Module 2

Question 1

The nurse is conducting a preoperative interview with a client who is scheduled for an elective hysterectomy and the client tells the nurse, “I am afraid that I will die in surgery like my mother did!” Which of the following responses by the nurse is most appropriate?
A. “Tell me more about what happened to your mother.”
B. “You will receive medications to reduce your anxiety.”
C. “You should talk to the doctor again about the surgery.”
D. “Surgical techniques have improved a lot in recent years.”

Answer 1

A. “Tell me more about what happened to your mother.”

Question 2

A client arrives at the ambulatory surgery centre for a scheduled outpatient surgery. Which of the following information is of most concern to the nurse?
A. The client has not had outpatient surgery before.
B. The client is planning to drive home after surgery.
C. The client’s insurance does not cover the scheduled procedure.
D. The client had a glass of water a few hours before arriving.

Answer 2

B. The client is planning to drive home after surgery.

Question 3

The nurse is admitting a female client for an outpatient surgery procedure. Which of the following information is most important to report to the anaesthesiologist before surgery?
A. The client’s lack of knowledge about postoperative pain control measures
B. The client’s statement that her last menstrual period was 8 weeks previously
C. The client’s history of a postoperative infection following a prior cholecystectomy
D. The client’s concern that she will be unable to care for her children postoperatively

Answer 3

B. The client’s statement that her last menstrual period was 8 weeks previously

Question 4

A client who is scheduled for surgery in a week tells the nurse doing the preoperative assessment about an allergy to bananas, kiwifruit, and latex products. Which of the following actions is most important for the nurse to take?
A. Notify the dietitian about the food allergies.
B. Alert the surgery centre about the latex allergy.
C. Reassure the client that all allergies are noted on the medical record.
D. Ask whether the client uses antihistamines to reduce allergic reactions.

Answer 4

B. Alert the surgery centre about the latex allergy.

Question 5

According to the ASA Physical Status Classification System, which of the following assessments is consistent with a rating of ASA III?
A. Chronic asthma, controlled with an inhaler and corticosteroids
B. Poorly controlled asthma and is wheezing
C. Is in status asthmaticus and on a ventilator
D. Has no significant health problems

Answer 5

A. Chronic asthma, controlled with an inhaler and corticosteroids

Question 6

. The nurse is completing a preoperative assessment of a client scheduled for a colon resection and the client tells the nurse about using St. John’s wort to prevent depression. Which of the following information should the nurse alert the staff in the postanaesthesia recovery area about?
A. Increased pain
B. Hypertensive episodes
C. Increased postanaesthesia waking time
D. Increased postoperative bleeding

Answer 6

C. Increased postanaesthesia waking time

Question 7

On the day of surgery, the nurse is admitting a client with a history of cigarette smoking. Which of the following actions is most important at this time?
A. Auscultate for adventitious breath sounds.
B. Ask whether the client has smoked recently.
C. Remind the client about harmful effects of smoking.
D. Calculate the cigarette smoking history in pack-years.

Answer 7

A. Auscultate for adventitious breath sounds.

Question 8

. A client is seen at the health care provider’s office several weeks before hip surgery for preoperative assessment. The client reports use of Echinacea, ginseng, glucosamine, and chondroitin. Which of the following actions should the nurse take?
A. Ascertain that there will be no interactions with anaesthetic agents.
B. Discuss the supplement use with the client’s health care provider.
C. Teach the client that these products may be continued preoperatively.
D. Advise the client to stop the use of all herbs and supplements at this time.

Answer 8

B. Discuss the supplement use with the client’s health care provider.

Question 9

. Before the administration of preoperative medications, the nurse is preparing to witness the client signing the operative consent form when the client says, “I do not really understand what the doctor said.” Which of the following actions is best for the nurse to take?
A. Provide an explanation of the planned surgical procedure.
B. Notify the surgeon that the informed-consent process is not complete.
C. Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications.
D. d. Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure.

Answer 9

B. Notify the surgeon that the informed-consent process is not complete.

Question 10

Which of the following topics is most important for the nurse to discuss preoperatively with a client who is scheduled for a colon resection?
A. Care for the surgical incision
B. Medications used during surgery
C. Deep-breathing and coughing techniques
D. Oral antibiotic therapy after discharge home

Answer 10

C. Deep-breathing and coughing techniques

Question 11

Ten minutes after the nurse administered the ordered preoperative opioid by intravenous (IV) injection, the client asks to get up to go to the bathroom to urinate. Which of the following actions is best for the nurse to implement?
A. Assist the client to the bathroom and ensure a call bell is within reach.
B. Offer a urinal or bedpan and position the client in bed to promote voiding.
C. Allow the client up to the bathroom because the onset of the medication takes more than 10 minutes.
D. Ask the client to wait because catheterization is performed at the beginning of the surgical procedure.

Answer 11

B. Offer a urinal or bedpan and position the client in bed to promote voiding.

Question 12

The nurse is caring for a client with diabetes who is scheduled for a mastectomy at 1:00 PM today and it is now 8:30 AM. The client uses insulin to control blood glucose and has been NPO since midnight. Which of the following actions should the nurse take?
A. Withhold the usual scheduled insulin dose because the client is NPO.
B. Obtain a blood glucose measurement before any insulin administration.
C. Administer the usual insulin dose because stress will increase the blood glucose.
D. Administer a lower dose of insulin because there will be no oral intake before surgery.

Answer 12

B. Obtain a blood glucose measurement before any insulin administration.

Question 13

The clinic nurse is reviewing the complete blood cell count (CBC) results for a client who is scheduled for surgery in a few days. The results are white blood cell count (WBC)
10.2 ́ 109/L; hemoglobin 150 g/L; hematocrit 45%; platelets 150 ́ 109/L. Which of the following actions should the nurse take?
A. Send the CBC results to the surgery facility.
B. Call the surgeon and anaesthesiologist immediately.
C. Ask the client about any symptoms of a recent infection.
D. Discuss the possibility of blood transfusion with the client.

Answer 13

A. Send the CBC results to the surgery facility.

Question 14

The nurse is preparing to administer atropine to a client before surgery. Which of the following symptoms should the nurse teach the client to expect? 
A.	Dizziness 
B.	Weakness 
C.	Dry mouth 
D.	Forgetfulness

Answer 14

C. Dry mouth

Question 15

The nurse is interviewing a client who is to have outpatient surgery using a general anaesthetic. Which of the following information is most important to communicate to the surgeon and anaesthesiologist before surgery?
A. The client drinks three or four cups of coffee every morning before going to work.
B. The client takes a baby Aspirin daily but stopped taking aspirin 2 weeks ago.
C. The client drank 120 mL of apple juice 3 hours before coming to the hospital.
D. The client’s father died after receiving general anaesthesia for abdominal surgery.

Answer 15

D. The client’s father died after receiving general anaesthesia for abdominal surgery.

Question 16

The nurse is preparing a client for surgery. Which of the following information about medication use is most important for the nurse to communicate to the health care provider?
A. The client uses acetaminophen occasionally for aches and pains.
B. The client takes garlic capsules daily but did not take any on the surgical day.
C. The client has a history of cocaine use but quit using the drug over 10 years ago.
D. The client took a sedative medication the previous night to assist in falling asleep.

Answer 16

B. The client takes garlic capsules daily but did not take any on the surgical day.

Question 17

The nurse is analyzing a client’s preoperative blood studies. Which of the following blood studies should the nurse review to assess for anemia and infection in a client with no known health problems? (Select all that apply.) 
A.	Red blood cell count 
B.	White blood cell count 
C.	Serum potassium 
D.	Hematocrit 
E.	Prothrombin (INR) time

Answer 17

A. Red blood cell count
B. White blood cell count
D. Hematocrit

Question 18

Which of the following descriptions best define the role of the nurse anaesthetist as a member of the surgical team?
A. Is able to administer anaesthetics
B. Has the same credentials and responsibilities as an anaesthesiologist
C. Is responsible for intraoperative administration of anaesthetics ordered by the anaesthesiologist
D. Does not require supervision by the anaesthesiologist while administering anaesthesia to a client

Answer 18

A. Is able to administer anaesthetics

Question 19

Which of the following outcome measures is best for the operating room (OR) nurse manager to use in determining the effectiveness of the physical environment and traffic control measures in the operating room?
A. Smooth functioning of the OR team
B. Effective protection of client privacy
C. Rapid completion of surgical procedure
D. Low incidence of perioperative infection

Answer 19

D. Low incidence of perioperative infection

Question 20

Which of the following actions should the scrub nurse use to maintain aseptic technique during surgery?
A. Use waterproof shoe covers.
B. Wear personal protective equipment.
C. Insist that all operating room (OR) staff perform a surgical scrub.
D. Change gloves after touching the thigh of a surgeon’s sterile gown.

Answer 20

D. Change gloves after touching the thigh of a surgeon’s sterile gown.

Question 21

After orienting a new staff member to the scrub nurse role, the nurse preceptor will know that the teaching was effective if the new staff member implements which of the following actions?
A. Documents all client care accurately.
B. Labels all specimens to send to the laboratory.
C. Keeps both hands above the operating table level.
D. Takes the client to the postanaesthesia recovery area.

Answer 21

C. Keeps both hands above the operating table level.

Question 22

Data that were obtained during the perioperative nurse is assessing a client in the preoperative holding area. Which of the following findings would indicate a need for special protection techniques during surgery?

1. A stated allergy to cats and dogs
2. A history of spinal and hip arthritis
3. Verbalization of anxiety by the client
4. Having a sip of water 2 hours previously

Answer 22

2. A history of spinal and hip arthritis

Question 23

The nurse is caring for a preoperative adult client who is scheduled for a routine surgery and is in the holding area. The client asks the nurse, “Will the doctor put me to sleep with a mask over my face?” Which of the following responses is most appropriate?
A. “A drug will be given to you through your IV line, which will cause you to go to sleep almost immediately.”
B. “Only your surgeon can tell you for sure what method of anaesthesia will be used. Should I ask your surgeon?”
C. “General anaesthesia is now given by injecting medication into your veins, so you will not need a mask over your face.”
D. “Masks are not used anymore for anaesthesia. A tube will be inserted into your throat to deliver a gas that will put you to sleep.”

Answer 23

A. “A drug will be given to you through your IV line, which will cause you to go to sleep almost immediately.”

Question 24

The nurse is preparing a client with a dislocated shoulder for a closed, manual reduction of the dislocation with procedural sedation. Which of the following medications should the nurse anticipate administering for this procedure?

1. IV midazolam
2. Inhaled desflurane
3. Epidural lidocaine
4. Eutectic mixture of local anaesthetics (EMLA)

Answer 24

1. IV midazolam

Question 25

Which of the following actions should the nurse include in the plan of care immediately after surgery for a client who received ketamine as an anaesthetic agent?
A. Administer larger doses of analgesic agents.
B. Monitor for severe slowing of the heart rate.
C. Provide a quiet environment in the postanaesthesia care unit.
D. Avoid the use of benzodiazepines in the postoperative period.

Answer 25

C. Provide a quiet environment in the postanaesthesia care unit.

Question 26

A client in surgery receives a neuro-muscular blocking agent as an adjunct to general anaesthesia. At completion of the surgery, it is most important that the nurse monitor the client for which of the following adverse effects? 
A.	Nausea 
B.	Confusion 
C.	Bronchospasm 
D.	Weak chest-wall movement

Answer 26

D. Weak chest-wall movement

Question 27

Which of the following actions by a member of the surgical team requires rapid intervention by the charge nurse?
A. Wearing street clothes into the nursing station
B. Wearing a surgical mask into the holding room
C. Walking into the hallway outside an operating room without the hair covered
D. Putting on a surgical mask, cap, and scrubs before entering the operating room

Answer 27

C. Walking into the hallway outside an operating room without the hair covered

Question 28

The nurse is positioning a client in the operating room for a transurethral resection of the prostate. Which of the following client positions should the nurse place this client in?

a. Prone
b. Supine
c. Trendelenburg
d. Lithotomy

Answer 28

d. Lithotomy

Question 29

The nurse is caring for a client who is recovering from anaesthesia in the postanaesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure is 112/60, with a pulse of 72 and warm, dry skin. Which of the following actions is the most appropriate for the nurse to implement at this time?
A. Increase the rate of the IV fluid replacement.
B. Continue to take vital signs every 15 minutes.
C. Administer oxygen therapy at 100% per mask.
D. Notify the anaesthesia care provider (ACP) immediately.

Answer 29

B. Continue to take vital signs every 15 minutes.

Question 30

The nurse is caring for a client who is recovering from anaesthesia in the postanaesthesia care unit (PACU), and the vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The client is sleepy but awakens easily. Which of the following actions should the nurse take at this time?
A. Place the client in a side-lying position.
B. Encourage the client to take deep breaths.
C. Prepare to transfer the client from the PACU.
D. Increase the rate of the postoperative IV fluids.

Answer 30

B. Encourage the client to take deep breaths.

Question 31

The nurse is preparing an older-adult client for discharge from the ambulatory surgical unit following left eye surgery. The client tells the nurse, “I do not know if I can take care of myself with this patch over my eye.” Which of the following actions is the most appropriate for the nurse to implement?
A. Refer the client for home health care services.
B. Discuss the specific concerns regarding self-care.
C. Give the client written instructions regarding care.
D. Assess the client’s support system for care at home.

Answer 31

B. Discuss the specific concerns regarding self-care.

Question 32

After removal of the nasogastric (NG) tube on the second postoperative day, the client is placed on a clear liquid diet. Four hours later, the client complains of sharp, cramping gas pains. Which of the following actions should the nurse take? 
A.	Reinsert the NG tube. 
B.	Give the PRN IV opioid. 
C.	Assist the client to ambulate. 
D.	Place the client on NPO status

Answer 32

C. Assist the client to ambulate.

Question 33

The nurse is caring for a client following gallbladder surgery, and the client’s T-tube is draining dark green fluid. Which of the following actions should the nurse take?
A. Place the client on bed rest.
B. Notify the client’s surgeon.
C. Document the colour and amount of drainage.
D. Irrigate the T-tube with sterile normal saline.

Answer 33

C. Document the colour and amount of drainage.

Question 34

In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative client on the first postoperative day, which of the following actions by the nurse is most helpful?
A. Discuss the complications of immobility and poor cough effort.
B. Teach the client the purpose of respiratory care and ambulation.
C. Administer ordered analgesic medications before these activities.
D. Give the client positive reinforcement for accomplishing these activities.

Answer 34

C. Administer ordered analgesic medications before these activities.

Question 35

The nurse is caring for a client who has begun to awaken after 30 minutes in the postanaesthesia care unit (PACU), who is restless and shouting at the nurse. The client’s oxygen saturation is 99%, and recent laboratory results are all normal. Which of the following actions by the nurse is most appropriate?
A. Insert an oral or nasal airway.
B. Notify the anaesthesia care provider.
C. Orient the client to time, place, and person.
D. Be sure that the client’s IV lines are secure.

Answer 35

D. Be sure that the client’s IV lines are secure.

Question 36

The nurse is caring for an older adult in the postanaesthesia unit. Which of the following age-related considerations may impact postoperative recovery?
A. Increased thoracic compliance
B. Decreased ability to cough
C. Increased lung tissue
D. Decreased compliance with deep breathing and coughing

Answer 36

B. Decreased ability to cough

Question 37

The nurse is caring for a client who is just waking up after having a general anaesthetic and the client is agitated and confused. Which of the following actions should the nurse take first? 
A.	Check the O2 saturation. 
B.	Administer the ordered opioid. 
C.	Take the blood pressure and pulse. 
D.	Notify the anaesthesia care provider.

Answer 37

A. Check the O2 saturation.

Question 38

The nurse is caring for a postoperative client who has not voided for 7 hours after return to the postsurgical unit. Which of the following actions should the nurse take first?
A. Notify the surgeon.
B. Assess for bladder distension.
C. Assist the client to ambulate to the bathroom.
D. Insert a straight catheter as indicated on the PRN order.

Answer 38

B. Assess for bladder distension.

Question 39

The nurse is caring for a client with abdominal surgery and on the first postoperative day, the nurse notices new bright-red drainage about 6 cm in diameter on the dressing. Which of the following actions should the nurse implement first?
A. Reinforce the dressing.
B. Take the client’s vital signs.
C. Recheck the dressing in 1 hour for increased drainage.
D. Notify the client’s surgeon of a potential hemorrhage.

Answer 39

B. Take the client’s vital signs.

Question 40

The nurse is caring for a client and during the second postoperative day after abdominal surgery, the nurse obtains an oral temperature of 38.2°C (100.8°F). Which of the following actions should the nurse take first?
A. Have the client use the incentive spirometer.
B. Assess the surgical incision for redness and swelling.
C. Administer the ordered PRN acetaminophen.
D. Notify the client’s health care provider about the fever

Answer 40

A. Have the client use the incentive spirometer.

Question 41

The nurse is caring for an unconscious client who was transferred to the postanaesthesia care unit (PACU) 10 minutes previously and has an oxygen saturation of 88%. Which of the following actions should the nurse take first? 
A.	Elevate the client’s head. 
B.	Suction the client’s mouth. 
C.	Increase the oxygen flow rate. 
D.	Perform the jaw-thrust manoeuvre

Answer 41

D. Perform the jaw-thrust manoeuvre

Question 42

The nurse is caring for a client in the PACU and the client’s blood pressure has dropped from an admission blood pressure of 138/84 to 100/58 with a pulse change of 68–94. SpO2 is 98% on 3L of oxygen. In which order should the nurse take these actions?

a. Raise the IV infusion rate.
b. Assess the client’s dressing.
c. Increase the oxygen flow rate.
d. Check the client’s temperature

Answer 42

c. Increase the oxygen flow rate.
a. Raise the IV infusion rate.
b. Assess the client’s dressing.
d. Check the client’s temperature

Question 43

When performing a physical assessment, the first technique the nurse will always use is:

a. Palpation
b. Inspection
c. Percussion
d. Auscultation

Answer 43

b. Inspection

Question 44

The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase:
A. Usually yields little information.
B. Takes time and reveals a significant amount of information.
C. May be somewhat uncomfortable for the expert practitioner.
D. Requires a quick glance at the patient’s body systems before proceeding with palpation.

Answer 44

B. Takes time and reveals a significant amount of information.

Question 45

The nurse is assessing a patient’s skin during an office visit. What part of the hand and technique should be used to best assess the patient’s skin temperature?
A. Fingertips—they are more sensitive to small changes in temperature.
B. Dorsal surface of the hand—the skin is thinner on this surface than on the palms.
C. Ulnar portion of the hand—increased blood supply in this area enhances temperature sensitivity.
D. Palmar surface of the hand—this surface is the most sensitive to temperature variations because of its increased nerve supply in this area.

Answer 45

B. Dorsal surface of the hand—the skin is thinner on this surface than on the palms.

Question 46

The nurse would use bimanual palpation technique in which situation?
A. Palpating the thorax of an infant
B. Palpating the kidneys and uterus
C. Assessing pulsations and vibrations
D. Assessing the presence of tenderness and pain

Answer 46

B. Palpating the kidneys and uterus

Question 47

The nurse is preparing to percuss the abdomen of a patient. The purpose of the percussion is to assess the _____of the underlying tissue.

a. Turgor
b. Texture
c. Density
d. Consistency

Answer 47

c. Density

Question 48

When percussing over the liver of a patient, the nurse observes a dull sound. The nurse should:
A. Consider this a normal finding.
B. Palpate this area for an underlying mass.
C. Reposition the hands, and attempt to percuss in this area again.
D. Consider this an abnormal finding and refer the patient for additional treatment.

Answer 48

A. Consider this a normal finding.

Question 49

A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is best for the nurse to take when further assessing the patient?
A. Count the patient’s respirations
B. Bilaterally percuss the thorax, noting any differences in percussion tones
C. Call for a chest x-ray study, and wait for the results before beginning an assessment
D. Inspect the thorax for any new masses and bleeding associated with respirations

Answer 49

B. Bilaterally percuss the thorax, noting any differences in percussion tones

Question 50

Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse
should:

a. Warm the endpiece of the stethoscope by placing it in warm water.
b. Leave the gown on the patient to ensure that he or she does not get chilled during
the examination.
c. Ensure that the bell side of the stethoscope is turned to the “on” position.
d. Check the temperature of the room and offer blankets to the patient if he or she
feels cold.

Answer 50

d. Check the temperature of the room and offer blankets to the patient if he or she
feels cold.

Question 51

Which of these statements is true regarding the use of practices in the health care setting?

a. Routine practices apply to all body fluids, including sweat.
b. Use alcohol-based hand rub if hands are visibly dirty.
c. Routine practices are intended for use with all patients, regardless of their risk or
presumed infection status.
d. Routine Practices are to be used only when nonintact skin, excretions containing
visible blood, or expected contact with mucous membranes is present.

Answer 51

c. Routine practices are intended for use with all patients, regardless of their risk or
presumed infection status.

Question 52

During examination of a patient’s abdomen, the nurse notes that the abdomen is rounded
and firm to the touch. During percussion, the nurse notes a drumlike quality of the sounds
across the quadrants. This type of sound indicates:

a. Constipation
b. Air-filled areas
c. Presence of a tumour
d. Presence of dense organs

Answer 52

b. Air-filled areas

Question 53

During auscultation of a patient’s heart sounds, the nurse hears an unfamiliar sound. The
nurse should:

a. Document the findings in the patient’s record.
b. Wait 10 minutes, and auscultate the sound again.
c. Ask the patient how he or she is feeling.
d. Ask another nurse to double check the finding.

Answer 53

d. Ask another nurse to double check the finding.

Question 54

The nurse is performing a general survey. The nurse:

a. Observes the patient’s body stature and nutritional status.
b. Interprets the subjective information the patient has reported.
c. Measures the patient’s temperature, pulse, respirations, and blood pressure.
d. Observes specific body systems while performing the physical assessment.

Answer 54

a. Observes the patient’s body stature and nutritional status.

Question 55

When measuring a patient’s weight, the nurse will:

a. Weigh the patient wearing only undergarments.
b. Aim for similar daily weights regardless of type of scale used.
c. Allow the patient to keep the jacket and shoes on as long as these are documented
next to the weight.
d. Weigh the patient at the same time daily for a sequence of weights

Answer 55

d. Weigh the patient at the same time daily for a sequence of weights

Question 56

The nurse assesses a 1-month-old infant to have a head measurement of 34 cm and a chest
circumference of 32 cm. The nurse will:

a. Refer the infant to a physician for further evaluation.
b. Document the findings as normal for a 1-month-old infant.
c. Request that another nurse recheck the findings.
d. Ask the parent to return in 2 weeks to re-evaluate the head and chest
circumferences

Answer 56

b. Document the findings as normal for a 1-month-old infant.

Question 57

The nurse is assessing an 80-year-old male patient. Which assessment findings would be
considered normal?

a. Increase in body weight from his younger years
b. Additional deposits of fat on the thighs and lower legs
c. Presence of kyphosis and flexion in the knees and hips
d. Change in overall body proportion, including a longer trunk and shorter
extremities

Answer 57

c. Presence of kyphosis and flexion in the knees and hips

Question 58

The nurse should measure rectal temperatures in which of these patients?

a. School-age child
b. Older adult
c. Comatose adult
d. Patient receiving oxygen by nasal cannula

Answer 58

c. Comatose adult

Question 59

When assessing an older adult, which vital sign changes occur with aging?

a. Increase in pulse rate
b. Widened pulse pressure
c. Increase in body temperature
d. Decrease in diastolic blood pressure

Answer 59

b. Widened pulse pressure

Question 60

When evaluating the temperature of older adults, the nurse knows that:

a. The body temperature of the older adult is lower than that of a younger adult.
b. An older adult’s body temperature is approximately the same as that of a young
child.
c. Body temperature depends on the type of thermometer used.
d. In the older adult, the body temperature varies widely because of less effective heat
control mechanisms

Answer 60

a. The body temperature of the older adult is lower than that of a younger adult.

Question 61

A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen
today in the clinic for an “unexplained” weight loss of 10 pounds over the past 6 weeks. The
nurse knows that:

a. Weight loss is probably the result of unhealthy eating habits.
b. Chronic diseases, such as hypertension, cause weight loss.
c. Unexplained weight loss often accompanies short-term illnesses.
d. Weight loss is probably the result of a mental health dysfunction

Answer 61

c. Unexplained weight loss often accompanies short-term illnesses

Question 62

When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a
tripod position, leaning forward with arms braced on the chair. The nurse:

a. Assumes that the patient is eager and interested in participating in the interview.
b. Evaluates the patient for abdominal pain, which may be exacerbated in the sitting
position.
c. Assumes that the patient is having difficulty breathing and assists him to the supine
position.
d. Recognizes that a tripod position is often used when a patient is having respiratory
difficulties.

Answer 62

d. Recognizes that a tripod position is often used when a patient is having respiratory
difficulties.

Question 63

When assessing the radial pulse of a patient, the nurse will count the pulse for:

a. 1 minute, if the rhythm is irregular.
b. 15 seconds and then multiply by 4, if the rhythm is regular.
c. 2 full minutes to detect any variation in amplitude.
d. 10 seconds and then multiply by 6, if the patient has no history of cardiac
abnormalities.

Answer 63

a. 1 minute, if the rhythm is irregular.

Question 64

When assessing a patient’s pulse, the nurse will also assess:

a. Force.
b. Pallor.
c. Capillary refill time.
d. Timing in the cardiac cycle.

Answer 64

a. Force.

Question 65

When assessing the force, or strength, of a pulse, the nurse recalls that the pulse:

a. Is usually recorded on a 0-2–point scale.
b. Demonstrates elasticity of the vessel wall.
c. Is a reflection of the heart’s stroke volume.
d. Reflects the blood volume in the arteries during diastole

Answer 65

c. Is a reflection of the heart’s stroke volume.

Question 66

While measuring a patient’s blood pressure, the nurse recalls that certain factors, such as, help determine blood pressure.

a. Pulse rate
b. Pulse pressure
c. Vascular output
d. Peripheral vascular resistance

Answer 66

d. Peripheral vascular resistance

Question 67

A nurse is helping at a health fair at the local mall. When taking blood pressures on a variety of people, the nurse keeps in mind that:

a. After menopause, blood pressure readings in women are usually lower than those
in men.
b. The blood pressure of an adult of African descent is usually higher than that of an
adult of European descent and of the same age.
c. Blood pressure measurements in people who are overweight should be the same as
those of people who are at a normal weight.
d. A teenager’s blood pressure reading will be lower than that of an adult.

Answer 67

b. The blood pressure of an adult of African descent is usually higher than that of an
adult of European descent and of the same age.

Question 68

The nurse notices that a colleague is preparing to check the blood pressure of a patient who
is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading
to:

a. Yield a falsely low blood pressure.
b. Yield a falsely high blood pressure.
c. Be the same, regardless of cuff size.
d. Vary as a result of the technique of the person performing the assessment.

Answer 68

b. Yield a falsely high blood pressure.

Question 69

A patient is seen in the clinic for complaints of “fainting episodes that started last week.”
How should the nurse proceed with the examination?

a. Blood pressure readings are taken in both the arms and the thighs.
b. The patient is assisted to the lying position, and his blood pressure is taken.
c. His blood pressure is recorded in the lying, sitting, and standing positions.
d. His blood pressure is recorded in the lying and sitting positions; these numbers are
then averaged to obtain a mean blood pressure.

Answer 69

c. His blood pressure is recorded in the lying, sitting, and standing positions.

Question 70

When considering the concepts related to blood pressure, the nurse knows that the concept
of mean arterial pressure (MAP) is best described by which statement?

a. MAP is the pressure of the arterial pulse.
b. MAP reflects the stroke volume of the heart.
c. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle.
d. MAP is an average of the systolic and diastolic blood pressures and reflects tissue
perfusion.

Answer 70

c. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle.

Question 71

A patient is to receive local anaesthesia for removal of a lymph node from his groin. Why does the physician add epinephrine to the local anaesthetic during the preparation?

a. Epinephrine prevents an anaphylactic reaction from occurring.
b. The anaesthetic enhances the effect of the epinephrine.
c. Epinephrine contributes to a balanced anaesthetic state.
d. Vasoconstrictive effects keep the anaesthetic at its local site of action.

Answer 71

d. Vasoconstrictive effects keep the anaesthetic at its local site of action.

Question 72

During the postoperative recovery period, what should be the nurse’s immediate main concern?

a. Pupil responses
b. Return to sensation
c. Level of consciousness
d. Airway, breathing, and circulation

Answer 72

d. Airway, breathing, and circulation

Question 73

Which individual is at high risk for an altered response to anaesthesia?

a. The 30-year-old male who has never had surgery before
b. The 45-year-old female who stopped smoking 10 years ago
c. The 20-year-old male who is to have a lymph node removed
d. The 78-year-old female who is to have her gallbladder removed

Answer 73

d. The 78-year-old female who is to have her gallbladder removed

Question 74

A patient is undergoing abdominal surgery and has been anaesthetized for 3 hours. Which of the following nursing diagnoses is appropriate for him?

a. Anxiety related to the use of an anaesthetic
b. Risk for injury related to increased sensorium from general anaesthesia
c. Decreased cardiac output related to systemic effects of local anaesthesia
d. Impaired gas exchange related to central nervous system (CNS) depression produced by general anaesthesia

Answer 74

d. Impaired gas exchange related to central nervous system (CNS) depression produced by general anaesthesia

Question 75

A patient is being prepared for an oral endoscopy, and the nurse reminds him that he will be awake during the procedure but probably will not remember it. What type of anaesthetic technique is used in this situation?

a. Twilight sleep
b. Moderate sedation
c. Adjunctive anaesthesia
d. Spinal anaesthesia

Answer 75

b. Moderate sedation