Exam 3 Flashcards
(270 cards)
1
Q
The nurse is preparing hydrochlorothiazide 50-mg tablet from unit stock. The health care provider orders 75 mg of hydrochlorothiazide PO for the client’s hypertension. How many tablets of hydrochlorothiazide will the nurse administer to the client?
A
1.5 tablets
2
Q
The client is prescribed digoxin 0.125 mg PO every day. The nurse obtains the medication from unit stock and discovers that digoxin only comes in a 0.25-mg tablet. How many tablets of digoxin should the nurse administer to the client?
A
0.5 tablet
3
Q
The nurse has administered a client’s medication. Which action would be most appropriate if the client vomits immediately, or soon after administration?
A
Check the vomit/emesis for pills or pill fragments and call the client’s health care provider.
4
Q
The nurse prepares the client’s nightly medication doses and needs to administer an as needed dose of a hypnotic medication for sleep. The sleep medication is in a unit-dose package. What action does the nurse take?
A
Open the package after the client confirms the dose is wanted.
5
Q
The nurse is preparing to administer a sublingual medication. Which instruction to the client is correct?
A
“Try not to swallow while the pill dissolves.”
6
Q
The nurse is preparing a liquid medication for a client. The health care provider prescribes cimetidine hydrochloride 600 mg PO for gastrointestinal bleeding. The pharmacy sends cimetidine hydrochloride 300 mg/5 mL. How many teaspoons should the nurse administer?
A
2 teaspoons
7
Q
The nurse is administering routine medications to a postsurgical client and the client asks, “Could I have something for pain?” The nurse checks the medication administration record (MAR) and notes that the medication is an opioid. What should the nurse do?
A
Place the opioid into a separate cup.
8
Q
Which route of medication administration is most commonly prescribed?
A
Oral
9
Q
A nurse is preparing several oral medications for administration. One of the medications requires the nurse to obtain the client’s apical pulse before administering it. Which action would be most appropriate?
A
Placing the medication requiring the assessment in a separate medication cup.
10
Q
The nurse administers the client’s scheduled morning medications. The previous dose of antihypertensive was held due to a blood pressure that was too low according the health care provider’s parameters. What does the nurse do with this scheduled unit-dose packaged antihypertensive medication?
A
Set the antihypertensive dose aside pending assessment.
11
Q
The nurse opens the multidose container of oxycodone. The nurse needs 1.5 tablets to deliver the as needed dose, and the tablets in the container are not scored. What action by the nurse is best?
A
Call the pharmacy to request a supply change.
12
Q
When administering medications to a client, what information should the nurse know about the medication?
A
Adverse effects, purpose, safe dose range, action
13
Q
A nurse is measuring a liquid medication in a graduated liquid medication cup. The nurse determines the correct amount by reading:
A
The bottom of the meniscus.
14
Q
The nurse is preparing to administer a transdermal medication. Which placement is appropriate?
A. Inner aspect of the forearm.
B. Posteriorly on the shoulder.
C. Site of the client’s discomfort.
D. Anteriorly over the sternum.
A
B. Posteriorly on the shoulder.
15
Q
The nurse teaches the client about home use of a transdermal medication patch for pain. The nurse evaluates the teaching as effective when the client makes which statement?
A. I should place this patch over my back where the pain is worst.”
B. “If the dose feels too high, I can cut the next patch in half to use.”
C. “The patch is replaced whenever I feel the medication effects diminishing.”
D. “I can’t use my heating pad in the same area as the patch.”
A
D. “I can’t use my heating pad in the same area as the patch.”
16
Q
The new nurse places a transdermal medication patch on a client. The preceptor stops the new nurse for which action?
A. Wears gloves to remove old patch.
B. Writes date on medication patch.
C. Applies patch to flank skin.
D. Presses the patch onto the skin.
A
B. Writes date on medication patch.
17
Q
The nurse is preparing to apply a new transdermal patch to a client’s chest. What would the nurse do first?
A. Wash the area of the old patch with soap and water.
B. Initial and write the date and time on the label of the new patch.
C. Remove the old patch from the client’s skin.
D. Remove the new patch from its protective covering.
A
C. Remove the old patch from the client’s skin.
18
Q
The nurse is preparing to administer a transdermal medication. How should the nurse proceed?
A. Inject the medication into a body cavity.
B. Apply the medication directly to the skin.
C. Ask the client to swallow the medication.
D. Inject the medication just below the dermis of the skin.
A
B. Apply the medication directly to the skin.
19
Q
The nurse is administering prescribed eye drops to a client. What action would cause the nurse to stop the administration?
A. The dropper touches the client’s eyelid.
B. The drops fall into the lower conjunctival sac.
C. The client looks upward at the ceiling.
D. The client blinks while administering the eye drops.
A
A. The dropper touches the client’s eyelid.
20
Q
What instructions should the nurse give a client following the administration of prescribed eye drops? Select all that apply.
A. “Do not rub the medicated eye(s).”
B. “Damage may occur if you touch the dropper to the eye.”
C. “Allow the drops to flow into the other eye.”
D. “Apply gentle pressure to the inner canthus hourly.”
E. “Wash your hands before and after you use the eye drops.”
A
A. “Do not rub the medicated eye(s).”
B. “Damage may occur if you touch the dropper to the eye.”
E. “Wash your hands before and after you use the eye drops.”
21
Q
Prior to the nurse administering eye drops to the client, what should the nurse do?
A. Clean the eyelids of any loose eyelashes.
B. Have the client focus downward toward the dropper.
C. Ask the client to blink several times.
D. Tell the client to rub the eye.
A
A. Clean the eyelids of any loose eyelashes.
22
Q
The nurse is preparing to administer eye drops to a client. What purposes are commonly associated with instilling medications via eye drops? Select all that apply.
A. Infection treatment
B. Pupil constriction
C. Control of intraocular pressure
D. Pupil dilation
E. Allergy testing
A
A. Infection treatment
B. Pupil constriction
C. Control of intraocular pressure
D. Pupil dilation
23
Q
The nurse is administering eye drops to a client. Where should the nurse place the drops?
A. Cornea
B. Lower conjunctival sac
C. Outer eyelid margin
D. Inner canthus
A
B. Lower conjunctival sac
24
Q
The nurse is preparing to administer ear drops to an adult client. In what direction would the nurse position the pinna?
A. Laterally toward the skull base
B. Up and back
C. Down and forward
D. Outward, away from the nose
A
B. Up and back
25
The client is prescribed ear drops to be given in both ears. After administering the ear drops in one ear, how long would the nurse wait before administering the ear drops in the other ear?
A. 10 minutes
B. 15 minutes
C. 5 minutes
D. 20 minutes
C. 5 minutes
26
After administering ear drops to a client, how does the nurse ensure the medication is delivered completely?
A. Place gentle pressure on the tragus after administration.
B. Straighten the ear canal during administration.
C. Place the client's head to the side prior to administration.
D. Ensure the dropper does not touch the ear during administration.
A. Place gentle pressure on the tragus after administration.
27
The nurse is preparing to administer ear drops to a 2-year-old client. The nurse would pull the pinna in which direction?
A. Laterally toward the skull base
B. Up and back
C. Down and backward
D. Outward, away from the nose
C. Down and backward
28
The nurse is teaching a parent how to administer ear drops to a 3-year-old client with an ear infection. What instructions should the nurse give the parent?
A. "Keep the drops refrigerated until just before you administer and apply the drops onto a cotton ball then insert into the ear."
B. "Pull the child's pinna up and backward to straighten the ear canal before administration of the drops."
C. "Have the child lie down with the affected ear facing the ceiling while administering the drops and then wait for 5 minutes after the drops are in."
D. "Administer the eardrops while holding the dropper 2 to 3 in (5 to 7.5 cm) above the ear canal."
C. "Have the child lie down with the affected ear facing the ceiling while administering the drops and then wait for 5 minutes after the drops are in."
29
The nurse is teaching a client how to use nasal spray. What will the nurse include in the teaching plan? Select all that apply.
A. Tilt the head slightly forward.
B. Insert the tip of the nose piece into one nostril.
C. Hold the breath for a few seconds after administering the spray.
D. Sit up comfortably in the bed.
E. Blow the nose 1 minute after administering the spray.
B. Insert the tip of the nose piece into one nostril.
C. Hold the breath for a few seconds after administering the spray.
D. Sit up comfortably in the bed.
30
A nurse has just administered a medication to client via nasal spray. The nurse instructs the client to refrain from blowing the nose for a minimum of how long?
A. 30 seconds
B. 1 minute
C. 5 minutes
D. 3 minutes
C. 5 minutes
31
What instruction will the nurse include when teaching a client how to administer nasal drops?
A. Hold the dropper just above the nostril to administer the drops.
B. Administer drops when in a supine position to improve absorption.
C. Tilt the head forward and blow the nose after administering the drops.
D. Breathe in deeply through the nose when administering the drops
A. Hold the dropper just above the nostril to administer the drops.
32
The nurse has just completed administering a nasal spray to a client. What should the nurse do next?
A. Evaluate client for level of discomfort.
B. Assess the client for any allergies.
C. Assess the client's nose for any drainage.
D. Evaluate client for medication effectiveness.
D. Evaluate client for medication effectiveness.
33
The nurse caring for a client has just inserted a rectal suppository. What is the best instruction by the nurse at this time?
A. "You can go home now."
B. "Remain in horizontal position for 10 to 20 minutes."
C. "You may go to the bathroom as soon as you feel the urge."
D. "Sit up and hold it as long as you can."
B. "Remain in horizontal position for 10 to 20 minutes."
34
When administering a rectal suppository, in which position would the nurse position the client?
A. Supine
B. Prone
C. Side-lying
D. Semi-Fowler's
C. Side-lying
35
The nurse is inserting a medication via a rectal suppository to a client. What would the nurse instruct the client to do?
A. Inhale for a count of 10.
B. Hold the breath.
C. Take slow, deep breaths.
D. Use panting breaths.
C. Take slow, deep breaths.
36
The nurse is preparing to administer a rectal suppository to an adult client. How many inches (or centimeters) should the nurse plan to insert the suppository?
A. 3 inches (7.5 cm)
B. 2 inches (5 cm)
C. 5 inches (12.5 cm)
D. 1 inch (2.5 cm)
A. 3 inches (7.5 cm)
37
The nurse is caring for an adult client by inserting a rectal suppository. Which action would be most appropriate by the nurse?
A. Insert the suppository to a depth of about 1 inch (2.5 cm).
B. Lubricate the suppository and gloved finger.
C. Insert the suppository's flat end first.
D. Encourage the client to remain still for about 30 minutes.
B. Lubricate the suppository and gloved finger.
38
Adequate studies in pregnant people have not demonstrated a risk to the fetus in the first trimester of pregnancy, and there is no evidence of risk in later trimester. This is category ____.
A
39
This is an example of which category? Animal studies have not demonstrated a risk to the fetus, but there are no adequate studies in pregnant people, or animal studies have shown an adverse effect, but adequate studies in pregnant people have not demonstrated a risk to the fetus during the first trimester of pregnancy, and there is no evident of risk in later trimesters.
B
39
Animal studies have shown an adverse effect on the fetus, but there are no adequate studies in humans; the benefits from the use of the drug in pregnant people may be acceptable despite its potential risks, or there are no animal reproduction studies and no adequate studies in humans. This is category ____.
C
40
This explains category _____. There is evidence of human fetal risk, but the potential benefits from the use of the drug in pregnant people may be acceptable despite its potential risks.
D
41
Studies in animals or humans demonstrate fetal abnormalities or adverse reactions; reports indicate evidence of fetal risk. The risk of use in a pregnant women clearly outweighs any possible benefit. This is an example of category ___.
X
42
Category ____ is least harmful and category ___ is the most harmful.
A; X
43
Explain schedule I.
High abuse potential and no accepted medical use (heroin, LSD).
44
High abuse potential with severe dependence liability (narcotics, amphetamines, and barbiturates). This is explaining schedule ___.
II
45
Less abuse potential than schedule II drugs and moderate dependence liability (nonbarbiturate sedatives, nonamphetamine stimulants). This explains schedule ___.
III
46
What is schedule IV?
Less abuse potential than schedule III and limited dependence liability (some sedatives, antianxiety agents, and nonnarcotic analgesics).
47
Schedule ___ is limited abuse potential. Primary small amount of narcotics used as antitussives or antidiarrheals.
V
48
Schedule I is the ____ addictive and schedule V is the ____ addictive.
Most; least
49
_____ is the study of interactions between the chemical components of living systems and foreign chemicals.
Pharmacodynamics
50
What is pharmacokintetics?
The study of how medications travel through the body. This includes absorption, distribution, metabolism, and excretion of drugs.
51
The ____ _____ is the ratio of the blood concentration at which a drug becomes toxic to the concentration at which the drug is effective.
Therapeutic index.
52
_____ ____ is used if a drug is needed to get to the patient quickly.
Loading dose.
53
_______ is what happens to the drug from the time it is introduced to the body until it reaches the circulating fluids and tissue.
Absorption
54
The route of administration influences _____.
Absorption
55
Passive diffusion, active transport, and filtration are apart of the _____ process.
Absorption
56
Explain passive diffusion.
Is like a natural, easy movement of tiny particles from one place to another, and it does not require energy.
57
Explain active transport.
Its a process in your body where your cells use energy to move things around.
58
Active transport allows your body to ____ and _____ the levels of specific substances.
Control and regulate.
59
Filtration is a natural way your body ____ _____.
Separates things.
60
Distribution involves the _____ of a drug to the body's ______.
Movement; tissues
60
Why is filtration so importnt?
Because it helps your body get rid of waste and keep what is needed.
60
What is protein binding?
The more bound to the protein, the more difficult it can be for the medication to be released and to cross the membrane to get to the tissue cells. The drug must be freed from the proteins binding site to act on the tissue. Some drugs are tightly bound and are released very slowly. Some drugs are loosely bound and tend to act quickly and be excreted quickly.
61
A nurse has administered a dose of a drug that is known to be highly protein bound. What are the implications of this characteristic?
A. The client must consume adequate protein in order to achieve a therapeutic effect.
B. The molecules of the drug that are bound to protein are inactive and do not affect body cells.
C. Increased levels of serum protein will increase the effect of the drug.
D. Each molecule of the drug must bind to a protein molecule to become effective
B. The molecules of the drug that are bound to protein are inactive and do not affect body cells.
62
The blood-brain barrier is protective system of cellular activity that keeps many things away from the _____ _____ _____.
Central nervous system
63
What is the first-pass effect?
Its a process that occurs in the liver after the drug is absorbed from the GI tract. It refers to the fact that some of the drug is broken down before it even reaches the bloodstream.
64
Not all drugs are ____ in the same way.
Excreted.
65
_____ ____ is the time it takes for the drug in your body to decrease by one half of its peak level.
Half life.
66
Your patient is taking 50 mg of a medication with a half-life of 12 hours. How long will it take for the drug to be out of the patients system?
It would take about 9 half-lives or about 4.5 days.
67
After a discussion about the half-life of a drug, a nursing instructor concludes further teaching is necessary when nursing students choose which facts as true? Select all that apply.
A. It can be decreased in clients with renal disease.
B. It can help determine dosing frequency.
C. It does not change throughout a client's life.
D. Liver disease can increase half-life.
E. It is the measure of the rate at which drugs are removed from the body.
A. It can be decreased in clients with renal disease.
C. It does not change throughout a client's life.
68
What are factors that affect the body's response to a drug?
Weight, age, sex, physiological factors, pathological factors, immunological factors, psychological factors, environment factors, drug intolerance, accumulation effects, and interactions.
69
A patient who has kidney impairment may not be able to excrete the drug and may accumulate the drug in the body, this causes ____ _____.
Toxic effects
70
What are the four classifications for drug allergies?
Type I, type II, type III, and type IV.
71
What is type I classification for drug allergies?
Immediate hypersensitivity disorders.
72
Antibody-mediated disorders falls under which classification for drug allergies?
Type II.
73
Type III classification for drug allergies is....
Immune complex-mediated disorders.
74
Which classification for drug allergies is cell-mediated hypersensitivity disorders?
Type IV
75
A client is receiving antibiotics for treatment of infection. The nurse should assess for what potential indications of superinfection? Select all that apply.
A. Fever
B. Glossitis
C. Joint pain
D. Difficulty swallowing
E. Epistaxis
A. Fever
B. Glossitis
76
Drugs can produce a wide variety of effects in addition to the desired pharmacological effect. Sometimes the drug dose can be adjusted so that the desired effect is achieved without producing undesired secondary reactions. Which are examples of this secondary action? Select all that apply.
A. Spontaneous bleeding after taking warfarin (Coumadin)
B. Reports of dizziness after starting amlodipine (Norvasc)
C. Reports of drowsiness after taking an diphenhydramine (Benadryl)
D. Diarrhea after taking cefuroxime (Ceftin)
C. Reports of drowsiness after taking an diphenhydramine (Benadryl).
D. Diarrhea after taking cefuroxime (Ceftin).
77
How long does acute pain last?
30-60 days
78
What is chronic pain?
Lasts longer than 3-6 months; constant or intermittent pain.
79
What are some examples of somatic pain?
Strained muscle or sprain.
80
_____ pain originates in tendons, ligaments, blood vessels, and nerves.
Somatic
81
Somatic pain responds well to mild _____.
Analgesics
82
Gastroenteritis and appendicitis are example of _____ pain.
Visceral
83
Where does visceral pain originate?
Internal organs and linings of body cavities in the cranium, chest, abdomen, and pelvic area.
84
Which type of pain responds well to opioids?
Visceral pain.
85
What is an example of referred pain?
When you have cardiac pain it radiates to the left arm.
86
What are some examples of deafferentation pain?
Phantom pain, poststroke pain, or pain after spinal cord injury.
87
______ ______ pain is associated with dysregulation of the autonomic nervous system.
Sympathetically maintained
88
What is an example of sympathetically maintained pain?
Complex regional pain syndrome.
89
is pain felt along the distribution of many peripheral nerves.
Peripherally generated pain.
90
What are some examples of peripherally generated pain?
Diabetic neuropathy, alcohol nutritional neuropathy, some types of neck, shoulder, and back pain, and pain of Guillain-Barre syndrome.
91
Usually associated with a known peripheral nerve injury. Pain is felt at least partly along the distribution of the damaged nerve.
Painful mononeuropathies
92
Nerve root compression, nerve entrapment, trigeminal neuralgia. Some neck, shoulder, and back pain. These are example of what type of pain?
Painful mononeuropathies
93
The nurse is caring for a client who had a below-the-knee amputation to the left leg 8 months ago. The client is reporting left foot pain of 7 on a 1-to-10 scale. The pain began earlier today. How will the nurse document this type of pain? Select all that apply.
A. Somatic
B. Visceral
C. Referred
D. Neuropathic
E. Acute
D. Neuropathic
E. Acute
94
A nurse is assessing an adult client with back pain. The client is unable to speak the dominant language. Which pain scale is most appropriate for the nurse to use?
A. PAINAD scale
B. 0 to 10 numeric rating scale
C. CPOT scale
D. FLACC scale
B. 0 to 10 numeric rating scale
95
A client is prescribed pain medication every 4 to 6 hours as needed. When the nurse enters the client's room to administer the medication, the client is laughing with visitors. The client's pulse rate is 64, respirations 16, and blood pressure 120/80. The client reports pain and wants the medication. What is the most appropriate action by the nurse?
A. Hold the pain medication at this time.
B. Administer the pain medication.
C. Reassess the need for pain medication in 30 min.
D. Encourage the client to use alternative pain relief measures.
B. Administer the pain medication.
96
A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse?
A. Assess for medication prescription for breakthrough pain.
B. Tell the client he or she will have to wait for 1 hour.
C. Administer the next dose of the pain medication.
D. Assess the client for signs of opioid addiction.
A. Assess for medication prescription for breakthrough pain.
97
What is a PCA?
A button the patient pushes to receive a prescribed dose of analgesic at a set time interval.
98
What is a basal rate?
A continuous rate being given to the patient.
99
The nurse is caring for a client receiving opioid therapy and notes that the client's respirations are 7. What is the first action by the nurse?
A. Tell the client loudly to breathe.
B. Take the client's blood pressure.
C. Begin cardiac compressions.
D. Administer naloxone.
D. Administer naloxone.
100
A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. When assessing the client, she notes that his respiratory rate is 4. What should the nurse do first?
A. Notify the health care provider.
B. Stop the PCA pump.
C. Administer naloxone.
D. Increase the primary IV rate.
B. Stop the PCA pump.
101
Chronic insomnia occurs at lease _____ times per week and persists for ____ months.
3; 3
102
The nurse is teaching a preoperative client how to cough following a surgical procedure. Which statement accurately describes a step in this procedure?
A. Inhale and exhale three times, inhale and hold the breath for three seconds, and lightly cough three times.
B. Inhale and hold the breath for five seconds; let the breath out in five short coughs.
C. Inhale and hold the breath for five seconds; let the breath out in five deep hacking coughs.
D. Inhale and exhale five times, inhale and hold the breath for three seconds, and lightly cough five times.
A. Inhale and exhale three times, inhale and hold the breath for three seconds, and lightly cough three times.
103
When initiating deep-breathing exercises for a postoperative client, what would be the nurse's instructions for the first breath?
A. Exhale first and breathe in through the mouth.
B. Exhale first and breathe in through the nose.
C. Inhale deeply and exhale through pursed lips.
D. Inhale through the mouth and exhale through the nose.
B. Exhale first and breathe in through the nose.
104
The nurse is teaching deep-breathing exercises to a client who is undergoing thoracic surgery. In what position would the nurse place the client for these exercises?
A. Fowler's
B. Trendelenburg
C. Side-lying
D. Prone
A. Fowler's
104
The nurse is teaching a preoperative client how to perform deep-breathing exercises. What is the next step the client would take after exhaling first and breathing in through the nose?
A. Breathe out through the mouth and inhale again through the nose.
B. Hold the breath for ten seconds and exhale through pursed lips.
C. Hold the breath for five seconds and exhale through pursed lips.
D. Breathe out through the nose and inhale again through the mouth.
C. Hold the breath for five seconds and exhale through pursed lips.
104
A nurse is explaining to a client about coughing following surgery. Which teaching statements follows the recommended guidelines?
A. "Try not to cough following surgery as it might disrupt your stitches."
B. "If you cough, turn your head away from the incision to protect it from microorganisms."
C. "When coughing, apply firm pressure on the incision with a bath blanket to minimize discomfort."
D. "If you need to cough, try to cough as lightly as possible so your incision will not be disturbed."
C. "When coughing, apply firm pressure on the incision with a bath blanket to minimize discomfort."
105
The nurse is teaching a preoperative client how to perform deep-breathing exercises. How many times and how often would the client be instructed to perform these exercises following surgery?
A. Two times, every one to two hours.
B. Three times every one to two hours.
C. Three times every three to four hours.
D. Two times every three to four hours
B. Three times every one to two hours.
106
The nurse is teaching a client about splinting and coughing postoperatively. What position would the nurse teach the client to assume for coughing?
A. Lying flat on the side.
B. Sitting up and leaning forward.
C. Sitting up partially reclined.
D. Lying flat on the back.
B. Sitting up and leaning forward.
107
The preoperative nurse is teaching a client about deep-breathing exercises. The client asks, "Why do I need to learn about this?" Which response by the nurse is correct?
A. "After surgery, deep-breathing exercises help to remove anesthetic gasses and mucus and improve oxygen supply to body tissues."
B. "These types of exercises help distract you from the postoperative pain."
C. "These techniques will prevent trapped air from accumulating in your lungs."
D. "If you learn how to perform these exercises correctly, you will not need supplemental oxygen during surgery."
A. "After surgery, deep-breathing exercises help to remove anesthetic gasses and mucus and improve oxygen supply to body tissues."
108
The nurse is caring for a postoperative client after abdominal surgery. Why is it important to splint the client's incision during coughing exercises?
A. It will decrease risk of postoperative pneumonia.
B. It will ensure that no incisional bleeding will occur.
C. It will decrease risk of incisional infection.
D. It will support the incision and decrease pain
D. It will support the incision and decrease pain
109
The nurse is caring for a client who had abdominal surgery yesterday and is reluctant to cough and perform deep breathing. Which strategy will most likely increase the client's willingness to cough and perform deep breathing?
A. Assist the client to a side-lying position to cough.
B. Remind the client of the serious complications that can result from ineffective coughing and deep breathing.
C. Teach the client how to splint the abdomen while coughing.
D. Administer respiratory treatments to encourage coughing.
C. Teach the client how to splint the abdomen while coughing
110
The nurse is teaching a preoperative client how to perform deep-breathing exercises after back surgery. What is the best method to ensure that the client understands the procedure?
A. Follow up with printed materials.
B. Have the client watch a video of the procedure.
C. Ask the client's family to describe the procedure.
D. Ask the client for a return demonstration.
D. Ask the client for a return demonstration.
111
After positioning the client to teach deep-breathing exercises, the nurse asks the client to place the hands on the rib cage. What is the rationale for this action?
A. To feel the lungs collapse.
B. To feel the chest rise.
C. To feel the chest lower.
D. To protect the surgical incision.
B. To feel the chest rise.
112
Which postoperative complications can be reduced by appropriate client teaching about deep-breathing exercises? Select all that apply.
A. Pneumonia
B. Severe hypoxemia
C. Deep vein thrombophlebitis
D. Bronchitis
E. Wound infection
F. Atelectasis
A. Pneumonia
B. Severe hypoxemia
D. Bronchitis
F. Atelectasis
113
A nurse is assisting a surgeon who will be placing a hollow, open-ended rubber tube in a client with an abscess to drain the wound. This drain will be placed such that one end will be in the abscess and the other will pass through an opening in the skin known as a stab wound. The nurse recognizes that which type of drain is needed?
A. Hemovac drain
B. Jackson–Pratt drain
C. Penrose drain
D. T-tube drain
C. Penrose drain
114
What is the best way for the nurse to clean the wound site in a client with a Penrose drain?
A. in a wedge pattern from pin site to outer edge of wound and repeat
B. in a circular motion beginning at the pin site and moving outward toward the edge of the wound
C. in a circular motion beginning at the outer edge of the wound and moving in toward the pin site
D. in an up-and-down pattern beginning on left side of pin and then to right side
B. in a circular motion beginning at the pin site and moving outward toward the edge of the wound
115
The nurse need to place a dressing under and around a Penrose drain. Which dressing would be best for the nurse to obtain?
A. A precut 4 × 4 sterile drain sponge
B. Roll of sterile prewoven gauze
C. Nonadherent petrolatum dressing gauze
D. Sterile 2 × 2 gauze sponge
A. A precut 4 × 4 sterile drain sponge.
116
When removing the old dressing from the site of a Penrose drain, the nurse notes that some of the dressing material has stuck to the client's skin. What action should the nurse take next?
A. Gently pull the dressing material off the client's skin and observe for irritation.
B. Administer an analgesic to the client and warn the client this may be a little painful.
C. Apply sterile saline to loosen the dressing material from the skin.
D. Use an alcohol based adhesive remover to aid in removal of the dressing.
C. Apply sterile saline to loosen the dressing material from the skin.
117
The nurse is caring for a client who has a Penrose drain. On assessment, the nurse notes that there is a safety pin on the drain just outside the wound incision area. What action should the nurse take related to this finding?
A. Obtain a wound culture to test for possible infection.
B. Document the presence and location of the safety pin.
C. Notify the health care provider of the finding at the incision site.
D. Remove the safety pin and clean with an antiseptic preparation.
B. Document the presence and location of the safety pin.
118
How would the nurse secure a Jackson–Pratt drain after emptying it?
A. With a safety pin, secure the drain to the client's gown above the wound.
B. With a safety pin, secure the drain to the side of the bedding.
C. With a safety pin, secure the drain to the client's gown below the wound.
D. With tape, secure the drain to the client's gown above the wound.
C. With a safety pin, secure the drain to the client's gown below the wound.
119
The nurse is caring for a client with a Jackson–Pratt drain. Which intervention by the nurse is priority before beginning the dressing change?
A. Assessing the need for analgesia
B. Gathering the needed supplies
C. Checking the client's latest laboratory values
D. Assessing the client's need to void
A. Assessing the need for analgesia
120
What is the best way for the nurse to ensure there is not any tension on the tubing when caring for a client with a Jackson–Pratt drain?
A. Tape the drain to the dressing material securely below the level of the wound.
B. Allowed the Jackson–Pratt drain to hang freely to avoid any kinks in the tubing.
C. Secure the drain to the client's gown with a safety pin below the level of the wound.
D. Apply an abdominal binder over the entire wound and drain to support the site
C. Secure the drain to the client's gown with a safety pin below the level of the wound.
121
The nurse is caring for a client's wound that has a Jackson–Pratt drain in place. What would be the nurse's next step after emptying the chamber's contents into the graduated collection container?
A. Put on clean gloves.
B. Fully compress the chamber.
C. Replace the cap on the chamber.
D. Use a gauze pad to clean the outlet.
D. Use a gauze pad to clean the outlet.
122
How often will the nurse empty a Jackson–Pratt drain? Select all that apply.
A. When the drain is one-half to two-thirds full
B. At least every 4 hours
C. Only when the drain is full
D. At least every shift
E. Once every 24 hours
A. When the drain is one-half to two-thirds full
B. At least every 4 hours
123
After emptying the drainage from a Jackson–Pratt drain, how will the nurse re-establish suction to the drain?
A. This type of drain does not use suction.
B. Turn the suction back on at the wall unit.
C. Reapply the cap and fully compress the bulb.
D. Fully compress the bulb and reapply the cap.
D. Fully compress the bulb and reapply the cap.
124
The nurse has emptied the drainage from a Hemovac drain. How will the nurse re-establish the suction?
A. Recap the drain and keep tubing to gravity.
B. Turn the suction back on at the wall outlet.
C. Fully compress the drain and reapply the cap.
D. Milk and then clamp the drain tubing.
C. Fully compress the drain and reapply the cap.
125
After emptying a client's Hemovac drain, the nurse re-establishes suction and closes the cap. Which action would the nurse do next?
A. Change the dressing at the drain site.
B. Perform hand hygiene.
C. Measure the amount of drainage in the graduated container.
D. Secure the drain to the client's gown below the level of the wound.
D. Secure the drain to the client's gown below the level of the wound.
126
A nurse is gathering the necessary equipment to empty a client's Hemovac drain. Which personal protective equipment (PPE) would be most essential for the nurse to use at a minimum?
A. Clean gloves
B. Gown
C. Mask
D. Face shield
A. Clean gloves
127
A client has undergone surgery and has a Hemovac drain in place. When providing care to this client, the nurse would monitor the drain status at which frequency?
A. Every 8 hours
B. Every 4 hours
C. Every 2 hours
D. Every hour
B. Every 4 hours
128
What is the first thing you do when a patient returns from surgery?
Vital signs. Observe color and level of consciousness.
129
Inflammation of the alveoli is _____.
Pneumonia
130
What helps causes pneumonia?
- Not breathing right.
- Immobility and impaired ventilation cause the lungs aren't moving in a clearing as much and possibly promoting pathogen growth in the lungs.
131
Increase in drainage, sickness, mucus, sputum. Dyspnea, lower spo2, temperature, cough, and possible chest pain are all signs and symptoms of.....
Pneumonia
132
What are some things to prevent pneumonia?
- Deep breathing and coughing.
- Incentive spirometer.
- Encourage ambulation.
- If they will not walk sit them up.
133
What is atelectasis?
When alveoli collapse and are not ventilated. Its reducing the lung expansion.
134
______ can lead to pneumonia.
Atelectasis
135
Analgesics, immobility, increased mucus can cause ____. This is not due to an infection.
Atelectasis
136
What are signs and symptoms of atelectasis?
Dyspnea, tachypnea, tachycardia, anxiety, pleural pains, decreased chest wall movement, dull or absent breath sounds.
137
What are some ways to prevent or treat atelectasis?
Deep breathing exercises, coughing, and early ambulation.
138
_____ is where you have a decreased amount of fluid in the body.
Hypovolemia.
139
What causes hypovolemia?
Blood loss
140
Decreased oxygen saturations, low blood pressure, increased pulse, and decreased urine output are S/S for _____.
Hypovolemia
141
Hypovolemia affects your ____ system.
Circulatory
142
Hypovolemia can be caused by ____.
Hemorrhaging
143
What are some ways to prevent hypovolemia?
Fluid replacement IV and oral, may actually give blood if needed, iron, increase water intake the week before surgery.
144
What is hemorrhaging?
Internal or external bleeding.
145
What are signs and symptoms of hemorrhaging?
Paleness, shortness of breath, increased respirations, increased pulse. Might be having to reinforce the dressing a lot or lots of drainage from the drains. Watch for hematomas (bruises) and swelling around the incision.
146
What is the treatment for a hemorrhage?
Going back to surgery to fix the bleeding. After they fix the problem replace the blood.
147
What is a thrombus?
A localized blood clot.
148
What is an embolus?
A blood clot that has shifted or moved into another part of the area.
149
Pulmonary embolism is when a blood clot.......
moves from one part of the body into the lungs.
150
What are some causes of thrombus or embolus?
Immobility, having vascular disease, high cholesterol, being off blood thinners for surgery.
151
Cramping pain, swelling to a certain area, and discomfort are all signs of a _____ or ____.
Thrombus or Embolus
152
What are some preventions for a thrombus or embolus?
Early ambulation, leg exercises, range of motion in bed, ted hose, adequate fluid intake.
153
How can you prevent constipation?
Early ambulation, increase oral and IV fluids, start them on stool softeners
154
What is an ileus?
An intestinal obstruction that's characterized by the lack of peristaltic activity.
155
An ileus is caused by.....
Constipation and increase in opioids
156
What are some signs and symptoms of an ileus?
They are similar to constipation S/S. Abdominal pain, distention, faint or no bowel sounds.
157
What are some ways to prevent an ileus?
Early ambulation, chewing gum (this encourages your peristaltic to start moving), early oral intake, increase fluids.
158
What are signs and symptoms of infection?
Redness around the wound, possible drainage, Purulent drainage, warmth, pain
159
What is dehiscence?
This is the separation of the suture line before the incision heals.
160
How can you prevent dehiscence?
Putting a pillow over the incision site when sneezing or coughing.
161
What are some signs and symptoms of dehiscence?
Increased incision drainage and tissue under the skin becomes visible.
162
_____ is the extrusion of internal organs and tissue through the incision.
Evisceration
163
What causes evisceration?
Malnutrition, poor circulation, strain on the wound
164
What are signs and symptom's of evisceration?
They will feel a strain, a pull, and the burn and then its open.
165
What would you do if a patient experienced an evisceration?
Soak gauze with sterile water, pack the wound, hold it closed, and call the surgical team.
166
____ ____ is the inability to empty the bladder.
Urinary retention
167
When would you empty a patients bladder with a strait cath?
When they have 250 mL or more.
168
How do you prevent urinary retention?
Early ambulation, increasing fluids, and monitor urine cultures.
169
When do you use airborne precautions?
For patients who have infections that spread through the air.
170
Tuberculosis, varicella (chicken pox), and rubeola (measles) are all examples of _____ precautions.
Airborne
171
_____ precautions are used for patients with an infection that is spread by large particle droplets such as rubella, mumps, diphtheria, and flu.
Droplet
172
MRSA, VRE, CRE (klebsiella and E.coli), acinetobacter baumannii, and C. diff are _____ precautions.
Contact
173
What are some risk factors for vancomycin resistant enterococci (VRE)?
Compromised immune system, recent surgery, invasive devices, prolonged antibiotic use, and prolonged hospitalization.
174
How does VRE spread?
Contact with feces, urine, or blood of an infected or colonized person.
175
What are the risk factors for Klebsiella and E.coli (CRE)?
Bladder or venous catheters, ventilators, open surgical wound, taking antibiotics for a lengthy period of time, frequent hospitalizations, or long-term care facility.
176
What is acinetobacter baumannii?
Gram-negative bacterium found primarily in hospitals.
177
What are risk factors for acinetobacter baumannii?
immunocompromised, chronic lung disease, and diabetes.
178
You must _____ _____ and _____ everything when leaving acinetobacter baumannii and C. diff rooms.
Wash hands and bleach
179
What is C. diff usually caused from?
Taking antibiotics (particularly broad-spectrum) for a prolonged period of time that destroys good bacteria.
180
How long can acute inflammation last?
2 weeks
181
Acute inflammation is _____ and chronic inflammation is ____ ____.
good; not good
182
How long can chronic inflammation last?
Can last years.
183
_____ is the reaction that occurs to localize and eliminate microbes, foreign particles, and abnormal cells to allow the injured tissue to be repaired.
Inflammation
184
What are the signs of local inflammation?
Heat, redness, swelling, pain, loss of function.
185
Vasodilation is caused by ____ ____ such as histamines, prostaglandins, and leukotrienes, which cause _____.
Chemical mediators; redness
186
During the inflammation process, when their is increased blood flow what happens to the patient's skin?
The site will become hot.
187
During the inflammation process, what is happening when the site is beginning to swell?
Their is increased capillary permeability.
188
During the inflammation process, why does pain occur?
Stimulation of nerve endings from edema.
189
What does the patient have to have for Systemic Inflammatory Response Syndrome (SIRS)?
- WBC <4,000 or >12,000
- Temp <95 or >100.4
- HR >90
- RR >20
190
What is cholecystitis?
Inflammation of the gallbladder.
191
What is the main cause of cholecystitis?
Gallstones (Cholelithiasis)
192
What are some acute signs of cholecystitis?
- Acute onset of RUQ or epigastric pain (may radiate to right shoulder). \
- Mild fever
- Anorexia
- N/V
193
What are some chronic signs of cholecystitis?
Intolerance to fatty foods, belching, and colicky pain
194
Who is most likely to have gallstones?
Obese women >40 years old who have had multiple pregnancies.
195
What are some signs of cholelithiasis (gallstones)?
- Many times its asymptomatic.
- Indigestion
- Pain in RUQ or epigastric area (may radiate to upper back, right shoulder, or midscapular region). This may occur after eating fatty foods.
- Jaundice (if large stones obstruct blood flow).
- Dark urine or gray colored stool.
196
Stones in the common bile duct are known as _____.
Choledocholithiasis
197
Common duct stones can obstruct the outflow of the _____ duct, causing _______.
Pancreatic; pancreatitis
198
What would be a good diet for someone who has cholecystitis?
- Low-fat diet
- Avoid alcohol, greasy, and fried food
- NPO during an acute attack or if surgery is required.
199
What are some pre-op measures for cholecystectomy?
- Chest X-ray, EKG, labs (AST, ALT, Bilirubin, PT)
- Teach how to turn and deep breathe and early ambulation.
- Drainage tubes (T-Tube) or NGT may be necessary if open cholecystectomy is performed.
- Patient should be educated that an open cholecystectomy might be necessary.
200
Explain what a CPAP does.
Prevents airway collapse.
201
Explain what a BiPAP does.
Makes breathing easier and results in a lower average airway pressure.
202
How long should a patient keep a sleep diary?
1-2 weeks
203
The client being seen in the employee wellness clinic reports difficulty sleeping for the past several months. The most important assessment the nurse could make is:
A. reviewing the client's sleep diary for the past 2 weeks.
B. identifying specific foods that negatively impact sleep.
C. having the client recall the number of sleep hours each night for the past week.
D. asking the client's bed partner to describe the sleep problem.
A. reviewing the client's sleep diary for the past 2 weeks.
check
204
The nurse is preparing a care plan for a client with insomnia. Which would be an appropriate outcome criterion for the goal of having the client report fewer problems falling asleep?
A. The client will fall asleep faster.
B. The nurse will administer the client's hypnotic at bedtime each night.
C. The client will report a decrease in sleep latency to 10 to 15 minutes within 30 days.
D. The nurse will give the client a backrub at bedtime each night.
C. The client will report a decrease in sleep latency to 10 to 15 minutes within 30 days.
205
A client who works night shift is struggling with sleeping during the day after working all night. What actions can the nurse suggest to help promote sleep? Select all that apply.
A. sleeping in a room with curtains that block the light
check
B. sleeping in a different location for day sleeping
C. reading and drinking coffee before going to bed
D. eating breakfast before going to sleep
close
E. having an alcoholic drink before trying to sleep
F. leaving the television on while attempting sleep
A. sleeping in a room with curtains that block the light
check
206
What is malignant hyperthermic?
is a severe reaction to certain drugs used during anesthesia.
207
You are completing the history on a patient who is scheduled to have surgery. What health history increased the risk for surgery for the patients?
A. UTI
B. History of premature ventricular beats.
C. Abuse of street drugs
D. Hyperthyroidism
C. Abuse of street drugs
208
The physical environment of a surgery suite is designed primarily to promote:
A. Electrical safety
B. Medical and surgical asepsis
C. Comfort and privacy of the patient.
D. Communication among the surgical team.
B. Medical and surgical asepsis
209
Which medications are given for comfort?
Acetaminophen, Aspirin, and Ibuprofen.
210
What medications are given for infection?
Trimethoprim-sulfamethoxazole, Ciprofloxacin, Erythromycin, Tetracycline, and Amoxicillin.
211
What is the most important thing we can do to prevent disease from spreading?
Hand washing
212
What are the stages of the infectious process?
Incubation period, prodromal period, period of illness, period of decline, and period of convalescence.
213
The ____ ____ is the period of the infectious process where the person is most contagious.
Prodromal period
214
____ is a severe reaction to infection.
Sepsis
215
____ ____ can cause low blood pressure due to widespread infection. It also leads to diffuse cell and tissue injury, which can cause organ failure.
Septic shock
216
What is needed to say a patient has sepsis?
2 SIRS criteria and a source of infection
217
What is needed to say a patient has septic shock?
Sepsis, persistent hypotension, and lactic acid greater than 4.
218
Infections that occur within the first 48 hours of hospitalization are considered ____ ___.
Community acquired.
219
During an interaction with a client who is HIV positive, the nurse learns that the client has nonspecific symptoms such as nausea, fever, general weakness, aches, and pain. The nurse interprets these findings as reflecting which stage of the communicable period?
A. Incubation period
B. Prodromal period
C. Acute phase of illness
D. Convalescent period
B. Prodromal period
220
This is when normal flora gets into the dermis through a break in the skin. They multiply and cause an inflammatory response with classic signs of inflammation.
Cellulitis
221
What is the most common cause of cellulitis?
Staphylococcus aureus
222
____ ____ is the ability of a drug to attack only systems with foreign cells (only killing the bad guys while not targeting the good guys)
Selective toxicity
223
Is the amount of a drug needed to reach its therapeutic effect.
Critical concentration
224
What are the three stages of surgery?
Preoperative phase
Intraoperative phase
Postoperative phase
225
What are the four types of anesthesia?
- General
- Moderate or conscious
- Regional
- Topical and local
226
What is the treatments and nursing interventions for cellulitis?
- Elevate the affected area 3 to 6 inches above the heart.
- Apply cool moist packs to the site every 2-4 hours until inflammation has resolved.
- Transition to warm moist packs.
227
A client presented to the emergency department of the hospital with a swollen, reddened, painful leg wound and has been diagnosed with MRSA cellulitis. The client's physician has ordered a complete blood count and white cell differential. Which blood component would the physician most likely anticipate to be elevated?
A. Basophils
B. Eosinophils
C. Platelets
D. Neutrophils
D. Neutrophils
228
What are risk factors for a UTI?
Females, inability to empty bladder, catheterization, obstruction of urinary flow, prostate issues.
229
What is a upper UTI called?
Pyelonephritis
230
What is a lower UTI called?
Cystitis
231
What are S/S of a UTI?
Dysuria, burning upon urination, frequency and urgency, nocturia, incontinence, cloudy, foul-smelling urine.
232
_____ is a bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys.
Pyelonephritis
233
The nurse advises the patient with chronic pyelonephritis that he should:
A. Limit his fluid intake 1.5 L/day to minimize bladder fullness, which could cause backward pressure on the kidneys.
B. Decrease his sodium intake to prevent fluid retention.
C. Increase fluids to 3-4 L/24 hours to dilute the urine.
D. Decrease his intake of calcium rich foods to prevent kidney stones.
C. Increase fluids to 3-4 L/24 hours to dilute the urine.
234
Inflammation is always a ______ response that serves a protective function.
Nonspecific
235
The main cause of appendicitis is obstruction due to _____ and is most common in ______.
Fecalith; kids
236
What are some side affects of ciprofloxacin?
Aortic dissection/aneurism, rash, hyperglycemia, hypoglycemia.
237
What is the category class for ciprofloxacin?
Anti-infective
238
What is the category class for amoxicillin?
Penicillin
239
What are the side effects of amoxicillin?
Seizures, c-diff, serum sickness, rash, diarrhea, increased liver enzymes.
240
What is the generic name for amoxicillin?
Amoxil or larotid
241
What is the brand name for acetaminophen?
Tylenol
242
What is the category class for acetaminophen (Tylenol)?
Antipyretics and nonopioid analgesics
243
What are side effects for acetaminophen (Tylenol)?
Steven-Johnson syndrome, toxic epidermal necrosis, hepatotoxicity, constipation, increased liver enzymes, hypertension, rash, fatigue.
244
What are the side effects of aspirin?
Dyspepsia, GI ulcers, bleeding, epigastric distress, nausea, and tinnitus.
245
The three category classes for _____ are NSAIDS, antipyretic, and blood thinner.
Aspirin
246
Why is aspirin used?
To reduce inflammation or fever and to decrease clotting.
247
What is action for aspirin?
Inhibits production of prostaglandins and decrease’s platelet aggregation.
248
What is another name for tetracycline?
Sumycin
249
Tetracyclines are _____ _____ antibiotics that inhibits microorganism growth by preventing protein synthesis.
Broad-spectrum
250
Why is tetracycline (Sumycin) used?
Treats rickettsial infections, infections of the urethra or cervix, Lyme disease, anthrax, GI infections.
251
What are the side effects of tetracycline (Sumycin)?
GI discomfort, yellow or brown tooth discoloration, hepatotoxicity, Supra infection.
252
What are the side effects of erythromycin lactobionate (Pediazole)?
GI discomfort and prolonged QT intervals.
253
What is the generic name for erythromycin lactobionate?
Pediazole
254
What does erythromycin lactobionate treat?
Treats infections in patients who have penicillin allergy and streptococcal infections.
255
Should you take erythromycin lactobionate with food?
No take it on an empty stomach.
256
What is the generic name for ibuprofen?
Advil or Motrin
257
What is the category class for ibuprofen (Advil, Motrin)?
Non-steroidal anti-inflammatory drugs
258
What are side effects of ibuprofen (Advil, Motrin)?
GI discomfort, dyspepsia, heartburn, increased risk of heart attack and strokes, Reye’s syndrome.
259
You should never give more than ____ mg a day when giving amoxicillin.
4000 mg.
260
When giving ciprofloxacin you should never exceed ______ mg.
1500 mg
261
When giving acetaminophen (Tylenol) you should never give more than ____ mg in 24 hours.
4000 mg
262
What is the safe range for aspirin?
Do not give more than 4 g in 24 hours.
263
What is the max dose for tetracycline?
2000 mg
264
What is the max does of ibuprofen?
3200 mg per day.
265
What is the brand name for trimethoprim-sulfamethoxazole?
Bactrim
