TEST 1 - CHAPTER REVIEW QUESTIONS

Question 1

1. When repositioning an immobile client, you notice redness over a bony prominence. When the area is assessed, the red spot blanches with a fingertip touch, indicating
2. A local skin infection requiring antibiotics.
3. This client has sensitive skin and requires special bed linen.
4. A stage III pressure ulcer needing the appropriate dressing.
5. Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area.

Answer 1

1. The correct answer is 4.

When the skin is being compressed, blood flow is slowed and the skin becomes pale. After the pres- sure is relieved, the skin in the affected area turns red (erythe- ma), which is a result of the blood vessels expanding (vasodilation) to allow more blood into the area to overcome the ischemic episode. This process is called normal reactive hyperemia. Assess the reddened area by pressing a fingertip over it. If the area blanches (turns white or a pale colour) and the erythema returns when the finger is removed, the reactive hyperemia is likely transient. If, however, the reddened area does not blanch when finger pressure is applied (abnormal reactive hyperemia), suspect deep tissue damage.

Question 2

2. This type of pressure ulcer is an observable, pressure-related alteration of intact skin, whose indicators, compared with an adjacent or opposite area on the body, may include changes in one or more of the following: skin temperature (warmth or cool- ness), tissue consistency (firm or beefy feel), and sensation (pain or itching).
3. Stage I.
4. Stage II.
5. Stage III.
6. Stage IV.

Answer 2

2. The correct answer is 1.

A stage I pressure ulcer is an observable pressure-related alteration of intact skin, whose indicators, as compared with an adjacent or opposite area on the body, may include changes in skin temperature (warmth or coolness), tissue consistency (firm or beefy feel), and sensation (pain or itching).

Question 3

3. When obtaining a wound culture to determine the presence of a wound infection, the specimen should to be taken from the
4. Necrotic tissue.
5. Wound drainage.
6. Drainage on the dressing.
7. Wound after it has first been cleansed with normal saline.

Answer 3

3. The correct answer is 4.

If purulent or suspicious-looking wound drainage is present or there is a change in a previously healing chronic wound, obtaining a specimen of the drainage for culture may be necessary. The wound culture sample should never be collected from old drainage. Resident colonies of bacteria from the skin grow within exudate and may not be the true causative organisms of a wound infection. Before culturing a wound, clean the base of the wound with normal saline to remove superficial slough and debris. Select the cleanest part of the wound bed (granulating tissue is optimal), press the swab into a 1-cm-square area of this cleanest part of the wound, and rotate fully, pressing to express fluid beneath the surface of the
wound bed.

Question 4

4. Postoperatively, the client with a closed abdominal wound reports a sudden “pop” after coughing. When you examine the surgical wound site, the sutures are open and pieces of small bowel are noted at the bottom of the now opened wound. The correct intervention would be to
5. Allow the area to be exposed to air until all drainage has stopped.
6. Place several cold packs over the areas, protecting the skin around the wound.
7. Cover the areas with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration.
8. Cover the area with sterile gauze, place a tight binder over the areas, and ask the client to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly.

Answer 4

4. The correct answer is 3.

When evisceration occurs, place sterile towels soaked in sterile saline over the extruding tissues to reduce chances of bacterial invasion and drying of the tissues. If the organs protrude through the wound, blood supply to the tissues is compromised. The client should be allowed nothing by mouth (NPO), observed for signs and symptoms of shock, and prepared for emergency surgery.

Question 5

5. Serous drainage from a wound is defined as
6. Fresh bleeding.
7. Thick and yellow.
8. Clear, watery plasma.
9. Beige to brown and foul-smelling.

Answer 5

5. The correct answer is 3.

Serous drainage is clear, watery plasma.

Question 6

6. Before changing a dressing, you should
7. Read the medical orders and follow them exactly.
8. Gather together all the supplies that might be required for the dressing change and remove the dressing from the wound.
9. Discuss the plan to change the dressing with the client, assess the need for analgesia, and provide it, if necessary.
10. Tell the family to leave the room because dressings can be dif- ficult for non–health care professionals to see.

Answer 6

6. The correct answer is 3.

Ensuring the client understands the plan of care will decrease anxiety and increase the client’s feel- ing of control. Pain can also have a negative impact on wound healing; thus, assessing the need for analgesia and providing it before the dressing change supports optimal healing and
patient comfort and control.

Question 7

7. Interventions to manage a client who is experiencing fecal and urinary incontinence include
8. Keeping the buttocks exposed to air at all times.
9. Use of large absorbent diapers that are changed when saturated.
10. Utilization of an incontinence cleanser, followed by application of a moisture barrier ointment.
11. Frequent cleansing, application of an ointment, and coverage of the areas with a thick, absorbent towel.

Answer 7

7. The correct answer is 3.

Exposure to fecal and urinary incontinence creates a caustic environment on the skin that leads to excoriation and further breakdown, once the skin is no longer intact. An incontinence cleanser and a moisture barrier oint- ment will remove urine and feces from the skin, leaving a pro- tective (usually silicone-based) barrier that repels moisture.

Question 8

8. The best description of a hydrocolloid dressing is
9. A seaweed derivative that is highly absorptive.
10. Premoistened gauze placed over a granulating wound.
11. A debriding enzyme that is used to remove necrotic tissue.
12. A dressing that forms a gel that interacts with the wound surface.

Answer 8

8. The correct answer is 4.

Hydrocolloid dressings are dressings with complex formulations of colloidal, elastomeric, and adhesive components that are both adhesive and occlusive. The wound contact layer of this dressing forms a gel as fluid is absorbed and maintains a moist healing environment.

Question 9

9. A binder placed around a surgical client with a new abdominal wound is indicated for
10. Collection of wound drainage.
11. Reduction of abdominal swelling.
12. Reduction of stress on the abdominal incision.
13. Stimulation of peristalsis (return of bowel function) by direct pressure.

Answer 9

9. The correct answer is 3.

An abdominal binder will support the wound and reduce stress on large abdominal incisions that are vulnerable to tension or stress as the client moves or coughs.

Question 10

10. Clients with pressure ulcers require
11. Repositioning every 4 to 6 hours.
12. Bedrest and a quiet environment.
13. Frequent dressing changes.
14. Nutritional assessment from a dietitian.

Answer 10

10. The correct answer is 4.

The body requires additional energy to heal pressure ulcers. Dietitians are trained in thorough assessment of caloric requirements and intake for effective wound healing and, thus, are essential members of the health care team looking after clients with skin breakdown. In addition, dietitians are knowledgeable about different sources of nutrition, including supplements or tube feeding, if required.

Question 11

Prevention of skin _______________ is a major nursing focus for all clients, irrespective of their age or the health care setting.

Answer 11

breakdown

Question 12

Clients should be assessed for risk of skin breakdown with the use of a validated risk assessment tool, such as the ____________ ____________ ___________ ___________, on admission to care and subsequently at least once per week.

Answer 12

Braden Risk Assessment Tool

Question 13

Alterations in mobility, sensory, perception, level of consciousness, and nutrition, as well as the presence of moisture increase the risk of _________ ____________ development.

Answer 13

pressure ulcer

Question 14

Preventive skin care is aimed at controlling external pressure on __________ _____________ and keeping the skin clean, well-lubricated, hydrated, and free of __________ _________.

Answer 14

bony prominences

excess moisture

Question 15

Wounds require pressure off-loading, adequate ____________ and __________, _________ ___________, and an absence of _____________ to heal.

Answer 15

nutrition
hydration
blood flow
infection

Question 16

Arterial, venous, and diabetic wounds are often the result of impaired ______________ ___________ to the extremities.

Answer 16

peripheral circulation

Question 17

Wound irrigation should be at room or body temperature and provide ______ to ______ psi of pressure to avoid damaging fragile ______________ tissue.

Answer 17

4 - 15

granulating

Question 18

Direct nutritional interventions at improving wound healing through increasing ___________ and ___________ levels, as required.

Answer 18

protein

calorie

Question 19

When extensive tissue loss occurs, a wound heals by ____________ intention.

Answer 19

secondary

Question 20

The chances of wound infection are ___________ when the wound contains dead or necrotic tissue, when foreign bodies lie on or near the wound, and when the blood supply and tissue defences are reduced.

Answer 20

greater

Question 21

A __________ environment supports wound healing

Answer 21

moist

Question 22

When cleansing wounds or drain sites, clean from the least to most contaminated area, away from ________ __________.

Answer 22

wound edges

Question 23

Apply a bandage or binder in a manner that does not _____________ circulation or irritate the skin.

Answer 23

impair

Question 24

1. Pain is viewed as:
2. A separate disease
3. A symptom of an illness
4. A symptom of a condition
5. An objective finding

Answer 24

1. The correct answer is 1.

In the past, pain was viewed simply as a symptom of an illness or condition. Pain itself is now considered to be a separate disease.

Question 25

2. This type of pain lasts longer than anticipated and a minimum of 6 months, may not have an identifiable cause, and leads to great personal suffering:
3. Cancer pain
4. Chronic pain
5. Acute pain
6. Idiopathic pain

Answer 25

2. The correct answer is 2.

Chronic pain is generally defined as pain that has been present for at least 6 months, persists beyond the normal time of healing, may not have an identifiable cause, serves no biological benefit, and leads to great personal suffering.

Question 26

3. One of the reasons that many nurses avoid acknowledging a client’s pain is:
4. Inadequate pain management skills
5. Insufficient time to respond to the client
6. Fear that the intervention may cause addiction
7. Inability to manage their client load

Answer 26

3. The correct answer is 3.

One of the common misconceptions about pain management is that regular administration of analgesics will lead to drug addiction.

Question 27

4. Cognitively, this age group is unable to recall explanations about pain, or associate pain with experiences that can occur in various situations:
5. Preschoolers
6. Adolescents
7. Young adults
8. Older adults

Answer 27

4. The correct answer is 1.

Cognitively, toddlers and preschoolers are often unable to recall explanations about pain, or associate pain with experiences that can occur in various situations.

Question 28

5. An 82-year-old man with Alzheimer’s disease is restless and moaning. The client’s daughter states that the client did not sleep well most of the night. The nurse’s first response would be to:
6. Recommend giving the client sleeping medication
7. Obtain a psychiatric evaluation
8. Administer pain medication as ordered
9. Assess and document physical and behavioural data

Answer 28

5. The correct answer is 4.

You can only make an accurate diagnosis of pain after you have performed a complete client assessment. You will consider the client’s withdrawal from communication, grimacing, moaning, and verbalizations of discomfort.

Question 29

6. The client requests medication for her abdominal incision pain, which she rates as 5 (scale of 0 to 10, with 10 being the worst pain). One hour after administration of her pain medication, she is able to walk in the hall for 10 minutes, and rates her pain as a 7. This indicates that the dosage of pain medication was:
7. Adequate
8. Excessive
9. Insufficient
10. Unnecessary

Answer 29

6. The correct answer is 3.

Descriptive scales are used both to assess pain severity and to evaluate changes in a client’s condition. A rating of 7 or more on a 0 to 10 scale requires immediate attention. The dose was insufficient.

Question 30

7. When a client is anticipating a painful procedure, the nurse:
8. Teaches about the procedure, avoiding focusing on the associated discomfort
9. Teaches about the procedure and its associated discomfort
10. Orders an analgesic
11. Tells the client that the discomfort will be minimal

Answer 30

7. The correct answer is 2.

Teaching clients about pain reduces anxiety and helps them to achieve a sense of control. When a client is anticipating pain, you need to explain procedures and any associated discomfort. A confident explanation of the procedure helps you to gain a client’s trust. When clients are informed about an upcoming painful experience, they often perceive the actual experience as less unpleasant.

Question 31

8. Relaxation and guided imagery are examples of:
9. Cognitive–behavioural interventions
10. Physical interventions
11. Pharmacological interventions
12. Adjuvants

Answer 31

8. The correct answer is 1.

Nonpharmacological interventions include cognitive-behavioural and physical approaches. The goals of cognitive-behavioural interventions are to change pain perceptions, alter pain behaviour, and provide a greater sense of control. Relaxation and guided imagery are examples.

Question 32

9. The Canadian Pain Society recommends that if pain is antici- pated for the majority of the day, health care professionals should consider administering opioids:
10. On an as-needed (prn) basis
11. With complementary therapies
12. On an around-the-clock (ATC) basis
13. When the pain tolerance level is exceeded

Answer 32

9. The correct answer is 3.

One way to maximize pain relief while minimizing drug toxicity is to administer medication on a regular around-the-clock (ATC) basis rather than on an as- needed (prn) basis. The Canadian Pain Society, the American Pain Society, and the AHCPR all have stated that if pain is anticipated for the majority of the day, ATC administration should be considered. This is to prevent breakthrough pain, which is hard to control once it appears.

Question 33

10. One of the reasons that patient-controlled analgesia (PCA) pumps are frequently used for postoperative and cancer pain management is to:
11. Enable family members to control the drug doses
12. Enable improved nursing control over drug doses
13. Enable sustained pain relief, with the client in control
14. Increase medication use

Answer 33

10. The correct answer is 3.

A drug delivery system called patient- controlled analgesia (PCA) is a safe method for postoperative and cancer pain management that most clients prefer. The client gains control over his or her pain, and pain relief does not depend on nurse availability. Small doses of medications are delivered at short intervals, stabilizing serum drug concentrations for sustained pain relief.

Question 34

_____________ nursing is nursing care provided to the surgical client before, during, and after surgery.

Answer 34

Perioperative

Question 35

___________ is classified by level of severity, urgency, and purpose.

Answer 35

Surgery

Question 36

Preoperative assessment of vital signs and physical findings provides an important ____________ with which to compare postoperative
assessment data.

Answer 36

baseline

Question 37

Structured preoperative teaching has a ____________ influence on a client’s postoperative recovery

Answer 37

positive

Question 38

All medications taken before surgery are automatically ____________ after surgery unless a physician reorders the drugs.

Answer 38

discontinued

Question 39

Family members or other supportive networks are ______________ in assisting clients with any physical limitations and in providing emotional support during postoperative recovery and ongoing care at home.

Answer 39

important

Question 40

Accurate pain assessment and intervention are necessary for ______________.

Answer 40

healing

Question 41

Nurses in the postoperative surgical unit provide the ___________ ___________ required so that the client and the family can manage at home.

Answer 41

discharge education

Question 42

1. An obese client is at risk for poor wound healing and for wound infection postoperatively because
2. Ventilatory capacity is reduced
3. Fatty tissue has a poor blood supply
4. Risk for dehiscence is increased
5. Resuming normal physical activity is delayed

Answer 42

The correct answer is 2.

The obese client is susceptible to poor wound healing and to wound infection because of the structure of fatty tissue, which contains a poor blood supply. This slows delivery of essential nutrients and enzymes needed for wound healing.

Question 43

2. You should ask each client preoperatively for the name and dose of all prescription and over-the-counter medications taken before surgery because they
3. May cause allergies to develop
4. Are automatically ordered postoperatively
5. May create greater risks for complications or interact with
   anaesthetic agents
6. Should be taken on the morning of surgery with sips of water

Answer 43

2. The correct answer is 3.

If a client regularly uses prescription or over-the-counter medications, the surgeon or anaesthesiolo- gist may temporarily discontinue the drugs before surgery or adjust the dosages. Certain medications have special implica- tions for the surgical client, creating greater risks for complica- tions or interacting negatively with anaesthetic agents.

Question 44

3 A client who smokes two packs of cigarettes per day is most at risk postoperatively for

1. Infection
2. Pneumonia
3. Hypotension
4. Cardiac dysrhythmias

Answer 44

3. The correct answer is 2.

The client who smokes is at greater risk for postoperative pulmonary complications than a client who does not.

Question 45

4. Family members should be included when you teach the client preoperative exercises so that they can
5. Supervise the client at home
6. Coach the client postoperatively
7. Practise with the client while waiting to be taken to the operating room
8. Relieve you by getting the client to do his or her exercises every 2 hours

Answer 45

4. The correct answer is 2.

The family is an important resource for a client with physical limitations and provides the emo- tional support needed to motivate the client to return to a pre- vious state of health. Often, a family member can become the client’s coach, offering valuable support during the postoper- ative period.

Question 46

5. In the postoperative period, measuring input and output helps assess
6. Renal and circulatory function
7. Client comfort
8. Neurological function
9. Gastrointestinal function

Answer 46

5. The correct answer is 1.

Accurate recording of intake and out- put helps assess renal and circulatory function. For example, you measure all sources of output, including urine, surgically placed drains, gastric drainage, and drainage from wounds, and note any insensible loss from diaphoresis.

Question 47

6. In the PACU, one measure taken to maintain airway patency is to
7. Suction the pharynx and bronchial tree
8. Give oxygen through a mask at 10 L/minute
9. Position the client so that the tongue falls forward 4. Ask the client to use an incentive spirometer

Answer 47

6. The correct answer is 3.

Position the client on one side with the face downward and the neck slightly extended to facilitate a forward movement of the tongue and the flow of mucous secretions out of the mouth.

Question 48

7. Which one of the following measures promotes normal venous return and circulatory blood flow?
8. Suctioning artificial airways and the oral cavity
9. Monitoring fluid and electrolyte status during every shift
10. Having the client use incentive spirometry
11. Encouraging the client to perform leg exercises at least once
    an hour while awake

Answer 48

7. The correct answer is 4. To promote normal venous return and circulatory blood flow, encourage clients to perform leg exercises at least every hour while awake. Other measures include applying elastic stockings or pneumatic compression stockings as ordered, encouraging early ambulation, position- ing the client so that blood flow is not interrupted, administering anticoagulant drugs as ordered, and promoting adequate fluid intake.

Question 49

8. A client with an international normalized ratio (INR) or an activated partial thromboplastin time (APTT) greater than normal is at risk postoperatively for
9. Anemia
10. Bleeding
11. Infection
12. Cardiac dysrhythmias

Answer 49

8. The correct answer is 2.

International normalized ratio (INR) and activated partial thromboplastin time (APTT) indicate the clotting ability of blood, which if greater than normal reveal clients at risk for bleeding tendencies.

Question 50

When the client is engaging in deep breathing and coughing exercises, it is important to have the client sitting because this position

1. Is more comfortable
2. Facilitates expansion of the thorax
3. Increases the client’s view of the room and is more relaxing
4. Helps the client to splint with a pillow

Answer 50

9. The correct answer is 2.

Maintaining an upright position facil- itates diaphragm excursion and enhances expansion of the thorax.

Question 51

In the postoperative period, if a client has unexpected tachycardia and tachypnea; jaw muscle rigidity; body rigidity of limbs, abdomen, and chest; or hyperkalemia, you should suspect

1. Infection
2. Hypertension
3. Pneumonia
4. Malignant hyperthermia

Answer 51

10. The correct answer is 4.

Malignant hyperthermia is a potentially lethal condition that can occur in clients who received general anaesthesia. It should be suspected when there is unexpected tachycardia and tachypnea; jaw muscle rigidity; body rigidity of limbs, abdomen, and chest; or hyperkalemia. Temperature elevation is a late sign.

Question 52

1. Which of the following indicates that an obese client is at risk for poor wound healing postoperatively?
   A. Risk for bleeding is increased.
   B. Ventilatory capacity is reduced.
   C. Fatty tissue has a poor blood supply.
   D. Resumption of normal physical activity is delayed.

Answer 52

c

The obese client is susceptible to poor wound healing and wound infection because of the structure of fatty tissue, which contains a poor blood supply. This slows delivery of the essential nutrients, antibodies, and enzymes needed for wound healing. Ventilatory capacity could affect postoperative healing but is not necessarily decreased by obesity. Risk for bleeding is not related to obesity’s effect on wound healing. If the wound healing was poor, the resumption of normal activity could be delayed, but this delay would be caused by the poor wound healing, not vice versa.

Question 53

2. The nurse asks each client preoperatively for the name and dose of all prescription and over-the-counter medications taken before surgery for which of the following reasons?
   A. These medications may cause allergies to develop.
   B. These medications are automatically ordered postoperatively.
   C. These medications may increase the risks for anaesthetic and surgical complications.
   D. These medications should always be taken the morning of surgery with sips of water.

Answer 53

c

All medications must be reviewed to ensure that they will not increase the risks associated with anaesthesia and surgery. Medications routinely taken by the client before surgery will not cause allergies to develop during or after surgery. Not all medications are automatically ordered postoperatively. Medications are taken as prescribed, or held as necessary, at the appropriate time, not just in the morning.

Question 54

3. A client who smokes two packs of cigarettes per day is most at risk postoperatively for which of the following?
   A. Atelectasis, fever, and pneumonia
   B. Hypotension, confusion, and elevated glucose level
   C. Hypotension, cardiac dysrhythmias, and fever
   D. Urinary infection, fever, and malignant hyperthermia

Answer 54

a

After surgery, clients who smoke have greater difficulty than nonsmokers in clearing the airways of mucous secretions, and the importance of postoperative deep breathing and coughing should be emphasized to such clients. Urinary infection, hypotension, confusion, and elevated glucose levels are not necessarily associated with smoking.

Question 55

4. Family members should be included when the nurse teaches the client preoperative exercises so that they can do which of the following?
   A. Coach the client postoperatively
   B. Demonstrate the exercises to the client at home
   C. Relieve the nurse by getting the client to do the exercises every 2 hours
   D. Practise the exercises with the client while the client waits to be taken to the operating room

Answer 55

a

Often a family member serves as the client’s coach when the client performs postoperative exercises after returning from surgery. The coach may also help at home, but the client should be able to do his or her exercises correctly before surgery and should not need demonstration. Practising exercises while waiting to be taken to the operating room may not be practical. The nurse is always responsible for ensuring that the exercises are initiated.

Question 56

5.	
Maintaining normal glucose levels during the postoperative period reduces which complication?
A.	Ileus
B.	Bleeding
C.	Wound infection
D.	Deep vein thrombosis

Answer 56

c

Evidence indicates that maintaining normal glucose levels during the postoperative period reduces the incidence of infections. Glucose levels are not associated with ileus, bleeding, or deep vein thrombosis.

Question 57

6. In the postanaesthesia care unit (PACU), the nurse notes that the client is having difficulty breathing because of an obstruction. What would be the nurse’s first action?
   A. Suction the pharynx and bronchial tree.
   B. Give oxygen through a mask at 10 L/minute.
   C. Ask the client to use an incentive spirometer.
   D. Position the client so that the tongue falls forward.

Answer 57

d

In clients recovering from anaesthesia, the tongue causes the majority of airway obstructions. Clients should remain lying on their sides until they are able to maintain their own airways. Suctioning before removing a structural obstruction will not be helpful. Supplemental oxygen may be helpful after the obstruction is removed. Clients in this state will not be able to use the incentive spirometer.

Question 58

7. Because an older adult is at increased risk for respiratory complications after surgery, the nurse should do which of the following?
   A. Withhold pain medications and ambulate the client every two hours.
   B. Monitor fluid and electrolyte status every shift and measure vital signs, including temperature, every four hours.
   C. Orient the client to the surrounding environment frequently and ambulate the client every two hours.
   D. Encourage the client to turn, breathe deeply, and cough frequently and ensure adequate pain control.

Answer 58

d

The nurse should encourage the client to perform coughing exercises every two hours while awake and should maintain pain control to promote deep, productive coughing. Pain medications should not be withheld from a client. Checking vital signs every four hours is appropriate.

Question 59

8.	
A client with a greater than normal international normalized ratio (INR) or activated partial thromboplastin time (APTT) is at risk postoperatively for which of the following?
A.	Bleeding
B.	Infection
C.	Low urine output
D.	Cardiac dysrhythmias

Answer 59

a

Both INR and APTT are measures of clotting ability. A client with a prolonged INR or APTT is at risk for bleeding. These tests do not measure urine output, infection, or cardiac rhythm.

Question 60

9. When a nonbariatric client is breathing deeply and coughing, why should the client be in the sitting position?
   A. Sitting is more comfortable.
   B. Sitting facilitates expansion of the thorax.
   C. Sitting helps the client to splint with a pillow.
   D. Sitting increases the client’s view of the room and is more relaxing.

Answer 60

b

The thorax can expand better when the client is upright. This position may or may not be more comfortable for the client. The changed view of the room may or may not be of interest to the client. It is easier for the client to splint when upright, but the primary purpose for having the client sit upright is to facilitate expansion of the thorax.

Question 61

10. The nurse notes that a postsurgical client in the PACU has a heart rate of 130 beats per minute and a respiratory rate of 32 breaths per minute. The nurse also assesses jaw muscle rigidity and rigidity of the limbs, abdomen, and chest. What does the nurse suspect, and what intervention is indicated?
    A. The nurse suspects infection and should notify the surgeon and anticipate administration of antibiotics.
    B. The nurse suspects pneumonia and should listen to breath sounds, notify the surgeon, and anticipate an order for chest radiography.
    C. The nurse suspects hypertension and should check blood pressure, notify the surgeon, and anticipate administration of antihypertensives.
    D. The nurse suspects malignant hyperthermia and should notify the surgeon or anaesthesiologist immediately, prepare to administer dantrolene sodium, and monitor vital signs frequently.

Answer 61

d

Malignant hyperthermia is a potentially lethal condition that can occur in clients receiving general anaesthesia. It should be suspected when the client has unexpected tachycardia and tachypnea; elevated carbon dioxide levels; jaw muscle rigidity and rigidity of the limbs, abdomen, and chest; and hyperkalemia. The nurse will immediately administer dantrolene sodium ordered by the health care team. The other options are incorrect.

Question 62

11. Through experience and knowledge, the nurse knows that the client will commonly experience the most severe postoperative pain at what time?
    A. The third postoperative day
    B. The fourth postoperative day
    C. Immediately after the surgery
    D. The first 12 to 36 hours after surgery

Answer 62

d

Postoperative pain generally decreases after the second or third day. Immediately following surgery, the anaesthetic is still effective. Commonly, the most severe pain is experienced 12 to 36 hours after surgery. The nurse must keep in mind that all clients should be treated individually.

Question 63

12.	
Surgical procedures are classified in terms of seriousness, urgency, and purpose. The designation of a procedure as an "emergency surgical procedure" relates to which of the following categories?
A.	Purpose
B.	Urgency
C.	Diagnostic
D.	Seriousness

Answer 63

b

“Emergency surgery,” “elective surgery,” and “urgent surgery” are designations based on urgency. The urgency classification describes a time factor. The seriousness of a surgical procedure is designated by the terms major and minor, which indicate extensive and minimal alteration of body parts, respectively. Diagnostic is one of seven descriptors indicating the purpose of a surgical procedure. The others are ablative, palliative, reconstructive or restorative, procurement for transplant, constructive, and cosmetic.

Question 64

13. The American Society of Anesthesiologists has assigned surgical classifications to clients based on what characteristic?
    A. Physical status of the client
    B. Type of anaesthesia used
    C. Purpose and seriousness of the procedure
    D. Seriousness and urgency of the procedure

Answer 64

a

The American Society of Anesthesiologists has assigned classifications to clients based on the client’s physiological condition independent of the proposed surgical procedure. Difficulties during surgery occur more frequently for clients whose assigned classification reflects poor physical status. Clients in classes I and II and stable clients in class III are considered acceptable candidates for ambulatory or outpatient surgery. The surgical procedure itself is classified according to seriousness, urgency, and purpose.

Question 65

14. On admission to the ambulatory surgical unit, the client tells the nurse, “I take naproxen for arthritic pain.” Why should the nurse inform the surgeon of this?
    A. Nonsteroidal anti-inflammatory drugs (NSAIDs) do not interfere in any way.
    B. NSAIDs may cause mild respiratory depression.
    C. NSAIDs inhibit platelet aggregation and may prolong bleeding time.
    D. NSAIDs impair cardiac conduction during anaesthesia.

Answer 65

c

NSAIDs increase the client’s susceptibility to postoperative bleeding by inhibiting platelet aggregation and prolonging bleeding time. Antidysrhythmics, not NSAIDs, impair cardiac conduction during anaesthesia. NSAIDs do not cause mild respiratory depression.

Question 66

15. While assessing a client after surgery, the nurse notes dull breath sounds and dyspnea. What are the most appropriate nursing interventions?
    A. Continue observations.
    B. Promote adequate fluid intake
    C. Apply antiembolism stockings and turn the client every 1½ hours.
    D. Encourage deep breathing and coughing exercises and increase mobility.

Answer 66

d

Dull breath sounds and dyspnea may suggest atelectasis. Therefore, it is important for the client to do deep breathing and coughing exercises and to increase mobility and activity. Turning the client is beneficial. Sudden chest pain is associated with pulmonary embolism. Antiembolism stockings are used as a preventive measure for emboli. Gastrointestinal complications can be lessened or prevented by adequate fluid intake.

Question 67

16. Nursing has made significant contributions in what areas promoting positive client outcomes after surgery?
    A. Discovery of effective anaesthetics
    B. Development of the germ theory
    C. Discovery of multiple aseptic techniques
    D. Demonstration of the benefits of preoperative education

Answer 67

d

Nursing knowledge has made important contributions to the perioperative care of the client. Structured preoperative teaching and return demonstrations of postoperative exercises have been shown to improve outcomes in such areas as pain management, pulmonary function, length of stay, and the client’s level of anxiety. The other contributions listed were not based specifically on nursing assessments but rather were more physician-driven.

Question 68

17. When taking a medication history, the nurse preoperatively asks the client about allergies. Which of the following is the most appropriate way of asking the client about this issue?
    A. “Do any medications make you sick?”
    B. “Do you have any medication allergies?”
    C. “Have you ever had a problem with a medication or substance?”
    D. “Have you ever had difficulty breathing after taking medication?”

Answer 68

c

“Have you ever had a problem with a medication or substance?” is a broad question that may elicit more information from the client than the other styles of question. The nurse needs to distinguish allergies from unpleasant side effects. For example, codeine may cause nausea, constipation, or hypotension (side effects) or skin rash (an allergy) in a client. The term allergy can be confusing to some clients. Therefore, the nurse will get more information from the client by asking about any problems instead of being so specific.

Question 69

18.	
Surgical procedure permitting, in what position should the client be placed during the immediately postanaesthetic stage of recovery?
A.	High-Fowler’s
B.	Semi-Fowler’s
C.	Supine with pillow
D.	Side-lying, face down

Answer 69

d

Placement in a side-lying position with the face slightly down (recovery position) protects the client from possible aspiration, and in this position, the client’s tongue falls forward. Placement in a supine position may increase the possibility of aspiration. Both Fowler’s positions are appropriate only once the client’s vital signs and airway are stable and the surgical procedure allows this position.

Question 70

19. The nurse conducts a nursing assessment immediately once the client arrives in the PACU. Which of the following assessments should the nurse perform immediately in the postanaesthesia stage?
    A. Airway, family support, and safety
    B. Respirations, level of consciousness, and family support
    C. Anxiety, pain, and presence of coping mechanisms
    D. Airway, cardiovascular status, level of consciousness, and safety

Answer 70

d

Clinical assessments to be completed immediately in the postanaesthetic phase include assessments for an adequate airway, cardiovascular status, level of consciousness, pain, and safety. Assessments of anxiety, presence of coping mechanisms, and family support are important but not a priority at this specific point in time.

Question 71

20.	
Encouraging the client to perform coughing exercises every 2 hours while awake is an appropriate measure for the majority of postsurgical clients. After what surgical procedures may coughing exercises be contraindicated?
A.	Abdominal and spinal
B.	Abdominal and thoracic
C.	Thoracic, rectal, and eye
D.	Eye, intracranial, and spinal

Answer 71

d

For clients who have had eye, intracranial, or spinal surgery, coughing may be contraindicated because of the potential increase in intraocular or intracranial pressure. Coughing exercises are recommended after other surgeries to promote removal of pulmonary secretions, if present.

Question 72

21. Minimally invasive surgery has changed the preparation of clients for surgery and their time in hospital to recovery. In response to these techniques, nurses now must focus on which of the following? (Select all that apply.)
    A. Readiness for self-care
    B. Potential complications at home
    C. Pain control at home
    D. Getting out of bed in hospital for the first time on day 4

Answer 72

a,b,c

Clients who have minimally invasive surgery are often in hospital just on the day of surgery or overnight. Therefore, they would not be attempting to mobilize for the first time on day 4. With minimally invasive surgery, nurses must do extensive pre- and postoperative teaching to ensure that the client will be able to return home and provide self-care or have the support to help with care. Clients are taught, for example, how to care for incision sites, manage pain, and what to do if complications arise.

Question 73

1. Which of the following signs or symptoms in an opioid-naive client is the nurse’s greatest concern when assessing the client one hour after administering an opioid?
   A. Respiratory rate of 10 breaths per minute
   B. Oxygen saturation of 95%
   C. Pain intensity rating of 5 on a scale of 10
   D. Difficulty arousing the client

Answer 73

d

Sedation always occurs before respiratory depression, so the nurse should monitor for sedation or difficulty arousing the client. A pain intensity rating of 5 on a scale of 10 means that the client probably needs a higher dose of medication. The oxygen saturation and respiratory rate are probably acceptable but should be compared with the client’s baseline values for vital signs.

Question 74

2. A physician wrote the following order for an opioid-naive client who has returned from the operating room after total hip replacement: “Fentanyl patch 100 mcg, change every 3 days.” Based on this order, the nurse takes which of the following actions?
   A. Calls the physician and question the order.
   B. Applies the patch on the third postoperative day.
   C. Applies the patch as soon as the client reports pain.
   D. Places the patch as close to the hip dressing as possible.

Answer 74

a

The nurse calls the physician and questions this order. Onset of pain relief can take 18 to 36 hours after a fentanyl patch is applied. Fentanyl patches are used for long-term management of severe pain, so this is not an appropriate order for this client, who needs immediate, short-term relief. The patch should not be applied until the order is clarified and confirmed by the physician after short-term relief is started.

Question 75

3.	
A client is being discharged to home with an order for an around-the-clock opioid for relief of chronic back pain. Because of this drug regimen, for which class of medication does the nurse request an order?
A.	Stool softener
B.	Stimulant laxative
C.	H2 receptor blocker
D.	Proton pump inhibitor

Answer 75

b

All clients receiving opioid therapy should also be placed on a bowel program to ensure that constipation related to opioid use is avoided. The other medications are not required with around-the-clock opioid use.

Question 76

4.	
An intern new to the service writes an order for OxyContin SR 10 mg by mouth every 12 hours as needed. Which part of the order does the nurse question?
A.	The dose
B.	The drug
C.	The time interval
D.	The route

Answer 76

c

OxyContin SR is a long-acting opioid that requires regular dosing to be effective. This medication should be prescribed for regular use and a short-acting medication provided for as-needed dosing for breakthrough pain. The rest of the elements in the drug order are correct.

Question 77

5. The nurse notices that a client has been receiving oxycodone–acetaminophen (Percocet), 2 tablets by mouth every 2 to 3 hours for the past 3 days. The nurse is most concerned about which of the following?
   A. Risk for gastrointestinal bleeding
   B. Client’s level of pain
   C. Potential for addiction
   D. Amount of acetaminophen received daily

Answer 77

d

The maximum dosage of acetaminophen is 4 g every 24 hours. This client is receiving over 14.0 g, which could cause liver damage. A check of the client’s level of pain to assess the need for the high dose of acetaminophen could indicate that the client requires a different medication. The potential for addiction if the client is taking the medication as prescribed is minimal. Gastrointestinal bleeding is usually associated with the use of acetylsalicylic acid.

Question 78

6.	
A client with chronic low back pain who has been receiving an opioid around the clock for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this client is experiencing symptoms related to which of the following?
A.	Physical dependence
B.	Tolerance
C.	Pseudoaddiction
D.	Withdrawal

Answer 78

d

Withdrawal results after a client has been taking a medication for a period of time. This also is not pseudoaddiction or tolerance.

Question 79

7. After a client receives 0.2 mg of naloxone via intravenous push, the client’s respiratory rate and depth are within normal limits. The nurse now plans to implement which of the following actions?
   A. Discontinue all ordered opioids.
   B. Close the room door to allow the client to recover.
   C. Administer the remaining naloxone over 4 minutes.
   D. Assess the client’s vital signs every 15 minutes for 2 hours.

Answer 79

d

Clients who receive naloxone should be reassessed every 15 minutes for 2 hours after drug administration because of the risk of renarcotization and the return of respiratory depression. The nurse should not close the door to the room or leave the client where the client cannot be observed quickly. If the dose was effective, a further dose is unnecessary unless the client shows signs of renarcotization. The type and dosages of opioids should be re-evaluated.

Question 80

8. Which of the following instructions is it crucial for the nurse to give to both the client and family members when the client is about to be started on morphine delivered via a patient-controlled analgesia (PCA) device?
   A. The PCA button should not be pushed until the pain is severe.
   B. Only the client should push the PCA button.
   C. The nurse should be notified when the button is pushed.
   D. The PCA system prevents overdoses from occurring.

Answer 80

b

Only the client should push the PCA button because the client should be the one to decide when medication is needed. The client should use the button whenever he or she has pain and should not wait until the pain is severe. The nurse does not need to be notified when the button is pushed unless the medication is not relieving pain. The PCA system does prevent accidental overdoses, but the most important feature is that the client controls the analgesia.

Question 81

9. A client with a history of a stroke that left her confused and unable to communicate has returned from the interventional radiology department after placement of a gastrostomy tube. The physician’s order reads as follows: “Percocet, 1 tablet, per tube, every 4 hours as needed.” Which is the nurse’s best action?
   A. Take no action because the order is appropriate.
   B. Request to have the order changed to around-the-clock administration for the first 48 hours.
   C. Begin the Percocet when the client shows nonverbal signs of pain.
   D. Ask for a change of medication to meperidine (Demerol) 50 mg by intravenous push every 3 hours as needed.

Answer 81

b

This client is nonverbal and cannot communicate her pain level. Changing the client’s medication to around-the-clock administration for 48 hours allows the client to receive some continual pain relief. If the client begins to show nonverbal symptoms of pain, this approach needs to be reconsidered. Meperidine is typically not used in more than a single dose because of toxicity.

Question 82

10.	
The results of many diagnostic tests performed to identify the cause of a client's chronic low back pain come back negative. This indicates to the physician and the nurse that the client's pain is which of the following?
A.	Psychological
B.	Overestimated
C.	Currently idiopathic
D.	Caused by low pain tolerance

Answer 82

c

The fact that a cause for pain cannot be identified through laboratory or diagnostic tests does not mean that the pain is not real. The results may indicate that the current tests are not sophisticated enough to detect the abnormality.

Question 83

11. Just before friends visit, a client reports to the nurse that his pain level is 7 out of 10. The nurse returns to the room with the ordered analgesic and find the client laughing and joking with the friends. The nurse decides to do which of the following?
    A. Administer the analgesic immediately.
    B. Record the pain intensity as 2 out of 10.
    C. Make a note that the client’s behaviours do not indicate pain.
    D. Withhold the analgesic until the client requests it again.

Answer 83

a

Pain is what the client says it is. Pain does not manifest itself in a single way. Clients may be temporarily distracted from their pain when friends are visiting. Clients in pain may not want their friends and family members to know how much pain they are experiencing. In addition, laughing with friends or family members may be a distraction that diverts attention from the pain. Pain rated at 7 out of 10 requires immediate treatment.

Question 84

12. When setting goals for a client with chronic pain, the nurse should begin by doing which of the following?
    A. Identifying the cause of the pain
    B. Asking “What pain rating is acceptable to your family?”
    C. Asking “What does your pain prevent you from doing that you used to do?”
    D. Getting an idea of what pain intensity will allow the client to perform the activities of daily living (ADLs)

Answer 84

c

Understanding what the pain prevents the client from doing that is important helps in establishing a goal that the nurse can measure. This also assists in identifying what is important to the client. A pain rating that is acceptable to the client is more important than one that is acceptable to family members. An acceptable pain rating is unique and individual to the client. Clients may perform ADLs even though they are in pain because ADLs are often necessary for survival. Although identifying the cause of pain is important, it is not essential in establishing goals.

Question 85

13.	
A client describes the pain radiating down the leg as sharp, shooting, and electriclike. The nurse recognizes this as indicative of which of the following?
A.	Somatic pain
B.	Visceral pain
C.	Idiopathic pain
D.	Neuropathic pain

Answer 85

d

Neuropathic pain is usually described as burning, shooting, or electriclike. It is important to report these characteristics to the physician because neuropathic pain may not respond as well to opioids. Visceral and somatic pain are often described as “aching,” “throbbing,” and “pounding.” Idiopathic pain does not have specific descriptive terms.

Question 86

14. Which of the following are myths regarding pain and pain treatment in older adults? (Select all that apply.)
    A. Pain is an inevitable part of aging.
    B. Older clients are unable to tolerate opioids.
    C. The pain centre in older adults diminishes over time.
    D. Older adult clients are at greater risk for the development of conditions that are painful.

Answer 86

a,b,c

Pain is not an inevitable part of aging. Older adult clients can tolerate opioids, although these drugs are best begun at a low dosage and the dosage gradually increased as needed. The brain does not have a single pain centre, and the components of the nervous system associated with pain transmission do not diminish over time. It is true that as one ages, one is at greater risk for the development of painful conditions.

Question 87

15.	
Which of the following are important adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs) for which the nurse continually assesses older adult clients receiving long-term NSAID therapy? (Select all that apply.)
A.	Diarrhea
B.	Liver failure
C.	Renal insufficiency
D.	Gastrointestinal (GI) bleeding

Answer 87

b,c,d

Renal insufficiency and GI bleeding are frequent adverse effects of long-term NSAID use in older clients. The normal aging process results in decreased renal function, and the addition of NSAIDs may accelerate this process. NSAIDs are common over-the-counter drugs, and, as a result, clients may believe these drugs are safe in high dosages. Liver failure can occur with consumption of acetaminophen and ibuprofen. Diarrhea is not usually an adverse effect of NSAID use.

Question 88

16. Which of the following strategies would be best to relieve postoperative pain in opioid-naive clients? The nurse would thus advocate for the clients by consulting with the ordering physician. (Select all that apply.)
    A. Give opioids as needed for pain exceeding the established goal.
    B. Apply a fentanyl patch and change it every three days.
    C. Administer small doses of intravenous (IV) morphine around the clock.
    D. Provide patient-controlled analgesia (PCA) basal dosing along with demand dosing.

Answer 88

b, d

PCA basal dosing is not recommended for postoperative treatment of surgical pain. PCA basal dosing places the client at increased risk for respiratory depression. Fentanyl is much more potent than other opioids and thus is reserved for clients with chronic pain that has been stabilized with opioids over an extended period. Small doses of opioid given IV around the clock and as-needed opioids for pain that exceeds the client goal are acceptable pain-relieving strategies.

Question 89

1. When repositioning an immobile client, the nurse notices redness over a bony prominence. When the area is assessed, the red spot blanches with fingertip touch, indicating which of the following?
   A. A local skin infection requiring antibiotics
   B. A stage III pressure ulcer needing the appropriate dressing
   C. Sensitive skin that calls for the use of special bed linen
   D. Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area

Answer 89

d

This observation is indicative of reactive hyperemia. This is not a local skin infection or a stage III pressure ulcer. Not enough information is given to determine whether the client has sensitive skin.

Question 90

2.	
Which type of pressure ulcer consists of an observable pressure-related alteration of intact skin that may show changes in skin temperature (warmth or coolness), tissue consistency (firm or beefy feel), or sensation (pain, itching) compared with an adjacent or opposite area on the body?
A.	Stage I
B.	Stage II
C.	Stage III
D.	Stage IV

Answer 90

a

In stage I, the ulcer appears as a defined area of persistent redness in lightly pigmented skin and as a darker red, blue, or purple area in darker pigmented skin, with no open skin areas. The skin will be warmer or cooler than other areas, with a change in consistency and sensation. A stage II ulcer is characterized by partial-thickness skin loss involving the epidermis and possibly the dermis. In stage III, the ulcer appears as a full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, the underlying fascia. In stage IV, the ulcer shows as a full-thickness loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

Question 91

3. When a wound specimen is obtained for culture to determine whether infection is present, the specimen should to be taken from which of the following?
   A. Necrotic tissue
   B. Wound drainage
   C. Drainage on the dressing
   D. The wound after it has first been cleansed with normal saline

Answer 91

d

The wound should be cleansed with saline, and then a culture specimen should be obtained from the cleanest (granulating) part of the wound. Necrotic tissue, drainage on the dressing, and old wound drainage can harbour old bacteria that may not necessarily be infecting the wound.

Question 92

4. Postoperatively, a client with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the nurse sees that the sutures are open and that pieces of small bowel are visible at the bottom of the now opened wound. What is the correct intervention?
   A. Allow the area to be exposed to air until all drainage has stopped.
   B. Place several cold packs over the area, with care taken to protect the skin around the wound.
   C. Cover the area with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration.
   D. Cover the area with sterile gauze; place a tight binder over the areas; ask the client to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly.

Answer 92

c

In wound evisceration, the bowel extrudes from the body. The nurse should cover the visible bowel with sterile saline-soaked towels and notify the surgical team. The area should not be allowed to be exposed or to dry out. Cold packs and binders are not acceptable options.

Question 93

5. Serous drainage from a wound is defined as which of the following?
   A. Fresh bleeding
   B. Thick and yellow drainage
   C. Clear, watery plasma
   D. Beige to brown and foul-smelling drainage

Answer 93

c

Serous drainage is clear, watery plasma. Bleeding is not serous. A thick, yellow drainage or beige to brown drainage is indicative of an infection.

Question 94

6.	
What item is not part of an assessment of skin regarding the risk of skin breakdown?
A.	Nutritional status
B.	Cognitive status
C.	Hearing status
D.	Mobility status

Answer 94

c

Nutrition is key because poor intake will decrease the ability of the body to retain elasticity and the protective layer of the skin. Impaired cognitive status can lead to difficulty in recognizing pain or the need to move, and mobility status reflects the ability of the individual to move independently (in the bed or a chair) off bony prominences. Hearing has no impact on skin breakdown.

Question 95

7. Which of the following interventions is most appropriate in managing fecal and urinary incontinence in a client?
   A. Keeping the buttocks exposed to air at all times
   B. Applying a large absorbent diaper that is changed when completely saturated
   C. Using an incontinence cleanser, followed by application of a moisture barrier ointment
   D. Cleansing frequently, applying an ointment, and covering the areas with a thick, absorbent towel

Answer 95

c

The use of an incontinence cleanser followed by application of a moisture barrier helps to protect the skin when a client is incontinent. A diaper should be used to collect the feces and urine; however, the diaper should be changed as soon as it is wet—the nurse should not wait until the diaper is completely saturated. The client’s dignity should be maintained by keeping the client covered.

Question 96

8.	
Which of the following is the most effective intervention for problems with skin integrity?
A.	Sterile technique
B.	Moist wound dressings
C.	Thorough assessment
D.	Prevention

Answer 96

d

Preventing skin breakdown is the best way to optimize skin integrity. Thorough assessment is important but must be acted upon. Moist wound dressings are useful tools when a wound has developed. Technique (clean or sterile) is relevant for wounds (chronic or surgical).

Question 97

9. Placement of a binder around a surgical client with a new abdominal wound is indicated for which of the following?
   A. Collection of wound drainage
   B. Reduction of abdominal swelling
   C. Reduction of stress on the abdominal incision
   D. Stimulation of peristalsis (return of bowel function) from direct pressure

Answer 97

c

The binder helps to support the abdominal muscles and prevent stress on the incision. It should be used with proper dressings that will collect wound drainage. A binder will not reduce swelling and will not stimulate peristalsis.

Question 98

10.	
When the skin and subcutaneous layers adhere to the surface of the bed, and the layers of muscle and the bones slide in the direction of body movement, this is known as which of the following?
A.	Venous injury
B.	Friction
C.	Traction
D.	Shear

Answer 98

d

Shear is the force exerted parallel to skin resulting from both gravity pushing down on the body and resistance (friction) between the client and a surface. This occurs, for example, when the head of the bed is elevated and the sliding of the skeleton starts, but the skin is fixed because of friction with the bed. Shear injury creates deep tissue damage, where friction is a superficial “sheet burn” injury. Venous injury and traction have nothing to do with this sliding of skin against bone.

Question 99

11.	
Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, which results in tissue ischemia and, ultimately, tissue death. Pressure ulcer formation has four stages. The nurse observes partial-thickness skin loss involving the epidermis and possibly the dermis. What stage of ulcer will the nurse document?
A.	Stage I
B.	Stage II
C.	Stage III
D.	Stage IV

Answer 99

b

Partial-thickness skin loss involving the epidermis and possibly the dermis is classified as a stage II ulcer. In stage I, the ulcer appears as a defined area of persistent redness in lightly pigmented skin or a darker red, blue, or purple area in darker pigmented skin, with no open skin areas. In stage III, the ulcer appears as a full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, the underlying fascia. In stage IV, the ulcer appears as a full-thickness loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

Question 100

12.	
Wound healing has three phases. The nurse observes granulation tissue in a client's pressure ulcer. What phase of wound healing is represented by granulation tissue?
A.	Maturation phase
B.	Hemostasis phase
C.	Proliferative phase
D.	Inflammatory phase

Answer 100

c

Tissue granulation occurs in the proliferative phase. Maturation is the final stage of wound healing. Hemostasis occurs during the inflammatory phase.

Question 101

13. A nurse observes all wounds closely. At what time is the risk of hemorrhage the greatest for surgical wounds?
    A. Between 48 and 60 hours after surgery
    B. Between 60 and 72 hours after surgery
    C. During the first 24 to 48 hours after surgery
    D. Seven days after surgery, when the client is more active

Answer 101

c

The risk is highest during the first 24 to 48 hours after surgery because of the possibility of poor clot formation, slipped surgical suture, or trauma to a blood vessel by a foreign object. The more time that passes after surgery, the greater the amount of healing, which lessens the risk of hemorrhage.

Question 102

14.	
The autolytic, mechanical, chemical, and surgical methods that are often used during wound management are all methods of accomplishing what?
A.	Wound dressing
B.	Wound cleansing
C.	Wound debridement
D.	Stimulation of growth factors

Answer 102

c

Methods of debridement include mechanical, autolytic, chemical, and surgical methods. All of these methods share the common objective of removing nonviable, necrotic tissue. Dressing, cleansing, and stimulation of growth factors are not part of debridement.

Question 103

15. Several instruments are available for assessing clients who are at high risk for developing a pressure ulcer. The Braden Scale is the most commonly used. What risk factors are assessed using the Braden Scale?
    A. Infection, hemorrhage, dehiscence, evisceration, and fistulas
    B. Physical condition, mental condition, activity, mobility, and incontinence
    C. Sensory perception, moisture, activity, mobility, nutrition, friction, and shear
    D. Nutrition, tissue perfusion, infection, age, shear force and friction, and moisture

Answer 103

c

The Braden Scale measures the following risk factors: sensory perception, moisture, activity, mobility, nutrition, friction, and shear. The Norton Scale measures five risk factors: physical condition, mental condition, activity, mobility, and incontinence. Infection, hemorrhage, dehiscence, evisceration, and fistulas are the complications of wound healing. The factors that influence pressure ulcer formation and wound healing are nutrition, tissue perfusion, infection, age, shear force and friction, and moisture.

Question 104

16. A 40-year-old client recently became paraplegic. The client is about to be discharged from the rehabilitation centre. Prevention of pressure ulcers has been an important part of the client’s education. In providing this education, the nurse should have included which of the following guidelines?
    A. The client should sit in a chair for no longer than three hours.
    B. The client should use a donut-shaped chair cushion.
    C. The client should use a rigid cushion for full support.
    D. The client should shift the weight in a chair every 15 minutes.

Answer 104

d

Shifting weight frequently prevents prolonged pressure that may lead to pressure ulcer formation. The guideline for sitting up in a chair is to sit for two hours or less, but it is only a guideline. You should individualize activity for each client. Sitting on rigid or donut-shaped cushions is contraindicated because they reduce blood supply to the area, which increases the area of ischemia.

Question 105

17. During the skin assessment of an older adult client who had a stroke, the nurse noted a reddened area over the coccyx. The nurse’s next action for this client should include which of the following?
    A. Massaging the reddened area and repositioning the client
    B. Placing the client in the Fowler’s position and returning in two hours
    C. Inserting a urinary catheter to prevent accumulation of moisture from urinary incontinence
    D. Repositioning the client off the coccygeal area and reassessing the area in one hour

Answer 105

d

Repositioning the client and reassessing the area in one hour are the most appropriate actions. When pressure is relieved from an area, the blood flow returns and the redness will disappear if no damage has occurred. This is the appropriate assessment. Placement in the Fowler’s position would only increase pressure on the coccyx. Massaging of a reddened area is not recommended because it could cause further injury if the tissue is already compromised. Insertion of a urinary catheter will not relieve pressure on the coccyx.

Question 106

18. Which of the following applies to an infected wound?
    A. It requires systemic antibiotics
    B. It will have increased drainage, pain, periwound erythema
    C. It should be covered with an occlusive dressing
    D. It always requires a swab for a culture specimen

Answer 106

b

Signs and symptoms of wound infection include increased drainage, pain, and periwound erythema. Infected wounds ONLY require swab for culture to determine the virulence and type of bacteria present in the wound bed, in order to provide appropriate systemic antibiotic coverage. Superficial wound infections do not require systemic antibiotics as topical treatment will suffice. Occlusive dressings should not be used on infected wounds because they promote bacterial proliferation.

Question 107

19. Which of the following is typical of venous stasis ulcers?
    A. They are located on the arms and trunk.
    B. They are shallow, irregularly shaped wounds on the lower legs.
    C. They are deep and “punched out,” with a pale wound bed.
    D. They are easy to heal.

Answer 107

b

Venous stasis wounds are characteristically located on the lower legs. They appear as superficial and irregularly shaped and are difficult to heal because of the underlying circulatory issues of edema and poor tissue perfusion. Deep, “punched-out,” pale wound bed ulcers are arterial.

Question 108

20.	
Diabetic ulcers occur most commonly over bony prominences located on the plantar surface of the foot, over the metatarsal heads, and beneath the heels due to which of the following?
A.	Neuropathic changes
B.	Nutritional deficits
C.	Reflex vasodilation
D.	The aging process

Answer 108

a

Neuropathic changes affect microcirculation, decrease sensation, and decrease moisture in skin. Clients with diabetes often cannot feel pressure to the feet; hence, too tight footwear or abrasions within footwear cannot be felt. Dry skin is prone to calluses that create more pressure to the foot. Although nutritional deficits and the aging process have some impact on wound development, they are not the primary cause of diabetic ulcers. Reflex vasodilation occurs when an application of cold is left on too long.

Question 109

1. The nurse is having difficulty reading a physician’s order for a medication. The nurse knows that the physician is very busy and does not like to be called. What should the nurse do?
   A. Call a pharmacist to interpret the order.
   B. Call the physician to have the order clarified.
   C. Consult the unit manager to help interpret the order.
   D. Ask the unit secretary to interpret the physician’s handwriting.

Answer 109

b

The nurse is responsible for delivering medication safely to clients. To prevent medication errors, never attempt to interpret illegible handwriting. Always clarify the order directly with the health care professional who prescribed the medication. Consulting with the unit manager, secretary, or pharmacist could lead to further misinterpretation of the order, which could lead to a medication error. The pharmacist is a good resource for providing information about medication side effects, toxicity, interactions, and incompatibilities but is not responsible for interpreting the prescriber’s handwriting.

Question 110

2.	
The client has an order for 2 tablespoons of milk of magnesia. The nurse converts this dose to the metric system. How much should the nurse give the client?
A.	2 mL
B.	5 mL
C.	16 mL
D.	30 mL

Answer 110

d

Each teaspoon is 5 mL and 2 tablespoons is 6 teaspoons, so 5 × 6 = 30 mL.

Question 111

3. Most medication errors occur when the nurse does which of the following?
   A. Cares for too many clients
   B. Fails to follow standard precautions/routine practices
   C. Administers unfamiliar medications
   D. Is responsible for administering numerous medications

Answer 111

b

The most common cause of medication errors by the nurse is failing to adhere to the seven rights of medication administration (right client, right medication, right dose, right route, right time, right reason, and right documentation). The other options are incorrect as it is the nurse’s professional responsibility to adhere to best practice policies and protocols.

Question 112

4.	
A client is to receive cephalexin (Keflex) 500 mg by mouth. The pharmacy has sent 250-mg tablets. How many tablets does the nurse give?
A.	½ tablet
B.	1 tablet
C.	1½ tablets
D.	2 tablets

Answer 112

d

Two 250-mg tablets = 500 mg.

Question 113

5. When identifying a new client before administering medications, the nurse asks the client to state his name. The client does not give the correct name. The nurse asks again, and the client states yet another name. What is the nurse’s next action?
   A. Laugh at the client and tell him to “quit kidding.”
   B. Give the medications without any further questioning.
   C. Investigate the client’s mental status before administering any further medications.
   D. Look at the client’s identification bracelet to correctly identify the client. Reorient the client to person, place, and time and report client confusion to the primary health care professional.

Answer 113

d

Even if the client verbalizes the correct name, the nurse should always check the client’s identification band to ensure accuracy prior to administering ordered medications. This is one of the “seven rights” that must be adhered to for safe medication administration. Additionally, the nurse should always assess clients who exhibit confusion and intervene to ensure that physiological changes related to an altered state of health are not interfering with consciousness and orientation.

Question 114

6. A client is transitioning from the hospital to the home environment. A home health referral has been obtained. In terms of safe medication administration, what is the nurse’s priority as the discharge nurse?
   A. Set up the follow-up physician appointments for the client.
   B. Ensure that someone will provide housekeeping for the client at home.
   C. Make sure that the client has plenty of diapers and blue pads to take home.
   D. Ensure that the home health care agency is aware of medication and health teaching needs.

Answer 114

d

Consistent with primary health care principles, intersectoral collaboration between the acute care hospital and home care agencies should occur to facilitate positive health outcomes for clients. To ensure client safety, the home care agency should be aware of all prescribed medications and additional health education needs of all clients. The other options are issues that should be addressed, but the question is specific to safe medication administration.

Question 115

7. The nurse is taking an antibiotic to administer to a client. The client asks what the medication is and why he should take it. What should the nurse tell the client?
   A. Inform the client that only the client’s physician can give this information.
   B. Provide the name of the medication and a description of its desired effect.
   C. Tell the client that information about medications is confidential and cannot be shared.
   D. Explain that because of the limits placed on nursing students, the client will have to speak with his assigned nurse about this.

Answer 115

b

The nurse is responsible for knowing the correct medication name, dose, route, time, and reason for the medication that the nurse will be administering. Part of building a therapeutic relationship and providing client teaching is sharing this information with the client. The client has the right to this information, and the nurse should present this information without waiting for a physician or the client’s assigned nurse.

Question 116

8. The nurse is administering a sustained-release capsule to a new client. The client insists that he cannot swallow pills. Which is the best course of action?
   A. Ask the physician to change the order.
   B. Crush the pill with a mortar and pestle.
   C. Hide the capsule in a piece of solid food.
   D. Open the capsule and sprinkle it over pudding.

Answer 116

a

Sustained-release medications should never be crushed or sprinkled on food. Hiding the capsule in a piece of solid food is not an appropriate nursing step. The nurse should contact the physician for an order change.

Question 117

9.	
The nurse selects the route for administering medication according to which following protocol?
A.	Hospital policy
B.	The prescriber’s orders
C.	The type of medication ordered
D.	The client’s size and muscle mass

Answer 117

b

Facilities have protocols for medication administration that the nurse must follow. If a physician’s order contradicts the protocols, then the order must be clarified with the physician and the protocol explained. The protocol will include specifics for the type of medication ordered and the client’s size and muscle mass.

Question 118

10. A client is receiving an intravenous (IV) push medication. If this type of drug infiltrates into the outer tissues, what will the nurse do?
    A. Continue to let the IV run
    B. Apply a warm compress to the infiltrated site
    C. Follow facility policy or the drug manufacturer’s directions. Notify the prescriber if necessary
    D. Not worry about this because vesicant filtration is not a problem

Answer 118

c

The infusion of the medication should be halted immediately and the facility policy or drug manufacturer’s directions followed. Infiltration of some medications will create no harm. For others, harm can be averted by the application of warm compresses. Still others may require other treatments if infiltration occurs.

Question 119

11.	
If a client who is receiving intravenous (IV) fluids develops tenderness, warmth, erythema, and pain at the site, what does the nurse suspect?
A.	Sepsis
B.	Phlebitis
C.	Infiltration
D.	Fluid overload

Answer 119

b

Warmth, redness, and tenderness of an IV site indicate phlebitis. Infiltration usually presents as a cool, swollen, and pale IV site. Sepsis is an infection, and signs of sepsis may or may not be present at the site. Fluid overload will not produce specific changes at the IV site.

Question 120

12. A nurse administering medications has many responsibilities. Among these responsibilities is a knowledge of pharmacokinetics. Which statement is the best description of pharmacokinetics?
    A. The passage of medication molecules into the blood from the site of administration
    B. The degree to which medications bind to serum proteins, which affects distribution
    C. The study of how medications enter the body, reach their site of action, metabolize, and exit the body
    D. The method by which a medication, after absorption, is moved within the body to tissues, organs, and specific sites of action

Answer 120

c

Pharmacokinetics is the study of how medications enter the body, travel to the site of action, metabolize, and exit the body. Distribution refers to the method by which medication, after absorption, is moved within the body. Absorption is the passage of medication molecules into the blood from the site of administration. The degree to which medications bind to serum protein is protein binding.

Question 121

13. When the nurse delivers a medication to a client, who has the ultimate responsibility for the medication that is being administered?
    A. The client taking the medication
    B. The nurse administering the medication
    C. The pharmacist providing the medication
    D. Both the prescriber and the nurse administering the medication

Answer 121

d

The nurse does not have sole responsibility for medication administration. When administering medications, the nurse is accountable for knowing which medications are prescribed for the client, their therapeutic and nontherapeutic effects, the nursing implications, and the level of the client’s knowledge. The prescriber is responsible for ordering medications that are consistent with the client’s health and illness, as well as ensuring safe dosage and frequency. The pharmacist can also help to ensure the right medication gets to the right client.

Question 122

14. The following orders were written by a prescriber. Which order is written correctly?
    A. Aspirin 2 tablets prn
    B. Haloperidol (Haldol) ½ tablet at bedtime
    C. Zolpidem (Ambien) 5 mg PO at bedtime prn
    D. Levothyroxine (Synthroid) 0.05 mg 1 tablet

Answer 122

c

The order for zolpidem is the only medication order that contains the essential components of a drug order—name of medication, dose, route of administration, and frequency.

Question 123

15.	
To better control the client's blood glucose level, the physician orders a high regular insulin dosage of 20 units of U-500 insulin. The nurse has only a U-100 syringe. How many units will be given?
A.	4
B.	5
C.	10
D.	20

Answer 123

a

U-500 insulin is five times as strong as U-100 insulin. Therefore, the amount of U-500 insulin should be divided by 5; 20 units ÷ 5 = 4 units.

Question 124

16. The nurse is administering an intramuscular (IM) injection. Why is the Z-track method a suggested method for IM injections?
    A. It is easier for the nurse to use.
    B. It allows for repeated injections into the same site.
    C. It does not require the nurse to aspirate before injecting the medication.
    D. It minimizes local skin irritation by sealing the medication in muscle tissue.

Answer 124

d

The Z-track method minimizes local skin irritation, providing more comfort for the client. Repeated injections in the same muscle can cause severe discomfort and poor absorption. The Z-track method of injection is not easier but requires practice by the nurse to achieve a smooth injection technique because of the increased number of steps in the method. Aspiration is still required when the Z-track method is used.

Question 125

17. What is the best nursing practice for administrating a controlled substance if part of the medication must be discarded?
    A. The nurse documents on the medication administration record.
    B. The nurse discards the unused portion and documents on the control inventory form.
    C. The nurse does not discard any controlled substance to prevent environmental contamination.
    D. The nurse documents on the medication administration record and the control inventory form and has a second nurse witness the medication being discarded.

Answer 125

d

The nurse signs both records and has a second nurse witness the discarding of the controlled substance and sign the control inventory form. Agency policy dictates how the substance is discarded to avoid environmental concerns.

Question 126

18.	
When administering medications, it is essential for the nurse to have an understanding of basic arithmetic to calculate doses. The physician has ordered 250 mg of a medication that is available in a 1-g amount. The vial reads 2 mL = 1 g. What dose would the nurse give?
A.	0.25 mL
B.	0.5 mL
C.	1 mL
D.	2.5 mL

Answer 126

b

0.5 mL = 250 mg of this medication.
(Dose ordered/dose on hand) × amount on hand = amount administered
[250 mg/1000 mg (1 g)] × 2 mL = 500/1000 = ½ mL or, in decimals, 0.5 mL

Question 127

19. While the nurse is administering medication, the client says, “This pill looks different from what I usually take.” What is the best action for the nurse to take?
    A. Recheck the medication order, taking along the medication.
    B. Ignore the statement because the client has a history of confusion.
    C. Leave the medication at the bedside and recheck the order.
    D. Tell the client that pill manufacturers often change the colour of pills.

Answer 127

a

This is a safety issue and should not be ignored. Leaving the medication at the bedside is an unsafe practice and does not demonstrate the nurse’s responsibility. If checking the medication order does not clarify the situation, then the nurse should check with the pharmacist regarding pill shape, colour, and so on. Different manufacturers will design their own brands to look different from their competitors’ brands. Checking the client’s statement can avoid a potential medication error.

Question 128

20. The client is a 40-year-old man who weighs 72.7 kg and is 175.26 cm tall. The order is for 5 mL of a medication to be given as a deep intramuscular (IM) injection. What size of syringe and gauge and length of needle should the nurse use for best practice?
    A. One 5-mL syringe, 20- to 23-gauge 2.5-cm needle
    B. Two 2-mL syringes, 25-gauge 2.5-cm needle
    C. Two 3-mL syringes, 23-gauge, 1.27-cm needle
    D. Two 3-mL syringes, 20- to 23-gauge, 3.8-cm needle

Answer 128

d

A medication dose of 5 mL administered IM is unlikely to be absorbed properly. Therefore, dividing the dose is correct. Dividing the doses equally allows 2.5 mL to be given in two different sites, so the nurse will need two 3-mL syringes. A deep IM injection must pass through subcutaneous tissue and penetrate deep muscle; therefore, the needle must be long enough (3.8 cm) and the gauge heavy enough (20 to 23 is the best choice).

Question 129

21.	
A site that was a traditional location for intramuscular (IM) injections in the past is no longer recommended because its use carries the risk of striking the underlying sciatic nerve or major blood vessel. What is the name of this site?
A.	Plexor
B.	Dorsogluteal
C.	Ventrogluteal
D.	Vastus lateralis

Answer 129

b

The dorsogluteal is the not-so-safe traditional site. The ventrogluteal muscle is situated deep and away from major nerves and blood vessels. The vastus lateralis muscle is thick and well developed. The plexor is the middle finger of the dominant hand used during percussion or a percussion hammer used to strike the pleximeter and is not related to IM sites.

Question 130

Each medication order should include the 4 following:

Answer 130

1. the client’s name;
2. the order date;
3. the medication name, dosage, route, time of administration, and indication;
4. and the prescriber’s signature.

Question 131

The seven rights of medication administration ensure accurate ___________ and ____________ of medication doses.

Answer 131

preparation

administration

Question 132

During the initial assessment of a patient in the postanesthesia care unit (PACU), the nurse notes bleeding that is beginning to seep through the top layer of the dressing. What actions should the nurse take immediately?
A) Assess the patient’s vitals signs and notify the surgeon
B) Mark the drainage with a felt-tip marker and continue to monitor
C) Lift the dressing to assess the bleeding and raise the patient’s legs
D) Circle the drainage on the dressing and check it again within 10 minutes

Answer 132

d

The action requires both an assessment and an immediate implementation. A felt-tip marker should never be used to mark drainage because of the chance that it may leak into the underlying dressings, thereby contaminating the wound. Reinforcing the dressing merely allows for extra absorption and does not create a pressure dressing.

Question 133

A patient underwent a short procedure under procedural sedation and is in the recovery area. What action by the nurse would be expected to best promote the patient’s respiratory function?
A) Position the patient with his head elevated with slight neck flexion
B) Place the patient on his side with his head elevated and arms over his chest
C) Position the patient on his side with his neck slightly extended
D) Place the patient flat supine or on his side

Answer 133

c

A primary objective after a short procedure under procedural sedation is to provide a patent airway with appropriate oxygenation. The patient should be positioned on the side with head facing down and neck slightly extended. Positioning the arms over the chest reduces chest expansion and is contraindicated. Remaining flat for an extended period of time may be necessary after spinal anesthesia. Page 958

Question 134

A patient is unable to perform the lower leg exercises postoperatively because of a spinal cord injury that occurred many years ago. Nursing care would be appropriate if the nurse was observed performing which activity?
A) Encouraging the patient to perform active range of motion of the feet and knees
B) Placing a footboard to give the patient something to press his feet against
C) Providing passive range of motion to the lower extremities every 2 hours
D) Wrapping 4-inch elastic bandages on both legs from ankle to calf

Answer 134

c

If the patient is unable to perform the leg exercises postoperatively, then staff must provide passive range of motion to the lower extremities every 2 hours when the patient is awake. The patient cannot do the exercises; the elastic bandages could constrict circulation considering where they begin and end, and the footboard could help prevent footdrop, but promotion of circulation is the goal.

Question 135

The patient asks the nurse why she has to stop smoking at least a month before surgery. Which response by the nurse would be most accurate?
A) “Withdrawing nicotine gives the physician a better assessment of your true pain level.”
B) “If any respiratory problems occur, your physician will be able to detect them immediately.”
C) “The use of tobacco products prevents the blood from clotting as effectively as usual.”
D) “The use of nicotine decreases wound healing and increases the chance of infection.”

Answer 135

d

Because nicotine is a vasoconstrictor, less circulation and therefore fewer nutrients and oxygen will get to the wound site, thereby increasing the chance of infection and poor wound healing. None of the other options are correct.

Question 136

The nurse in the postanesthesia care unit (PACU) is caring for several patients. Which
patient needs to be watched most carefully for postoperative thrombus formation?
A) A 45-year-old woman with poor pedal pulses who takes oral contraceptives
B) A 68-year-old man who is slightly hypertensive and anemic
C) A 38-year-old woman who has just had his appendix removed
D) A 56-year-old overweight male who plays golf twice every week

Answer 136

a

Women over the age of 35 who take birth control pills and have poor circulation are at highest risk for developing postoperative thrombus formation among all patients listed. None of the other patients have as significant a risk for blood clot. Page 949

Question 137

The nurse is performing a surgical scrub. Which action by the nurse would require an intervention?
A) The arms are divided mentally into thirds for scrubbing
B) The arms are rinsed from elbows to fingertips
C) Each finger and hand is visualized as having four sides
D) The hands are dried from fingertips to elbows

Answer 137

b

The arms are rinsed from fingertips to elbows. This prevents contamination of the scrubbed areas. All of the other options are correct. Page 73

Question 138

The circulating nurse is assisting the surgical team into their gowns. Which action by the circulating nurse would be expected?
A) Documenting in the patient’s record the use of sterile technique
B) Helping the surgeon pull his gown on, exposing his hands
C) Holding the sterile paper tab attached to the sterile gown tie
D) Handing the sterile gloves individually to the surgeon

Answer 138

c

The circulating nurse who is not sterile will hold the sterile paper attached to the tie of the sterile gown. The surgical team member who is wearing the gown extends this part to the circulating nurse, who then removes it, exposing the other sterile tie, which the surgical team member ties after turning around to bring it around the body. Page 975

Question 139

A “time out” procedure is being conducted before the scheduled surgery is begun.
What activity would the circulating nurse expect during this time?
A) Checking the numbers of sponges and sharps
B) Ensuring that all members of the surgical team have scrubbed
C) Verifying the correct operative site and side
D) Placing the ECG electrodes on the patient

Answer 139

c

The “time out” procedure verifies correct operative site and side, patient identification, correct procedure, presence of specialized equipment and supplies, and correct patient position. Page 968

Question 140

The scrub nurse sees a nurse who is gowned and gloved brush up against something
unsterile. The nurse disputes that she is contaminated. What is the appropriate action by the scrub nurse?
A) Allow the nurse to continue with the assigned surgical responsibilities
B) Change the activities the nurse would perform during the procedure
C) Tell the director of the operating room about the incident
D) Insist that the nurse rescrub and regown before continuing

Answer 140

d

When in doubt, surgical personnel should consider themselves contaminated. If someone else thinks someone has become contaminated, they should not argue. Rescrub, then regown for safety. Page 967

Question 141

The scrub nurse is in surgical garb and is standing with his arms crossed in front of his chest with the hands in his axillary region, and the surgery is about to start. What is the correct action for this nurse to take?
A) Continue with the procedure as scheduled
B) Rescrub, regown, and reglove
C) See if anyone notices his action
D) Ask the surgeon what he should do

Answer 141

b

The hands should not be placed in the axillary region because of the chance that perspiration may strike through the surgical gown. The nurse should excuse himself without anyone having to tell him what to do and should remove his gown and gloves, rescrub, and put on a new surgical gown and gloves. Page 968

Question 142

The patient asks the nurse why he has a drain in his abdomen after surgery. Which response by the nurse is most accurate?
A) “The drain removes abdominal fluids to reduce stress on the suture line.”
B) “You have a drain to prevent any swelling of the surgical area.”
C) “The drain allows the antibiotics that were instilled in the wound to drain.”
D) “The drain removes fluid from the surgical area to promote healing.”

Answer 142

d

The drain removes any accumulation of drainage from the wound bed, which promotes wound healing. The answer is truthful and uses no technical words. Page 993

Question 143

A patient with a large abdominal incision is being discharged. Which statement by the patient indicates that teaching by the nurse has been effective?
A) “I can sit out in the sun a little, which will help to heal the incision.”
B) “As long as I don’t have pain, I can do just about anything I want.”
C) “I don’t have to worry about further drainage now that the staples are out.”
D) “I need to avoid lifting anything heavy for at least several weeks.”

Answer 143

d

Lifting heavy objects can cause a strain on the suture line and must be avoided for several weeks. Exposure of the skin to sun can cause scarring of the area. Drainage would be minimal but still could occur. Page 993

Question 144

While removing the patient’s staples, the nurse notices that the incision starts to open
larger than the width of two staples. Which action should the nurse initially take?
A) Place several Steri-Strips to close the open area
B) Remove one more staple to see if the open area enlarges
C) Notify the physician of the opening in the wound
D) Palpate the edges of the wound

Answer 144

a

Steri-Strips would be applied first to prevent any further opening of the incision. The patient’s physical needs must be met first. The physician would be notified and the wound status documented. No additional staples should be removed at this time. The staples may need to remain in longer. Page 992

Question 145

A patient needs to have his abdominal wound irrigated. Which part of the procedure may the nurse delegate to nursing assistive personnel (NAP)?
A) Documenting the description of the wound
B) Packing the wound with sterile gauze pads
C) Taping the dressing once the wound is covered
D) Performing the wound irrigation

Answer 145

c

NAP cannot have a wound irrigation delegated to them. Because chronic wounds may be cleansed using clean technique, the NAP would be able to tape the dressing after the irrigation, once it has been covered by the nurse. Page 984

Question 146

An older diabetic patient with a lot of abdominal fat had abdominal surgery 4 days ago involving an 8-inch vertical incision. The nurse would be most concerned if which observation of the incision was made?
A) The incision line is slightly pink and elevated where the staples are
B) Serosanguineous drainage has increased since 2 days ago
C) The incision line has a light crust on it
D) The patient’s pain level has changed from “5” yesterday to “2” today

Answer 146

b

An increase in serosanguineous drainage is an early indication that the wound is not healing as expected and that dehiscence could occur. The patient has obesity, advanced age, and diabetes as stressors that could cause a negative outcome. Page 981, 982

Question 147

A nurse is administering multiple medications to multiple patients on a very busy unit. Which action by the nurse requires an intervention?
A) He performs dosage calculations and has them checked by another nurse as needed.
B) He keeps unit dose medications closed in their wrappers until arriving at the patient’s bedside.
C) He administers clear liquid medication containing sediment at the bottom of the bottle.
D) He checks medications at least 3 times before administering them to the patient.

Answer 147

c

If sediment is seen at the bottom of the container of a clear liquid medication, the medication should be discarded or sent back to the pharmacy with an explanation according to institutional policy. The medication components may have gone through a change during transport or storage, or the medication may have expired. Page 524

Question 148

The home health nurse notes that an elderly patient uses mouthwash three or four times every day and that he periodically swallows some of it. Which action is most appropriate for the nurse to take?
A) Tell the patient not to use the mouthwash as often.
B) Ask the patient if he smokes.
C) Obtain a dietary history from the patient for the past 2 days.
D) Check the patient’s medications and the mouthwash label.

Answer 148

d

Most mouthwash formulas contain alcohol. More than half of the 100 most commonly prescribed drugs have at least one ingredient that is known to interact adversely with alcohol. The nurse needs to check if the mouthwash contains alcohol and to check the medications for possible interactions. The pharmacist or physician also could be contacted. The nurse could recommend switching to a non?alcohol-based mouthwash, unless it is contraindicated. This question requires the nurse to assess initially. None of the other answers are important or relevant. Page 524

Question 149

The nurse is reviewing the physician’s order sheet and finds an order for morphine sulfate, 5 to 8 mg IM q 3-4h prn. What is the appropriate initial nursing action?
A) Contact the pharmacist to approve the order.
B) Ask another nurse if she can give the medication.
C) Contact the physician for clarification, including a “read-back.”
D) Administer the medication as ordered by the physician.

Answer 149

c

The Joint Commission now discourages the use of range dosages because they can be unclear. The nurse needs to call the physician who prescribed the order for clarification and to read back the order to the physician. This order would have to follow institutional guidelines, then be transcribed as a verbal order, with this noted per institutional policy. Page 518

Question 150

The nurse administered a medication that is excreted partially through the sweat glands. What would be a primary nursing responsibility?
A) Administer a narcotic reversal agent.
B) Assess the oxygen saturation level.
C) Provide skin care more frequently.
D) Monitor the patient's urinary output.

Answer 150

c

The patient would need skin care more frequently because of the mechanism and location of drug excretion. Page 510

Question 151

The nurse, during the admission history, determines that his 80-year-old patient is currently taking a salmon-colored blood pressure pill, a yellow “muscle-relaxing” pill, a pink liquid to calm his stomach, and a green and yellow “joint” pill. What action should the nurse take first?
A) Ask the patient if he brought the medications with him.
B) Check the patient’s armband before administering any medications.
C) Try to identify the medications by the patient’s descriptions.
D) Call the pharmacist to see if she can figure out what the medications are.

Answer 151

a

These medications may be appropriate or inappropriate for this patient, but this will not be known until they are identified. The nurse is attempting to assess and obtain a medication history. Because the patient doesn’t know the names of the medications, the nurse is checking to see if the patient brought the medications with him. Identification of medications is essential and is best done by the pharmacist who can see the actual medications. In the older adult, alterations in the absorption, distribution, metabolism, and excretion of medications occur and need to be monitored. Having the medications at hand provides an opportunity for the nurse to assess the patient’s visual acuity and ability to understand directions and to determine whether the patient needs assistance with medication administration when discharged. Answer 2 has nothing to do with the question. Page 526

Question 152

A patient is being instructed, by the nurse, on how to use a vaginal medication for a yeast infection. Which statement by the patient indicates that the teaching was understood?
A) “I need to void before inserting the medication.”
B) “I can stop the medication when my symptoms are gone.”
C) “I should sit on the toilet when inserting the medication.”
D) “I should use a little petroleum jelly to ease insertion of the applicator.”

Answer 152

a

Voiding helps the procedure to be more comfortable and effective because an empty bladder makes insertion of suppositories or a cream applicator easier. The patient should be in the dorsal recumbent position. All of the medication should be used as prescribed even after the symptoms have subsided. A water-based lubricant, not petroleum jelly, should be used to ease insertion, if needed. Page 565

Question 153

A nurse is instilling ear drops in an adult. The procedure will be correct if the nurse uses which technique?
A) The nurse inserts the tip of the medication dropper into the ear canal deep enough to occlude it.
B) The nurse uses warmed medication directed toward the lower part of the ear canal.
C) The nurse holds the tip of the medication dropper an inch above the opening of the ear canal.
D) The nurse pulls the pinna down and back to facilitate instillation of the medication.

Answer 153

c

When the tip of the irrigation syringe is held slightly above the ear canal, there is less pressure within the ear. The tip of the irrigation syringe should not occlude the ear canal, nor should it be directed toward the lower part of the ear canal. The syringe tip should be directed toward the top part of the ear canal. If mineral oil is used, only a few drops are used to loosen the cerumen (earwax) before the irrigation is performed. Page 551

Question 154

A patient is to use a new metered-dose inhaler. The instructions the nurse gives will be correct if the patient demonstrates which technique?
A) Holds breath, breathes in slowly for 2 to 3 seconds, shakes inhaler, then exhales quickly through his mouth
B) Shakes inhaler, places inhaler in mouth, takes a deep breath, exhales completely, then depresses the medication canister completely
C) Positions inhaler 1 to 2 inches in front of his slightly opened mouth, takes three to four deep breaths, depresses medication canister, then holds his breath for 10 seconds
D) Removes mouthpiece cover, shakes inhaler, breathes normally while medication canister is depressed twice, then holds breath for 30 seconds

Answer 154

b

Answer 2 has the correct information. The medication is exhaled slowly, not quickly, through the nose or mouth. If the inhaler is placed in the mouth, then the mouth needs to be open wide, not slightly opened. The breath is not held after the medication is delivered. The number of depressions (sprays) is ordered by the physician and is not standardized for all patients. Page 558

Question 155

A nurse is teaching a patient how to use a small-volume nebulizer. Teaching will be effective if the patient makes which statement?
A) “I can use my bronchodilator medication whenever I feel I need it.”
B) “I need to rinse my mouth with water after receiving a steroid treatment.”
C) “I should wash the nebulizer parts with vinegar and water after each use.”
D) “If medication is left in the nebulizer, I can add to it for the next treatment.”

Answer 155

b

Rinsing the mouth with water and then gargling with warm water after nebulized steroids are received removes medication residue from the oral cavity and helps prevent oral candidiasis, a possible adverse side effect of inhaled steroid therapy. Page 564

Question 156

A patient is opening a new metered-dose inhaler and notes there are 200 inhalations in the canister. The physician has ordered two treatments daily using two inhalations per treatment. How long should the canister last?
A) 25 days
B) 50 days
C) 75 days
D) 100 days

Answer 156

b

Note the number of inhalations on the canister, how often per day the medication is ordered, and how many inhalations or sprays are ordered for each treatment. Two inhalations per treatment times two sprays equals four sprays per day. Divide the total number of inhalations in the canister (200) by the number of inhalations or sprays per day (four), and the number obtained will determine how long the inhaler should last (50 days). Page 561

Question 157

A patient receiving pain medication via a patient-controlled analgesia (PCA) pumps states that his pain is getting worse. What actions by the nurse are most appropriate?
A) Review the number of times the patient pushed the PCA button as well as how many doses were delivered
B) Notify the physician of the patient’s current status after checking the intravenous site
C) Raise the patient’s head slightly after repositioning in an attempt to make the patient more comfortable
D) Find out the patient’s pain level followed by administration of a dose of antianxiety medication

Answer 157

a

This evaluation assists in determining the effectiveness of the PCA dose and the frequency in relieving pain. The next thing to be assessed would be the status of the patient’s intravenous line and the PCA pump. Page 383

Question 158

A patient from a nursing home with bilateral paralysis from a stroke and a clotting disorder has a PCA pump ordered after surgery. What intervention should be taken by the nurse to best meet this patient’s needs?
A) Show the patient how to push the button on the PCA machine
B) Contact the physician regarding using a continuous dose of pain medication
C) Ask the patient if there is someone who can stay at the hospital while PCA is being used
D) Find out from the physician if pain medication can be given intramuscularly on a PRN basis

Answer 158

b

The patient is unable to manipulate the PCA button because of the prior stroke. Because the patient has a clotting disorder, the patient is not a good candidate for intramuscular injections. The best approach would be most likely be a continuous infusion, but at a low dose. Page 384

Question 159

A patient is to have a bolus of pain medication administered through an epidural catheter. An intervention is indicated if which action by the nurse is observed?
A) Preservative-free medication is drawn up
B) Alcohol is used to prep the injection port
C) The injection port is cleaned with povidone-iodine
D) The patient’s sedation level is monitored after the medication is given

Answer 159

b

Alcohol causes pain and is toxic to neural tissue. All of the other options are correct. Page 389

Question 160

During assessment of a patient with an epidural catheter, the nurse sees blood on the epidural dressing. What action is most important for the nurse to take initially?
A) Assess the patient’s vital signs and oxygen saturation
B) Stop the infusion of the epidural pain medication
C) Ask the patient how she is feeling in general
D) Perform a complete head-to-toe assessment

Answer 160

b

Blood seen on the dressing indicates that the catheter has probably punctured a blood vessel. The infusion needs to be stopped and the physician notified. Page 390

Question 161

A patient has a local analgesia infusion pump with the catheter in the shoulder where the surgery was performed. Since the catheter will be removed by a family member, the patient and family teaching needs to include which statement by the nurse?
A) “Once the catheter is removed, put a Band-Aid over the opening.”
B) “If you meet resistance while removing the catheter, stop and cover the site.”
C) “Ask the patient what his pain level is before you remove the catheter.”
D) “Wash your hands first, then remove the dressing, then the catheter.”

Answer 161

b

The catheter is either twisted or in an unusual position in the shoulder and should be left for the physician to remove. The catheter needs to be removed when the pump finishes delivering the medication regardless of the patient’s pain level. The patient has oral pain medication along with the pump. Option 4 did not include the use of gloves which is necessary. Page 392

Question 162

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

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

Answer 162

a

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

Question 163

Which of the following is the primary reason for accurately recording the patient’s current medications during a preoperative assessment?

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

Answer 163

c

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

Question 164

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

a) Insist the patient remove the ring for safety purposes.
b) Explain that the hospital will not be responsible for the ring.
c) Tape the ring securely to the finger and document this on the preoperative checklist.
d) Note the presence of the ring in the nurse’s notes of the chart and on the preoperative checklist.

Answer 164

c

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

Question 165

While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that

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

Answer 165

c

Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidence-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight.

Question 166

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

a) Tell the patient that using kava to help sleep is often helpful.
b) Inform the anesthesiologist of the patient’s recent use of kava.
c) Tell the patient that the kava should continue to help him relax before surgery.
d) Inform the patient about the dangers of taking herbal medicines without consulting his health care provider.

Answer 166

b

Kava may prolong the effects of certain anesthetics. Thus the anesthesiologist needs to be informed of recent ingestion of this herbal supplement.

Question 167

Which of the following preoperative patients likely faces the greatest risk of bleeding as a result of their medication?

a) A woman who takes metoprolol (Lopressor) for the treatment of hypertension
b) A man whose type 1 diabetes is controlled with insulin injections four times daily
c) A man who is taking clopidogrel (Plavix) after the placement of a coronary artery stent
d) A man who recently started taking finasteride (Proscar) for the treatment of benign prostatic hyperplasia

Answer 167

c

Any drug that inhibits platelet aggregation, such as clopidogrel (Plavix), represents a bleeding risk. Insulin, metoprolol (Lopressor), and finasteride (Proscar) are less likely to contribute to a risk for bleeding.

Question 168

A 70-year-old woman has been admitted prior to a bilateral mastectomy and breast reconstruction. Which of the following elements should the nurse include in the patient’s preoperative teaching (select all that apply)?

a) Information about various options for reconstructive surgery
b) Information about the risks and benefits of her particular surgery
c) Information about risk factors for breast cancer and the role of screening
d) Information about where in the hospital she will be taken postoperatively
e) Information about performing postoperative deep breathing and coughing exercises

Answer 168

d, e

Question 169

Before administering celecoxib (Celebrex), the nurse will assess the patient’s medical record for which of the following medications that would increase the risk of adverse effects?

a) Aspirin
b) Scopolamine
c) Theophylline
d) Acetaminophen

Answer 169

a

Celecoxib is a nonsteroidal antiinflammatory drug (NSAID) of the cyclooxygenase-2 (COX-2) inhibitor type. Although celecoxib does not inhibit COX-1 and thus has a decreased risk of bleeding, bleeding is still of concern as an adverse effect. For this reason, the drug should not be taken with other drugs that increase risk of bleeding, such as aspirin.

Question 170

After administering acetaminophen and oxycodone (Percocet) for complaints of pain, which of the following interventions would be of highest priority for the nurse to complete before leaving the patient’s room?

a) Leave the overbed light on at low setting.
b) Ensure that the upper two side rails are raised.
c) Offer to turn on the television to provide distraction.
d) Ensure that documentation of intake and output is accurate.

Answer 170

b

Percocet has acetaminophen and oxycodone (a class III controlled substance) as ingredients. Since the medication contains an opioid analgesic with sedative properties, the nurse must ensure patient safety before leaving the room, such as leaving the top two bedrails raised. This will help prevent the patient from falling from bed, while not restraining the patient (as four side rails would do).

Question 171

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

a) Pain rating
b) Blood pressure
c) Respiratory rate
d) Level of consciousness

Answer 171

c

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

Question 172

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

a) Blurred vision
b) Nasal stuffiness
c) Urinary retention
d) Black or tarry stools

Answer 172

d

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

Question 173

Which of the following nursing interventions is most appropriate when preparing to administer an opioid analgesic agent?

a) Give the medication on an empty stomach.
b) Count the number of doses on hand before administration.
c) Give the medication with a glass of juice or other cold beverage.
d) Assess the patient for allergies to aspirin before administration.

Answer 173

b

Because opioid analgesics are controlled substances, the nurse needs to count the number of doses and check that it matches the number recorded before removing and administering the medication.

Question 174

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

a) Teach the caregiver not to push the button for the patient.
b) Instruct the patient not to push the button too frequently.
c) Ask the patient to do deep breathing exercises every hour.
d) Administer medications to prevent the occurrence of diarrhea.

Answer 174

a

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

Question 175

You would question an order written for Percocet for a patient exhibiting which of the following clinical manifestations?

a) Severe jaundice
b) Oral candidiasis
c) Increased urine output
d) Elevated blood glucose

Answer 175

a

Acetaminophen and oxycodone are the ingredients in Percocet. Because acetaminophen is metabolized in the liver, the patient could develop acetaminophen toxicity in the presence of severe liver disease (evidenced by jaundice). The prudent nurse would question the order before administration.

Question 176

You have been assigned to care for a postoperative patient who has been switched from patient-controlled analgesia with meperidine (Demerol) to morphine sulfate after experiencing restlessness and agitation. The caregiver asks why the change has been made. Which of the following replies is most appropriate?

a) “Restlessness and agitation are symptoms of meperidine toxicity.”
b) “Meperidine is not controlling the surgical pain effectively.”
c) “Meperidine has caused the respiratory rate to drop too low.”
d) “Meperidine can only be used for 24 hours postoperatively.”

Answer 176

a

Confusion, restlessness, and agitation are signs of toxicity from normeperidine, a toxic metabolite of meperidine.

Question 177

A patient with osteoarthritis has been taking ibuprofen (Motrin) 400 mg every 8 hours. The patient states that the drug does not seem to work as well as it used to in controlling the pain. The most appropriate response to the patient is based on knowledge of which of the following?

a) Another NSAID may be indicated because of individual variations in response to drug therapy.
b) The patient is probably not compliant with the drug therapy and therefore the nurse must initially assess the patient’s knowledge base and initiate appropriate teaching.
c) If NSAIDs are not effective in controlling symptoms, systemic corticosteroids are the next line of therapy.
d) It may take several months for NSAIDs to reach therapeutic levels in the blood and thus be effective.

Answer 177

a

Patients vary in their response to medications so when one NSAID does not provide relief, another should be tried. There is no evidence in the stem of the question to ascertain any noncompliance to drug therapy.

Question 178

When assessing a patient receiving morphine sulfate 2 mg every 10 minutes via PCA pump, the nurse should take action as soon as the patient’s respiratory rate would drop down to or below which of the following parameters?

a) 16 Breaths/min
b) 14 Breaths/min
c) 12 Breaths/min
d) 10 Breaths/min

Answer 178

c

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

Question 179

Which of the following clinical manifestations would you attribute to adverse effects of morphine sulfate administered via PCA?

a) Urinary incontinence
b) Increased blood pressure
c) Diarrhea
d) Nausea and vomiting

Answer 179

d

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

Question 180

A patient asks you why a dose of morphine sulfate by IV push is given before starting the medication via PCA. Which of the following responses is most appropriate?

a) “PCA takes at least 2 hours to begin working, so the IV push dose will provide pain relief in the interim.”
b) “The IV push dose will enhance the effects of the PCA for the next 8 hours.”
c) “The IV push dose will provide for immediate pain relief, which can be maintained by using the PCA.”
d) “PCA will never be effective unless a loading dose is given first.”

Answer 180

c

An IV push loading dose of an opioid analgesic provides an effective opioid level in the body, which results in immediate pain control. The PCA medication doses may be smaller and can be used more frequently to maintain pain control when the loading dose begins to wear off.

Question 181

You are caring for a patient who is receiving morphine sulfate via PCA. Which of the following patient assessment data demonstrate the most therapeutic effect of this medication?

a) Pain rating 1/10, drowsy but arousable, respirations 16
b) Pain rating 2/10, awake and alert, respirations 18
c) Pain rating 3/10, awake and alert, respirations 20
d) Pain rating 2/10, drowsy but arousable, respirations 18

Answer 181

b

Effective pain management is achieved when there is adequate pain control (rating of 3 or less on a scale of 1 to 10) with normal respirations and an absence of sedation. These data exhibit the best effectiveness of the pain medication in all of these areas.

Question 182

You should teach a patient to avoid which of the following medications while taking ibuprofen?
 Morphine sulfate (generic)
 Nitroglycerin (Nitro-Bid)
 Correct Aspirin
 Furosemide (Lasix)

Answer 182

The patient should not take aspirin while taking ibuprofen because the combination could increase the risk of GI bleeding.

Question 183

A patient admitted with metastatic lung cancer is ordered to receive morphine sulfate for pain. You should assess for which of the following common adverse reactions to this medication?

a) Constipation
b) Agitation
c) Diarrhea
d) Urinary incontinence

Answer 183

a

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

Question 184

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

a) Pupillary dilation
b) Hypertension
c) Urinary incontinence
d) Decreased respiratory rate

Answer 184

d

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

Question 185

You are caring for a postoperative patient receiving epidural fentanyl for pain relief. For which of the following common side effects will you monitor the patient (select all that apply)?

a) Nausea
b) Itching
c) Urinary retention
d) Ataxia

Answer 185

b, c, d

Question 186

You are caring for a patient receiving morphine sulfate 10 mg IV push prn for pain. Upon assessment, the nurse finds the patient obtunded with a respiratory rate of 8. Which of the following medications would you prepare to administer to treat these symptoms?

a) Naloxone (Narcan)
b) Atropine sulfate
c) Protamine sulfate
d) Neostigmine bromide (Prostigmin)

Answer 186

a

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

Question 187

The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates

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

Answer 187

b

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

Question 188

Before admitting a patient to the operating room, the nurse recognizes that which of the following must be in the chart of all patients (select all that apply)?

a) Electrocardiogram
b) Signed consent form
c) Functional status evaluation
d) Renal and liver function tests
e) A physical examination report

Answer 188

b,e

Question 189

Which of the following intraoperative nursing responsibilities would be performed by the scrub nurse (select all that apply)?

a) Documenting intraoperative care
b) Keeping track of irrigation solutions for monitoring of blood loss
c) Passing instruments and supplies to the surgeon by anticipating his or her needs
d) Coordinating the flow and activities of members of the surgical team in the surgical suite
e) Performing the count of sponges, needles, and instruments used during the surgical procedure

Answer 189

b, c, e

Question 190

Which of the following events in the surgical suite represents a violation of aseptic technique?

a) A drape contacts the leg of the table that supports the sterile field.
b) The cuff of the scrub nurse’s sterile gown contacts the sterile field.
c) The sterile field was established at 0650 and the current time is 0900.
d) Bacteria are present in the nares and upper respiratory passages of the nurse.

Answer 190

a

The sterile gown below the point 2 inches above the elbow is considered sterile. The passage of time in and of itself does not necessarily render a field contaminated. Bacteria are inevitable in the respiratory passages of team members, but they present a threat to sterility only if they are not confined by attire. Tables are sterile only at tabletop level; areas below this are considered contaminated.

Question 191

The perioperative nurse would recognize the need to monitor the patient for hallucinations and agitation when which of the following anesthetic agents is administered?

a) Nitrous oxide
b) Ketamine (Ketalar)
c) Thiopental (Pentathal)
d) Halothane (Fluothane)

Answer 191

b

A disadvantage of ketamine (Ketalar) is the associated risk of agitation, hallucinations, and nightmares. These unwanted effects are not associated with the use of thiopental (Pentathal), halothane (Fluothane), or nitrous oxide.

Question 192

A surgical patient’s premedication regimen includes midazolam (Versed). The most likely desired effects of this medication are

a) Monitored anesthesia care and amnesia.
b) Induction and maintenance of anesthesia.
c) Analgesia and prevention of intraoperative vomiting.
d) Relaxation of skeletal muscles and facilitation of endotracheal intubation.

Answer 192

a

Midazolam is a benzodiazepine that is widely used for its ability to induce amnesia and provide conscious sedation.

Question 193

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

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

Answer 193

b

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

Question 194

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

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

Answer 194

b

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

Question 195

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

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

Answer 195

c

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

Question 196

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

a) Administering adequate analgesics to promote relief or control of pain
b) Asking the patient to demonstrate the postoperative exercises every 1 hour
c) Giving the patient positive feedback when the activities are performed correctly
d) Warning the patient about possible complications if the activities are not performed

Answer 196

a

Even when a patient understands the importance of postoperative activities and demonstrates them correctly, it is unlikely that the best outcome will occur unless the patient has sufficient pain relief to cooperate with the activities.

Question 197

Bronchial obstruction by retained secretions has contributed to a postoperative patient’s recent pulse oximetry reading of 87%. Which of the following health problems is the patient experiencing?

a) Correct Atelectasis
b) Bronchospasm
c) Hypoventilation
d) Pulmonary embolism

Answer 197

The most common cause of postoperative hypoxemia is atelectasis, which may be the result of bronchial obstruction caused by retained secretions or decreased respiratory excursion. Bronchospasm involves the closure of small airways by increased muscle tone, whereas hypoventilation is marked by an inadequate respiratory rate. Pulmonary emboli do not involve blockage by retained secretions.

Question 198

When assessing a patient who is receiving cefazolin (Ancef) for treatment of a bacterial infection, the nurse would conclude that treatment has been effective based upon which of the following data?

a) White blood cell (WBC) count 16,500/μl, temperature 98.8○ F
b) White blood cell (WBC) count 8000/μl, temperature 101○ F
c) White blood cell (WBC) count 8500/μl, temperature 98.4○ F
d) White blood cell (WBC) count 4000/μl, temperature 100○ F

Answer 198

c

This response is correct because both the WBC count and the temperature are within the normal range. A normal WBC is 4000 to 11,000/μl. An elevated WBC count is an indicator of infection.

Question 199

A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102° F. Which of the following parameters would the nurse monitor, other than temperature, if the patient requires this medication?

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

Answer 199

b

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

Question 200

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

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

Answer 200

c

The finding of an increased number of band neutrophils in circulation is called a shift to the left, which is commonly found in patients with acute bacterial infections.

Question 201

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

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

Answer 201

c

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

Question 202

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

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

Answer 202

a

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

Question 203

A patient with pneumonia is having a fever of over 103o F. The nurse should manage the patient’s fever by

a) Administering aspirin on a scheduled basis around the clock.
b) Providing acetaminophen every 4 hours to maintain consistent blood levels.
c) Providing drug interventions if complementary and alternative therapies have failed.
d) Administering acetaminophen when the patient’s oral temperature exceeds 103.5° F.

Answer 203

b

Antipyretics should be given around the clock to prevent acute swings in temperature. ASA would not be the drug of choice because of its antiplatelet action and accompanying risk of bleeding. When treating fever, drug interventions are not normally withheld in lieu of complementary therapies.

Question 204

A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. Which of the following is a priority nursing assessment?

a) Frequent examination of the character and quantity of exudate
b) Monitoring for signs and symptoms of local or systemic infections
c) Assessment of the patient’s circulation distal to the location of the dressing
d) Assessment of the range of motion of the ankle and the patient’s activity tolerance

Answer 204

c

Any compression dressing requires vigilant assessment of the circulation distal to the dressing site, since tissue and nerve damage is a significant risk. This supersedes the importance of assessing the patient’s mobility. Exudate and infection would not normally accompany a soft tissue injury such as a sprain.