Which one of the following would indicate a therapeutic response?

Answer 34

decrease in pain.

Question 35

Your client has shedding, silvery white, scaling plaques on her shins and elbows. Which one of the following actions should be the first one taken by the nurse for treatment of psoriasis?

Answer 35

administer and instruct the client regarding daily soaks and tepid, wet compresses to the affected area.

Question 36

Which of the following is a risk factor for the development of decubitus ulcers?

Answer 36

immobility.

shearing and friction.

prolonged exposure to moisture.

nutrition.

Question 37

Your client has a sterile wet-to-dry dressing change ordered. After you remove the old dressing, you note a wound on the right heel of your client measuring 3 x 4 x 1 cm with a small amount of black eschar present in the base of the wound and visible muscle and tendons. There is purulent exudate present. Which of the following describes the stage of decubitus ulcer formation?

Answer 37

stage 4.

Question 38

Your client has sustained a burn to her left leg. The area has many large blisters and has a wet, shiny, mottled red base with weeping surface. She reports that it is quite painful. You recognize this as which one of the following burn depths?

Answer 38

partial thickness.

Question 39

Drug therapy in a client with SLE does not include which one of the following?

Answer 39

keratolytic agents.

Question 40

Mrs. P tells the nurse that she has not gone out of the house for weeks because she hasn’t been able to cover the lesions on her face with makeup. Based on this information, which of the following would be an appropriate nursing diagnosis?

Answer 40

disturbed body image R/T change in personal appearance.

Question 41

The nurse instructs a patient who has a drain in a surgical wound that his wound will heal by which of the following?

Answer 41

tertiary intention.

Question 42

The day following surgery, the nurse notes bloody drainage on the dressing. The nurse should document this type of drainage as which of the following?

Answer 42

sanguineous.

Question 43

When the nurse discovers that a gauze dressing has adhered to a wound, the nurse should do which of the following?

Answer 43

moisten it with sterile saline.

Question 44

The nurse follows the basic concept of wound irrigation when they direct the flow of the irrigant in which of the following ways?

Answer 44

from the area of least contaminated to most contaminated.

Question 45

The nurse is horrified to see a loop of bowel protruding from the surgical incision. Which of the following should be the initial action taken by the nurse?

Answer 45

cover the bowel with a sterile saline dressing.

Question 46

Because the physician has not ordered a dressing change for a draining wound, the nurse should assess the amount of drainage by doing which of the following?

Answer 46

circling and dating the outline of the exudate on the dressing.

Question 47

The nurse prepares a patient by telling him that a wet-to-dry dressing is applied wet and allowed to dry. Which of the following occurs as a result of adherence of the dressing to the wound after this drying process?

Answer 47

mechanical debridement.

Question 48

During assessment of the postoperative patient, the nurse discovers that the pulse is rapid, the blood pressure is lower, urinary output has decreased, and the dressing is dry. Which of the following does the nurse believe that this indicates?

Answer 48

internal hemorrhage.

Question 49

When the nurse assess that blood and fluid flow into the vascular space and produce edema, erythema, heat and pain, the nurse is aware that the phase of healing is which of the following?

Answer 49

inflammatory.

Question 50

In an attempt to keep the patient comfortable during a dressing change, when should the nurse best administer an analgesic?

Answer 50

at least 30 minutes before the change.

Question 51

Which of the following is the major advantage of primary intention over other phases of wound healing?

Answer 51

minimal scarring results.

Question 52

Suture removal may be done by the nurse. The nurse would explain to the patient that which of the following is the usual length of time before the sutures will be removed?

Answer 52

7 to 10 days.

Question 53

A patient has come to the PACU (post-anesthesia care unit) after hp replacement surgery. Following your assessment, you need to set up a plan of care. Which of the following nursing diagnoses would have the highest priority?

Answer 53

impaired skin integrity.

Question 54

The physician has ordered a sterile dry dressing change. Which of the following is the most appropriate way to cleanse the wound and surrounding area?

Answer 54

using an antiseptic swab, start from the incision outward, one stroke per swab, then allow to air dry.

Question 55

When removing staples from a surgical incision, which of the following interventions is most appropriate?

Answer 55

remove every other staple first and replace with steri-strips while monitoring that the incision remains closed.

Question 56

You are the nurse caring for a patient with a wound on the right arm. The wound is covered by a bandage. For which of the following sings would you most observe when assessing the skin distal to the bandage?

Answer 56

circulatory impairment.

Question 57

When classifying wounds, which of the following classifications results from the presence of gastrointestinal products?

Answer 57

contaminated.

Question 58

When caring for a pressure ulcer, which of the following is true?

Answer 58

eschar must be removed before the wound will heal.

Question 59

A wound that is infected is not immediately closed because the infection has to first be controlled. Tertiary intention results in the weaving together of a special tissue which develops as healing occurs. Which of the following is the name of this tissue?

Answer 59

granulation.

Question 60

Which one of the following is the major purpose for application of any dressing to a wound?

Answer 60

to absorb drainage.

Question 61

Nursing diagnosis for the post surgical patient may include all of the following except:

Answer 61

impaired stagnant column.

Question 62

Two considerations of the older adult surgical patient include:

Answer 62

pre and post operative teaching.

surgery causes much physiological stress.

Question 63

Which of the following is not a classification of surgery?

Answer 63

explanative.

Question 64

A preoperative patient is required to sign and informed consent. After the Doctor has explained the procedure to the patient, your responsibilities are?

Answer 64

to witness the patient’s signature on the consent form.

Question 65

When teaching post operative incentive spirometer exercises to the preoperative patient, your teaching should include:

Answer 65

practice breath control techniques.

teach the patient to examine sputum for consistency, amount and color changes.

have the patient return demonstration of the procedure.

Question 66

The primary reasons for using the incentive spirometer include all the following except:

Answer 66

to induce a collapsing of the lungs.

Question 67

Sudden chest pain combined with dyspnea, cyanosis, and tachycardia is an indication of:

Answer 67

pulmonary embolus.

Question 68

Which of the following patients would be at greatest risk during surgery?

Answer 68

27 year old taking an anticoagulant agent.

Question 69

Which of the following early postoperative observations is abnormal and should be reported immediately?

Answer 69

emesis that is red in color.

Question 70

A patient will have an incision in the lower abdomen. Which of the following measures by the nurse will help decrease discomfort in the incisional area when she coughs post operatively?

Answer 70

apply a pillow directly over the lower abdomen.

Question 71

Although informed about the proposed surgical procedure, the patient has only vague responses about the post-operative period. A nursing diagnosis at this time would be:

Answer 71

deficient knowledge, post operative.

Question 72

A patient and a nurse develop a preoperative teaching plan. In teaching the patient to cough effectively after surgery, the nurse should tell her to practice:

Answer 72

taking three deep breaths and coughing from the chest.

Question 73

What is the responsibility of the nurse regarding informed consent?

Answer 73

obtain the patient’s signature.

Question 74

Guidelines for ensuring that all nursing interventions are completed on the day of surgery are located on which document?

Answer 74

preoperative checklist.

Question 75

The patient is a 38 year old and is in her second post operative day after surgery on her left femur. She is receiving analgesia via a patient-controlled analgesia (PCA) device. Which of the following is not a nursing intervention related to the use of a PCA?

Answer 75

administering analgesia to the patient.

Question 76

Which of the following nursing interventions would be appropriate after a wound evisceration?

Answer 76

apply a moist normal saline sterile dressing.

Question 77

A 45 year old patient has had a repair of a cerebral aneurysm and is presenting signs of increased intracranial pressure (ICP). Which of the following post operative nursing interventions would be contraindicated?

Answer 77

coughing every 2 hours.

Question 78

A male patient, age 80, has had a total hip replacement. Anxiety, hypotension, and jarring during transfer from the recovery room to his room can cause a post operative increase in which of his vital signs?

Answer 78

pulse rate.

Question 79

Your patient is on her second post operative day. The nurse is aware that the most effective way to increase her peristalsis is?

Answer 79

ambulation.

Question 80

A patient is transferred from the operating room to the recovery room after undergoing an open reduction and internal fixation (ORIF) of his left ankle. Which is the first assessment to make?

Answer 80

check airway for patency.

Question 81

Frequent assessment of a post operative patient is essential. One of the first signs and symptoms of hemorrhage may be:

Answer 81

restlessness.

Question 82

Surgery is performed for various purposes, which include all the following except:

Answer 82

retentive.

Question 83

A 73 year old patient with diabetes was admitted for below the knee amputation of his right leg. Removal of his right leg is an example of which type of surgery?

Answer 83

ablative.

Question 84

The Patient’s Bill of Rights states that a patient must give his or her permission for any specific test or procedure to be performed. What is the legal term for this permission?

Answer 84

informed consent.

Question 85

An informed consent was to be obtained from the patient scheduled for surgery. Which of the following circumstances could prevent him from signing his informed consent?

Answer 85

an injection of Demerol 75mg IM, 1 hour ago.

Question 86

The anesthesiologist provides this type of anesthesia by inhalation and IV administration routes:

Answer 86

general.

Question 87

A type of anesthesia which requires a depressed level of consciousness is?

Answer 87

conscious sedation.

Question 88

The older adult patient may not respond to surgical treatment as well as a younger adult because of:

Answer 88

his or her body’s response to physiological anesthesia.

Question 89

Decreased activity in an obese surgical patient predisposes the patient to which complication?

Answer 89

pneumonia.

Question 90

A patient, age 65, underwent open abdominal surgery one week ago. Her surgical wound dehisced. This means:

Answer 90

there is a partial or complete wound separation.