Test 5 Test Bank Questions Flashcards

Question

The nurse is caring for a severely ill patient with AIDS who now requires ventilator support. Which intervention is considered futile? a. Administering the influenza vaccine b. Providing oral care every 5 hours c. Applying fentanyl patches prn for pain d. Supporting the patient’s lower extremities with pillows

Answer 1

ANS: A Futile refers to something that is hopeless or serves no useful purpose and in nursing refers to interventions that are unlikely to produce benefit for the patient. Care delivered to a patient at the end of life is focused on pain management and comfort measures. A vaccine is administered to prevent or lessen the likelihood of contracting an infectious disease at some time in the future.

Answer 2

ANS: B Focusing on the greatest good for the most people, the organizations decide to ensure that as many health care workers as possible will survive to care for other members of the community.

Answer 3

ANS: C Determinations regarding quality of life are value judgments. This means that they are judgments based on what individuals believe is desirable. Beliefs about what people find desirable vary from person to person.

Answer 4

B, E, F, A, C, D Using the steps of processing an ethical dilemma, once the nurse identifies that an ethical dilemma exists, the nurse then gathers information relevant to the case; clarifies values and distinguishes between fact, opinion, and values; and verbalizes the problem. Then the nurse identifies possible solutions or actions, works with the health care team to negotiate a plan, and evaluates the plan over time.

Answer 5

ANS: B The Joint Commission requires accredited hospitals to have written nursing policies and procedures. These internal standards of care are specific and need to be accessible on all nursing units. For example, a policy/procedure outlining the steps to follow when changing a dressing or administering medication provides specific information about how nurses are to perform. The nurse being observed may not be doing the procedure according to the agency’s policy or procedure. The procedure taught in nursing school may not be consistent with the policy or procedure for this agency. The patient is not responsible for maintaining the standards of practice. Patient input is important, but it’s not what directs nursing practice.

Answer 6

ANS: C The privacy section of the HIPAA provides standards regarding accountability in the health care setting. These rules include patient rights to consent to the use and disclosure of their protected health information, to inspect and copy their medical record, and to amend mistaken or incomplete information. This document limits who is able to access a patient’s record. It establishes the basis for privacy and confidentiality about patients in any manner. The book is located where only staff would have access. It is not the responsibility of the new nurse to move items used by others on the patient unit. The listing is protected as long as it is used appropriately as needed to provide care. There is no need to move the book to a more secluded area.

Answer 7

ANS: B An individual over age 18 may sign the form allowing organ donation upon death. In this situation, the parents would need to sign the form because the teenager is under age 18. The nurse cannot allow the patient to sign the organ donation document because he is younger than age 18. The physician will be notified about the patient’s wishes after the parents agree to donate the organs. The nurse caring for the patient does not contact the United Network for Organ Sharing. A transplant coordinator will be the liaison for this organization.

Answer 8

ANS: C An obstetric nurse would not have been trained in performing a tracheostomy or a cricotomy, and doing so would be beyond what she has been trained or educated to do. The nurse did not do what another nurse would have done in the same situation. The nurse is not protected by the Good Samaritan Law because she acted outside of her scope of practice and training. The nurse should have acted within what she was trained and educated to do in this circumstance, not just stay with the patient.

Answer 9

ANS: A Certain criteria are necessary to establish nursing malpractice. In this situation, although harm was caused, it was not because of failure of the nurse to perform a duty according to standards the way other nurses would have performed in the same situation. The nurse would have had to have done the procedure correctly, or the patient most likely would not have survived without any residual problems such as brain damage. The fact that the patient sustained injury as a result of age and physical status does not mean the nurse breached any duty to the patient. The nurse would need to make sure the defense attorney knew that the cardiopulmonary resuscitation (CPR) was done correctly. Without intervention, the patient most likely would not have survived. The prosecution would try to prove that a breach of duty had occurred, which had caused injury, not that cardiopulmonary resuscitation was done correctly. The defense team, not the prosecution, would explain the correlation between brittle bones and rib fractures during CPR.

Answer 10

ANS: C An official interpreter must be present to explain the terms of consent if a patient speaks only a foreign language. A family member or acquaintance who speaks a patient’s language should not interpret health information. Family members can tell those caring for the patient what the patient is saying, but privacy regarding the patient’s condition, assessment, etc., must be protected. There is no way that the nurse can know that the family member is translating exactly what the nurse is saying. Privacy must be ensured and accurate information must be provided to the patient. After consent is obtained for treatment, the health care provider would be notified because little can be done without consent. The health care provider needs to have the translator available during the history and physical, as well as at other times, but the first step is to get a translator to obtain informed consent because this is not an emergency situation. Using hand gestures and medical equipment is inappropriate when communicating with a patient who does not understand the language spoken. Certain hand gestures may be acceptable in one culture and not appropriate in another. The medical equipment may be unknown and frightening to the patient, and the patient still doesn’t understand what is being said.

Answer 11

ANS: B Nurses who float need to inform the supervisor of any lack of experience in caring for the type of patients on the nursing unit. They also need to request and receive an orientation to the unit. Supervisors are liable if they give a staff nurse an assignment that he or she cannot safely handle. Before accepting employment, learn the policies of the institution regarding floating, and have an understanding as to what is expected. A basic orientation is needed, whereas a complete orientation of the functioning of the entire unit would take a period of time that would exceed what the nurse has to spend on orientation. Allowing the nurse to choose which meal time she would like is a nice gesture of thanks for the nurse, but it does not enable safe care. Having nursing assistive personnel may help the nurse complete basic tasks such as hygiene and turning, but it does not enable safe nursing care that she is ultimately responsible for.

Answer 12

ANS: D Each health care facility has personnel who are familiar with the state laws and can assist the patient in revising a living will. They may be in the admissions or risk management department. Checking with the health care provider about the presence of a living will on the chart has nothing to do with the patient’s desire to change the living will. The question states that the patient wants to change his living will. Asking whether he has talked to his lawyer recently is a closed-ended question that passes the responsibility to someone else, that is, the attorney, and does not address the patient’s current desire to change the living will. It is the nurse’s responsibility to find an appropriate person in the facility to assist the patient. A living will can be changed whenever the patient decides to change it, as long as the patient is competent.

Answer 13

ANS: B The nurse has a duty to report this situation to protect the children. Any health care professional who does not report suspected child abuse or neglect may be liable for civil or criminal legal action. The person making the report has legal immunity if the report is made in good faith. Talking with the parents is not mandated by law. There is no obligation to tell the parents that they will be reported to authorities. There is no obligation for the nurse to take pictures of the children.

Answer 14

ANS: B The risks associated with the use of restraints are serious. A restraint-free environment is the first goal of care for all patients. Many alternatives to the use of restraints are available, and the nurse should try all of them before notifying the patient’s health care provider. The situation states that the patient is touching the items, not trying to pull them out. At this time, the patient’s well-being is not at risk. The nurse will have to check on the patient frequently and then will determine if the health care provider needs to be informed of the situation. Restraints can be used (1) only to ensure the physical safety of the resident or other residents, (2) when less restrictive interventions are not successful, and (3) only on the written order of a health care provider. The health care provider needs to know the situation but also needs to know that all approaches possible have been used before writing an order for restraints. Allowing the patient to pull out any of these items could cause harm to the patient.

Answer 15

ANS: B An autopsy or postmortem examination may be requested by the patient or the patient’s family, as part of an institutional policy, or if required by law. Because the patient’s death occurred as a result of long-term illness, not under suspicious circumstances, and more than 24 hours after admission to the hospital, whether to conduct a postmortem examination would be decided by the family, and consent would have to be obtained from the family. The nurse needs to know the policy to follow regarding removal of lines when an autopsy is to be done. Asking about bathing the deceased patient is a valid question but is not priority, because the nurse needs to know the protocol to follow if an autopsy is to be done. Finding out which funeral home the deceased patient is to be transported to is valid but is not priority, because other actions must be taken before the deceased patient is transported from the hospital. Removal of lines and tubes is not a decision made by the family if an autopsy is to be done. The nurse must first check the protocol to be followed.

Answer 16

ANS: B In some cases, information about a scientific discovery or a major medical breakthrough or an unusual situation is newsworthy. In this case, anyone seeking information needs to contact the hospital’s public relations department to ensure that invasion of privacy does not occur. It is not the nurse’s responsibility to decide independently the legality of disclosing information. The nurse does not have the right to allow the cameraman access to the neonatal unit. This would constitute invasion of privacy. The physician has no responsibility regarding this situation and cannot allow the cameraman on the unit. It is not the nurse’s responsibility to find out how the pictures are to be used. This is a task for the public relations department.

Answer 17

ANS: A Although nursing students are not employees of the health care agency where they are having their clinical experience, they are expected to perform as professional nurses would in providing safe patient care. Different levels of standards do not apply. Nursing students, just as nurses, provide safe, complete patient care, or they don’t. No standard is used for nursing students other than that they must meet the standards of a professional nurse. The nursing instructor, not the nurse assigned to the patient, is responsible for the actions of the nursing student.

Answer 18

ANS: B Malpractice insurance provided by the employing institution covers nurses only while they are working within the scope of their employment at that institution. It is always wise to find out if malpractice insurance is provided by a secondary place of employment, in this case, the pharmacy, or the nurse should carry an individual malpractice policy to cover situations such as this.

Answer 19

ANS: D When nursing students work as nursing assistants or nurse’s aides when not attending classes, they should not perform tasks that do not appear in a job description for a nurse’s aide or assistant. The nursing student should always follow the directions of the nurse, unless doing so violates the institution’s guidelines or job description under which the nursing student was hired. The nursing student should be able to safely complete the procedures delegated as a nursing assistant, and reviewing those not done recently is a good idea, but it has nothing to do with the situation. This option does not address the situation that the nursing student acted outside the job description for the nursing assistant position. The focus of the discussion between the nursing faculty member and the nursing student should be on following the job description under which the nursing student is working.

Answer 20

ANS: A, B Nurses follow health care providers’ orders unless they believe the orders are in error or may harm patients. Therefore, the nurse needs to assess all orders. If an order seems to be erroneous or harmful, further clarification from the health care provider is necessary. If the health care provider confirms an order and the nurse still believe that it is inappropriate, the nurse should inform the supervising nurse or follow the established chain of command. The supervising nurse should be able to help resolve the questionable order, but only the health care provider who wrote the order or a health care provider covering for the one who wrote the order can change the order. Harm to the infant could occur if the medication dosage was too high. The nurse cannot change an order. Giving the amount calculated to be correct would not be what another nurse would do in the same situation. Although the pharmacy is an excellent resource, only the health care provider can change the order.

Answer 21

ANS: A, E, F Examples of an occurrence include an error in technique or procedure such as failing to properly identify a patient. Institutions generally have specific guidelines to direct health care providers how to complete the occurrence report. The report is confidential and separate from the medical record. The nurse is responsible for providing information in the medical record about the occurrence. It is also best for the nurse to discuss the occurrence with nursing management only. The risk management department of the institution also requires complete documentation. The fact that an occurrence report was completed is not documented in the patient’s medical record. No discussion of why the omission in procedure occurred should be documented in the patient’s medical record. Errors should be discussed only with those who need to know such as the health care provider, appropriate administrative personnel, and risk management.

Answer 22

ANS: A, C Slander occurred when the physician spoke falsely about the nurse, and libel occurred when the physician wrote false information in the chart. Both of these situations could cause problems for the nurse’s reputation. Invasion of privacy is the release of a patient’s medical information to an unauthorized person such as a member of the press, the patient’s employer, or the patient’s family. Assault is any action that places a person in apprehension of a harmful or offensive contact without consent. No actual contact is necessary. Battery is any intentional touching without consent.

Answer 23

ANS: A, B, D, E The ethical doctrine of autonomy ensures the patient the right to refuse medical treatment. Living wills are written documents that direct treatment in accordance with a patient’s wishes in the event of a terminal illness or condition. With this legal document, the patient is able to declare which medical procedures he or she wants or does not want when terminally ill or in a persistent vegetative state. Each state providing for living wills has its own requirements for executing the health care proxy or durable power of attorney for health care (DPAHC). This is a legal document that designates a person or persons of one’s choosing to make health care decisions when the patient is no longer able to make decisions on his or her own behalf. This agent makes health care treatment decisions based on the patient’s wishes. Cardiopulmonary resuscitation (CPR) is an emergency treatment provided without patient consent. Health care providers perform CPR on an appropriate patient unless a do not resuscitate (DNR) order has been placed in the patient’s chart. The statutes assume that all patients will be resuscitated unless a written DNR order is found in the chart. Legally competent adult patients can consent to a DNR order verbally or in writing after receiving appropriate information from the health care provider. Differences among the states have been noted regarding advance directives, so the patient should check state laws to see if a state will honor an advance directive that was originated in another state.

Answer 24

ANS: B, C Clear, concise, and timely communication is essential whenever charting in the patient’s medical record occurs. Nursing students are not permitted to receive verbal orders. Documentation regarding communication with the health care provider must contain what was communicated by the nurse and the health care provider, orders if given, date, time, and identification of who is documenting the situation.

Answer 25

ANS: C When you are a student in a clinical setting, confidentiality and compliance with the Health Insurance Portability and Accountability Act (HIPAA) are part of professional practice. When a student nurse shares patient information with a friend, confidentiality and HIPAA standards have been violated. You can review your patients’ medical records only to seek information needed to provide safe and effective patient care. For example, when you are assigned to care for a patient, you need to review the patient’s medical record and plan of care. You do not share this information with classmates and you do not access the medical records of other patients on the unit.

Answer 26

ANS: A Reports are oral, written, or audiotaped exchanges of information among caregivers. A patient’s record or chart is a confidential, permanent legal document consisting of information relevant to his or her health care. Consultations are another form of discussion in which one professional caregiver gives formal advice about the care of a patient to another caregiver. Nurses document referrals (arrangements for the services of another care provider).

Answer 27

ANS: A The patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing, education, research, and auditing/monitoring. The auditing/monitoring purpose involves nurses auditing records throughout the year to determine the degree to which standards of care are met and to identify areas needing improvement and staff development. The legal documentation purpose involves the concept that even though nursing care may have been excellent, in a court of law, “care not documented is care not provided.” The financial billing or reimbursement purpose involves diagnosis-related groups (DRGs) as the basis for establishing reimbursement for patient care. For research purposes, the researcher compares the patient’s recorded findings to determine whether the new method was more effective than the standard protocol. Analysis of data from research contributes to evidence-based nursing practice and quality health care.

Answer 28

ANS: D A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells. An objective description is the result of direct observation and measurement. For example, “B/P 80/50, patient diaphoretic, heart rate 102 and regular.” Avoid vague terms such as appears, seems, or apparently because these words suggest that you are stating an opinion, do not accurately communicate facts, and do not inform another caregiver of details regarding behaviors exhibited by the patient. Use of exact measurements establishes accuracy. For example, a description such as “Intake, 360 mL of water” is more accurate than “Patient drank an adequate amount of fluid.”

Answer 29

ANS: C Use of exact measurements establishes accuracy. Charting that an abdominal wound is “5 cm in length without redness, drainage, or edema” is more descriptive than “large wound healing well.” Include objective data to support subjective data, so your charting is as descriptive as possible. Avoid using generalized, empty phrases such as “status unchanged” or “had a good day.” It is essential to avoid the use of unnecessary words and irrelevant details or personal opinions. “Patient is hard to care for” is a personal opinion and should be avoided. It is also a critical comment that can be used as evidence for nonprofessional behavior or poor quality of care. Just chart, “Refuses all treatments and medications.”

Answer 30

ANS: B Chart consecutively, line by line (not every other line); if space is left, draw a line horizontally through it, and sign your name at the end. Every other line should not be left blank. Record all entries legibly and in black ink. End each entry with your signature and title. For computer documentation, keep your password to yourself. Using black ink, ending each entry with signature and title, and keeping the password secure are all appropriate behaviors.

Answer 31

ANS: A Record all entries legibly. Do not write personal opinions. Enter only objective and factual observations of patient’s behavior; quote all patient comments. For example, patient refuses to cough and deep breathe, saying, “I don’t care what you say, I will not do it.” Do not erase, apply correction fluid, or scratch out errors made while recording. Chart only for yourself.

Answer 32

ANS: B A unique feature of an electronic health record (EHR) is its ability to integrate all pertinent patient information into one record, regardless of the number of times a patient enters a health care system. Although the electronic medical record (EMR) contains patient data gathered in a health care setting at a specific time and place and is a part of the EHR, the two terms are frequently used interchangeably. There are no such terms as electronic charting record or electronic problem record.

Answer 33

ANS: C A second progress note method is the PIE format. The narrative note includes P—Problem, I—Intervention, and E—Evaluation. The intervention is “Demonstrated use of crutches.” “Patient went up and down stairs” and “Used crutches with no difficulties” are examples of the E. “Deficient knowledge regarding crutches” is the P.

Answer 34

ANS: D In a source record, the patient’s chart has a separate section for each discipline (e.g., nursing, medicine, social work, respiratory therapy) in which to record data. Graphic sheets and flow sheets are records of repeated observations and measurements such as vital signs, daily weights, and intake and output. In the problem-oriented medical record, the database section contains all available assessment information pertaining to the patient (e.g., history and physical examination, the nurse’s admission history and ongoing assessment, the dietitian’s assessment, laboratory reports, radiologic test results). In the source record, the medical history and examination contain results of the initial examination performed by the physician, including findings, family history, confirmed diagnoses, and medical plan of care. In the source record, the progress notes contain an ongoing record of the patient’s progress and response to medical therapy and a review of the disease process; it often is interdisciplinary and includes documentation from health-related disciplines (e.g., health care providers, physical therapy, social work).

Answer 35

ANS: C A variance occurs when the activities on the critical pathway are not completed as predicted, or the patient does not meet expected outcomes. An example of a variance is when a patient develops pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse oximetry. A positive variance occurs when a patient progresses more rapidly than expected (e.g., use of a Foley catheter may be discontinued a day early). When a nurse is using the problem-oriented medical record, after analyzing data, health care team members identify problems and make a single problem list. A type of narrative format charting is focus charting. It involves the use of DAR notes, which include D—Data (both subjective and objective), A—Action or nursing intervention, and R—Response of the patient (i.e., evaluation of effectiveness).

Answer 36

ANS: A Ideally, discharge planning begins at admission. Right before discharge is too late for discharge planning. After the congestion is treated is also too late for discharge planning. Usually the primary care provider writes the order too close to discharge, and nurses do not need an order to begin the teaching that will be needed for discharge. By identifying discharge needs early, nursing and other health care professionals can begin planning for home care, support services, and any equipment needs at home.

Answer 37

ANS: B Discharge documentation includes medications, diet, community resources, follow-up care, and whom to contact in case of an emergency or for questions. A patient’s acuity level, usually determined by a computer program, is based on the type and number of nursing interventions (e.g., intravenous [IV] therapy, wound care, ambulation assistance) required over a 24-hour period. Acuity level can be used for staffing and billing. Some institutions use standardized care plans to make documentation more efficient. The plans, based on the institution’s standards of nursing practice, are preprinted, established guidelines used to care for patients who have similar health problems. In some settings, a Kardex, a portable “flip-over” file or notebook, is kept at the nurses’ station. Most Kardex forms have an activity and treatment section and a nursing care plan section, which organize information for quick reference.

Answer 38

ANS: C List actual time of discharge, mode of transportation, and who accompanied the patient for discharge summary information. In some settings, a Kardex, a portable “flip-over” file or notebook, is kept at the nurses’ station. A Kardex is for nurses, not for patients to take upon discharge. A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style.

Answer 39

ANS: D Information in the home care medical record includes patient assessment, referral and intake forms, interprofessional plan of care, a list of medications, and reports to third party payers. An interprofessional plan of care is used rather than a nursing process form. A step-by-step skills manual and a list of possible procedures are not included in the record.

Answer 40

ANS: B You assess each resident in a long-term care agency receiving funding from Medicare and Medicaid programs using the Resident Assessment Instrument/Minimum Data Set (RAI/MDS). This documentation provides standardized protocols for assessment and care planning and a minimum data set to promote quality improvement within and across facilities. A focused assessment is limited to a specific body system. An admission assessment and acuity level is performed in the hospital. An intake assessment is for home health. There is no such thing as an auditing phase.

Answer 41

ANS: C Relay to staff significant changes in the way therapies are to be given (e.g., different position for pain relief, new medication). Don’t simply describe results as “good” or “poor.” Be specific. Don’t use critical comments about patient’s or family’s behavior, such as “Mrs. Wills is so demanding.” Don’t engage in idle gossip.

Answer 42

ANS: A Properly performed, a hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care. Reimbursement costs and research priorities/opportunities are functions of the medical record. The purpose of the change-of-shift report is not to establish relationships but to ensure patient safety and continuity of care.

Answer 43

ANS: D Elements in a change-of-shift report include identification of significant changes in measurable terms (e.g., pain scale) and by observation. Report elements do not include normal findings or routine information retrievable from other sources or derogatory or inappropriate comments about the patient or family, which could possibly lead to legal charges if overheard by the patient or family. This kind of language contributes to prejudicial opinions about the patient. Don’t simply describe results as “good” or “poor.” Be specific.

Answer 44

ANS: B A registered nurse makes a telephone report when significant events or changes in a patient’s condition have occurred. Telephone orders and verbal orders usually occur at night or during emergencies. Because the time is 1AM (0100 military time) and the primary care provider is not present, the nurse will need to call the primary care provider for a telephone order. A verbal order (VO) involves the health care provider giving orders to a nurse while they are standing near each other. Just reading an order that is correctly written in the chart does not require a telephone order.

Answer 45

ANS: C The nurse receiving a TO writes down the complete order or enters it into the computer as it is being given. Then he or she reads the order back to the health care provider, called read back, and receives confirmation from the person who gave the order that it is correct. An example follows: “10/16/2011: 0815, Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Knight/J. Woods, RN, read back.” VO stands for verbal order, not telephone order. The doctor’s name and read back must be included in the chart entry.

Answer 46

ANS: A If the staff needs more education, then an incorrect statement is made. Competence in informatics is not the same as computer competency. To become competent in informatics, you need to be able to use evolving methods of discovering, retrieving, and using information in practice. This means that you learn to recognize when information is needed and have the skills to find, evaluate, and use that information effectively. For example, you need to know how to acquire, critique, and apply scientific evidence from literature databases. Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice.

Answer 47

ANS: C One design model for Nursing Information Systems (NIS) is the protocol or critical pathway design. With this design, all health care providers use a protocol system to document the care they provide. A clinical decision support system is based on “rules” and “if-then” statements, linking information and/or producing alerts, warnings, or other information for the user. The nursing process design is the most traditional design for an NIS. This design organizes documentation within well-established formats such as admission and postoperative assessments, problem lists, care plans, discharge planning instructions, and intervention lists or notes. Computerized provider order entry (CPOE) is a process by which the health care provider directly enters orders for patient care into the hospital information system.

Answer 48

ANS: D To increase accuracy and decrease unnecessary duplication, many health care agencies keep records or computers near a patient’s bedside to facilitate immediate documentation of information as it is collected from a patient. A good system requires frequent and random changes in personal passwords to prevent unauthorized persons from tampering with records. When using a health care agency computer system, it is essential that you do not share your computer password with anyone under any circumstances. You destroy (e.g., shred) anything that is printed when the information is no longer needed. Taking nursing notes home is a violation of the Health Insurance Portability and Accountability Act (HIPAA) and confidentiality.

Answer 49

ANS: D Note that you do not include mention of the incident report in the patient’s medical record. Instead you document in the patient’s medical record an objective description of what happened, what you observed, and follow-up actions taken. It is important to evaluate and document the patient’s response to the error or incident. Always contact the patient’s health care provider whenever an incident happens.

Answer 50

ANS: A Accurate documentation of supplies and equipment used assists in accurate and timely reimbursement. Your documentation clarifies the type of treatment a patient receives and supports reimbursement to the health care agency. None of the other options had equipment or supplies listed. Avoid using generalized, empty phrases such as “status unchanged” or “had a good day.” Do not enter personal opinions—stating that the patient is cooperative is a personal opinion and should be avoided. “Finally, patient had no complaints” is a critical comment about the patient and if charted can be used as evidence of nonprofessional behavior or poor quality of care.

Answer 51

ANS: B Nurses’ documentation practices in home health, long-term care, and hospitals can determine reimbursement for health care. Sentinel events do not determine reimbursement. About 60% of the worst types of medical errors, called sentinel events (involving death or severe physical/psychological injury), relate to communication problems that often arise during telephone reports. A clinical information system (CIS) does not have to be installed by 2014 to obtain reimbursement. CIS programs include monitoring systems; order entry systems; and laboratory, radiology, and pharmacy systems. Diagnosis-related groups (DRGs) are the basis for establishing reimbursement for patient care, not HIPAA. Legislation to protect patient privacy regarding health information is the Health Insurance Portability and Accountability Act (HIPAA).

Answer 52

ANS: B Advantages associated with the nursing information system include increased time to spend with patients (not more time to read charts); better access to information; enhanced quality of documentation; reduced errors of omission; reduced, not increased, hospital costs; increased nurse job satisfaction; compliance with requirements of accrediting agencies (e.g., TJC); and development of a common, not varied, clinical database.

Answer 53

ANS: D, E When you are a student in a clinical setting, confidentiality and compliance with HIPAA are part of professional practice. Reading the progress notes of an assigned patient’s record and giving a change-of-shift report to the oncoming nurse about the patient are behaviors that follow HIPAA and confidentiality guidelines. Students and health care professionals may not discuss a patient’s examination, observation, conversation, diagnosis, or treatment with other patients or staff not involved in the patient’s care. To protect patient confidentiality, ensure that written materials used in your student clinical practice do not include patient identifiers (e.g., room number, date of birth, demographic information), and never print material from an electronic health record for personal use.

Answer 54

ANS: A, B, C, D, E The patient record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing (reimbursement), education, research, and auditing/monitoring. Nursing process is a way of thinking and performing nursing care; it is not a purpose of a health care record.

Answer 55

ANS: C, D, E, F When faxing, use programmed speed-dial keys to eliminate the chance of a dialing error and misdirected information. An automatic sign-off is a safety mechanism that logs a user off the computer system after a specified period of inactivity. An automatic sign-off is used in most patient care areas and other departments that handle sensitive data. Disciplinary action, including loss of employment, occurs when nurses or other health care personnel inappropriately access patient information. All papers containing PHI (e.g., Social Security number, date of birth or age, patient’s name or address) must be destroyed. Most agencies have shredders or locked receptacles for shredding and later incineration. Strong passwords use combinations of letters, numbers, and symbols that are difficult to guess. A firewall is a combination of hardware and software that protects private network resources (e.g., the information system of the hospital) from outside hackers, network damage, and theft or misuse of information and should not be bypassed.

Answer 56

ANS: C Pain is a subjective measure. Therefore, the best way to assess a patient’s pain is to ask the patient to rate the pain. Nonverbal communication, such as body language, is not as effective in assessing pain, especially when the patient is oriented. Heart rate sometimes increases when a patient is in pain, but this is not a symptom that is specific to pain. Pain sometimes affects a patient’s ability to cope, but assessing the effect of pain on coping assesses the patient’s ability to cope; it does not assess the patient’s pain.

Answer 57

ANS: D The nurse must believe that a patient is in pain whenever the patient reports that he or she is in pain, even if the patient does not appear to be in pain. Whenever the patient reports pain, the nurse needs to collaborate with the patient to determine the best method of pain relief, whether it be medication, meditation, or repositioning. The nurse must be careful to not judge the patient based on vital signs or nonverbal communication and must not assume that the patient is seeking narcotics. The patient is a partner in pain management, so going to get narcotics to treat the pain without consulting with the patient first is not appropriate.

Answer 58

ANS: A The gate theory states that pain impulses cause pain when they get through gates that are open. Pain is blocked when the gates are closed. Nonpharmacologic pain relief measures, such as meditation, work by closing the gates, which keeps pain impulses from coming through. Meditation does not open pain gates or stop pain from occurring. Meditation also does not have an effect on pain neuro regulators.

Answer 59

ANS: B Aging does not affect the ability to perceive pain. Sometimes older adults have difficulty interpreting their pain and determining its cause because multiple diseases and vague symptoms affect similar parts of the body. Opioids are safe to use in older adults as long as they are slowly titrated and the nurse frequently monitors the patient. Current evidence shows that patients with dementia most likely experience unrelieved pain because their pain is difficult to assess.

Answer 60

ANS: C The patient’s perception of pain is influenced by psychological factors, such as anxiety and coping, which in turn influence the patient’s experience of pain. Each patient’s experience is different. The degree and quality of pain perceived by a patient are related to the meaning of the pain. Neurological factors can interrupt or influence pain perception, but neither of these patients is experiencing alterations in neurological function. The knowledge, attitudes, and beliefs of nurses, physicians, and other health care personnel about pain affect pain management but do not necessarily influence a patient’s pain perceptions.

Answer 61

ANS: C A fentanyl patch is an extended-relief opioid that provides pain relief for 24 hours a day. This is ideal for patients who have chronic severe pain, such as those who have cancer. The other patients are expected to experience acute pain. Therefore, they will most likely benefit from oral or IV opioids for short-term pain relief.

Answer 62

ANS: C To reduce the accidental administration of IV medications into the epidural catheter, the tubing that leads to the epidural catheter needs to be labeled clearly. Medications used to reverse the action of the anesthetic medication need to be kept in a secured location, not in the patient’s room in an unsecured location. The epidural insertion site needs to be covered by a clear occlusive dressing to prevent infection and allow the nurse to assess the site. Patients receiving epidural anesthesia need to be monitored every 15 minutes until stabilized and then at least hourly.

Answer 63

ANS: A Some cultures prefer nonpharmacological measures for pain control. In the case of a patient in labor, relaxation with guided imagery is often an effective supplement for pain management because it provides women with a sense of control over their pain. Relaxation and guided imagery can be used during any phase of health or illness. TENS units are typically used to manage postsurgical and procedural pain. Herbal supplements need to be evaluated for safety during pregnancy. Additionally, some patients consider herbal supplements to be another form of medication, and they are not typically used to control acute pain. A pudendal block is a type of regional anesthesia; use of it does not respect the patient’s wishes for nonpharmacological pain control.

Answer 64

ANS: C A PCA is a device that allows the patient to determine the level of pain relief delivered, reducing the risk of oversedation. Its use often eases anxiety because the patient is not reliant on the nurse for pain relief. Other medications, such as oral analgesics, can be given in addition to the PCA machine. The PCA does have a time limit to prevent overdose, but the patient can lengthen the amount of time between doses. One benefit of PCA is that the patient does not need to rely on the nurse to administer pain medication; the patient determines when to take the medication.

Answer 65

ANS: C The best way to manage pain is to develop a schedule of medications that are given around the clock to prevent breakthrough pain. The nurse should not wait until pain is experienced because it takes medications 10-30 minutes to begin to relieve pain. The nurse administers pain medications before painful activities, such as walking, and administers intravenous medications when a patient is having severe pain.

Answer 66

ANS: B A patient’s culture often influences the patient’s expression of pain. In this case, the patient has just had surgery, and the nurse knows that this surgical procedure usually causes patients to experience pain. It is important at this time for the nurse to examine cultural and ethnic factors that are possibly affecting the patient’s lack of expression of pain at this time. Even if surgery corrects neurological factors that create chronic pain, surgery causes pain in the acute period. Urinary retention usually creates pain and does not mask surgical pain. The nurse is not allowing personal beliefs to influence pain management because the nurse is attempting to determine the reason why the patient is not verbalizing the experience of pain.

Answer 67

ANS: C A common side effect of opioid analgesics is constipation. Therefore, the nurse encourages the patient to drink fluids and eat fiber to prevent constipation. Although medications can be irritating to the stomach, eating a diet high in fat does not prevent gastric ulcers. To best manage pain, the patient needs to take pain medication before painful procedures or activities or before pain becomes severe. As the patient’s pain gets better, the strength of the medications will decrease. IM, IV, and topical analgesics are used for more severe and chronic pain.

Answer 68

ANS: C The appropriate nonpharmacological pain management intervention is to quietly play music that the patient finds relaxing. Music diverts a person’s attention away from pain and creates relaxation. Reassessing the patient’s pain scores is done during evaluation. Building the patient’s expectation of the provider’s arrival does not address the patient’s pain. Although yoga promotes relaxation, nurses teach relaxation techniques only when a patient is not experiencing acute pain. Because the patient is having acute pain, this is not an appropriate time to provide patient teaching.

Answer 69

ANS: D This patient is losing the ability to feel pain owing to peripheral neuropathy. The patient will no longer have protective reflexes to prevent injury to the feet. Wearing shoes prevents the patient from injuring the foot because they protect the feet. Shoes do not block pain perception, nor do they help people adapt to pain. Shoes are not a form of nonpharmacological pain relief. Wearing shoes will not have an effect on opening or closing the pain gates.

Answer 70

ANS: D Visceral pain comes from visceral organs, such as those from the gastrointestinal tract. Visceral pain is diffuse and radiates in several directions. Superficial pain has a short duration and is usually a sharp pain. Pain of an unknown cause is called idiopathic pain. Chronic pain lasts longer than 6 months.

Answer 71

ANS: B The effectiveness of pain relief measures is determined by the patient. If the patient is satisfied with the amount of pain relief, then pain measures are effective. A patient who is sleeping and is difficult to arouse is possibly oversedated; the nurse needs to assess this patient further. The amount of medication left in the PCA syringe does not indicate whether pain management is effective. Pressing the button shows that the patient knows how to use the PCA but does not evaluate pain management.

Answer 72

ANS: B The nurse can take measures to ease the patient’s anxiety and fear related to pain. Age, gender, culture, and previous pain experience are all nonmodifiable factors that the nurse can help the patient to understand, but the nurse cannot alter them.

Answer 73

ANS: A The purpose of guided imagery is to allow the patient to alter the perception of pain. Guided imagery works in conjunction with analgesic medications, potentiating their effects. If the patient needs less pain medication during dressing changes, then guided imagery is helping to manage the patient’s pain. A rating of 6 on a 0 to 10 scale indicates that the patient is having moderate pain and shows that this patient is not experiencing pain relief at this time. A person who is stoic is not showing feelings, which makes it difficult to know whether or not the patient is experiencing pain. The ability to change dressings more frequently is not a way to evaluate the effectiveness of guided imagery.

Answer 74

ANS: C NSAIDs like ibuprofen most likely work by decreasing the synthesis of prostaglandins to inhibit cellular responses to inflammation. Ibuprofen does not remove factors that cause pain, nor does it enhance coping with pain. Opioids bind with opiate receptors to modify perceptions of pain.

Answer 75

ANS: C STAT doses of medication can be given to patients in certain circumstances, as with an extensive dressing change. By asking to hold off on the dose, the patient is indicating that the dressing changes are extremely painful. The regularly scheduled dose might not be as effective for the patient. Oral medications take 30 to 60 minutes to take effect. If the nurse began the dressing change right then, the medication would not have been absorbed yet. The patient has the right to refuse to take a medication. It is the nurse’s responsibility to communicate with the provider and with the patient about a pain control plan that works for both.

Answer 76

ANS: B The maximum 24-hour dosage for acetaminophen is 4 grams. If the patient took 2 tablets of Vicodin ES every 6 hours, the patient would take in 6 grams of acetaminophen in 24 hours. This exceeds the safe dosage of acetaminophen, so the best action is to question this order. Giving the medication as ordered would possibly result in the patient taking more acetaminophen than what is considered a safe dose. Acetaminophen overdose can result in liver failure. NSAIDs are used to treat mild to moderate pain. At this moment, the patient is experiencing severe pain. Implementing music therapy is a nursing intervention and is an independent nursing action. Thus, an order to start music therapy is not needed.

Answer 77

ANS: B Assessing pain intensity in children requires special techniques. Young children often have difficulty expressing their pain. The FACES scale assesses pain in children who are verbal. Because a 4-year-old is verbal, this is an appropriate scale to use with this child. Parents’ statement of pain is not an effective way to assess pain in children because children’s statements are the most important. The 0 to 10 pain scale is too difficult for a 4-year-old child to understand. Previous documentation by nurses will tell you what the child’s pain has been but will not tell you the child’s current pain intensity.

Answer 78

ANS: B In providing effective pain management, it is important to understand the patient’s history, what drugs the patient has already tried, and what interventions work best or have negative actions. It is not the nurse’s responsibility to judge or question a patient’s pain or label her as a drug seeker. Nurses need to avoid labeling patients as drug seekers because this term is poorly defined and creates bias and prejudice among other health care providers. Although certain recreational drugs do have pharmaceutical counterparts, this is not the sole purpose of assessing drug use. The nurse needs more information beyond a patient’s medical and medication history to determine whether a patient needs teaching about drug abstinence.

Answer 79

ANS: C Because oral medications usually peak in about an hour, you need to reassess the patient’s pain within an hour of administration. Nurses must believe any patient report of pain, even if nonverbal communication is not consistent with pain ratings. The patient is the only person who should push the PCA button. Pushing the PCA when a patient is sleeping is dangerous and may lead to narcotic overdose or respiratory depression. Giving the patient a placebo and telling her it is her medication is unethical.

Answer 80

ANS: B Because the nurse is interested in knowing whether the patient’s pain is affecting mobility, the priority assessment question is to ask the patient how the pain affects his or her ability to participate in normal activities of daily living. Although a physical therapist is a good resource to have, especially if pain is severely affecting mobility, considering working with a physical therapist does not describe the effect of pain on the patient’s mobility. Assessing quality of pain and effectiveness of pain medication does not help the nurse to understand how it is affecting the patient’s mobility.

Answer 81

ANS: C To gain a better understanding of a patient’s current pain status and to determine what interventions are needed, the nurse should assess both current and previous pain scores. A patient who rates pain at 4 might find the pain manageable if over the previous 24 hours, he had rated his pain at 10. Some patients do not express their pain or do not wish to take medications to relieve the pain. This does not mean they aren’t in pain; the nurse can try nonpharmacological therapies for this patient.

Answer 82

ANS: D STAT medications need to be given as soon as possible. In addition, this patient is the priority because of the report of severe pain. The other patients need pain medication, but their situations are not as high a priority as that of the patient with the STAT medication order.

Answer 83

ANS: A Opioid tolerance occurs when a patient needs higher doses of an opioid to control pain. Naloxone (Narcan) is an opioid antagonist that is given to reverse the effects of opioid overdose. Taking pain medications regularly around the clock is an effective way to control pain. The pain medication for this patient is most likely effectively managing the patient’s pain because the patient is not asking for the medication before it is due. A patient no longer experiencing a side effect of an opioid does not indicate opioid tolerance.

Answer 84

ANS: A The major adverse effect of acetaminophen is hepatotoxicity. Because both alcohol and acetaminophen are metabolized by the liver, when taken together, they can cause liver damage. Smoking cigarettes and smoking marijuana are not healthy behaviors, but their effects on health are not affected by acetaminophen. Antianxiety medications can be taken with acetaminophen.

Answer 85

ANS: B The nurse’s ability to establish a nursing diagnosis, plan and implement care, and evaluate the effectiveness of care depends on an accurate and timely assessment. The other responses are all interventions; the nurse cannot know which intervention is appropriate until the nurse completes the assessment, makes a nursing diagnosis, and plans care.

Answer 86

ANS: D The patient is responding well to the oral pain medication and it can take up to 2 hours for oral medications to relieve pain. Trying nonpharmacological interventions as an addition to opioid medications is appropriate at this time. If nonpharmacological interventions combined with the oral opioid are ineffective, the nurse needs to notify the health care provider and ask for a change in the medication or for additional pain medication. Saying that the patient has to wait 4 hours for additional pain medication is inaccurate because the nurse needs to provide further nursing interventions if pain is not relieved at an acceptable level for the patient. Admission to an intensive care unit is not typically necessary to manage pain following surgery for a hernia.

Answer 87

ANS: C When a patient with arthritis has chronic pain, the best way to manage pain is to take medication regularly throughout the day to maintain constant pain relief. “Before activity” is nonspecific, and the medication may not have time to work before activity. If the patient waits until having pain to take the medication, pain relief takes longer. Nonpharmacological measures are used in conjunction with medications unless requested otherwise by the patient.

Answer 88

ANS: B Somatic pain comes from bone, joint, or muscle. Visceral pain arises from the visceral organs such as the GI tract and pancreas. Peripherally generated pain can be caused by polyneuropathies or mononeuropathies. Centrally generated pain results from injury to the central or peripheral nervous system.

Answer 89

ANS: D Infants cannot verbally express their pain, but they do express pain with behavioral cues and physiological indicators. Infants can tolerate analgesics, but proper dosing and close monitoring are essential. Infants and older children have the same sensitivity to pain. Pain can be assessed even though the neonate cannot verbalize; the nurse can observe behavioral clues. Nurses use behavioral cues and physiological responses to assess pain in infants.

Answer 90

ANS: A, C NSAIDs can cause bleeding, especially in the gastrointestinal (GI) tract; therefore, NSAIDs are most likely contraindicated in this patient. Patients with an allergy to aspirin are sometimes also allergic to other NSAIDs. The nurse needs to verify that the health care provider is aware of the history of GI bleeding and of allergy to aspirin before administering ibuprofen. NSAIDs do not interfere with bowel function and are used for the treatment of mild to moderate acute intermittent pain. NSAIDs also do not suppress the central nervous system.

Answer 91

ANS: C This is an analogy that compares different therapies within specific categories. Both yoga and breath work are mind-body therapies, whereas both Reiki and therapeutic touch therapies are energy field therapies. The other options have different design structures; thus, they do not fit the analogy.

Answer 92

ANS: C By using electromechanical instruments, a person can receive information or feedback on his or her stress level. Having this knowledge allows the patient to develop awareness and voluntary control over his or her physiological symptoms. Biofeedback does not address energy fields. Directing energies is therapeutic touch. Manipulation of body alignment and joints is done by a chiropractor.

Answer 93

ANS: B Warfarin and blood thinners interact with ginkgo biloba as designed to improve memory. All herbal supplements should be evaluated with current pharmacological medications. The other options do not have drug interactions with each other.

Answer 94

ANS: A Meditation is indicated for stress-related illness. A person can learn to calm down and cope with stress through the use of meditation. Ayurvedic herbs have been used for centuries to treat illness. Acupuncture focuses on redirecting Qi via the body’s meridian energy lines to influence deeper internal organs. Chiropractic therapy involves manipulation of the spinal column and includes physiotherapy and diet therapy.

Answer 95

ANS: A Allopathic medicine is synonymous with traditional Western medicine, which is highly effective in treating numerous physical ailments, but it is in general less effective in preventing disease, decreasing stress-induced illness, managing chronic disease, and caring for the emotional and spiritual needs of individuals. Complementary, alternative, and mind-body types of medicine can be used in tandem with allopathic medicine but are distinctly different.

Answer 96

ANS: D Receptivity is defined as the ability to tolerate and accept experiences that are uncertain, unfamiliar, or paradoxical. Passivity is the ability to stop unnecessary goal-directed and analytical activity. Focusing is the ability to identify, differentiate, maintain attention on, and return attention to simple stimuli for an extended period. Mindfulness is not a cognitive skill needed in relaxation therapy.

Answer 97

ANS: A An integrative medical program allows health care consumers to be treated by a team of providers consisting of both allopathic and complementary practitioners. The other options are solely complementary clinics.

Answer 98

ANS: B Progressive relaxation training teaches the individual how to effectively rest and reduces tension in the body. The technique used in this scenario involves the use of slow, deep abdominal breathing while tightening and relaxing an ordered succession of muscle groups. Although meditation does include abdominal breathing, along with psychotherapy and biofeedback, it does not include tightening and relaxing of muscle groups in an ordered succession.

Answer 99

ANS: B The therapeutic touch practitioner scans the body to identify areas of accumulated tension. The practitioner will then attempt to redirect these accumulated energies back into balance. Chiropractic therapy involves balancing structural and functional imbalance through spinal manipulation. Qi is involved in traditional Chinese medicine. Chakras are involved in Reiki therapy.

Answer 100

ANS: A Electro-acupuncture can be described as percutaneous electrical nerve stimulation. Individuals with a pacemaker or with cardiac arrhythmias or epilepsy, or who are pregnant, should not use electro-acupuncture because the electrical current can impair functioning. Traditional acupuncture is not contraindicated in these patient groups. Needles are inserted at specific acupoints along identified meridians. Whether or not an infection is present, electro-acupuncture should not be used if the patient experiences cardiac dysrhythmias.

Answer 101

ANS: A Chiropractors use their hands as instruments to restore structural and functional balance. Practitioners of chiropractic care believe that general health is affected via the nervous system. Chiropractic care is not risk free, just as allopathic medical care is not risk free. Subluxation eventually can cause permanently restricted joint movement, but this is not a basic foundational principle of chiropractic care. Although hands-on care is used in chiropractic care, a natural diet and regular exercise are critical components for the body to function properly.

Answer 102

ANS: B Mind-body-spirit is important to a nurse with a holistic style of nursing. Nursing involves caring for the entire patient. A vegan diet is an aspect of dietary treatment, but it does not allow for alternative viewpoints or well-rounded care. Spiritual literature and knowing about resources are excellent alternative aspects of allopathic medicine, but they are not specific to holistic nurses.

Answer 103

ANS: C Allopathic medical providers are not formally trained in complementary and alternative therapies. These providers often feel uncomfortable recommending CAM because of that lack of knowledge and training. In addition, research on CAM is limited, making guidelines difficult to create—another barrier for providers who use CAM.

Answer 104

ANS: A Pupils dilate during stressful situations to increase visual capacity and sight, especially in darkened conditions; this is a survival mechanism. The physiological cascade of changes associated with the stress response includes increased heart and respiratory rates, muscle tightening, increased metabolic rate, a sense of foreboding, fear, nervousness, irritability, and a negative mood. Also included is elevated blood pressure.

Answer 105

ANS: A Long-term relaxation therapy focuses on active recognition and release of stress. It is not realistic to expect a tension-free life. Delta brain waves are high-amplitude brain waves associated with the deepest stages of sleep. The outcome of relaxation therapy is not to put a person to sleep or to increase the focus on self.

Answer 106

ANS: C Meditation involves relaxing the body and stilling the mind, which anyone can do through a variety of measures. Meditation does not improve a person’s communication skills, cure any illness, or balance any bodily hormones.

Answer 107

ANS: B The Dietary Supplement Health and Education Act of 1994 allowed companies to sell herbs as dietary supplements as long as no health claims are written on their labels. Herbal medicines do not undergo the same rigorous research as pharmaceuticals, so most have not received approval for use as drugs and are not regulated. Therefore, they cannot be labeled as “safe.” Herbs do not come with classification systems. Herbal supplements come in a variety of packages, elixirs, pills, salves, and tinctures, and being labeled a dietary supplement does not necessarily imply that the supplement is a food product.

Answer 108

ANS: C Chamomile is known to cause drowsiness. Other herbal supplements can affect serotonin levels in the brain and can affect antidepressant medication. A patient should check with a provider before combining herbal supplements with medications. Antidepressants do not interact with digoxin, aspirin, or ginger.

Answer 109

ANS: A The National Center for Complementary and Alternative Medicine was created in 1998. It is a part of the National Institute of Medicine. The Food and Drug Administration (FDA) is an agency within the U.S. Department of Health and Human Services. The American Holistic Nurses Association (AHNA) is a nonprofit membership association for nurses and other holistic health care professionals.

Answer 110

ANS: B Imagery and visualization techniques have a powerful psychophysiological response. Imagery is commonly used in cancer patients to improve their immune system despite radical treatments such as chemotherapy. Biofeedback teaches the patient to analyze triggers of stress. Acupuncture punctures the skin and may increase risk of infection and should be used with caution in someone who is immunocompromised. Breath work involves using a variety of breathing patterns to relax, invigorate, or open emotional channels.

Answer 111

ANS: A Perioperative nursing care occurs before, during, and after a surgery. Preadmission testing occurs before surgery and is considered preoperative. Nursing care provided during the surgical procedure is considered intraoperative, and in the postanesthesia care unit, it is considered postoperative. All of these are parts of the perioperative phase, but each individual phase does not explain the term completely.

Answer 112

ANS: B Reviewing the patient’s laboratory tests and allergies is done before surgery in the preoperative phase. Perioperative means before, during, and after surgery. Intraoperative means during the surgical procedure in the operating suite; postoperative means after the surgery and could occur in the postanesthesia care unit, in the ambulatory surgical area, or on the hospital unit.

Answer 113

ANS: C An emergency procedure must be done immediately to save life or preserve function of a body part. An example would be repair of a perforated appendix, repair of a traumatic amputation, or control of internal hemorrhaging. An urgent procedure is necessary for a patient’s health and often prevents additional problems form developing. An example would be excision of a cancerous tumor, removal of a gallbladder for stones, or vascular repair for obstructed artery. An elective procedure is performed on the basis of the patient’s choice; it is not essential and is not always necessary for health. An example would be a bunionectomy, plastic surgery, or hernia reconstruction. A major procedure involves extensive reconstruction or alteration in body parts; it poses great risks to well-being. An example would be a coronary artery bypass or colon resection.

Answer 114

ANS: C A P3 is a patient with a severe systemic disease. Patients with hypertension, obesity, diabetes mellitus, and asthma fit into this category. A P1 is a normal healthy patient. A P2 is a patient with mild systemic disease. A P4 is a patient with severe systemic disease that is a constant threat to life.

Answer 115

ANS: B Moderate sedation (conscious sedation) is used routinely for procedures that do not require complete anesthesia, but rather a depressed level of consciousness. Not all patients who are treated on an outpatient basis receive moderate sedation. Regional anesthesia such as local anesthesia provides loss of sensation in an area of the body. General anesthesia is used for patients who need to be immobile and to not remember the surgical procedure.

Answer 116

ANS: C Induction of regional anesthesia results in loss of sensation in an area of the body. The peripheral nerve block influences the portion of sensory pathways that are anesthetized in the targeted area of the body. Decreased pulse, toes cool to touch, and cyanosis are indications of decreased blood flow and are not expected findings. Reports of pain the in the left foot may indicate that the block is not working or is subsiding and is not an expected finding in the immediate postoperative period.

Answer 117

ANS: A The aim of assessment of the patient before surgery is to establish the patient’s normal preoperative function to prevent and minimize possible postoperative complications. Gathering appropriate equipment, planning care, and educating the patient and family are all important interventions that must be provided for the surgical patient; they are part of the nursing process but are not the reason for completing an assessment of the surgical patient.

Answer 118

ANS: A Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen inhibit platelet aggregation and prolong bleeding time, increasing susceptibility to postoperative bleeding. Acetaminophen is a pain reliever that has no special implications for surgery. Vitamin C actually assists in wound healing and has no special implications for surgery. Miconazole is an antifungal and has no special implications for surgery.

Answer 119

ANS: B Warfarin is an anticoagulant that is utilized for different maladies, but its action is to increase the time it takes for the blood to clot. This action can put the surgical patient at risk for bleeding tendencies. Typically, if at all possible, this medication is held several days before a surgical procedure to decrease this risk. INR, PT (prothrombin time), APTT (activated partial thromboplastin time), and platelet counts reveal the clotting ability of the blood. Chest x-ray, BUN, and CBC are diagnostic screening tools for surgery but are not specific to warfarin.

Answer 120

ANS: C During general anesthesia, the lungs are not fully inflated during surgery and the cough reflex is suppressed, so mucus collects within airway passages. After surgery, patients may have reduced lung volume and may require greater effort to cough and deep breathe; inadequate lung expansion can lead to atelectasis and pneumonia. Purposely utilizing diaphragmatic breathing can decrease this risk. Diaphragmatic breathing, except for the components of distraction, minimal increased level of oxygen, and minimal chest wall movement, does not influence pain, healing time, or thrombus formation. Better, more effective interventions are available for these situations.

Answer 121

ANS: D After general anesthesia, circulation slows, and when the rate of blood slows, a greater tendency for clot formation is noted. Immobilization results in decreased muscular contractions in the lower extremities; these promote venous stasis. Coughing, diaphragmatic breathing, and incentive spirometry are utilized to decrease atelectasis.

Answer 122

ANS: A If the patient is unable to perform leg exercises after sound educational principles and demonstration are provided, the nurse should look for circumstances that may be impacting the patient’s ability to learn. In this case, the patient can be anticipating the upcoming surgery and may be experiencing anxiety. The patient may also be in pain or may be fatigued; both of these can affect the ability to learn. Assessment of educational methods may be needed, but in this case, sound principles and demonstration are being utilized. Asking anyone why can cause defensiveness and may not help in attaining the answer. In this case, the patient really may want to participate and may not know why he is unable to learn. The nurse is aware that the patient is unable to do the exercises. Moving forward without ascertaining that learning has occurred will not help the patient in meeting goals.

Answer 123

ANS: A Positioning the hands along the borders of the rib cage allows the patient to feel movement of the chest and abdomen as the diaphragm descends and the lungs expand. As the patient takes a deep breath and slowly exhales, the middle fingers will touch while the chest wall contracts. The fingers will separate as the chest wall expands. The patient will feel normal downward movement of the diaphragm during inspiration and normal upward movement during expiration.

Answer 124

ANS: B Surgical incisions cut through muscles, tissues, and nerve endings. Deep breathing and coughing exercises place additional stress on the suture line and cause discomfort. Splinting incisions with hands and a pillow provides firm support and reduces incisional pull. Providing a pillow during coughing does not provide distraction or reduce anxiety. Providing a pillow does not provide pain relief. Coughing can increase anxiety because it can cause pain.

Answer 125

ANS: C If coughing is done correctly with proper support of the incision, it will not harm the incision. Deep breathing and coughing help to clear out mucus in the respiratory system that has been caused by the anesthesia. Although it is correct that a patient may experience atelectasis and pneumonia if deep breathing and coughing are not performed, the way this is worded sounds threatening and could be communicated in a more therapeutic manner. Deep breathing and coughing is encouraged every 2 hours while the patient is awake.

Answer 126

ANS: D Instruct the patient to place right hand over incisional area to splint it, providing support and minimizing pulling during turning. Closing one’s eyes, holding one’s breath, and holding the nurse’s shoulders do not help support the incision during a turn.

Answer 127

ANS: A Performing hand hygiene reduces microorganisms. Placing the patient in the correct position such as high Fowler’s or reverse Trendelenburg for the bariatric patient would be the next step in the process. Demonstration of use of the mouthpiece followed by the instruction to inhale slowly would be the last step in this scenario.

Answer 128

ANS: B The nurse may delegate activities to individuals who are competent, within their scope of practice, and willing to be legally responsible—all while maintaining responsibility for follow-up and outcome. The nurse can delegate to a nursing assistant to encourage patients to practice postoperative exercises regularly after instruction, and to inform the nurse if the patient is unwilling to perform these exercises. The skills of demonstrating and teaching postoperative exercises and documenting are not within the scope of practice for the nursing assistant. Doing nothing is not appropriate.

Answer 129

ANS: A The type of surgery that patients undergo determines how quickly they can resume normal physical activity and regular eating habits. It is normal to progress gradually in activity and eating, and if the patient tolerates activity and diet well, he/she can progress more quickly. A common complication after surgery is nausea and vomiting. This can be caused by the anesthesia, fluid imbalance from being NPO, and pain. The gastrointestinal tract may be hypoactive owing to anesthesia. It is best to start with a clear liquid to see if the patient can tolerate the liquid without vomiting. If so, progressing to soup and crackers and advancing as the patient tolerates is appropriate. Starting with a heavy, greasy meal could cause nausea and vomiting. There is no need to stay on clear liquids for 24 hours after this procedure. Putting a time frame on the progression is too prescriptive. Progression should be adjusted for the patient’s needs.

Answer 130

ANS: C Pain after surgery is expected and is one of the patient’s fears. Anesthesia will be provided during the procedure itself, and the patient should not experience pain during the procedure. Pain management is utilized after the postoperative phase. Inform the patient of interventions available for pain relief, including medication, relaxation, and distraction. The patient needs to know and understand how to take the medications that the physician will prescribe postoperatively. During the stay in the facility, the level of pain is frequently assessed by the nurses. Coordinating pain medication with postoperative exercises helps to minimize discomfort and allows the exercises to be more effective.

Answer 131

ANS: C It is ideal to attempt perioperative education before admission, during the hospital stay, and after discharge. Including family members in perioperative education is advisable. Often a family member is a coach for postoperative exercises when the patient returns from surgery. If anxious relatives do not understand routine postoperative events, it is likely that their anxiety will heighten the patient’s fears and concerns. Perioperative preparation of family members before surgery helps to minimize anxiety and misunderstanding. An additional person is needed at the appointment if at all possible, and he or she needs to be involved in the process, not just waiting in the waiting room; however, it is certainly not a requirement for actually completing the surgery that someone comes to this appointment.

Answer 132

ANS: A Surgery cannot be legally or ethically performed until the patient understands the need for a procedure, the steps involved, the risks, expected results, and alternative treatments. It is the surgeon’s responsibility to explain the procedure and obtain informed consent. It is important for the nurse to pause to notify the physician of the patient’s questions. It is not within the nurse’s scope to explain the procedure for the first time. The nurse can certainly reinforce what the physician has explained, but the information needs to come from the physician. It is not prudent to ask a patient to sign a form for a procedure that he/she does not understand.

Answer 133

ANS: A For fatty, fried, and meat sources, the recommended fast is 8 hours. Fasting from intake of a light meal or from nonhuman milk for 6 or more hours, breast milk for 4 or more hours, and clear liquids for 2 to 3 hours before elective procedures requiring general anesthesia, regional anesthesia, or sedation is recommended. A delay in or cancellation of surgery will be in order for this case. Questions regarding components of the coffee (e.g., milk; can determine the length of time for a delay), asking why, and evaluating the preoperative education may all be items to be addressed, especially from a performance improvement perspective, but at this time in caring for this patient, a delay or cancellation is in order.

Answer 134

ANS: C Once a medication has been administered, instruct the patient to call for help when getting out of bed to prevent falls. For patient safety, explain the purpose of a preoperative medication and its effects. Reinforce to the patient to stay in the bed or on the stretcher. Raise the side rails and keep the bed or stretcher in the low position. Place the call light within easy reach of the patient. Notifying the operating suite that the medication has been given may be part of a facilities procedure but is not the best next step. It is important to have the patient sign consents before the patient has received medication that may make him/her drowsy. Wasting unused medication according to policy is important but is not the best next step.

Answer 135

ANS: A Innumerable products that contain latex are used in the operating suite and the postanesthesia care unit (PACU). When preparing for a patient with this allergy, special considerations are required from preparation of the room to the types of tubes, gloves, drapes, and instruments utilized. To ensure that the patient has a safe environment takes time, and if the correct supplies are not available, awaiting their arrival may cancel or delay the case. Obtaining vital signs, documenting, and administering medications are all part of the process and should be done—with the latex allergy in mind. However, making sure that the patient has a safe environment is the first step.

Answer 136

ANS: A Because errors have occurred in the past with patients undergoing the wrong surgery on the wrong site, the universal protocol has been implemented and is used with all invasive procedures. Part of this protocol includes marking the operative site with indelible ink. Knowing where the family is during a procedure, placing the patient in a clean gown, and asking the patient to remove all hairpins and cosmetics are important but are not most important in this list of items.

Answer 137

ANS: A The circulating nurse must be a registered nurse and has the responsibilities of preoperative assessment, establishing and implementing the plan of care, evaluating the care provided, and ensuring continuity of care postoperatively. The scrub nurse, who can be a registered nurse, a licensed practical nurse, or a surgical technologist, maintains the sterile field, assists with applying the sterile drapes, and hands sterile instruments and supplies to the surgeon.

Answer 138

ANS: C The temperature in the preoperative holding area and in adjacent operating suites is usually cool. Offer the patient an extra warm blanket. The main activities in this area include verification of the patient, the surgery to be performed, and physical and emotional readiness for the procedure. The intravenous catheter is usually inserted, and the preoperative checklist is reviewed. Vital signs are not normally monitored unless there is a specific reason, such as a medication being administered. Typically, ambulatory surgery patients will not come to the holding area with a urinary drainage bag or a surgical dressing. These activities if appropriate are performed in the postanesthesia care unit.

Answer 139

ANS: A A primary focus of intraoperative care is to prevent injury and complications related to anesthesia, surgery, positioning, and equipment use, including use of the electrical cautery grounding pad for prevention of burns. The perioperative nurse is an advocate for the patient during surgery and protects the patient’s dignity and rights at all times. Evaluation of many goals and outcomes does not occur until after surgery. Signs and symptoms of infection do not have the time to present during the intraoperative phase. During the intraoperative phase, the patient is anesthetized and unconscious and typically has an endotracheal tube that prevents conversation and complaints. These complaints typically begin in the postoperative phase of the experience.

Answer 140

ANS: B Although it may be necessary to place a patient in an unusual position, try to maintain correct alignment and protect the patient from pressure, abrasion, and other injuries. Special mattresses, use of foam padding, and attachments to the operating suite table provide protection for the extremities and bony prominences. Bathing before surgery helps to decrease the number of microbes on the skin. Periodically adjusting the patient during the surgical procedure is impractical and can present a safety issue with regard to maintaining sterility of the field and maintaining an airway. Measuring the time the patient is in one position may help with monitoring the situation but does not prevent skin breakdown.

Answer 141

ANS: A One of the greatest concerns after general anesthesia is airway obstruction. Choking and noisy, irregular respirations are classic signs and symptoms of airway obstruction. A number of factors contribute to obstruction, including a history of obstructive sleep apnea; weak pharyngeal/laryngeal muscle tone from anesthetics; secretions in the pharynx, bronchial tree, or trachea; and laryngeal or subglottic edema. In the postanesthetic patient, the tongue is a major cause of airway obstruction. Shallow respirations are indicative of respiratory depression. Moaning and reports of pain are common in all surgical patients and are an expected event. Disorientation is common when first awakening from anesthesia but can be a sign of hypoxia.

Answer 142

ANS: B A life-threatening, rare complication of anesthesia is malignant hyperthermia. Malignant hyperthermia causes hypercarbia, tachycardia, tachypnea, premature ventricular contractions, unstable blood pressure, cyanosis, skin mottling, and muscular rigidity. It often occurs during induction. Hypoxia would manifest with decreased oxygen saturation as one of its signs and symptoms. Fluid imbalance would be assessed with intake and output and can manifest with tachycardia and blood pressure fluctuations but does not have muscle rigidity. Hemorrhage can manifest with tachycardia and decreased blood pressure, along with a thread pulse. Usually some sign or symptom of blood loss is noted (e.g., drains incision, orifice, and abdomen).

Answer 143

ANS: B The operating suite and recovery room environments are cool. The patient’s anesthetically depressed level of body function results in lowering of metabolism and a fall in body temperature. The patient being dressed in a gown and laminar flow in the surgical suite can contribute to a decrease in temperature, but the length of time required for this procedure would minimize this effect. Also, the patient in this type of case does not have a large open body cavity to contribute to heat loss.

Answer 144

ANS: C Accurate recording of intake and output assesses renal and circulatory function. Measure and record all sources of intake and output. Encouraging copious amounts of water in a postoperative patient might encourage nausea and vomiting. In the PACU, it is impractical to weigh the patient while waking from surgery, but in the days afterward, it is a good assessment parameter for fluid imbalance. Starting an additional IV is not necessary and is not important at this juncture.

Answer 145

ANS: C Depending on the surgery, some patients do not regain voluntary control over urinary function for 6 to 8 hours after anesthesia. Assess the amount of fluid that the patient obtained while in surgery, and palpate the lower abdomen just above the symphysis pubis for bladder distention. If fluid intake is not excessive and the bladder is nondistended, allowing some time might be appropriate. Not everyone feels as if they need to go but can’t after surgery. If the bladder is distended and the patient is unable to void, a catheter might be in order.

Answer 146

ANS: B The PACU nurse reviews the patient’s information with the medical-surgical nurse, including the surgical and PACU course, physician orders, and the patient’s condition. Before leaving the medical-surgical unit, the PACU nurse waits while the medical-surgical nurse obtains a complete set of vital signs to compare with PACU findings. Minor vital sign variations normally occur after the patient is transported. Vital signs may or may not be the first action in a head-to-toe assessment. Following policy or ascertaining that the floor nurse checks on the patient is not a reason to obtain vital signs.

Answer 147

ANS: B Patients undergoing extensive surgery and requiring anesthesia of longer duration recover more slowly. If a patient is undergoing major surgery such as a procedure on the heart, a stay in the hospital and specifically in the intensive care unit is required to monitor for potential risks to well-being. This patient would require more care than can be provided on a medical-surgical unit. It is not appropriate for this type of patient to go home after the procedure or to stay in an extended stay area of an ambulatory surgery area because of the complexity and associated risks.

Answer 148

ANS: C Postoperative nausea and vomiting sometimes occur once the patient is at home even if symptoms were not present in the surgery center. Options for therapy include medications. Instructing the patient to call the physician and connecting the patient with the physician can help the patient to obtain relief. Taking deep breaths, drinking ginger ale, and eating crackers are interventions that may be helpful, but this patient needs additional help. Instructing the patient to go to the emergency department is an option with continued nausea and vomiting.

Answer 149

ANS: B, D, E, F Perioperative nursing is a fast-paced, changing, and challenging field and is based on the nurse’s understanding of several important principles, including high-quality, patient safety–focused care; multidisciplinary teamwork; effective therapeutic communication and collaboration with the patient, the patient’s family, and the surgical team; effective and efficient assessment and intervention in all phases of surgery; advocacy for the patient and the patient’s family; and understanding of cost containment. Purchasing the correct equipment is important in any specialty of nursing. Perioperative nursing cares not only for the “right” types of patients, but for all patients with surgical needs.

Answer 150

ANS: A, C, D, E To be discharged home, patients need to meet certain criteria. These criteria include meeting phase 1 criteria of activity, circulation, respiration, consciousness, and O2 saturation, as well as phase 2 criteria of dressing dry and intact, manageable pain, ambulation, able to drink fluids, and voiding. Eating and the ability to dress self are not included in these criteria.

Answer 151

ANS: A, B, C, D Performing hand hygiene before and after contact with the patient helps to decrease the number of microorganisms and break the chain of infection. Maintaining blood glucose levels at less than 150 mg/dL has resulted in decreased wound infection. Removing unwanted hair by clipping instead of shaving decreases the numbers of nicks and cuts caused by a razor and the potential for the introduction of microbes. Administration of an antibiotic within 30 to 60 minutes of incision time supports the defense against infection. Providing a bath and linen change is positive but is not necessarily important daily for infection control unless copious body fluids are present. The physician usually is the person who changes a dressing the first time to inspect the condition of the site, but this is done well before 7 days postoperatively.

Answer 152

ANS: A, B, D, E Very young and old patients are at risk during surgery because of immature or declining physiological status. Normal tissue repair and resistance to infection depend on adequate nutrients. Obesity increases surgical risk by reducing respiratory and cardiac function. During pregnancy, the concern is for the mother and the developing fetus. Because all major systems of the mother are affected during pregnancy, risks for operative complications are increased. Race and ambulatory surgery are not risks associated with a surgical procedure.

Answer 153

ANS: A, B, D, F The operating suite itself is kept cool to decrease microbial growth, so it can be very cold to patients as they enter the suite, particularly with limited clothing. The surgical staff is dressed in special clothing, hats, and masks—all for infection control. Families are not allowed in the operating suite for several reasons, which include infection control and the emotional effect of seeing a loved one in that condition. The nurse is there as the coordinator and patient advocate during a surgical procedure. The rooms are very bright so everyone can see, and the operating table is very uncomfortable for the patient.

Answer 154

ANS: A, B, D, E Vital signs are included in the checklist as a baseline for intraoperative vital signs. Laboratory work is included to assist health care providers in attaining an accurate picture of the patient’s health status. NPO, or nothing by mouth, is important, to decrease risks of vomiting and aspiration during the procedure. An ID band is important for identifying the patient, especially when anesthetized and unable to speak. A living will, although important for the patient’s stay at a facility, is not on the preoperative checklist. Family location, although important for communication, is not part of the list of items that need to be completed for the patient before going to surgery.

Answer 155

ANS: A, B, C, E Ideally the patient’s position provides good access to the operative site, sustains adequate circulatory and respiratory function, and ensures patient safety and skin integrity. It should not impair neuromuscular structures. Warmth and comfort are always concerns, but the other options are more important because they relate to positioning. Positioning does not support the use of equipment, rather the use of equipment complements the position of the patient to maintain patient safety.

Answer 156

ANS: B Anniversary reactions can reopen grief processes. A nurse should openly acknowledge the loss and talk about the common renewal of grief feeling around the anniversary of the individual’s death. This facilitates normal mourning. The nurse is not attempting to alleviate a physical pain. The actions are of open communication, not evaluation. Palliative care refers to comfort measures for symptom relief.

Answer 157

ANS: C The criterion for hospice care is being expected to live less than 6 to 12 more months. Patients with a terminal illness are not eligible until that point. Palliative care provides assistance with pain management when a patient is not eligible for hospice care. An advance directive can be completed by any person, even those who are healthy.

Answer 158

ANS: D Opioid medication is known to slow gastrointestinal transit time, which places the patient at high risk for constipation. Stimulant laxatives are indicated for opioid-induced constipation. Added water to the diet will allow water to be pulled into the GI tract, softening up stool. Massaging the patient’s abdomen may cause further discomfort. Discontinuing pain medication is inappropriate for a terminally ill patient. Enema administration is not the first step in the treatment of opioid-induced constipation.

Answer 159

ANS: B The concept of hope is vital to nursing; it enables a person to anticipate positive experiences. Being patient and friendly and creating positive relationships are key concepts in all areas of nursing, but especially with depressed patients. The nurse’s actions do not address time management, charity, or faith.

Answer 160

ANS: D Islamic culture calls for modesty and same-sex caregivers whenever possible. Muslim faith discourages cremation and autopsy to preserve the sanctity of the soul of the deceased.

Answer 161

ANS: D Yearning and searching characterize the second bereavement phase in the Bowlby Attachment Theory. Emotional outbursts are common in this phase. During the numbing phase, the family may feel a sense of unreality. During disorganization and despair, the reason why the loss occurred is constantly questioned. Bargaining is part of the Kübler-Ross stages, not of the Bowlby Attachment Theory.

Answer 162

ANS: A Nurses often witness suffering on a daily basis. Nurses, as humans, also experience grief and loss when they have been intensely involved in the patient’s suffering and death. Offer comfort and understanding to colleagues, and maintain a stable patient care environment. It is inappropriate to create guilt by telling a grieving nurse to hurry back to her patients or by indicating that she is a bad role model. Suggesting that a colleague take sedative during a shift is dangerous for the safety of patients in her care.

Answer 163

ANS: D It is a federal law to require facilities to develop policies about organ donation. The transplant coordinator has additional education on providing answers about organ donation. Not all religions allow for organ donation. A patient may be on life support during organ removal to preserve organ tissues. Autopsy compromises organ integrity; removal should occur prior.

Answer 164

ANS: B Jewish culture calls for family members or religious officials to stay with the decedent’s body until the time of burial. A male provider is unnecessary. Requesting or expecting the family to go home is not providing culturally sensitive care.

Answer 165

ANS: D The primary goal of palliative care is to help patients and families achieve the best quality of life. Providing support for the patient’s nurse is not the primary obligation when the patient is experiencing severe pain. Not all collaborative team members would be able to provide postmortem care, as is the case for nutritionists, social workers, and pharmacists. Teaching about stages of grief should not be the focus when severe pain is present.

Answer 166

ANS: B Loss of a body part from injury is a situational loss. Maturational losses occur as part of normal life transitions. Perceived loss is not obvious to other people. Uncomplicated is not a type of loss; it is a description of normal grief.

Answer 167

ANS: A The nurse facilitates mourning in family members who are still surviving. By acknowledging the pregnant woman’s emotions, the nurse helps the mother bond with her fetus and recognize the emotions that still exist for the deceased child. The nurse is not attempting to help the patient eradicate grief, which would be unrealistic. Curative therapy and spiritual promotion are not addressed by the nurse’s statement.

Answer 168

ANS: B Self-care strategies for nurses include talking with a close colleague and reflecting on feelings by writing in a journal. It is inappropriate for a nurse to talk with patients to resolve the nurse’s grief. Although exercise is important for self-care, sleep is also important. Shutting oneself away from friends is not self-care; the nurse should spend time with people who are nurturing.

Answer 169

ANS: B Complicated or dysfunctional grief occurs when an individual has a complicated grieving process that interferes with common routines of life for excessively long periods of time. Normal grief is the most common reaction to death; it involves a complex range of normal coping strategies. Disenfranchised grief involves a relationship that is not socially sanctioned. Perceived grief is not a type of grief; perceived loss is a loss that is not obvious to other people.

Answer 170

ANS: C The Worden Grief Tasks Model consists of four tasks. Task III is seen when the surviving family member begins to adjust to life without the deceased. Task I is accepting the reality of the loss, Task II is working through the pain of grief, and Task IV is emotionally relocating the deceased and moving on with life.

Answer 171

ANS: A Family members will grieve differently. One sign of normal grief is keeping the deceased individual’s room intact as a way to keep that person alive in the minds of survivors. This is happening after the family member is deceased, so it is not end-of-life grief. It is not abnormal or complicated grief; the child died recently.

Answer 172

ANS: C Listening to family members’ stories validates the importance of the dying individual’s life and reinforces the dignity of the person’s life. Taking pictures of visitors does not address the value of a person’s life. Calling organ donation and providing private visiting time are components of the dying process, but they do not validate a dying person’s life.

Answer 173

ANS: C Families can have limited knowledge when asked to make important ethical decisions. Nurses have the time, patience, and knowledge base to assist the family to understand their ethical situation and to help them make their own educated decision. Advance directives are completed by the person who is dying. Funeral guidance is best provided by a chaplain or a caretaker.

Answer 174

ANS: A Law often requires that an autopsy be performed if death occurred during incarceration; as the result of foul play, homicide, or suicide; or as an accidental death, as occurs in car accidents. The nurse must understand the policies that are applied in cases of foul play death and must ensure that the decedent’s body is properly cared for after death, despite the emotional feelings of individuals in close contact with the decedent.

Answer 175

ANS: B A dying individual will likely have a decline in renal and liver functioning. Because of reduced organ functioning, a decreased dose would be in order, so the individual does not develop toxic levels of the medications.

Answer 176

ANS: B The Jewish mourning ritual of Shiva incorporates the community’s helping behaviors toward those experiencing death, sets expectations for behaviors of the survivor, and provides the community with sustaining traditions and rituals. An understanding of the religious and cultural significance of Shiva allows the nurse to know how to appropriately respond.

Answer 177

ANS: C Kübler-Ross’ traditional theory involves five stages of dying. The anger stage of adjustment to an impending death can involve resistance, anger at God, anger at people, and anger at the situation. Denial would involve failure to accept a death. Bargaining is an action to delay acceptance of death by bartering. Depression would present as withdrawal from others.

Answer 178

ANS: D A child’s stage of development and chronological age will influence how he or she grieves. Toddlers can show grief through changes in their eating patterns, changes in their sleeping patterns, fussiness or irritability, and changes in their bowel and bladder habits. It is common for younger children to regress when under increased stress. Lack of outside playtime, dietary changes, and having too many toys are unlikely to cause enuresis.

Answer 179

ANS: D Symptoms of normal grief include headache, fatigue, oversensitivity to noise, insomnia, appetite disturbance, and choking sensation. Different people manifest different symptoms. Denial is assessed when the person indicates that he is not accepting that the loss happened.

Answer 180

ANS: B One of the functions of NSAIDs is to reduce body temperature.

Answer 181

ANS: B GI upset is a classic side effect of the NSAIDs; therefore the medication should be taken with meals.

Answer 182

ANS: A ASA is an anticoagulant that may increase the bleeding time when used with other anticoagulants.

Answer 183

ANS: C NSAIDs may increase the client’s bleeding time, which may increase bleeding time during menstrual periods.

Answer 184

ANS: A NSAIDs assist with pain and inflammation. Postoperative and incisional pain should be treated with narcotics. The NSAIDs should not be used with the client who is exhibiting gastrointestinal discomfort and bleeding.

Answer 185

ANS: B Gold therapy, or chrysotherapy, takes 3 to 4 months to reach effective levels.

Answer 186

ANS: D Agranulocytosis and thrombocytopenia are potentially life-threatening adverse reactions to the medication.

Answer 187

ANS: D The drug should be taken with food to avoid gastric upset.

Answer 188

ANS: A TNF may cause immunosuppression and increased risk for infection.

Answer 189

ANS: D The indomethacin would replace the first drug, allowing more of the first medication free for active drug levels.

Answer 190

ANS: D NSAIDs commonly cause gastrointestinal lining breakdown that may lead to ulceration.

Answer 191

ANS: D Allopurinol (Zyloprim) increases the effects of warfarin (Coumadin). Allopurinol does not interact with diphenhydramine, metoclopramide, and propranolol.

Answer 192

ANS: D A decrease in inflammation is the anticipated function of this medication.

Answer 193

ANS: D This medication does not need to go through the dissolution phase, so it is more rapidly absorbed.

Answer 194

ANS: A The most common side effect is gastric upset, so taking the medication with meals will alleviate/assist with these symptoms.

Answer 195

ANS: B The client who is being treated with Benemid should increase his fluid intake because this will promote the urinary excretion of uric acid.

Answer 196

ANS: B The client who is being treated with Ridaura may exhibit a slight increase in liver enzyme tests.

Answer 197

ANS: D Remicade is contraindicated when the client is elderly and is experiencing cardiac arrhythmias.

Answer 198

ANS: D An adverse reaction to allopurinol is the development of cataracts and retinopathy.

Answer 199

ANS: A, B, D Use of ASA following a viral infection has been related to Reye’s syndrome and is therefore contraindicated in children.

Answer 200

ANS: C Nonopioid analgesics are used for mild to moderate pain and may be available over the counter.

Answer 201

ANS: D Morphine sulfate should be used for severe pain.

Answer 202

ANS: B Medications containing salicylates are not recommended because of the possibility of developing Reye’s syndrome.

Answer 203

ANS: C Tylenol is metabolized by the liver and, with extended use, may be toxic to liver tissue.

Answer 204

ANS: A ASA may cause gastric irritation and lead to ulceration. Abdominal pain may indicate this and may be a medical emergency.

Answer 205

ANS: A Ibuprofen may cause gastric irritation, so food or fluid will decrease this effect.

Answer 206

ANS: C Opioids such as morphine sulfate may increase sedation when taken with St. John’s wort.

Answer 207

ANS: A Assessing respiratory rate is a priority with medications that may cause respiratory depression.

Answer 208

ANS: C Narcan is a opioid antagonist used with overdose or oversedation caused by opioids.

Answer 209

ANS: C Methadone is used to assist in detoxification and monitoring of people with drug addiction.

Answer 210

ANS: A Constipation and pruritus are known to occur with morphine use and should be assessed in patients.

Answer 211

ANS: C This medication may cause hypotension, so the nurse should assess vital signs with position changes.

Answer 212

ANS: D If respiratory depression occurs, the respiratory rate may decrease, causing hypoventilation. This allows CO2 to build up, causing cerebral vasodilation and increasing intracranial pressure.

Answer 213

ANS: C A common side effect of opioid agents is urinary retention.

Answer 214

ANS: D A lowering of the heart rate to within normal limits indicates relief of pain.

Answer 215

ANS: A Imitrex can be administered by mouth, by subcutaneous injection, or by intranasal route.

Answer 216

ANS: C Dizziness is a side effect of treatment with Imitrex but is not life threatening.

Answer 217

ANS: A Intravenous administration of Nubain should result in relief from pain within 2 to 3 minutes.

Answer 218

ANS: C When acetaminophen is combined with oral contraceptives, the result is a decrease in the effectiveness of the acetaminophen.

Answer 219

ANS: B, E, F, G These indicate relief of pain and represent normal vital and objective signs.