NSG 100 Exam 3

Question 1

The patient is receiving two different drugs. At current dosages and dosage forms, both drugs have the same concentration of active ingredients. Which term is used to identify this principle?

a. Bioequivalent
b. Synergistic
c. Prodrugs
d. Steady-state

Answer 1

a. Bioequivalent

Rationale: Two drugs absorbed into the circulation in the same amount (in specific dosage forms) have the same bioavailability; thus, they are bioequivalent.
A drug’s steady state is the physiologic state in which the amount of drug removed via elimination is equal to the amount of drug absorbed from each dose.
The term synergistic refers to two drugs, given together, with a resulting effect that is greater than the sum of the effects of each drug given alone.
A prodrug is an inactive drug dosage form that is converted to an active metabolite by various biochemical reactions once it is inside the body.

Question 2

When given an intravenous medication, the patient says to the nurse, “I usually take pills. Why does this medication have to be given in the arm?” What is the nurse’s best answer?

a. “The medication will cause fewer adverse effects when given intravenously.”
b. “The intravenous medication will have delayed absorption into the body’s tissues.”
c. “The action of the medication will begin sooner when given intravenously.”
d. “There is a lower chance of allergic reactions when drugs are given intravenously.”

Answer 2

c. “The action of the medication will begin sooner when given intravenously.”

Rationale: An intravenous (IV) injection provides the fastest route of absorption. The IV route does not affect the number of adverse effects, nor does it cause delayed tissue absorption (it results in faster absorption). The IV route does not affect the number of allergic reactions.

Question 3

The nurse is administering parenteral drugs. Which statement is true regarding parenteral drugs?

a. Parenteral drugs bypass the first-pass effect.
b. Absorption of parenteral drugs is affected by reduced blood flow to the stomach.
c. Absorption of parenteral drugs is faster when the stomach is empty.
d. Parenteral drugs exert their effects while circulating in the bloodstream.

Answer 3

a. Parenteral drugs bypass the first-pass effect.

Rationale: Drugs given by the parenteral route bypass the first-pass effect.
Reduced blood flow to the stomach and the presence of food in the stomach apply to enteral drugs (taken orally), not to parenteral drugs.
Parenteral drugs must be absorbed into cells and tissues from the circulation before they can exert their effects; they do not exert their effects while circulating in the bloodstream.

Question 4

When monitoring the patient receiving an intravenous infusion to reduce blood pressure, the nurse notes that the patient’s blood pressure is extremely low, and the patient is lethargic and difficult to awaken. This would be classified as which type of adverse
drug reaction?

a. Adverse effect
b. Allergic reaction
c. Idiosyncratic reaction
d. Pharmacologic reaction

Answer 4

d. Pharmacologic reaction

Rationale: A pharmacologic reaction is an extension of a drug’s normal effects in the body. In this case, the antihypertensive drug lowered the patient’s blood pressure levels too much.
The other options do not describe a pharmacologic reaction. An adverse effect is a predictable, well-known adverse drug reaction that results in minor or no changes in patient management.
An allergic reaction (also known as a hypersensitivity reaction) involves the patient’s immune system.
An idiosyncratic reaction is unexpected and is defined
as a genetically determined abnormal response to normal dosages of a drug.

Question 5

The nurse is reviewing pharmacology terms for a group of newly graduated nurses. Which sentence defines a drug’s half-life?

a. The time it takes for the drug to cause half of its therapeutic response
b. The time it takes for one-half of the original amount of a drug to reach the target cells
c. The time it takes for one-half of the original amount of a drug to be removed from the body
d. The time it takes for one half of the original amount of a drug to be absorbed into the circulation

Answer 5

c. The time it takes for one-half of the original amount of a drug to be removed from the body

Rationale: A drug’s half-life is the time it takes for one-half of the original amount of a drug to be removed from the body. It is a measure of the rate at which drugs are removed from the body. The other options are incorrect definitions of half-life.

Question 6

When administering drugs, the nurse remembers that the duration of action of a drug is defined as which of these?

a. The time it takes for a drug to elicit a therapeutic response
b. The amount of time needed to remove a drug from circulation
c. The time it takes for a drug to achieve its maximum therapeutic response
d. The time period at which a drug’s concentration is sufficient to cause a therapeutic response

Answer 6

d. The time period at which a drug’s concentration is sufficient to cause a therapeutic response

Rationale: Duration of action is the time during which drug’s concentration is sufficient to elicit a therapeutic response.
The other options do not define duration of action. A drug’s onset of action is the time it takes for the drug to elicit a therapeutic response.
A drug’s peak effect is the time it takes for the drug to reach its maximum therapeutic response.
Elimination is the length of time it takes to remove a drug from circulation.

Question 7

When reviewing the mechanism of action of a specific drug, the nurse reads that the drug works by selective enzyme interaction. Which of these processes describes selective enzyme interaction?

a. The drug alters cell membrane permeability.
b. The drug’s effectiveness within the cell walls of the target tissue is enhanced.
c. The drug is attracted to a receptor on the cell wall, preventing an enzyme from binding to that receptor.
d. The drug binds to an enzyme molecule and inhibits or enhances the enzyme’s action with the normal target cell.

Answer 7

d. The drug binds to an enzyme molecule and inhibits or enhances the enzyme’s action with the normal target cell.

Rationale: With selective enzyme interaction, the drug attracts the enzymes to bind with the drug instead of allowing the enzymes to bind with their normal target cells.
As a result, the target cells are protected from the action of the enzymes. This results in a drug effect.
The actions described in the other options do not occur with selective enzyme interactions.

Question 8

When administering a new medication to a patient, the nurse reads that it is highly protein-bound. Assuming that the patient’s albumin levels are normal, the nurse would expect which result, as compared to a medication, that is not highly protein-bound?

a. Renal excretion will be faster.
b. The drug will be metabolized quickly.
c. The duration of action of the medication will be shorter.
d. The duration of action of the medication will be longer.

Answer 8

d. The duration of action of the medication will be longer.

Rationale: Drugs that are bound to plasma proteins are characterized by a longer duration of action. Protein binding does not make renal excretion faster, does not speed up drug metabolism, and does not cause the duration of action to be shorter.

Question 9

The patient is experiencing chest pain and needs to take a sublingual form of nitroglycerin. Where does the nurse instruct the patient to place the tablet?

a. Under the tongue
b. On top of the tongue
c. At the back of the throat
d. In the space between the cheek and the gum

Answer 9

a. Under the tongue

Rationale: Drugs administered via the sublingual route are placed under the tongue. Drugs administered via the buccal route are placed in the space between the cheek and the gum; oral drugs are swallowed. The other options are incorrect.

Question 10

The nurse is administering medications to the patient who is in renal failure resulting from end-stage renal disease. The nurse is aware that patients with kidney failure would most likely have problems with which pharmacokinetic phase?

a. Absorption
b. Distribution
c. Metabolism
d. Excretion

Answer 10

d. Excretion

Rationale: The kidneys are the organs that are most responsible for drug excretion. The renal function does not affect the absorption and distribution of a drug. Renal function may affect the metabolism of drugs to a small extent.

Question 11

A patient who has advanced cancer is receiving opioid medications around the clock to keep him comfortable as he nears the end of his life. Which term best describes this type of therapy?

a. Palliative therapy
b. Maintenance therapy
c. Empiric therapy
d. Supplemental therapy

Answer 11

a. Palliative therapy

Rationale: The goal of palliative therapy is to make the patient as comfortable as possible.
It is typically used in the end stages of illnesses when all attempts at curative therapy have failed.
Maintenance therapy is used for the treatment of chronic illnesses such as hypertension.
Empiric therapy is based on clinical probabilities and involves drug administration when a certain pathologic
condition has an uncertain but high likelihood of occurrence based on the patient’s initial presenting symptoms.
Supplemental therapy (or replacement therapy) supplies the body with a substance needed to maintain normal function.

Question 12

The patient is stating that he has a headache and asks the nurse which over-the-counter medication form would work the fastest to help reduce the pain. Which medication form will the nurse suggest?

a. A capsule
b. A tablet
c. An enteric-coated tablet
d. A powder

Answer 12

d. A powder

Rationale: Of the types of oral medications listed, the powder form would be absorbed the fastest, thus having a faster onset. The tablet, the capsule, and, finally, the enteric-coated tablet would be absorbed next, in that order.

Question 13

The nurse will be injecting a drug into the superficial skin layers immediately underneath the epidermal layer of skin. Which route does this describe?

a. Intradermal
b. Subcutaneous
c. Intramuscular
d. Transdermal

Answer 13

a. Intradermal

Rationale: Injections under the more superficial skin layers immediately underneath the epidermal layer of skin and into the dermal layer are known as intradermal injections.
Injections into the fatty subcutaneous tissue under the dermal layer of skin are referred to as subcutaneous injections.
Injections into the muscle beneath the subcutaneous fatty tissue are referred to as intramuscular injections.
Transdermal drugs are applied to the skin via an adhesive patch.

Question 14

Which drugs would be affected by the first-pass effect when administered? (Select all that apply.)

a. Morphine given by IV push injection
b. Sublingual nitroglycerin tablets
c. Diphenhydramine (Benadryl) elixirs
d. Levothyroxine (Synthroid) tablets
e. Transdermal nicotine patches
f. Esomeprazole (Nexium) capsules
g. Penicillin given by IV piggyback infusion

Answer 14

c. Diphenhydramine (Benadryl) elixirs
d. Levothyroxine (Synthroid) tablets
e. Transdermal nicotine patches

Rationale: Orally administered drugs (elixirs, tablets, and capsules) undergo the first-pass effect, because they are metabolized in the liver after being absorbed into the portal circulation from the small intestine.
IV medications (IV push and IV piggyback) enter the
bloodstream directly and do not go directly to the liver. Sublingual tablets and transdermal patches also enter the bloodstream without going directly to the liver, thus avoiding the first-pass effect.

Question 15

Drug transfer to the fetus is more likely during the last trimester of pregnancy for which reason?

a. Decreased fetal surface area
b. Increased placental surface area
c. Enhanced blood flow to the fetus
d. Increased amount of protein-bound drug in maternal circulation

Answer 15

c. Enhanced blood flow to the fetus

Rationale: Drug transfer to the fetus is more likely during the last trimester of pregnancy as a result of enhanced blood flow to the fetus.
The other options are incorrect. Increased fetal surface area, not decreased, is a factor that affects drug transfer to the fetus.
The placenta’s surface area does not increase during this time. Drug transfer is increased because of an increased amount of free drugs, not protein-bound drugs, in the mother’s circulation.

Question 16

The nurse is monitoring a patient who is in the 26th week of pregnancy and has developed gestational diabetes and pneumonia. She is given medications that pose a possible fetal risk, but the potential benefits may warrant the use of the medications in her
situation. The nurse recognizes that these medications are in which U.S. Food and Drug Administration pregnancy safety category?

a. Category X
b. Category B
c. Category C
d. Category D

Answer 16

d. Category D

Rationale: Pregnancy category D fits the description given.
Category B indicates no risk to animal fetus; information for humans is not available.
Category C indicates adverse effects reported in animal fetus; information for humans is not available.
Category X
consists of drugs that should not be used in pregnant women because of reports of fetal abnormalities and positive evidence of fetal risk in humans.

Question 17

When discussing dosage calculation for pediatric patients with a clinical pharmacist, the nurse notes which type of dosage calculation is used most commonly in pediatric calculations?

a. West nomogram
b. Clark rule
c. Height-to-weight ratio
d. Milligram per kilogram of body weight formula

Answer 17

d. Milligram per kilogram of body weight formula

Rationale: The milligram per kilogram formula, based on body weight, is the most common method of calculating doses for pediatric patients.
The other options are available methods but are not the most commonly used. The height-to-weight ratio is not used.

Question 18

The nurse is assessing a newly admitted 83-year-old patient and determines that the patient is experiencing polypharmacy. Which statement most accurately illustrates polypharmacy?

a. The patient is experiencing multiple illnesses.
b. The patient uses one medication for an illness several times per day.
c. The patient uses over-the-counter drugs for an illness.
d. The patient uses multiple medications simultaneously.

Answer 18

d. The patient uses multiple medications simultaneously.

Rationale: Polypharmacy usually occurs when a patient has several illnesses and takes medications for each of them, possibly prescribed by different specialists who may be unaware of other treatments the patient is undergoing.
The other options are incorrect.
Polypharmacy addresses the medications taken, not just the illnesses.
Polypharmacy means the patient is taking several different medications, not just one, and can include prescription drugs, over-the-counter medications, and herbal products.

Question 19

The nurse is aware that confusion, forgetfulness, and increased risk for falls are common responses in an elderly patient who is taking which type of drug?

a. Laxatives
b. Anticoagulants
c. Sedatives
d. Antidepressants

Answer 19

c. Sedatives

Rationale: Sedatives and hypnotics often cause confusion, daytime sedation, ataxia, lethargy, forgetfulness, and increased risk for falls in the
elderly.
Laxatives, anticoagulants, and antidepressants may cause adverse effects in the elderly, but not the ones specified in the question.

Question 20

For accurate medication administration to pediatric patients, the nurse must take into account which criteria?

a. Organ maturity
b. Renal output
c. Body temperature
d. Height

Answer 20

a. Organ maturity

Rationale: To administer medications to pediatric patients accurately, one must take into account organ maturity, body surface area, age, and weight.
The other options are incorrect; renal output and body temperature are not considerations, and height alone is not sufficient.

Question 21

The nurse recognizes that an elderly patient may experience a reduction in the stomach’s ability to produce hydrochloric acid. This change may result in which effect?

a. Delayed gastric emptying
b. Increased gastric acidity
c. Decreased intestinal absorption of medications
d. Altered absorption of some drugs

Answer 21

d. Altered absorption of some drugs

Rationale: Reduction in the stomach’s ability to produce hydrochloric acid is an aging-related change that results in a decrease in gastric acidity and may alter the absorption of some drugs.
The other options are not results of reduced hydrochloric acid production.

Question 22

The nurse is administering drugs to neonates and will consider which factor may contribute the most to drug toxicity?

a. The lungs are immature.
b. The kidneys are small.
c. The liver is not fully developed.
d. Excretion of the drug occurs quickly.

Answer 22

c. The liver is not fully developed.

Rationale: A neonate’s liver is not fully developed and cannot detoxify many drugs. The other options are incorrect. The lungs and kidneys do not play major roles in drug metabolism.
Renal excretion is slow, not fast, because of organ immaturity, but this is not the factor that contributes the most to drug toxicity.

Question 23

An 83-year-old woman has been given a thiazide diuretic to treat heart failure. She and her daughter should be told to watch for which problems?

a. Constipation and anorexia
b. Fatigue, leg cramps, and dehydration
c. Daytime sedation and lethargy
d. Edema, nausea, and blurred vision

Answer 23

b. Fatigue, leg cramps, and dehydration

Rationale: Electrolyte imbalance, leg cramps, fatigue, and dehydration are common complications when thiazide diuretics are given to elderly
patients.
The other options do not describe complications that occur when these drugs are given to the elderly.

Question 24

An elderly patient with a new diagnosis of hypertension will be receiving a new prescription for an antihypertensive drug. The nurse expects which type of dosing to occur with this drug therapy?

a. Drug therapy will be based on the patient’s weight.
b. Drug therapy will be based on the patient’s age.
c. The patient will receive the maximum dose that is expected to reduce the blood pressure.
d. The patient will receive the lowest possible dose at first, and then the dose will be increased as needed.

Answer 24

d. The patient will receive the lowest possible dose at first, and then the dose will be increased as needed.

Rationale: As a general rule, dosing for elderly patients should follow the admonition, “Start low, and go slow,” which means to start with the lowest possible dose (often less than an average adult dose) and increase the dose slowly, if needed, based on patient response. The
other responses are incorrect.

Question 25

The nurse is trying to give a liquid medication to a 2 1
2 -year-old child and notes that the medication has a strong taste. Which technique is the best way for the nurse to give the medication to this child?

a. Give the medication with a spoonful of ice cream.
b. Add the medication to the child’s bottle.
c. Tell the child you have candy for him.
d. Add the medication to a cup of milk.

Answer 25

a. Give the medication with a spoonful of ice cream.

Rationale: Ice cream or another nonessential food disguises the taste of the medication. The other options are incorrect.
If the child does not drink the entire contents of the bottle, medication is wasted and the full dose is not administered.
Using the word candy with drugs may lead to the child thinking that drugs are actually candy.
If the medication is mixed with a cup of milk, the child may not drink the entire cup of milk, and the distasteful drug may cause the child to refuse milk in the future.

Question 26

The nurse is preparing to give an injection to a 4-year-old child. Which intervention is age-appropriate for this child?

a. Give the injection without any advanced preparation.
b. Give the injection, and then explain the reason for the procedure afterward.
c. Offer a brief, concrete explanation of the procedure at the patient’s level and with the parent or caregiver present.
d. Prepare the child in advance with details about the procedure without the parent or caregiver present.

Answer 26

c. Offer a brief, concrete explanation of the procedure at the patient’s level and with the parent or caregiver present.

Rationale: For a 4-year-old child, offering a brief, concrete explanation about a procedure just beforehand, with the parent or caregiver present, is appropriate. The other options are incorrect for any age group.

Question 27

Which statements are true regarding pediatric patients and pharmacokinetics? (Select all that apply.)

a. The levels of microsomal enzymes are decreased.
b. Perfusion to the kidneys may be decreased and may result in reduced renal function.
c. First-pass elimination is increased because of higher portal circulation.
d. First-pass elimination is reduced because of the immaturity of the liver.
e. Total body water content is much less than in adults.
f. Gastric emptying is slowed because of slow or irregular peristalsis.
g. Gastric emptying is more rapid because of increased peristaltic activity.

Answer 27

a. The levels of microsomal enzymes are decreased.
b. Perfusion to the kidneys may be decreased and may result in reduced renal function.
d. First-pass elimination is reduced because of the immaturity of the liver.
f. Gastric emptying is slowed because of slow or irregular peristalsis.

Rationale: In children, first-pass elimination by the liver is reduced because of the immaturity of the liver, and microsomal enzymes are decreased. In addition, gastric emptying is reduced because of slow or irregular peristalsis.
Perfusion to the kidneys may be decreased, resulting in reduced renal function. The other options are incorrect. In addition, remember that total body water content is greater in children than in adults.

Question 28

Which statements are true regarding the elderly and pharmacokinetics? (Select all that apply.)

a. The levels of microsomal enzymes are decreased.
b. Fat content is increased because of decreased lean body mass.
c. Fat content is decreased because of increased lean body mass.
d. The number of intact nephrons is increased.
e. The number of intact nephrons is decreased.
f. Gastric pH is less acidic.
g. Gastric pH is more acidic.

Answer 28

a. The levels of microsomal enzymes are decreased.
b. Fat content is increased because of decreased lean body mass.
e. The number of intact nephrons is decreased.
f. Gastric pH is less acidic.

Rationale: In the elderly, levels of microsomal enzymes are decreased because the aging liver is less able to produce them; fat content is increased because of decreased lean body mass; the number of intact nephrons is decreased as the result of aging; and gastric pH is less acidic because of a gradual reduction of the production of hydrochloric acid. The other options are incorrect statements.

Question 29

During the development of a new drug, which would be included in the study by the researcher to prevent any bias or unrealistic expectations of the new drug’s usefulness?

a. A placebo
b. FDA approval
c. Informed consent
d. Safety information

Answer 29

a. A placebo

Rationale: To prevent bias that may occur as a result of unrealistic expectations of an investigational new drug, a placebo is incorporated into the study. The other options are incorrect.
FDA approval, if given, does not occur until after phase III. Informed consent is required in all drug studies. Safety information is not determined until the study is underway.

Question 30

A member of an investigational drug study team is working with healthy volunteers whose participation will help to determine the optimal dosage range and pharmacokinetics of the drug. The team member is participating in what type of study?

a. Phase I
b. Phase II
c. Phase III
d. Phase IV

Answer 30

a. Phase I

Rationale: Phase I studies involve small numbers of healthy volunteers to determine optimal dosage range and the pharmacokinetics of the drug.
The other phases progressively involve volunteers who have the disease or ailment that the drug is designed to diagnose or treat.

Question 31

During discharge patient teaching, the nurse reviews prescriptions with a patient. Which statement is correct about refills for an analgesic that is classified as Schedule C-III?

a. No prescription refills are permitted.
b. Refills are allowed only by written prescription.
c. The patient may have no more than five refills in a 6-month period.
d. Written prescriptions expire in 12 months.

Answer 31

c. The patient may have no more than five refills in a 6-month period.

Rationale: Schedule C-III medications may be refilled no more than five times in a 6-month period.
The patient should be informed of this regulation. No prescription refills are permitted for Schedule C-II drugs.
Requiring refills by written prescription only applies to
Schedule C-II drugs.
Schedule C-III prescriptions (written or oral) expire in 6 months.

Question 32

A patient has been selected as a potential recipient of an experimental drug for heart failure. The nurse knows that when informed consent has been obtained, it indicates which of these?

a. The patient has been informed that he or she will need to stay in the study until it ends.
b. The patient will be informed of the details of the study as the research continues.
c. The patient will receive the actual drug during the experiment.
d. The patient has had the study’s purpose, procedures, and possible benefits, as well
as risks involved, explained to him.

Answer 32

d. The patient has had the study’s purpose, procedures, and possible benefits, as well as risks involved, explained to him.

Rationale: Informed consent involves the careful explanation of the purpose of the study, the procedures to be used, and the risks involved.
The other options do not describe informed consent. Participation in studies is voluntary and patients have the right to end participation at any time.

Question 33

For which cultural group must the health care provider respect the value placed on preserving harmony with nature and the belief that disease is a result of ill spirits?

a. Hispanics
b. Asian Americans
c. Native Americans
d. African Americans

Answer 33

c. Native Americans

Rationale: Some Native Americans believe in preserving harmony with nature and that disease is a result of ill spirits. The groups listed in the other options do not typically reflect these practices.

Question 34

The nurse is assessing an elderly Hispanic woman who is being treated for hypertension. During the assessment, what is important for the nurse to remember about cultural aspects?

a. The patient should be discouraged from using folk remedies and rituals.
b. The nurse will expect the patient to value protective bracelets and “root doctors” as healers.
c. The nurse will remember that the balance among body, mind, and environment is important for this patient’s health beliefs.
d. The nurse’s assessment needs to include gathering information regarding religious practices and beliefs regarding medication, treatment, and healing.

Answer 34

d. The nurse’s assessment needs to include gathering information regarding religious practices and beliefs regarding medication, treatment, and healing.

Rationale: All beliefs need to be considered clearly so as to prevent a conflict from arising between the goals of nursing and health care and the dictates of a patient’s cultural background.
Assessing religious practices and beliefs is part of a thorough cultural assessment.
The other options are incorrect.
The nurse should not ignore a patient’s cultural practices.
The concept of balance among body, mind, and environment and the valuing of protective bracelets and root doctors reflect beliefs or practices that usually do not apply to the Hispanic cultural group.

Question 35

When reviewing the various schedules of controlled drugs, the nurse knows which description correctly describes Schedule II drugs?

a. Drugs with high potential for abuse that have accepted medical use
b. Drugs with high potential for abuse that do not have accepted medical use
c. Medically accepted drugs that may cause moderate physical or psychologic dependence
d. Medically accepted drugs with limited potential for causing physical or psychological dependence

Answer 35

a. Drugs with high potential for abuse that have accepted medical use

Rationale: Schedule II drugs are those with high potential for abuse but that have accepted medical use.
Drugs that have a high potential for abuse but do not have accepted medical use are Schedule I drugs. Medically accepted drugs that have moderate physical or high psychologic dependence potential are Schedule III drugs.
Medically accepted drugs with limited potential for causing physical or psychological dependence are Schedule IV and V drugs.

Question 36

The nurse is reviewing facts about pharmacology for a review course. The term legend drug refers to which item?

a. Over-the-counter drugs
b. Prescription drugs
c. Orphan drugs
d. Older drugs

Answer 36

b. Prescription drugs

Rationale: The term legend drug refers to prescription drugs, which were differentiated from over-the-counter drugs by the 1951 Durham-Humphrey Amendment. Orphan drugs are drugs that are developed for rare diseases. The other options are not examples
of legend drugs.

Question 37

Nurses have the ethical responsibility to tell the truth to their patients. What is this principle known as?

a. Justice
b. Veracity
c. Beneficence
d. Autonomy

Answer 37

b. Veracity

Rationale: Veracity is defined as the duty to tell the truth. Justice is the ethical principle of being fair or equal in one’s actions.
Beneficence is the ethical principle of doing or actively promoting good. Autonomy is self-determination, or the ability to make one’s own decisions

Question 38

A patient is undergoing major surgery and asks the nurse about a living will. He states, “I don’t want anybody else making decisions for me. And I don’t want to prolong my life.” The patient is demonstrating which ethical term?

a. Autonomy
b. Beneficence
c. Justice
d. Veracity

Answer 38

a. Autonomy

Rationale: Autonomy includes self-determination, or the ability to act on one’s own, including making one’s own decisions about health care.
Veracity is defined as the duty to tell the truth.
Justice is the ethical principle of being fair or equal in one’s actions.
Beneficence is the ethical principle of doing or actively promoting good.

Question 39

The nurse is reviewing a list of scheduled drugs and notes that Schedule C-I drugs are not on the list. Which is a characteristic of Schedule C-I drugs?

a. No refills are permitted.
b. They may be obtained over-the-counter with a signature.
c. They are available only by written prescription.
d. They are used only with approved protocols.

Answer 39

d. They are used only with approved protocols.

Rationale: Schedule C-I drugs are used only with approved protocols.
Schedule C-II drugs are available only by written prescription, and refills are not permitted.
Being available over-the-counter with a signature may be true of Schedule C-V drugs in certain states.

Question 40

During a busy night shift, a new nurse administered an unfamiliar medication without checking it in a drug handbook. Later that day, the patient had a severe reaction because he has renal problems, which was a contraindication to that drug. The nurse maybe
liable for which of these?

a. Medical negligence
b. Nursing negligence
c. Nonmaleficence
d. Autonomy

Answer 40

b. Nursing negligence

Rationale: Negligence is the failure to act in a reasonable and prudent manner or failure of the nurse to give the care that a reasonably prudent
(cautious) nurse would render or use under similar circumstances.
Nurses are expected to assess patients thoroughly before medications are given, and to be familiar with medications they are administering (see Box 4-2). In this case, nursing negligence applies to nurses, not medical negligence.
Nonmaleficence is defined as the duty to do no harm; autonomy is defined as the right to
make one’s own decisions or self-determination.

Question 41

The nurse is reviewing the concept of drug polymorphism. Which factors contribute to drug polymorphism? (Select all that apply.)

a. The number of drugs ordered by the physician
b. Inherited factors
c. The patient’s diet and nutritional status
d. Different dosage forms of the same drug
e. The patient’s cultural practices
f. The patient’s drug history
g. The various available forms of a drug

Answer 41

b. Inherited factors
c. The patient’s diet and nutritional status
e. The patient’s cultural practices

Rationale: Inherited factors, diet and nutritional status, and cultural practices are some of the factors that contribute to drug polymorphism.
The other options are not factors that contribute to drug polymorphism.

Question 42

The nurse is performing an admission assessment. Which findings reflect components of a cultural assessment? (Select all that apply.)

a. The patient uses aspirin as needed for pain.
b. The patient has a history of hypertension.
c. The patient uses herbal tea to relax in the evenings.
d. The patient does not speak English.
e. The patient is allergic to shellfish.
f. The patient does not eat pork products because of religious beliefs.

Answer 42

a. The patient uses aspirin as needed for pain.
c. The patient uses herbal tea to relax in the evenings.
d. The patient does not speak English.
f. The patient does not eat pork products because of religious beliefs.

Rationale: The past use of medicines, use of herbal treatments, languages spoken, and religious practices and beliefs are components of a cultural assessment. The other options reflect components of a general medication assessment or health history.

Question 43

What is the study of physiochemical properties of drugs and how they influence the body called?

A. Pharmaceutics
B. Pharmacokinetics
C. Pharmacodynamics
D. Pharmacotherapeutics

Answer 43

C. Pharmacodynamics

Rationale: In simple terms, pharmacodynamics is the study of what drugs do to the body.

Question 44

A patient asks the nurse the difference between a generic drug and a trade or brand-name drug. Which of the following are true regarding generic drugs? (Select all that apply)

A. Have less potential for abuse and dependence
B. Have the same chemical composition as the brand-name drug
C. May have several brand names
D. May have several generic names
E. Are usually less expensive than a brand-name drug

Answer 44

B. Have the same chemical composition as the brand-name drug
C. May have several brand names
E. Are usually less expensive than a brand-name drug

Question 45

Patients with renal failure would most likely have problems with drug

A. excretion.
B. absorption.
C. metabolism.
D. distribution.

Answer 45

A. excretion.

Rationale: The kidneys are responsible for the majority of drug excretion

Question 46

A staff educator is preparing an in-service to review factors that influence medication metabolism. Which of the following would the educator include as a reason to administer a lower medication dosage? (Select all that apply)

A. Increased renal excretion
B. Increased medication-metabolizing enzymes
C. Liver failure
D. Peripheral vascular disease
E. Concurrent use of medication with the same pathway of metabolism

Answer 46

C. Liver failure
E. Concurrent use of medication with the same pathway of metabolism

Rationale:
(c)- liver failure decreases metabolism and increased the concentration of this med.
(e)- when the same pathway metabolizes two meds, they compete for metabolism.

Question 47

A patient asks the nurse why a lower dose of IV pain medication is being given than the previous oral dose. What is the nurse’s best response to the patient?

A. “Medications are given orally bypass the portal circulatory system.”
B. “Medications given intravenously are not affected by the first-pass effect.”
C. “Drugs administered intravenously enter the portal system before systemic distribution.”
D. “A large percentage of an intravenously administered drug is metabolized into inactive metabolites in the liver.”

Answer 47

B. “Medications given intravenously are not affected by the first-pass effect.”

Rationale: When drugs with a high first-pass effect are administered orally, a large amount of drug may be metabolized before it reaches the systemic circulation. The same drug given intravenously will bypass the liver.
This prevents the first-pass effect from taking place, and therefore more of the drug reaches the circulation. Parenteral doses of drugs with a high first-pass effect are much smaller than oral doses, yet they produce the same pharmacologic response.

Question 48

A patient is prescribed ibuprofen 200 mg PO every 4 hours as needed for pain. The pharmacy sends up enteric-coated tablets, but the patient refuses the tablets, stating that she cannot swallow pills. What will the nurse do?

A. Crush the tablets and mix them with applesauce or pudding.
B. Call the pharmacy and ask for the liquid form of the
medication.
C. Call the pharmacy and ask for the IV form of the medication
D. Encourage the patient to try to swallow the tablets

Answer 48

B. Call the pharmacy and ask for the liquid form of the
medication.

Rationale: The liquid form is appropriate because it is also given via the oral route. Enteric-coated tablets should not be crushed, and the patient should not be forced to take the tablets.
This medication does not have an IV form, but even if it did, the routes cannot be changed without a health care provider’s order.

Question 49

When teaching a pregnant woman about the use of drugs during pregnancy, which statement will the nurse include?

A. Exposure of the fetus to drugs is most detrimental during the second trimester of pregnancy.
B. Pregnant women must never take drugs to control high blood pressure.
C. Drug transfer to a fetus is most likely to occur during the last trimester of pregnancy.
D. A fetus is at greatest risk for drug-induced developmental defects during the second trimester of pregnancy.

Answer 49

C. Drug transfer to a fetus is most likely to occur during the last trimester of pregnancy.

Rationale: Drug transfer to the fetus is most likely to occur during the last trimester of pregnancy.
Exposure of a fetus to drugs is most detrimental during the first trimester of pregnancy, and fetuses are at greatest risk for drug-induced developmental defects during the first trimester of pregnancy.
Pregnant women need to take medications to control situations such as high blood pressure.

Question 50

When administering medications to pediatric patients, the nurse understands that the dosage calculations for pediatric patients are different than for adults because pediatric patients

A. are more likely to develop edema.
B. have more stomach acid.
C. have skin that is less permeable.
D. have immature liver and kidney function

Answer 50

D. have immature liver and kidney function

Rationale: In pediatric patients, body temperature is less well regulated, and dehydration occurs easily; pediatric patients lack stomach acid to kill bacteria and have skin that is thinner and more permeable.
It is true that pediatric patients have immature liver and kidney function, resulting in impaired drug metabolism and excretion.

Question 51

The nurse caring for a pediatric patient calculates the safe range for the prescribed medication. Based on the nurses calculations, the dose ordered exceeds the high limit. What is the nurse’s next action?

A. Contact the prescriber immediately.
B. Administer only half the ordered dose.
C. Proceed with administration of the prescribed dose.
D. Contact pharmacy to substitute the prescribed medication with one that will calculate in the safe range.

Answer 51

A. Contact the prescriber immediately.

Rationale: The nurse should contact the prescriber immediately and before administering the medications. Giving only half the prescribed dose is making a prescribed order which is not within the scope of practice for the nurse. Pharmacy cannot make treatment changes without the direction of the prescriber.

Question 52

What does the nurse identify as a pharmacokinetic change that occurs in older adults?

A. Gastric pH is more acidic.
B. Fat content is decreased because of increased lean body mass.
C. There is increased production of proteins by the liver.
D. The number of intact nephrons is decreased.

Answer 52

D. The number of intact nephrons is decreased.

Rationale: In older adults, the gastric pH is less acidic because of a gradual reduction in the production of hydrochloric acid in the stomach, fat content is increased because of decreased lean body mass, and there is decreased production of proteins by the aging liver and reduced protein intake. It is correct that the number of intact nephrons decreases in older adults.

Question 53

When calculating pediatric dosages, the nurse understands which method is most accurate for dosing calculations?

A. Use of drug reference recommendations based on mg/kg of body weight.
B. Calculated doses based on body weight need to be increased by 10% because of immature renal and hepatic function
C. Dosage calculation by body surface area because it takes into account the difference in size for children and neonates
D. Medication dosing calculated according to body weight because it is based on maturational growth and
development

Answer 53

C. Dosage calculation by body surface area because it takes into account the difference in size for children and neonates

Question 54

Knowing that the albumin in neonates and infants has a lower binding capacity for medications, the nurse anticipates the health care provider will perform which action to minimize the risk of toxicity?

A. Decrease the amount of drug given.
B. Increase the amount of drug given.
C. Shorten the time interval between doses.
D. Administer the medication intravenously.

Answer 54

A. Decrease the amount of drug given.

Rationale: A lower binding capacity leaves more drug available for action; thus, a lower dose would be required to prevent toxicity.
An increase in the drug dose would result in higher risk of toxicity. A shorter time interval between doses would increase the risk of toxicity. IV administration of a drug may increase the risk of toxicity due to quicker onset of action.

Question 55

The physiologic changes that normally occur in older adult patients have which implication for drug response?

A. Drug elimination is faster.
B. Drug metabolism is quicker.
C. Drug half-life is lengthened.
D. Protein binding is more efficient.

Answer 55

C. Drug half-life is lengthened.

Rationale: Drug half-life is extended secondary to the diminished liver and renal function in the older adult. Metabolism is slower, not faster, in older adults.
Drug elimination is also generally slower in the older adult, and protein binding is not more efficient in the older adult.

Question 56

A nurse working with older adult patients is concerned about the number of medications prescribed for each patient. Which older adult assessment should be of the highest priority related to polypharmacy?

A. Drug interactions
B. Cost of medications
C. Schedule of medications
D. Nonadherence to drug regimen

Answer 56

A. Drug interactions

Rationale: The highest priority for patients with multiple medications (polypharmacy) is the assessment for drug interactions. The more medications a patient takes, the higher is the risk of drug interactions.

Question 57

Which statement best reflects the nurse’s understanding of cultural influences on drug therapy and other health practices?

A. Dietary habits and practices can be of little value to the care of a sick adult.
B. Most cultures are fairly standard in reference to the use of medications during illness.
C. Administration of some drugs may elicit varied responses in specific racial/ethnic groups.
D. Regardless of one’s cultural background, it is crucial to adhere to recommended medical practices.

Answer 57

C. Administration of some drugs may elicit varied responses in specific racial/ethnic groups.

Rationale: Knowledge about drugs that may elicit varied responses in specific racial or ethnic groups must remain current.
For example, genetic changes in certain metabolic enzymes affect the rate of drug metabolism and thus affect drug levels and dosage amounts.
Cultural practices vary among individuals and should be implemented as an integral part of holistic nursing care.
Dietary habits and practices can affect the pharmacokinetics of medications and are thus an important aspect of the patient’s history.

Question 58

An emergency department nurse is documenting the medication history of a patient of Asian culture. The patient states, “I am not taking any medications,” but the nurse observes a bottle of capsules in the patient’s medicine bag. What information would the nurse collect next?

A. Health care provider name
B. Vital signs and pulse oximetry
C. Past use of medicine and home remedies
D. Use of herbs or over-the-counter medications

Answer 58

D. Use of herbs or over-the-counter medications

Rationale: The nurse should ask the patient whether the patient has taken any herbs, over-the-counter medications, or other non-prescribed medications. The patient is of Asian culture and may use herbal remedies that he or she does not consider medications.

Question 59

There are multiple factors that affect medication response. The nurse recognizes which factors have a possible effect on the medication response? (Select all that apply.)

A. Genetic influences
B. Body composition
C. Diet and nutrition
D. Level of education
E. Socioeconomic factors
F. Use of alternative therapies
G. Patient compliance with therapy

Answer 59

A. Genetic influences
B. Body composition
C. Diet and nutrition
D. Level of education
E. Socioeconomic factors
F. Use of alternative therapies
G. Patient compliance with therapy

Question 60

What response would the nurse give the patient when questioned about the effect of rheumatoid arthritis on the musculoskeletal system?

a. Muscle weakness
b. Muscle wasting
c. Joint inflammation
d. Joint spasticity

Answer 60

c. Joint inflammation

Rationale: Rheumatoid arthritis and osteoarthritis cause inflammation of joints, resulting in pain and limited joint mobility, not muscle mobility.
Genetic disorders such as muscular dystrophy result in muscle weakness and gradual muscle wasting. Spasticity (increased muscle tone) occurs in developmental disorders, such as cerebral palsy, and results in reduced range of motion (ROM)
and abnormal movement patterns.

Question 61

The nurse is implementing generalized falls precautions for patients who are at risk for falls. Which intervention indicates a lack of understanding of these precautions?

a. The bed is placed in the low position.
b. The patient is wearing socks.
c. The patient’s cell phone is by the bedside.
d. The patient’s call light is within reach.

Answer 61

b. The patient is wearing socks.

Rationale: If the patient is ambulatory, require the use of nonskid footwear. Socks can be slippery unless they have a grip surface on them.
Keep patient belongings (e.g., tissues, water, urinals, personal items) within the patient’s reach.
Keep the call light in reach and remind the patient to use it and keep the bed in the low position.

Question 62

The nurse is educating the family of a patient on falls risk precautions. Which statement by the family indicates a need for further education?

a. “I should keep the wheelchair locked unless using it to move Mom.”
b. “I should leave the bathroom light on as she does at her home.”
c. “I should leave her slippers by the wheelchair.”
d. “I should keep her cell phone close to her bed.”

Answer 62

c. “I should leave her slippers by the wheelchair.”

Rationale: Leave lights on or off at night, depending on the patient’s cognitive status and personal preference. Keep the wheels of any wheeled device (e.g., bed, wheelchair) in the locked position.
Keep patient belongings (e.g., tissues, water, urinals, personal items) within the patient’s reach. If the patient is ambulatory, require the use of nonskid footwear (socks or shoes).

Question 63

The nurse is performing passive range-of-motion exercises on a patient when the patient begins to complain of pain. What is the first thing the nurse should do?

a. Notify the health care provider.
b. Hyperextend the joint.
c. Stop the range of motion.
d. Switch to active range of motion.

Answer 63

c. Stop the range of motion.

Rationale: Stop range-of-motion exercises if the patient begins to complain of pain or if resistance to movement is experienced.
Never hyperextend or flex a patient’s joints beyond the position of comfort. Active range of motion is when the patient moves the joint.
Notifying the health care provider would happen later.

Question 64

The nurse recognizes which goal to be appropriate for the patient who is postoperative day one from a hip fracture with the nursing diagnosis Impaired mobility?

a. Patient will interact with others.
b. Patient will ambulate to the bathroom with assistance.
c. Patient will have no skin breakdown.
d. Patient will have a physical therapy consult.

Answer 64

b. Patient will ambulate to the bathroom with assistance.

Rationale: Patients with a diagnosis of Impaired mobility should have a goal aimed at improving their mobility. Although immobility can impact social isolation and skin breakdown, those goals are not appropriate for this diagnosis. Have a physical therapy consult is not a goal but an intervention.

Question 65

The nurse identifies which goal to be appropriate for the patient who is postoperative day one from abdominal surgery and on bed rest with the nursing diagnosis impaired skin integrity?

a. Patient will ambulate twice a day.
b. Patient will eat 50% of meals.
c. Patient will have no further skin breakdown.
d. Patient will interact with others.

Answer 65

c. Patient will have no further skin breakdown.

Rationale: The patient already has a wound, so the goal is focused on no further skin breakdown as a result of the bed rest and immobility.
Although nutrition is important to wound healing, it is not the focus of this Nursing diagnosis. Ambulating and interacting with others are not goals for this diagnosis.

Question 66

The nurse is providing education to the patient about isometric exercises. Which statement by the patient indicates a good understanding of these exercises?

a. “An example of this type of exercise is walking.”
b. “An example of this type of exercise is running.”
c. “An example of this type of exercise is Kegels.”
d. “An example of this type of exercise is weight lifting.”

Answer 66

c. “An example of this type of exercise is Kegels.”

Rationale: Isometric exercise requires tension and relaxation of muscles without joint movement. An example is tension and relaxation of pelvic floor muscles (i.e., Kegel exercise).
Isotonic exercise involves active movement with constant muscle contraction, such as walking, turning in bed, and self-feeding.
Aerobic exercise requires oxygen metabolism to produce energy. Patients may engage in
rigorous walking or repeated stair climbing to achieve the positive effects of aerobic exercise.
Anaerobic exercise builds power and body mass. Without oxygen to produce energy for activity, anaerobic exercise takes place, such as heavy weight lifting.

Question 67

The nurse is preparing to assist the patient to walk to the bathroom after medicating the patient with a narcotic for pain management. What possible adverse effect should the nurse be immediately aware?

a. Constipation
b. Depression
c. Dizziness
d. Pain relief

Answer 67

c. Dizziness

Rationale: Potential adverse side effects of narcotics include respiratory depression, hypotension, confusion, sedation, constipation, and dizziness.
The nurse should be immediately aware of dizziness during ambulation because of the safety risks.
Pain relief is expected. Depression is not an immediate adverse side effect. Constipation will not impact the nurse’s ability to safely ambulate the patient.

Question 68

The nurse correctly selects which intervention to avoid causing shear or friction when moving a patient in bed?

a. Using an airflow bed
b. Using a slide board
c. Using a trochanter roll
d. Using a gel mattress

Answer 68

b. Using a slide board

Rationale: A transfer or slide board is made of plastic-like material that reduces friction. Linens easily slide over the board, facilitating bed linen changes.
Patients can be repositioned or transferred with a minimum of force required.
A trochanter roll prevents outward rolling of the hip when a patient is lying on his/her back.
An air-fluidized bed uses airflow to move silicone particles in the bed, creating a watery, fluid-like movement and resulting in lower pressure to avoid or alleviate decubitus ulcers.
A foam or gel combination mattress reduces pressure.

Question 69

Which explanation by the nurse best describes active assistive range of motion?

a. The patient independently moves all joints.
b. The patient to partially moves all joints.
c. The caregiver must move the patient’s joints.
d. The patient performs isotonic exercises.

Answer 69

b. The patient to partially moves all joints.

Rationale: Active assistive range of motion occurs when the caregiver minimally assists the patient, or the patient minimally assists himself/herself in the movement of joints through a full motion.
Active range of motion occurs when the patient has full
independent movement of all joints; this is also known as isotonic exercise.
Passive range of motion occurs when the caregiver moves the patient’s joints through a full motion. This exercise does not maintain or improve strength but maintains flexibility and prevents contractures and atrophy

Question 70

The nurse identifies which instruction to be appropriate to delegate to the UAP (Unlicensed assistive personnel)?

a. Assess the patient’s skin during a bath.
b. Reposition the patient using the trapeze.
c. Assess the patient’s ability to perform range-of-motion exercises.
d. Notify the health care provider of any changes.

Answer 70

b. Reposition the patient using the trapeze.

Rationale: Repositioning a patient can be delegated to unlicensed assistive personnel (UAP); the nurse should provide proper instruction regarding specific positioning techniques, individualized patient concerns, and circumstances that require notifying a nurse.
UAP may not perform assessments or evaluations but should notify the nurse about any skin or musculoskeletal issues (not the healthcare provider).

Question 71

The nurse knows that manual lifting should only be done in which situation?

a. Patients who are less than 150 lb
b. Life-threatening situations
c. Postsurgical patients
d. Patients who are less than 200 lb

Answer 71

b. Life-threatening situations

Rationale: Many manual patient handling tasks are unsafe, because the weights lifted and movements required are beyond the ability of most caregivers.
The key is to identify the task to be accomplished, and then use the required equipment and personnel so that the task fits the capabilities of the staff (U.S. Department of Veterans Affairs, 2016). The patient’s level of cooperation is taken into
consideration when using the safe patient-handling and mobility (SPHM) algorithms to decide the best method of moving the patient.
The patient’s weight, medical conditions, and ability to assist are also considered (U.S. Department of Veterans Affairs,
2016). Postsurgical patients as well as patients less than 150 or 200 lb may not fit the criteria.

Question 72

The nurse is preparing to reposition the patient in bed. What is the first step in this process?

a. Position the patient’s arms across his/her chest.
b. Lower the side rails.
c. Grasp the draw sheet.
d. Raise the bed to a working height.

Answer 72

d. Raise the bed to a working height.

Rationale: Raising the bed to a working height is the first step before beginning the procedure. Proper positioning of equipment prevents provider discomfort and reduces the chance of possible injury.
Then lower the side rails as appropriate and safe and ensure that the bed wheels are locked.
Then you can have the patient position his/her arms and/or grasp the draw sheet.

Question 73

The nurse has delegated to the UAP to assist a patient with ambulating in the hallway with a cane. Which statement by the UAP indicates a need for further education?

a. “I should report any complaints of soreness to the nurse.”
b. “I should watch for indications that the patient has difficulties using the cane.”
c. “I should let the nurse or PT know if the cane doesn’t seem to fit correctly.”
d. “I should teach the patient how to walk with the cane.”

Answer 73

d. “I should teach the patient how to walk with the cane.”

Rationale: Educating patients on how to walk with assistive devices may not be delegated to unlicensed assistive personnel (UAP). UAP should report any of the following: noticeable incorrect usage or fit of assistive devices, complaints of soreness or weakness,
difficulties involving balance or strength, or difficulties in performing the procedure or other concerns verbalized by the patient.

Question 74

The nurse correctly teaches the patient to rise from a chair using crutches when which intervention is used?

a. Patient starts from the back of the chair.
b. The weak leg is closest to the chair.
c. The hand on the strong side holds the hand bar of the crutch.
d. The strong leg is closest to the chair.

Answer 74

d. The strong leg is closest to the chair.

Rationale: The patient’s strongest leg needs to be closest to the chair.
The patient’s hand on the weak side holds the hand bar of the crutches, and the hand on the patient’s strong side holds onto the armrest of the chair. The patient moves to the front edge of the chair.

Question 75

The nurse is teaching a patient about ways to decrease risk of bone fractures. Which statements by the patient indicate a good understanding of decreasing this risk? (Select all that apply.)

a. “I should do weight-bearing exercises.”
b. “I should get adequate intake of calcium and vitamin D.”
c. “I should exercise regularly.”
d. “I need to do yoga exercises.”
e. “I wish I could reduce my risk but I can’t do anything.”

Answer 75

a. “I should do weight-bearing exercises.”
b. “I should get adequate intake of calcium and vitamin D.”
c. “I should exercise regularly.”

Rationale: Inadequate dietary intake of calcium and vitamin D or impaired calcium metabolism may result in osteoporosis, which increases bone fragility and may lead to fractures.
Decreased physical exercise and lack of weight-bearing exercise also contribute to bone
fragility, deterioration, and loss of strength.
Any type of exercise will help; it does not need to be yoga, but it does need to include weight-bearing exercise.

Question 76

The nurse knows that a patient with a compromised cardiopulmonary system has a diminished capacity for exercise because of which conditions? (Select all that apply.)

a. Decreased tissue perfusion
b. Loss of sensation
c. Hemiparesis
d. Diminished respiratory capacity
e. Muscle weakness

Answer 76

a. Decreased tissue perfusion
d. Diminished respiratory capacity

Rationale: Compromised cardiac function, decreased tissue perfusion, and diminished respiratory capacity directly affect a person’s ability to perform activities of daily living (ADLs) and exercise.
Hemiparesis and loss of sensation are associated with nervous system disorders. Muscle weakness can be from a number of causes.

Question 77

The nurse is educating the patient about the effects of immobility on the body. Which statements by the patient indicate a need for further education? (Select all that apply.)

a. “I can become very weak.”
b. “I will gain weight.”
c. “I will lose muscle tone.”
d. “I can get bed sores.”
e. “I won’t have any lung problems.”

Answer 77

b. “I will gain weight.”
e. “I won’t have any lung problems.”

Rationale: Immobility may cause weakness, instability, anorexia, elimination alterations, decreased muscle tone, circulatory stasis, DVTs, pulmonary embolism, and skin breakdown.
Knowing the effects of immobility on various body systems allows the nurse to quickly assess a patient’s risk and recognize signs of impending complications.

Question 78

The nurse knows which items are included in the documentation for a patient on fall precautions? (Select all that apply.)

a. History of any falls
b. Falls risk assessment scores
c. Patient and family education
d. Use of assist devices
e. Any fall or reported fall

Answer 78

a. History of any falls
b. Falls risk assessment scores
c. Patient and family education
d. Use of assist devices
e. Any fall or reported fall

Rationale: The nurse should document the general assessment, include the patient’s medical history, subjective and objective data, medication
review, musculoskeletal status, and history of falls.
Falls assessment and reassessment, patient family education and use of assist devices are also documented. Thoroughly document a fall or reported fall.

Question 79

The nurse knows which findings indicate orthostatic hypotension? (Select all that apply.)

a. A decrease in systolic blood pressure by 30 mm Hg
b. A decrease in diastolic blood pressure by 10 mm Hg
c. An increase in heart rate by 30 beats/min
d. An increase in systolic blood pressure by 20 mm Hg
e. A decrease in heart rate by 20 beats/min

Answer 79

b. A decrease in diastolic blood pressure by 10 mm Hg
d. An increase in systolic blood pressure by 20 mm Hg

Rationale: A drop in systolic blood pressure of 20 mm Hg, an increase in heart rate of 20 beats/min, or a drop of diastolic blood pressure of 10 mm Hg when a patient stands is classified as orthostatic hypotension.

Question 80

The nurse appropriately delegates care of the unit’s patients to the properly trained UAP when that UAP is assigned which tasks? (Select all that apply.)

a. UAP assigned to reposition the patient.
b. UAP assigned to complete the MORSE falls risk scale.
c. UAP assigned to provide range-of-motion exercises.
d. UAP assigned to ambulate the patient in the hallway.
e. UAP assigned to time the patient on a TUG test.

Answer 80

a. UAP assigned to reposition the patient.
c. UAP assigned to provide range-of-motion exercises.
d. UAP assigned to ambulate the patient in the hallway.

Rationale: UAPs provide hands-on care for immobilized patients under the direct supervision of registered nurses.
Turning and positioning of patients, range-of-motion exercises, transfers, and assistance with ambulation may be delegated to properly trained UAP.
UAPs may not assess patients because that is a nursing responsibility.
The MORSE falls risk scale is a risk assessment as is the Timed Up and Go (TUG) test

Question 81

The nurse is correctly demonstrating the use of a transfer belt when engaging in which actions? (Select all that apply.)

a. The belt is placed around the patient’s hips.
b. The belt is secure, leaving only enough room for the nurse to grasp the belt.
c. The nurse stands on the weaker side.
d. The nurse holds the belt on the side of the patient.
e. The nurse stands behind the patient while ambulating.

Answer 81

b. The belt is secure, leaving only enough room for the nurse to grasp the belt.
c. The nurse stands on the weaker side.

Rationale: Transfer belts are used for patients with an unsteady gait or generalized weakness.
Canvas transfer or gait belts are applied snugly
around the patient’s waist, leaving only enough room for the nurse to grasp the belt firmly during ambulation.
Some belts may have handles. If the patient has a weaker side, the nurse should stand on that side and hold the gait belt firmly at the back of the patient’s
waist while ambulating.

Question 82

The nurse is correctly assisting the patient in using a cane when the patient demonstrates which activities? (Select all that apply.)

a. The top of the cane is level with the patient’s bent elbow.
b. The patient holds the cane on his/her weaker side.
c. The patient moves the cane forward first.
d. The patient’s arm is comfortably bent when walking.
e. The patient moves the strong leg forward first.

Answer 82

c. The patient moves the cane forward first.
d. The patient’s arm is comfortably bent when walking.

Rationale: The top of the cane should be level with the hip joint, and the patient’s arm should be comfortably bent when the patient is walking.
The patient should hold the cane on his/her stronger side and move the cane forward first, followed by the weaker leg and then the stronger leg.
This ensures that another point of support is always on the ground when the weaker leg is bearing weight and gives the patient a wide base of support. A patient using a cane should be encouraged to stand up straight and look forward. Leaning to
one side or looking down can jeopardize safety and cause poor posture.

Question 83

The nurse is providing discharge education for the patient who is going home with a walker. Which statements by the patient indicate a good level of understanding of safety in the home? (Select all that apply.)

a. “I need to remove the throw rugs.”
b. “I should make sure I only take a bath.”
c. “I cannot use the stairs.”
d. “I need to place a nonskid mat in front of the kitchen sink.”
e. “I wish I had two ways of leaving the house.”

Answer 83

a. “I need to remove the throw rugs.”
d. “I need to place a nonskid mat in front of the kitchen sink.”

Rationale: To ensure patients do not have hazards that can cause falls at home, the nurse should evaluate where the living quarters are.
If the patient has stairs, they need to be able to safely learn how to use the stairs. They need to remove throw rugs that are a trip hazard and place nonskid mats in front of sinks, tubs, and showers.
They can shower with a bench or chair in the shower for sitting.
Patients need a clear the exit so they can get out of the house quickly in case of an emergency, but do not specifically need two different exits because of the walker.

Question 84

The nurse identifies that knee-high SCD (Sequential Compression Device) sleeves are correctly placed on the patient when which conditions are met? (Select all that apply.)

a. Both sleeves are connected to the SCD device.
b. Two fingers fit inside when the SCDs are inflated.
c. There are no kinks in the tubing.
d. The ankle pressure is 55 to 65 mm Hg.
e. The cooling control is on.

Answer 84

a. Both sleeves are connected to the SCD device.
c. There are no kinks in the tubing.
e. The cooling control is on.

Rationale: Proper positioning of the SCD sleeve allows proper fit and application, which decreases the risk of constricting the blood flow or diminishing optimal outcomes. Wrap the sleeve around the leg and fasten it with Velcro straps.
Verify that two fingers fit between the leg and the sleeve when the sleeve is not inflated.
Connect the sleeves to the device, ensure that there are no kinks in the tubing, and turn on the cooling and set it to 35 to 55 mm Hg.

Question 85

A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening. What is the nurse’s best response?

a. “Your iron level is low. This is known as anemia.”
b. “Your immobility in the hospital is known as deconditioning.”
c. “Your poor appetite is known as malnutrition.”
d. “Your medications have caused drug induced weakness.”

Answer 85

b. “Your immobility in the hospital is known as deconditioning.”

Rationale: When a person is ill and immobile the body becomes weak. This is known as deconditioning. Anemia, malnutrition, and medications may have an adverse effect on the body, but this is not known as deconditioning which is the most likely cause in
this patient’s situation.

Question 86

An older patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. What is the nurse’s best response?

a. “Walk at least 5 miles every day for exercise.”
b. “Wear proper fitting shoes to prevent tripping.”
c. “Talk with your physician about a calcium supplement.”
d. “Stand up slowly so you don’t feel faint.”

Answer 86

c. “Talk with your physician about a calcium supplement.”

Rationale: Calcium strengthens the bones. A calcium supplement will help strengthen bones as they may be affected by aging, illness, or trauma.
Walking several miles will help strengthen the bones, but the patient should consult with the healthcare provider before any exercise regimen is implemented for the older adult.
Wearing proper shoes and standing slowly to prevent dizziness is important but they will not prevent fractures.

Question 87

Mobility for the patient changes throughout the lifespan. What is the term that best describes this process?

a. Aging and illness
b. Illness and disease
c. Health and wellness
d. Growth and development

Answer 87

d. Growth and development

Rationale: Growth and development happens from infancy to death. Muscular changes are always happening, and these changes affect the
individual and his or her performance in life. Aging, illness, health, and wellness do have an effect on a person, but they don’t always affect mobility.

Question 88

The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when making which statement?

a. “Patients must have a trapeze over the bed to move properly.”
b. “Patients should move themselves in bed to prevent immobility.”
c. “Patients should always have a two-person assist to move in bed.”
d. “Patients must be moved correctly in bed to prevent shearing.”

Answer 88

d. “Patients must be moved correctly in bed to prevent shearing.”

Rationale: Patients must be moved properly in bed to prevent shearing of the skin.
Having a trapeze over the bed is only functional if the patient can assist in the moving process.
A two-person assist is good, but the patient still needs to be moved properly.
A patient may move himself or herself if he or she is able; but shearing may still occur.

Question 89

The nurse and a student nurse are discussing the effects of bed immobility on patients. The nurse knows that the student nurse understands the concept of mobility when making which statement?

a. “Patients with impaired bed mobility have an increased risk for pressure ulcers.”
b. “Patients with impaired bed mobility like to have extra visitors.”
c. “Patients with impaired bed mobility need to have a mechanical soft diet.”
d. “Patients with impaired bed mobility are prone to constipation.”

Answer 89

a. “Patients with impaired bed mobility have an increased risk for pressure ulcers.”

Rationale: Patients who cannot move themselves in bed are more susceptible to pressure ulcers because they cannot relieve the pressure they feel. Extra visitors or diet consistency do not have any bearing on mobility. Constipation should not be a by-product of
immobility if a bowel regimen is instituted.

Question 90

What percentage of hip fractures is the result of falls?

a. 50%
b. 80%
c. 90%
d. 100

Answer 90

c. 90%

Rationale: About 90% of falls end with a hip fracture.

Question 91

The lack of weight-bearing leads to what effects on the skeletal system?

a. Demineralization, calcium loss
b. Thickened bones
c. Increased range of motion
d. Increased calcium deposition in the bones

Answer 91

a. Demineralization, calcium loss

Rationale: Weight-bearing helps to strengthen the bone. Lack of weight-bearing means that the bone is losing minerals and calcium that strengthen it. Thickened bones will not occur with the lack of weight-bearing. Range of motion may be decreased with a lack of weight-bearing movements.

Question 92

An older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to perform skin checks to assess for signs of skin cancer?

a. “Limit the time you spend in the sun.”
b. “Monitor for signs of infection.”
c. “Monitor spots for color change.”
d. “Use skin creams to prevent drying.”

Answer 92

c. “Monitor spots for color change.”

Rationale: The ABCDE method (check for asymmetry, border irregularity, color variation, diameter and evolving) should be used to assess lesions for signs associated with cancer. Color change could be a sign of cancer and needs to be looked at by a dermatologist.
Limiting time spent in the sun is a preventative measure but will not assist the patient in checking the skin or detecting skin cancer. Infection is usually not found in skin cancer. Skin creams have not been shown to prevent cancer nor would they assist in detecting skin cancer

Question 93

A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this patient?

a. Obtaining a complete blood count (CBC)
b. Protection from excessive heat
c. Protection from excessive ultraviolet (UV) exposure
d. Instructing the patient to take their multivitamin prior to treatment

Answer 93

c. Protection from excessive ultraviolet (UV) exposure

Rationale: Protection from excessive UV exposure is important to prevent tissue damage. Protection from heat is not the most important priority for this patient. There is no need for vitamins or a CBC for patients with psoriasis.

Question 94

A patient was given a patch test to determine what allergen was responsible for their atopic dermatitis. The provider prescribes a steroid cream. What important instructions should the nurse give to the patient?

a. Apply the cream generously to affected areas.
b. Apply a thin coat to affected areas, especially the face.
c. Apply a thin coat to affected areas; avoid the face and groin.
d. Apply an antihistamine along with applying a thin coat of steroid to affected areas.

Answer 94

c. Apply a thin coat to affected areas; avoid the face and groin.

Rationale: The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to administer oral steroid if the rash is generalized.

Question 95

A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on?

a. Decreasing pain
b. Decreasing pruritus
c. Preventing infection
d. Promoting drying of lesions

Answer 95

b. Decreasing pruritus

Rationale: Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity. The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring.

Question 96

To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to do which of the following?

a. Apply sunscreen 1 hour prior to exposure.
b. Drink plenty of water to prevent hot skin.
c. Use vitamins to help prevent sunburn by replacing lost nutrients.
d. Apply sunscreen 30 minutes prior to exposure.

Answer 96

d. Apply sunscreen 30 minutes prior to exposure.

Rationale: Wearing sunglasses and sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma.
Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamins do not prevent burn.

Question 97

A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that the need for additional teaching?

a. “I wear a hat and sit under the umbrella when not in the water.”
b. “I don’t bother with sunscreen on overcast days.”
c. “I use a sunscreen with the highest SPF number.”
d. “I wear a UV shirt and limit exposure to the sun by covering up.”

Answer 97

b. “I don’t bother with sunscreen on overcast days.”

Rationale: The sun’s rays are as damaging to skin on cloudy, hazy days as on sunny days. The other options will all prevent skin cancer.

Question 98

A patient has cellulitis on the right forearm. The nurse would anticipate orders to administer medications to eradicate which organism?

a. Candida albicans
b. Group A β-hemolytic streptococci
c. Staphylococcus aureus
d. E. Coli

Answer 98

c. Staphylococcus aureus

Rationale: Staphylococcus aureus is the usual cause of cellulitis, although other pathogens may be responsible. A small abrasion or lesion can provide a portal for opportunistic or pathogenic infectious organisms to infect deeper tissues.

Question 99

A nurse is conducting community education classes on skin cancer. One participant says to the nurse: “I read that most melanomas occur on the face and arms in fair-skinned women. Is this true?” How should the nurse respond?

a. “That is not correct. Melanoma is more commonly found on the torso or the lower legs of women.”
b. “That is correct, because the face and arms are exposed more often to the sun.”
c. “That is not correct. Melanoma occurs on the top of the head in men but is rare in women.”
d. “That is incorrect. Melanoma is most commonly seen in dark-skinned individuals.”

Answer 99

a. “That is not correct. Melanoma is more commonly found on the torso or the lower legs of women.”

Rationale: Melanoma is more commonly found on the torso or the lower legs in women. Melanoma can occur anywhere and is not associated with direct exposure. For example, an individual can have melanoma under the skin and on the soles of the feet.
Dark-skinned individuals are less likely to get melanoma.

Question 100

The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient. Which action indicates the nursing assistant has understood the nurse’s teaching?

a. Bathing and drying the skin vigorously to stimulate circulation
b. Keeping the head of the bed elevated 30 degrees
c. Limiting intake of fluid and offer frequent snacks
d. Turning the patient at least every 2 hours

Answer 100

d. Turning the patient at least every 2 hours

Rationale: The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently.
Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in
healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

Question 101

A patient asks the nurse what the purpose of the Wood’s light is. Which response by the nurse is accurate?

a. “We will put an anesthetic on your skin to prevent pain.”
b. “The lamp can help detect skin cancers.”
c. “Some patients feel a pressure-like sensation.”
d. “It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions.”

Answer 101

d. “It is used to identify the presence of infectious organisms and proteins associated with specific skin conditions.”

Rationale:
The Wood’s light examination is the use of a black light and darkened room to assist with physical examination of the skin. The examination does not cause discomfort.

Question 102

The nurse knows which description would be classified as a closed wound?

a. A large bruise on the side of the face
b. A surgical incision that is sutured closed
c. A puncture wound that is healing
d. An abrasion on the leg

Answer 102

a. A large bruise on the side of the face

Rationale: In a closed wound, as seen with bruising, the skin is still intact. An open wound is characterized by an actual break in the skin’s surface.
For example, an abrasion, a puncture wound, and a surgical incision are types of open wounds.

Question 103

The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education?

a. “The wound will be red.”
b. “The wound will have pus.”
c. “The wound will be warm.”
d. “The wound will need to be treated.”

Answer 103

b. “The wound will have pus.”

Rationale: An infected wound shows clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus), and has a bacterial count in the tissue of at least 105/g of tissue sampled when cultured. The wound will
need to be treated for the infection.

Question 104

The nurse identifies which type of wounds heal by tertiary intention?

a. An acute wound in which the patient has sutures placed when it happened.
b. A pressure ulcer that was treated with dressing changes and is healed.
c. An acute wound in which surgical glue was used to close the wound.
d. A wound that was left open initially and closed later with sutures.

Answer 104

d. A wound that was left open initially and closed later with sutures.

Rationale: When a delay occurs between injury and closure, the wound healing is said to happen by tertiary intention.
Wounds such as surgical incisions or traumatic wounds in which the edges of the wound can be approximated (brought together) to heal are examples of acute wounds.
This type of wound is said to heal by primary intention. When a wound heals by secondary intention,
new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue such as a pressure ulcer.

Question 105

The nurse is caring for a patient who is postoperative day one from an abdominal surgery. When the patient complains of a “popping sensation” and a wetness in the dressing, the nurse immediately suspects which complication?

a. A wound infection
b. The stitches came loose
c. Wound dehiscence
d. Wound crepitus

Answer 105

c. Wound dehiscence

Rationale: Wound dehiscence, which usually occurs in connection with surgical incisions, is the partial or complete separation of the tissue layers during the healing process.
This is an emergency situation. Stitches can come loose, but there is no popping sensation.
Wound infections are characterized by redness, warmth, and drainage, and crepitus is air trapped under the skin.

Question 106

The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when the nurse walks into the room. In addition to notifying the surgeon, what should the nurse do?

a. Cover the wound with a sterile gauze pad.
b. Cover the wound with a transparent dressing.
c. Put pressure on the wound with a sterile gauze pad.
d. Cover the wound with gauze soaked with normal saline.

Answer 106

d. Cover the wound with gauze soaked with normal saline.

Rationale: If dehiscence or evisceration occurs, cover the wound with gauze moistened with a sterile normal saline, and notify the surgeon immediately.
Putting pressure on the wound could cause further complications. Transparent films are used for autolytic
debridement. A gauze pad will allow the wound to become dry and cause further complications.

Question 107

The nurse identifies what goal to be the most appropriate goal for a patient with a stage 3 pressure ulcer who has a Nursing diagnosis of Impaired skin integrity?

a. Wound will be completely healed in 72 hours.
b. Wound will show signs of healing within 2 weeks.
c. Patient will develop no new pressure ulcers.
d. Patient will ambulate twice a day.

Answer 107

b. Wound will show signs of healing within 2 weeks.

Rationale: A stage 3 pressure ulcer is a more extensive wound and will take time to heal, so the most appropriate goal will be to show signs of
healing in 2 weeks.
It will not heal in 72 hours. The goal of no new pressure ulcers is good, but not the most appropriate, and
ambulating twice a day is more of an intervention.

Question 108

A new nurse is delegating care of a chronic, nonsterile wound to a UAP. What action by the new nurse causes the preceptor to intervene?

a. The nurse asks the UAP to assess the wound.
b. The nurse asks the UAP to report increased wound drainage.
c. The nurse asks the UAP to observe changes in dietary intake.
d. The nurse asks the UAP to change the dressing.

Answer 108

a. The nurse asks the UAP to assess the wound.

Rationale: Assessment and evaluation of a patient’s skin and wounds, and the effectiveness of the treatment plan, are a nurse’s responsibility
and cannot be delegated to unlicensed assistive personnel (UAP).
UAP should report to the nurse any changes in skin condition or integrity; elevation in temperature; complaints of pain; increased wound drainage or incontinence; and observed changes in dietary
intake. Some dressing changes can be performed by UAP in some situations.

Question 109

The nurse is repositioning the patient in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the nurse should place the head of the bed in which position?

a. Flat
b. 90 degrees
c. 30 degrees
d. 45 degrees

Answer 109

c. 30 degrees

Rationale: When side-lying, patients should be positioned at 30 degrees, as opposed to 90 degrees, to avoid positioning the patient directly on bony prominences such as the head of the trochanter.

Question 110

The nurse recognizes which intervention is not a form of mechanical debridement?

a. Wet to dry dressings
b. Whirlpool baths
c. Wet to damp dressing
d. Enzymatic dressing

Answer 110

d. Enzymatic dressing

Rationale: Enzymatic debridement is achieved through the application of topical agents containing enzymes that work by breaking down the fibrin, collagen, or elastin present in devitalized tissue, thus allowing for its removal.
Mechanical debridement is a nonselective
form of debridement because it not only removes the necrotic tissue, but also can remove or disturb exposed viable tissue that may be in the wound.
The main forms of mechanical debridement are wet/damp-to-dry dressings and whirlpools.

Question 111

The nurse is explaining the purpose of occlusive dressings to the student nurse. Which statement by the student nurse indicates a lack of understanding?

a. “Occlusive dressings are used for autolytic debridement.”
b. “Hydrocolloids are a type of occlusive dressing.”
c. “Occlusive dressings can be used on infected wounds.”
d. “Occlusive dressings support the most comfortable form of debridement.”

Answer 111

c. “Occlusive dressings can be used on infected wounds.”

Rationale: Occlusive dressings such as hydrocolloids and transparent films are used for autolytic debridement and are contraindicated in infected wounds. It is the most comfortable form of debridement for the patient.

Question 112

The nurse knows that a hydrocolloid dressing is appropriate for use on which type of wound?

a. A wound with a large amount of drainage
b. A wound that is tunneling
c. A postsurgical incision with staples
d. A wound with a moderate amount of drainage

Answer 112

d. A wound with a moderate amount of drainage

Rationale: Hydrocolloids are occlusive, adhesive dressings composed of gelling agents and carboxymethylcellulose.
They absorb a small to moderate amount of drainage over a 3- to 7-day period, forming a gel as drainage is absorbed.
A wound with a large amount of drainage would require a foam or alginate dressing, a postsurgical incision with staples could use Steri-Strips or gauze, and a
wound that is tunneling may require packing.

Question 113

When the nurse is caring for a patient with a Penrose drain, what care needs to be carried out?

a. The drain must be compressed after emptying to work properly.
b. The drain must be connected to suction if ordered.
c. The drain is not sutured in place so care is taken to not dislodge it.
d. The suction pulls drainage away from the wound as it re-expands.

Answer 113

c. The drain is not sutured in place so care is taken to not dislodge it.

Rationale: The Penrose drain, an open drain that is a flexible piece of tubing, is usually not sutured into place and is not connected to suction.
Closed drains are compressed or connected to suction if ordered and pull drainage away as they expand.

Question 114

The nurse is educating the patient about the use of heat/cold therapy at home. Which statement by the patient indicates the need for further education?

a. “I should fill my ice bag 2/3 full of ice.”
b. “I should use distilled water in my Aqua-K pad.”
c. “I can warm up my hot pack in the microwave.”
d. “I should check the order for how long to leave the compress on.”

Answer 114

c. “I can warm up my hot pack in the microwave.”

Rationale: Warm compresses and water for soaks should not be heated in the microwave unless the product and microwave are specifically designed for this type of heating.
Ice bags are filled two-thirds full, distilled water is used in Aqua-K pads, and application time for heat is as stated in the PCP order (for cold, it is a maximum of 20 to 30 minutes).

Question 115

The nurse identifies which syringe to use when irrigating a patient’s deep wound?

a. 5-mL syringe
b. 10-mL syringe
c. 3-mL syringe
d. 30-mL syringe

Answer 115

d. 30-mL syringe

Rationale: A deep wound is irrigated with a 30- to 50-mL piston syringe with an 18-gauge angiocath.
Unlike the 1 pound per square inch (psi) of pressure or less that is delivered by a standard bulb syringe, the use of a 30- to 50-mL syringe and 18-gauge catheter has been shown to achieve an irrigation force that falls within the recommended 4 to 15 psi.

Question 116

The nurse understands which rationale to be appropriate for drying a wound after irrigation?

a. Ensure the new dressing adheres to the wound.
b. Ensure the new dressing remains occlusive.
c. Prevent skin breakdown from moisture.
d. Prevent infection from irrigate solution.

Answer 116

c. Prevent skin breakdown from moisture.

Rationale: Proper drying prevents further skin breakdown from moisture.
Patting (rather than rubbing) prevents healthy tissue from being removed and reduces trauma to the wound.
The type of dressing will determine how it lays in the wound and whether it is occlusive. The drying does not prevent infection.

Question 117

The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What does the nurse do first?

a. Notify the provider.
b. Notify the wound care nurse.
c. Stop the procedure.
d. Give the patient pain medication.

Answer 117

c. Stop the procedure.

Rationale: If the patient is complaining of severe pain, the nurse should first stop the procedure and then determine if the pain is new or preexisting.
Then the nurse can determine what to do next based on the patient’s response.

Question 118

The nurse knows what goal to be appropriate for a patient with a stage 3 pressure ulcer with the nursing diagnosis impaired physical mobility?

a. Patient will remain free of wound infections during the hospitalization.
b. Patient will report pain management strategies and reduce pain to a tolerable level.
c. Patient will be able to assist with position changes using over bed trapeze within 1 week.
d. Patient will consume adequate nutrition to meet nutritional requirements within 1 week.

Answer 118

c. Patient will be able to assist with position changes using over bed trapeze within 1 week.

Rationale: Patient will be able to assist with position changes using over bed trapeze within 1 week is an appropriate goal for impaired mobility.
The patient remaining free of wound infections during the hospitalization is an appropriate goal for impaired tissue integrity.
The patient reporting pain management strategies to reduce pain to a tolerable level is an appropriate goal for acute pain.
The patient consuming adequate nutrition to meet nutritional requirements within 1 week is an appropriate goal for Impaired nutritional status.

Question 119

When discussing stage 3 pressure ulcers with the student nurse, which description would the staff nurse include?

a. A pressure ulcer that involves exposure of bone and connective tissue.
b. A pressure ulcer that does not extend through the fascia.
c. A pressure ulcer that does not include tunneling.
d. A partial-thick wound that involves the epidermis.

Answer 119

b. A pressure ulcer that does not extend through the fascia.

Rationale: Stage 3 pressure ulcers are full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue.
There may be undermining or tunneling present in the wound. Stage 4 pressure ulcers involve
exposure of muscle, bone, or connective tissue such as tendons or cartilage.
Stage 2 pressure ulcers are partial-thickness wounds
that involve the epidermis and/or dermis.

Question 120

The nurse identifies which skin layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect?

a. Stratum germinativum
b. Epidermis
c. Subcutaneous layer
d. Stratum corneum

Answer 120

c. Subcutaneous layer

Rationale: The subcutaneous layer delivers the blood supply to the dermis, provides insulation, and has a cushioning effect.
The stratum germinativum constantly produces new cells that are pushed upward through the other layers of the epidermis toward the stratum corneum, where they flatten, die, and are eventually sloughed off and replaced by new cells.
The epidermis is the outermost layer of the skin and the thinnest of the layers. The stratum corneum is made up of flattened dead cells.

Question 121

The nurse knows which factors contribute to the development of wounds and lead to delays in wound healing? (Select all that apply.)

a. A patient who has diabetes.
b. A patient with COPD.
c. A patient with on bed rest who is repositioned.
d. A patient who is obese and sweats excessively.
e. A patient on long-term steroid therapy.

Answer 121

a. A patient who has diabetes.
b. A patient with COPD.
c. A patient with on bed rest who is repositioned.
d. A patient who is obese and sweats excessively.
e. A patient on long-term steroid therapy.

Rationale: Factors that contribute to the development of wounds and lead to delays in wound healing include comorbidities such as vascular disease, which impacts the skin’s ability to obtain required oxygen and nutrients, or diabetes, which affects not only the
microvasculature, but also the skin’s normally acidic pH; malnutrition involving inadequate proteins, cholesterol and fatty acids, and vitamins and minerals; medications such as steroids, nonsteroidal, anti-inflammatories, and anticoagulants; excessive moisture from sweating; and external forces such as pressure, shear, and friction that occur when turning and repositioning the patient in bed.

Question 122

The nurse recognizes that the cause of pressure ulcers includes which factors? (Select all that apply.)

a. Intensity of the pressure
b. Duration of the pressure
c. Tissue’s ability to tolerate the pressure
d. Person’s age
e. Person’s nutritional status

Answer 122

a. Intensity of the pressure
b. Duration of the pressure
c. Tissue’s ability to tolerate the pressure
d. Person’s age
e. Person’s nutritional status

Rationale: The primary cause of pressure ulcers is, as the name suggests, pressure.
However, it is more than just pressure; it is the intensity of the pressure, the length of time that the tissue is subjected to the pressure, and intrinsic and extrinsic factors that affect the tissue’s ability to withstand or tolerate that pressure. Intrinsic and extrinsic factors can include nutrition status and age.

Question 123

When the nurse is performing a focused wound assessment on a patient, what information should be included in the documentation? (Select all that apply.)

a. Location and size
b. Characteristics of the wound bed
c. Patient’s response to wound treatment
d. Patient’s pain level
e. Presence of drainage

Answer 123

a. Location and size
b. Characteristics of the wound bed
c. Patient’s response to wound treatment
e. Presence of drainage

Rationale: A focused wound assessment includes an evaluation of the wound’s location, size, and color; presence of drainage; condition of the wound edges; characteristics of the wound bed; and patient’s response to the wound or wound treatment. The patient’s pain level would be documented with his/her pain assessment.

Question 124

The nurse is using the Braden scale to assess the patient’s risk for a pressure ulcer. Which risk categories are associated with the
Braden scale? (Select all that apply.)

a. Activity
b. Friction and shear
c. Moisture
d. Sensory perception
e. Cognition

Answer 124

a. Activity
b. Friction and shear
c. Moisture
d. Sensory perception

Rationale: The Braden scale ranks the patient on the risk categories of sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The scale does not include cognition.

Question 125

The nurse is caring for a postoperative orthopedic patient who has two Hemovac drains in place. Which interventions will the nurse perform? (Select all that apply.)

a. Measure the amount of drainage in the device prior to emptying.
b. Label each drain and record them separately.
c. Recompress the device after emptying.
d. Secure the device to the patient’s gown above the level of the wound.
e. Check for kinks in the tubing.

Answer 125

b. Label each drain and record them separately.
c. Recompress the device after emptying.
e. Check for kinks in the tubing.

Rationale: Use a marked, graduated measuring device to collect the drainage when emptying the reservoir to facilitate accurate measurement of the drainage.
After emptying, recompress the device to maintain suction.
Secure the container(s) to the patient’s hospital gown below the level of the wound, avoiding tension on the tubing and making sure there are no kinks. If there are multiple drains, label them and document observations by the drain label.

Question 126

The nurse recognizes that cold therapy is contraindicated in which conditions? (Select all that apply.)

a. Edema
b. Shivering
c. Bleeding
d. Circulatory problems
e. Advanced age

Answer 126

a. Edema
b. Shivering
d. Circulatory problems

Rationale: Cold should not be used if any of the following is present: edema (cold application slows reabsorption of the fluid), circulatory pathophysiology (cold application causes vasoconstriction, further reducing circulation to the area), and shivering (this is a comfort concern).
Bleeding is contraindicated in heat therapy. Advanced age would require frequent observation due to thin skin.