Test 5 Test Bank Questions Flashcards
Information regarding a patient’ s health status may not be released to non-health care team members because
A. Legal and ethical obligations require health care providers to keep information strictly confidential.
B. Regulations require health care institutions to document evidence of physical and emotional well-being.
C. Reimbursement issues related to patient care and procedures may be of concern.
D. Fragmentation of nursing and medical care procedures may be identified.
A. Legal and ethical obligations require health care providers to keep information strictly confidential.
A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record
A. An interpretation of patient behavior.
B. Objective data that are observed.
C. Lengthy entry using lay terminology.
D. Abbreviations familiar to the nurse.
B. Objective data that are observed.
A nurse records that the patient stated his abdominal pain is worse now than last night. This is an example of A. PIE documentation. B. SOAP documentation. C. Narrative charting. D. Charting by exception
C. Narrative charting.
A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to
A. Exchange information among health care members.
B. Provide information about patients from one unit to another unit.
C. Ensure proper care for the patient.
D. Aid in the hospital’s quality improvement program.
D. Aid in the hospital’s quality improvement program.
Your patient is about to undergo a controversial orthopedic procedure. The procedure may cause periods of pain. Although nurses agree to do no harm, this procedure may be the patient's only treatment choice. This example describes the ethical principle of: A. Autonomy. B. Fidelity. C. Justice. D. Nonmaleficence.
D. Nonmaleficence
If a nurse decides to withhold a medication
because it might further lower the patient’s blood
pressure, the nurse will be practicing the principle of:
A. Responsibility.
B. Accountability.
C. Competency.
D. Moral behavior.
B. Accountability
A nurse is working with a terminally ill adult patient. The nurse decides to tell the adult children that they need to decide how to advise their father about taking analgesics during the terminal phase of his illness. This step of processing an ethical dilemma is
A. Articulation of the problem.
B. Evaluation of the action.
C. Negotiation of the outcome.
D. Determination of values surrounding the problem.
C. Negotiation of the outcome
A nurse is caring for a patient who states, "I just want to die." For the nurse to comply with this request, the nurse should discuss A. Living wills. B. Assisted suicide. C. Passive euthanasia. D. Advance directives.
D. Advance Directives
A student nurse employed as a nursing assistant may perform care
A. As learned in school.
B. Expected of a nurse at that level.
C. Identified in the hospital’s job description.
D. Requiring technical rather than professional skills.
C. Identified in the hospital’s job description
You are about to administer an oral medication and you question the dosage. You should
A. Administer the medication.
B. Notify the physician.
C. Withhold the medication.
D. Document that the dosage appears incorrec
B. Notify the physician
. Four patients in labor all request epidural analgesia to manage their pain at the same time. Which ethical principle is compromised when only one nurse anesthetist is on call?
a. Justice
b. Nonmaleficence
c. Beneficence
d. Fidelity
ANS: A
Justice refers to fairness and is used frequently in discussion regarding access to health care resources. Here the just distribution of resources, in this case pain management, cannot be justly apportioned. Nonmaleficence means “do no harm,” beneficence means “to do good,” and fidelity means “to be true to, or honest.” Each of these principles is partially expressed in the question; however, justice is most comprised because not all laboring patients have equal access to pain management owing to lack of personnel resources
The patient tells the nurse that she is afraid to speak up regarding her desire to end care for fear of upsetting her husband and children. Which principle in the nursing code of ethics ensures that the nurse will promote the patient’s cause?
a. Responsibility
b. Advocacy
c. Confidentiality
d. Accountability
ANS: B
Nurses advocate for patients when they support the patient’s cause. A nurse’s ability to adequate advocate for a patient is based on the unique relationship that develops and the opportunity to better understand the patient’s point of view. Responsibility refers to respecting one’s professional obligations and following through on promises. Confidentiality deals with privacy issues, and accountability refers to owning one’s actions.
The patient’s son requests to view the documentation in his mother’s medical record. What is the nurse’s best response to this request?
a. “I’ll be happy to get that for you.”
b. “You will have to talk to the physician about that.”
c. “You will need your mother’s permission.”
d. “You are not allowed to see it.”
ANS: C
The nurse understands that sharing health information is governed by HIPAA legislation, which defines rights and privileges of patients for protection of privacy. Private health information cannot be shared without the patient’s specific permission. The other three responses either are outright false and/or use poor communication techniques.
When people work together to solve ethical dilemmas, individuals must examine their own values. This step is crucial to ensure that
a. The group identifies the one correct solution.
b. Fact is separated from opinion.
c. Judgmental attitudes are not provoked.
d. Different perspectives are respected.
ANS: D
Values are personal beliefs that influence opinions. To be able to negotiate differences in opinions, the nurse must first be clear about personal values, which will influence behaviors, decisions, and actions. Ethical dilemmas are a problem in that no one right solution exists.
- Ethical dilemmas are common occurrences when caring for patients. The nurse understands that dilemmas are a result of
a. Presence of conflicting values.
b. Hierarchical systems.
c. Judgmental perceptions of patients.
d. Poor communication with the patient.
ANS: A
Poor communication and the hierarchical systems that exist in health care, such as reporting structures within the hospital or the historically unequal relationship between physicians and nurses, may complicate dilemmas. The primary, underlying reason that ethical dilemmas occur is that there are no clear cut, universally accepted solutions to a problem when participating individuals do not share the same values. Without clarification of values, the nurse may not be able to distinguish fact from opinion or value, and this can lead to judgmental attitudes.
The nurse questions a physician’s order to administer a placebo to the patient. The nurse’s action is based on which ethical principle?
a. Autonomy
b. Beneficence
c. Justice
d. Fidelity
ANS: A
Autonomy refers to the freedom to make decisions free of external control. In this case, the nurse questions the physician’s order for a placebo because it supports the patient’s autonomy. Although beneficence, taking a positive action for others, has implications here, it is not the primary operating principle. Justice refers to fairness and is most often used in discussions about access to health care resources. Fidelity refers to the agreement to keep promises.
The nurse finds it difficult to care for a patient whose advance directive states that no extraordinary resuscitation measures should be taken. Which step may help the nurse to find resolution in this assignment?
a. Call for an ethical committee consult.
b. Decline the assignment on religious grounds.
c. Scrutinize her own personal values.
d. Convince the family to challenge the directive.
ANS: C
Values develop over time and are influenced by family, schools, religious traditions, and life experiences. The nurse must recognize that no two humans have the same set of experiences, and so differences in values are more likely the norm than the exception. Closer inspection of one’s values may be a step in gaining understanding of another person’s perspective. Calling for a consult, declining the assignment, and convincing the family to challenge the patient’s directive are not ideal resolutions because they do not address the reason for the nurse’s discomfort, which is the conflict between the nurse’s values and those of the patient.
The nurse values autonomy above all other principles. Which patient assignment will the nurse find most difficult to accept?
a. Teenager in labor who requests epidural anesthesia
b. Middle-aged father of three with an advance directive declining life support
c. Elderly patient who requires dialysis
d. Family elder who is making the decisions for a 30-year-old female member
ANS: D
Autonomy refers to freedom from external control. A person who values autonomy highly may find it difficult to accept situations where the patient is not the primary decision maker regarding his or her care. A teenager requesting an epidural, a father with an advanced directive, and an elderly patient requiring dialysis all describe a patient or family that can make their own decisions and choices regarding care.
Which philosophy of health care ethics would be particularly useful when making ethical decisions about vulnerable populations?
a. Feminist ethics
b. Deontology
c. Bioethics
d. Utilitarianism
ANS: A
Feminist ethics particularly focuses on the nature of relationships, especially those where there is a power imbalance or a point of view that is not routinely accepted. Examples of populations that are considered vulnerable include children, pregnant women, incarcerated persons, and minority groups. Deontology refers to making decisions or “right-making characteristics,” bioethics focuses on consensus building, and utilitarianism speaks to the greatest good for the greatest number.
A nurse argues that we need to reform our health care system because we have a large number of people who are uninsured and end up needing expensive emergent care when low-cost measures could have prevented their illnesses. What ethical framework is she using to make this case?
a. Deontology
b. Ethics of care
c. Feminist ethics
d. Utilitarianism
ANS: D
Utilitarianism is a system of ethics that believes that value is determined by usefulness. This system of ethics focuses on the outcome of the greatest good for the greatest number of people. Deontology would not look to consequences of actions. The ethics of care would not be helpful because consensus on this issue is not achievable. Relationships, which are an important component of feminist ethics, are not addressed in this case.
The nurse has become aware of missing narcotics in the patient care area. Which ethical principle obligates the nurse to report the missing medications?
a. Advocacy
b. Responsibility
c. Confidentiality
d. Accountability
ANS: B
Responsibility refers to one’s willingness to respect and adhere to one’s professional obligations. One of the obligations nursing has is to protect patients and communities, including other nurses. If narcotics are missing, this may indicate that patients have not received medications ordered for their care, or it may suggest that a health care professional may be working under the influence. Accountability refers to the ability to answer for one’s actions. Advocacy refers to the support of a particular cause. The concept of confidentiality is very important in health care and involves protecting patients’ personal health information.
A young woman who is pregnant with a fetus exposed to multiple teratogens consents to have her fetus undergo serial PUBS (percutaneous umbilical blood sampling) to examine how exposure affects the fetus over time. Although these tests will not improve the fetus’ outcomes and will expose it to some risks, the information gathered may help infants in the future. Which ethical principle is at greatest risk?
a. Autonomy
b. Fidelity
c. Nonmaleficence
d. Beneficence
ANS: C
Nonmaleficence is the ethical principle that focuses on avoidance of harm or hurt. The nurse must balance risks and benefits of care. Repeated PUBS may place the mother and fetus at risk for infection and increased pain, and may place the mother at risk for increased emotional health stress. Fidelity refers to the agreement to keep promises. Autonomy refers to freedom from external control, and beneficence refers to taking positive actions to help others.
Which issue has increased the attention paid to quality of life concerns in recent history?
a. Health care disparities
b. National movement regarding disabled persons
c. Aging of the population
d. Health care financial reform
ANS: B
Quality of life (QOL) is often at the center of ethical dilemmas, including futile care and DNR discussions, and has been reshaped in the United States. The national effort to better respect the abilities of the disabled has forced Americans to reconsider the definition of QOL. Health care disparities, an aging population, and health care reform are components impacted by personal definitions of quality but are not the underlying reason why QOL discussions have arisen in the United States.
Which patient is most likely to have difficulty with the ethical concept of autonomy?
a. 18-year-old patient in labor
b. 35-year-old patient with appendicitis
c. 53-year-old patient with pancreatitis
d. 78-year-old patient with rheumatoid arthritis
ANS: D
The principle of autonomy refers to freedom from external control and includes commitment to include patients in decisions about their care. People from different generations have differing expectations regarding inclusion in their care. Often, patients who are part of the Silent Generation (born 1925-1945) value formality and authority, which may make them less comfortable with making their own health care decisions.
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
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.
During a severe respiratory epidemic, the local health care organizations decide to give health care providers priority access to ventilators over other members of the community who also need that resource. Which philosophy would give the strongest support for this decision?
a. Feminist ethics
b. Utilitarianism
c. Deontology
d. Ethics of care
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.
Determinations regarding quality of life are
a. Based on a person’s ability to act according to ethical principles.
b. Based on a patient’s self-determination.
c. Value judgments that can vary from person to person.
d. Consistent and stable over the course of one’s lifetime.
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.
The nurse is caring for a patient supported with a ventilator who has been unresponsive since arrival via ambulance 8 days ago. The patient has not been identified, and no family members have been found. The nurse is concerned about the plan of care regarding maintenance or withdrawal of life support measures. The nurse determines that this is an ethical dilemma not resolved by scientific data. Place the steps the nurse will use to resolve this ethical dilemma in the correct order.
a. The nurse identifies possible solutions or actions to resolve the dilemma.
b. The nurse reviews the medical record, including entries by all health care disciplines, to gather information relevant to this patient’s situation.
c. Health care providers use negotiation to redefine the patient’s plan of care.
d. The nurse evaluates the plan and revises it with input from other health care providers as necessary.
e. The nurse arranges a meeting with health care team members to clarify opinions, values, and facts.
f. The nurse states the problem.
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.
A newly hired experienced nurse is preparing to change a patient’s abdominal dressing and hasn’t done it before at this hospital. Which action by the nurse is best?
a. Ask another nurse to do it so the correct method can be viewed.
b. Check the policy and procedure manual for the agency’s method.
c. Change the dressing using the method taught in nursing school.
d. Ask the patient how the dressing change has been recently done.
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.
A new nurse notes that the health care unit keeps a listing of patient names in a closed book behind the front desk of the nursing station so patients can be located easily. What action is most appropriate for the nurse to take?
a. Move the book to the upper ledge of the nursing station for easier access.
b. Talk with the nurse manager about the listing being a violation of the Health Insurance Portability and Accountability Act (HIPAA).
c. Use the book as needed while keeping it away from individuals not involved in patient care.
d. Ask the nurse manager to move the book to a more secluded area.
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.
A 17-year-old patient, dying of heart failure, wants to have his organs removed for transplantation after his death. What action by the nurse is correct?
a. Prepare the organ donation form for the patient to sign while he is still oriented.
b. Instruct the patient to talk with his parents about his desire to donate his organs.
c. Notify the physician about the patient’s desire to donate his organs.
d. Contact the United Network for Organ Sharing after talking with the patient.
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.
An obstetrical nurse comes across an automobile accident. The patient seems to have a crushed upper airway, and while waiting for emergency medical services to arrive, the nurse makes a cut in the trachea and inserts a straw from her purse to provide an airway. The patient survives and has a permanent problem with his vocal cords, making it difficult to talk. Which statement is true regarding the nurse’s performance?
a. The nurse acted appropriately and saved the patient’s life.
b. The nurse acted within the guidelines of the Good Samaritan Law.
c. The nurse took actions beyond those that are standard and appropriate.
d. The nurse should have just stayed with the patient and waited for help.
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.
A nurse performs cardiopulmonary resuscitation (CPR) on a 92-year-old with brittle bones and breaks a rib during the procedure, which then punctures a lung. The patient recovers completely without any residual problems and sues the nurse for pain and suffering, and for malpractice. What key point will the prosecution attempt to prove?
a. The CPR procedure was done incorrectly.
b. The patient would have died if nothing was done.
c. The patient was resuscitated according to policy.
d. Patients with brittle bones might sustain fractures when chest compressions are done.
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.
A recent immigrant who does not speak English is alert and requires hospitalization. What is the initial action that the nurse must take to enable informed consent to be obtained?
a. Ask a family member to translate what the nurse is saying.
b. Notify the health care provider that the patient doesn’t speak English.
c. Request an official interpreter to explain the terms of consent.
d. Use hand gestures and medical equipment while explaining in English.
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.
A pediatric oncology nurse floats to an orthopedic trauma unit. What actions should the nurse manager of the orthopedic unit take to enable safe care to be given by this nurse?
a. Provide a complete orientation to the functioning of the entire unit.
b. Determine patient acuity and care the nurse can safely provide.
c. Allow the nurse to choose which meal time she would like.
d. Assign nursing assistive personnel to assist her with care.
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.
While recovering from a severe illness, a hospitalized patient states that he wants to change his living will, which he signed nine months ago. Which response by the nurse is most appropriate?
a. “Check with your admitting health care provider whether a copy is on your chart.”
b. “Have you talked with your attorney recently about a living will?”
c. “Your living will can be changed only once each calendar year.”
d. “Let me check with someone here in the hospital who can assist you.”
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.
A nurse notices that his neighbor’s preschool children are often playing on the sidewalk and in the street unsupervised and repeatedly takes them back to their home and talks with the parent available, but the situation continues. What immediate action by the nurse is mandated by law?
a. Talk with both parents about safety needs of their children.
b. Contact the appropriate community child protection agency.
c. Tell the parents that the authorities will be contacted shortly.
d. Take pictures of the children to support the overt child abuse.
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.
A confused patient with a urinary catheter, nasogastric tube, and intravenous line keeps touching these needed items for care. The nurse has tried to explain to the patient that he should not touch these lines, but the patient continues. What is the best action by the nurse at this time?
a. Apply restraints loosely on the patient’s dominant wrist.
b. Try other approaches to prevent the patient from touching these care items.
c. Notify the health care provider that restraints are needed immediately to maintain the patient’s safety.
d. Allow the patient to pull out lines to prove that the patient needs to be restrained.
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.
A patient with sepsis as a result of long-term leukemia dies 25 hours after admission to the hospital. A full code was conducted without success. The patient had a urinary catheter, an intravenous line, an oxygen cannula, and a nasogastric tube. What question is priority for the nurse to ask the family before beginning postmortem care?
a. “Do you want to assist in bathing your loved one?”
b. “Is an autopsy going to be done?”
c. “To which funeral home do you want your loved one transported?”
d. “Do you want me to remove the lines and tubes before you see your loved one?”
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.
Conjoined twins are in the neonatal department of the community hospital until transfer to the closest medical center. A photographer from the local newspaper gets off the elevator on the neonatal floor and wants to take pictures of the infants. What initial action should the nurse take?
a. Escort the cameraman to the neonatal unit while a few pictures are taken quietly.
b. Tell the cameraman where the hospital’s public relations department is located.
c. Ask the cameraman to wait while permission is obtained from the physician.
d. Ask the cameraman how the pictures are to be used in the local newspaper.
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.
A nursing student has been written up several times for being late with providing patient care and for omitting aspects of patient care and not knowing basic procedures that were taught in the skills course one term earlier. The nursing student says, “I don’t understand what the big deal is. As my instructor, you are there to protect me and make sure I don’t make mistakes.” What is the best response from the nursing instructor?
a. “You are expected to perform at the level of a professional nurse.”
b. “You are expected to perform at the level of a nursing student.”
c. “You are practicing under the license of the nurse assigned to the patient.”
d. “You are expected to perform at the level of a skilled nursing assistant.”
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.
A nurse works full-time on the oncology unit at the hospital and works part-time on weekends giving immunizations at the local pharmacy. While giving an injection on a weekend, the nurse caused injury to the patient’s arm and is now being sued. How will the hospital’s malpractice insurance provide coverage for this nurse?
a. It will provide coverage as long as the nurse followed all procedures, protocols, and policies correctly.
b. The hospital’s malpractice insurance covers this nurse only during the time the nurse is working at the hospital.
c. As long as the nurse has never been sued before this incident, the hospital’s malpractice insurance will cover the nurse.
d. The hospital’s malpractice insurance will provide approximately 50% of the coverage the nurse will need.
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.
A nursing student in the final term of nursing school is overheard by a nursing faculty member telling another student that she got to insert a nasogastric tube in the emergency department while she was working as a nursing assistant. What advice is best for the nursing faculty member to give to the nursing student?
a. “Just be careful when you are doing new procedures and make sure you are following directions by the nurse.”
b. “Review your procedures before you go to work, so you will be prepared to do them if you have a chance.”
c. “The nurse should not have allowed you to insert the nasogastric tube because something bad could have happened.”
d. “You are not allowed to perform any procedures other than those in your job description even with the nurse’s permission.”
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.
The nurse calculates the medication dose for an infant on the pediatric unit and determines that the dose is twice what it should be. The pediatrician is contacted and says to administer the medication as ordered. What is the next action that the nurse should take? (Select all that apply.)
a.
Notify the nursing supervisor.
b.
Check the chain of command policy for such situations.
c.
Give the medication as ordered.
d.
Give the amount calculated to be correct.
e.
Contact the pharmacy for clarification.
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.
A nurse gives an incorrect medication to a patient without doing all of the mandatory checks, but the patient has no ill effects from the medication. What actions should the nurse take after reassessing the patient? (Select all that apply.)
a.
Notify the health care provider of the situation.
b.
Document in the patient’s medical record that an occurrence report was filed.
c.
Document in the patient’s medical record why the omission occurred.
d.
Discuss what happened with all of the other nurses and staff on the unit.
e.
Continue to monitor the patient for any untoward effects from the medication.
f.
Send an occurrence report to risk management after completing it.
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.
The nurse hears a physician say to the charge nurse that he doesn’t want that same nurse caring for his patients because she is stupid and won’t follow his orders. The physician also writes on his patient’s medical records that the same nurse, by name, is not to care for any of his patients because of her incompetence. What component(s) of defamation has the physician committed? (Select all that apply.)
a.
Slander
b.
Invasion of privacy
c.
Libel
d.
Assault
e.
Battery
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.
A patient has just been told that he has approximately six months to live and asks about advance directives. Which statements by the nurse give the patient correct information? (Select all that apply.)
a.
“You have the right to refuse treatment at any time.”
b.
“If you want certain procedures or actions taken or not taken, and you might not be able to tell anyone at the time, you need to complete documents ahead of time that give your health care provider this information.”
c.
“You will be resuscitated at any time to allow you the longest length of survival.”
d.
“You might want to think about choosing someone who will make medical decisions for you in the event that you are unable to make your desires known.”
e.
“We will get someone who knows the state’s guidelines to assist you in setting up your living will.”
f.
“If you travel to another state, your living will should cover your wishes.”
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.
A patient’s condition is slowly deteriorating. What actions should the nurse take to provide the best care possible? (Select all that apply.)
a.
Allow the nursing student to receive verbal orders from the physician in the room while the nurse is in the medication area down the hall.
b.
Document the patient’s status changes in the medical record in a timely manner.
c.
Document that the health care provider has been notified of the specific patient status, including date and time that messages were left.
d.
Check the chart for frequent orders.
e.
Omit charting what the health provider’s response is to notification of the patient’s status change.
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.
A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene?
a.
The student nurse reviews the patient’s medical record.
b.
The student nurse reads the patient’s plan of care.
c.
The student nurse shares patient information with a friend.
d.
The student nurse documents medication administered to the patient.
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.
A nurse prepared an audiotaped exchange with another nurse of information about a patient. Which action did the nurse complete? The nurse completed a
a.
Report.
b.
Record.
c.
Consultation.
d.
Referral.
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).
Which situation best indicates that the nurse has a good understanding regarding auditing and monitoring of patients’ health records?
a.
The nurse determines the degree to which standards of care are met by reviewing patients’ health records.
b.
The nurse realizes that care not documented in patients’ health records still qualifies as care provided.
c.
The nurse knows that reimbursement is based on the diagnosis-related groups documented in patients’ records.
d.
The nurse compares data in patients’ records to determine whether a new treatment had better outcomes than the standard treatment.
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.
After providing care, a nurse charts in the patient’s record. Which entry should the nurse document?
a.
Appears restless when sitting in the chair
b.
Drank adequate amounts of water
c.
Apparently is asleep with eyes closed
d.
Skin pale and cool
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.”
A nurse has provided care to a patient. Which entry should the nurse document in the patient’s record?
a.
“Patient seems to be in pain and states, ‘I feel uncomfortable.’”
b.
Status unchanged, doing well
c.
Left abdominal incision 1 inch in length without redness, drainage, or edema
d.
Patient is hard to care for and refuses all treatments and medications. Family present.
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.”
A preceptor is working with a new nurse on documentation. Which situation will cause the preceptor to intervene?
a.
The new nurse uses a black ink pen to chart.
b.
The new nurse charts consecutively on every other line.
c.
The new nurse ends each entry with signature and title.
d.
The new nurse keeps the password secure.
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.
A nurse is charting on a patient’s record. Which action is most accurate legally?
a.
Charts legibly
b.
States the patient is belligerent
c.
Uses correction fluid to correct error
d.
Writes entry for another nurse
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.
A nurse wants to integrate all pertinent patient information into one record, regardless of the number of times a patient enters the health care system. Which term should the nurse use to describe this system?
a.
Electronic medical record
b.
Electronic health record
c.
Electronic charting record
d.
Electronic problem record
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.
A nurse has taught the patient how to use crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the “I” in PIE charting?
a.
Patient went up and down stairs
b.
Deficient knowledge regarding crutches
c.
Demonstrated use of crutches
d.
Used crutches with no difficulties
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.
A nurse is using the source record and wants to find the daily weights. Where should the nurse look?
a.
Database
b.
Medical history and examination
c.
Progress notes
d.
Graphic sheet and flow sheet
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).
A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do?
a.
Focus charting using the DAR format.
b.
Add this data to the problem list.
c.
Document the variance in the patient’s record.
d.
Report a positive variance in the next interdisciplinary team meeting.
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).
A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient?
a.
Upon admission
b.
Right before discharge
c.
After the congestion is treated
d.
When the primary care provider writes the order
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.
A patient is being discharged home. Which information should the nurse include?
a.
Acuity level
b.
Community resources
c.
Standardized care plan
d.
Kardex
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.
A nurse developed the following discharge summary sheet. Which critical information should be added?
TOPIC DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge
a. Kardex form
b. Admission nursing history
c. Mode of transportation
d. SOAP notes
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.
A home health nurse is preparing for an initial home visit. Which information should be included in the patient’s home care medical record?
a.
Nursing process form
b.
Step-by-step skills manual
c.
A list of possible procedures
d.
Reports to third party payers
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.
A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning and for meeting quality improvement within and across facilities. Which task did the nurse just complete?
a.
A focused assessment/specific body system
b.
The Resident Assessment Instrument/Minimum Data Set
c.
An admission assessment and acuity level
d.
An intake assessment form and auditing phase
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.
A nurse is giving a hand-off report to the oncoming nurse. Which information is critical for the nurse to report?
a.
The patient had a good day with no complaints.
b.
The family is demanding and argumentative.
c.
The patient has a new pain medication, Lortab.
d.
The family is poor and had to go on welfare.
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.
A new nurse asks the preceptor why a change-of-shift report is important since care is documented in the chart. What is the preceptor’s best response?
a.
“A hand-off report provides an opportunity to share essential information to ensure patient safety and continuity of care.”
b.
“A change-of-shift report provides the oncoming nurse with data to help set priorities and establish reimbursement costs.”
c.
“A hand-off report provides an opportunity for the oncoming nurse to ask questions and determine research priorities.”
d.
“A change-of-shift report provides important information to caregivers and develops relationships within the health care team.”
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.
A nurse is preparing a change-of-shift report for a patient who had chest pain. Which information is critical for the nurse to include?
a.
Pupils equal and reactive to light
b.
The family is a “pain”
c.
Had poor results from the pain medication
d.
Sharp pain of 8 on a scale of 1 to 10
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.
Which situation will require the nurse to obtain a telephone order?
a.
As the nurse and primary care provider leave a patient’s room, the primary care provider gives the nurse an order.
b.
At 0100, a patient’s blood pressure drops from 120/80 to 90/50 and the incision dressing is saturated with blood.
c.
At 0800, the nurse and primary care provider make rounds and the primary care provider tells the nurse a diet order.
d.
A nurse reads an order correctly as written by the primary care provider in the patient’s medical record.
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.
A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document?
a.
12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back.
b.
12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN, read back.
c.
12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.
d.
12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN.
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.
A nurse has taught the staff about informatics. Which statement indicates that the staff needs more education?
a.
If a nurse has computer competency, the nurse is competent in informatics.
b.
To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice.
c.
A nurse needs to know how to acquire, critique, and apply scientific evidence from literature databases.
d.
Nursing informatics integrates nursing science, computer science, and information science to manage and communicate information in nursing practice.
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.
A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using?
a.
Clinical decision support system
b.
Nursing process design
c.
Critical pathway design
d.
Computerized provider order entry system
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.
A nurse wants to reduce data entry errors on the computer system. Which behavior should the nurse implement?
a.
Use the same password all the time.
b.
Share password with only one other staff member.
c.
Print out and review computer nursing notes at home.
d.
Chart on the computer immediately after care is provided.
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.
Which entry will require follow-up by the nurse manager?
0800 Patient states, “Fell out of bed.” Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, “Did not pass out.” Assisted back to bed. Call bell within reach. Bed monitor on.
——————-Jane More, RN
0810 Notified primary care provider of patient’s status. New orders received. ——————-Jane More, RN
0815 Portable x-ray of L hip taken in room. States, “I feel fine.” ——————-Jane More, RN
0830 Incident report completed and placed on chart.
——————-Jane More, RN
a.
0800
b.
0810
c.
0815
d.
0830
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.
A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement?
a.
Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse ox 86%. Oxygen per nasal cannula applied at 2 L/min per standing order.
b.
Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, “felt better.” Finally, patient had no complaints.
c.
Breathing without difficulty. Sitting up in bed watching TV. Had a good day.
d.
Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours.
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.
A nurse is teaching the staff about health care reimbursement. Which information should the nurse include?
a.
Sentinel events help determine reimbursement issues for health care.
b.
Home health, long-term care, and hospital nurses’ documentation can affect reimbursement for health care.
c.
A clinical information system must be installed by 2014 to obtain health care reimbursement.
d.
HIPAA is the basis for establishing reimbursement for health care.
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).
A nurse is discussing the advantages of standardized documentation forms in the nursing information system. Which advantage should the nurse describe?
a.
Varied clinical databases
b.
Reduced errors of omission
c.
Increased hospital costs
d.
More time to read charts
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.
Which behaviors indicate that the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.)
a.
Writes the patient’s room number and date of birth on a paper for school
b.
Prints/copies material from the patient’s health record for a graded care plan
c.
Reviews assigned patient’s record and another unassigned patient’s record
d.
Reads the progress notes of assigned patient’s record
e.
Gives a change-of-shift report to the oncoming nurse about the patient
f.
Discusses patient care with the hospital volunteer
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.
Identify the purposes of a health care record. (Select all that apply.)
a.
Communication
b.
Legal documentation
c.
Reimbursement
d.
Education
e.
Research
f.
Nursing process
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.
A nurse is creating a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.)
a.
Create a password with just letters.
b.
Bypass the firewall.
c.
Use a programmed speed-dial key when faxing.
d.
Implement an automatic sign-off.
e.
Impose disciplinary actions for inappropriate access.
f.
Shred papers containing personal health information (PHI).
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.
What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery?
a.
Assess the patient’s body language.
b.
Observe cardiac monitor for increased heart rate.
c.
Ask the patient to rate the level of pain.
d.
Ask the patient to describe the effect of pain on the ability to cope.
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.
A nurse is caring for a patient who recently had an abdominal hysterectomy and states that she is experiencing severe pain. The patient’s blood pressure is 110/60, and her heart rate is 60. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic?
a.
“Your vitals do not show that you are having pain; can you describe your pain?”
b.
“You do not look like you are in pain.”
c.
“OK, I will go get you some narcotic pain relievers immediately.”
d.
“What would you like to try to alleviate your pain?”
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.
Which of the following statements made by a patient reflects that the patient understands the relationship between the gate control theory of pain and the use of meditation to relieve pain?
a.
“Meditation controls pain by blocking pain impulses from coming through the gate.”
b.
“Meditation will help me sleep through the pain because it opens the gate.”
c.
“Meditation stops the occurrence of pain stimuli.”
d.
“Meditation alters the chemical composition of pain neuro regulators, which closes the gate.”
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.
A nursing student is planning care for an elderly patient who is experiencing pain. Which of the following statements made by the nursing student indicates the need for the nursing professor to clarify the nursing student’s knowledge?
a.
“Older patients often have difficulty determining what is causing their pain.”
b.
“It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient’s response to the medication.”
c.
“As adults age, their ability to perceive pain decreases.”
d.
“Patients who have dementia probably experience pain, and their pain is not always well controlled.”
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.
The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients?
a.
Neurological factors
b.
Competency of the surgeon
c.
Meaning of pain
d.
Postoperative support personnel
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.
The nurse anticipates administering an opioid fentanyl patch to which patient?
a.
A 15-year-old adolescent with a broken femur
b.
A 30-year-old adult with cellulitis
c.
A 50-year-old patient with prostate cancer
d.
An 80-year-old patient with a broken hip
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.
What nursing intervention is most effective in preventing injury to a patient following administration of epidural anesthesia?
a.
Keeping the reversal agent in a syringe in the patient’s bedside table
b.
Applying a gauze dressing to the epidural catheter insertion site
c.
Labeling the tubing that leads to the epidural catheter
d.
Asking the nursing assistive personnel to check on the patient at least once every 2 hours
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.
A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient?
a.
Relaxation and guided imagery
b.
Transcutaneous electrical nerve stimulation (TENS)
c.
Herbal supplements with analgesic effects
d.
Pudendal block
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.
Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective?
a.
“This is the only pain medication I will need to be on.”
b.
“I can administer the pain medication as frequently as I need to”
c.
“I feel less anxiety about the possibility of overdosing.”
d.
“I will need the nurse to notify me when it is time for another dose.”
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.
A nurse is caring for a patient who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the patient when providing patient education about effective pain management?
a.
“To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain.”
b.
“You should take your medication after you walk to make sure you do not fall while you are walking.”
c.
“We should work together to create a regular schedule of medications that does not allow for breakthrough pain.”
d.
“You need to take oral pain medications when you experience severe pain.”
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.
A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient’s behavior and response to surgery?
a.
The surgery successfully cured the patient’s pain.
b.
The patient’s culture is possibly influencing the patient’s experience of pain.
c.
The patient is experiencing urinary retention because of manipulation of the spine during surgery; this is preventing the patient from experiencing pain.
d.
The nurse is allowing personal beliefs about pain to influence pain management at this time.
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.
A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with Vicodin (5/325). What important patient education does the nurse provide?
a.
“Be sure to eat a meal high in fat before taking the medication, to avoid a stomach ulcer.”
b.
“Narcotics can be addictive, so do not take them unless you are in severe pain.”
c.
“You need to drink plenty of fluids and eat a diet high in fiber.”
d.
“As your pain severity lessens, you will begin to give yourself once-daily intramuscular injections.”
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.
A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. What nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider?
a.
Frequently reassesses the patient’s pain scores
b.
Reassures the patient that the provider will come to the emergency department soon
c.
Softly plays music that the patient finds relaxing
d.
Teaches the patient how to do yoga
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.
A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower legs, which is causing the patient to have a decreased ability to feel pain in the lower extremities. The nurse is providing education to the patient to prevent injury to the feet. The nurse tells the patient to always wear shoes or slippers when walking. Which of the following statements made by the nurse best explains the rationale for this instruction?
a.
“Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet.”
b.
“Shoes provide nonpharmacological pain relief to people with diabetes and peripheral neuropathy.”
c.
“Since you cannot feel pain as much in your feet, you need to open your neurological gates to allow pain sensations to come through. Wearing shoes helps to open those gates, which protects your feet.”
d.
“You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot.”
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.
A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, “The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most.” What type of pain does the nurse document that the patient is having at this time?
a.
Superficial pain
b.
Idiopathic pain
c.
Chronic pain
d.
Visceral pain
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.
A patient who had a motor vehicle accident 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). How does the nurse know that the patient is experiencing effective pain management with the PCA?
a.
The patient is sleeping and is difficult to arouse.
b.
The patient rates pain at an acceptable level of 3 on a 0 to 10 scale.
c.
Sufficient medication is left in the PCA syringe.
d.
The patient presses the control button to deliver pain medication.
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.
The nurse recognizes that which of the following is a modifiable contributor to a patient’s perception of pain?
a.
Age and gender
b.
Anxiety and fear
c.
Culture
d.
Previous pain experience
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.
The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which statement best describes that guided imagery is effectively controlling the patient’s pain during dressing changes?
a.
The patient’s need for analgesic medication decreases during the dressing changes.
b.
The patient rates pain during the dressing change as a 6 on a scale of 0 to 10.
c.
The patient’s facial expressions are stoic during the procedure.
d.
The patient can tolerate more pain, so dressing changes can be performed more frequently.
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.
A nurse is providing medication education to a patient who just started taking ibuprofen, a nonselective nonsteroidal antiinflammatory drug (NSAID). Which statement made by the nurse best indicates how ibuprofen works?
a.
“Ibuprofen helps to remove factors that cause or stimulate pain.”
b.
“Ibuprofen reduces anxiety, which will help you better cope with your pain.”
c.
“Ibuprofen helps to decrease the production of prostaglandins.”
d.
“Ibuprofen binds with opiate receptors to reduce your pain.”
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.
A nurse has brought the patient his scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic?
a.
“This medication will still be providing you relief at the time of your dressing change.”
b.
“OK, swallow this pain pill, and I will return in a minute to fill your wound.”
c.
“Would you like medication to be given for dressing changes on top of your regularly scheduled medication?”
d.
“Your medication is scheduled for this time, and I can’t adjust the time for you. I’m sorry, but you must take your pill right now.”
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.
A nurse receives an order from a health care provider to administer Vicodin ES, which contains 750 mg acetaminophen and 7.5 mg hydrocodone, to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurse’s best next action?
a.
Give the Vicodin ES to the patient immediately because the patient is experiencing severe pain.
b.
Ask the health care provider to verify the dosage and frequency of the medication.
c.
Ask the health care provider for an order for a nonsteroidal anti-inflammatory drug (NSAID).
d.
Ask the health care provider for an order to play music for the patient, in addition to providing the pain medication.
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.
The nurse knows that which technique is best for assessing pain in a child who is 4 years of age?
a.
Ask the parents if they think their child is in pain.
b.
Use the FACES scale.
c.
Ask the child to rate the level of pain on a 0 to 10 pain scale.
d.
Check to see what previous nurses have charted.
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.
Which statement made by a nursing educator best explains why it is important for nurses to determine a patient’s medical history and recent drug use?
a.
“Health care providers have a responsibility to prevent drug seekers from gaining access to drugs.”
b.
“This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief.”
c.
“Some recreational drugs have pharmaceutical counterparts that may be more effective in managing pain.”
d.
“Getting this information gives the nurse an opportunity to provide patient teaching about drug abstinence.”
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.
A nurse is supervising a student who is caring for a patient with chronic pain. Which statement by the student indicates an understanding of pain management?
a.
“This patient says her pain is a 5, but she is not acting like it. I am not going to give her any pain medication.”
b.
“The patient is sleeping, so I pushed her PCA button for her.”
c.
“I need to reassess the patient’s pain 1 hour after administering oral pain medication.”
d.
“It wasn’t time for the patient’s medication, so when she requested it, I gave her a placebo.”
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.
The nurse is assessing how a patient’s pain is affecting mobility. Which assessment question is most appropriate?
a.
“Have you considered working with a physical therapist?”
b.
“What activities, if any, has your pain prevented you from doing?”
c.
“Would you please rate your pain on a scale from 1 to 10 for me?”
d.
“What effect does your pain medication typically have on your pain?”
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.
The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates correct understanding?
a.
“You cannot use a pain scale to compare the pain of my patient with the pain of your patient.”
b.
“When patients say they don’t need pain medication, they aren’t in pain.”
c.
“Pain assessment scales determine the quality of a patient’s pain.”
d.
“A patient’s behavior is more reliable than the patient’s report of pain.”
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.
The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first?
a.
The patient who needs to take a scheduled dose of maintenance pain medication
b.
The patient who needs to be premedicated before walking
c.
The patient with a PCA running who needs to have the syringe replaced
d.
The patient who is experiencing 8/10 pain and has a STAT order for pain medication
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.
The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse’s assessment?
a.
Increasingly higher doses of opioid are needed to control pain.
b.
The patient needed a substantial dose of naloxone (Narcan).
c.
The patient asks for pain medication close to the time it is due around the clock.
d.
The patient no longer experiences sedation from the usual dose of opioid.
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.
A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain. Which part of the patient’s social history is the nurse most concerned about?
a.
Patient drinks 1 to 2 glasses of wine every night.
b.
Patient smokes 2 packs of cigarettes a day.
c.
Patient occasionally smokes marijuana.
d.
Patient takes antianxiety medications.
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.
The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse’s first priority?
a.
Call the rapid response team.
b.
Ask the patient to rate and describe the pain.
c.
Raise the head of the bed.
d.
Administer pain relief medications.
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.
The nurse is caring for a patient who recently had surgery to repair a hernia. The patient’s pain was 7 out of 10 before receiving pain medication. One hour after receiving an oral opioid, the patient ranks his pain at 3 out of 10. The patient asks the nurse why he isn’t receiving more pain medication. Which is the nurse’s best response?
a.
“This medication can be given only every 4 hours. It is not time for you to have any other pain medication right now.”
b.
“I will notify the health care provider to come perform an assessment if your pain doesn’t improve in 30 minutes.”
c.
“If the pain becomes severe, we may need to transfer you to an intensive care unit.”
d.
“It can take 2 hours for oral pain medication to work, and your pain is going down. Let’s try boosting you up in bed and putting an ice pack on the incision to see if that helps.”
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.
Which of the following is the best way for the nurse to manage pain for a patient with chronic pain from arthritis?
a.
Administer pain medication before any activity.
b.
Provide intravascular bolus as needed for breakthrough pain.
c.
Give medications around-the-clock.
d.
Administer pain medication only when nonpharmacological measures have failed.
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.
A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. What does type of pain does the nurse document that the patient has?
a.
Visceral pain
b.
Somatic pain
c.
Peripherally generated pain
d.
Centrally generated pain
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.
The nurse is caring for an infant in the intensive care unit. Which of the following is the most accurate description of factors that will influence the perception and management of pain for this patient?
a.
Infants cannot tolerate analgesics owing to an underdeveloped metabolism.
b.
Infants have an increased sensitivity to pain when compared with older children.
c.
Pain cannot be accurately assessed in infants.
d.
Infants respond behaviorally and physiologically to painful stimuli.
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.
The nurse is administering ibuprofen (Advil) to an older patient. Which of the following assessment data causes the nurse to hold the medication? (Select all that apply.)
a.
Past medical history of gastric ulcer
b.
Patient states last bowel movement was 4 days ago
c.
Stated allergy to aspirin
d.
Patient states has 2/10 intermittent joint pain
e.
Patient experienced respiratory depression after administration of an opioid medication
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.
A patient describes practicing a complementary and alternative therapy involving concentrating and controlling his respiratory rate and pattern, recognizing that breath work is to yoga as
a.
The “zone” is to acupressure.
b.
Massage therapy is to Ayurveda.
c.
Reiki therapy is to therapeutic touch.
d.
Prayer is to tai chi.
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.
A teen with an anxiety disorder is referred for biofeedback because her parents do not want her on anxiolytics. The nurse recognizes that the teen understands her health education on biofeedback when she states, “Biofeedback will
a.
Allow me to direct my energies in an intentional way when stressed.”
b.
Allow me to manipulate my stressed out joints.”
c.
Help me with my thoughts, feelings, and physiological responses to stress.”
d.
Let me assess and redirect my energy fields.”
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.
A 70-year-old patient is newly admitted to a skilled nursing facility with the diagnoses of Alzheimer’s dementia, lipidemia, and hypertension, and a history of pulmonary embolism. Medications brought on admission included lisinopril, hydrochlorothiazide, warfarin, low-dose aspirin, ginkgo biloba, and echinacea. The nurse contacts the patient’s medical provider over which potential drug-drug interaction?
a.
Lisinopril and echinacea
b.
Warfarin and ginkgo biloba
c.
Echinacea and warfarin
d.
Lisinopril and hydrochlorothiazide
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.
An acquaintance of a nurse asks for a nonmedical approach for excessive worry and work stress. The most appropriate CAM therapy that the nurse can recommend is
a.
Meditation
b.
Ayurvedic herbs
c.
Acupuncture
d.
Chiropractic therapy
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.
The therapy that is more effective in treating physical ailments than in preventing disease or managing chronic illness is _____ medicine.
a.
Allopathic
b.
Complementary
c.
Alternative
d.
Mind-body
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.
During a relaxation therapy skills group, the instructor discusses the cognitive skill of learning to tolerate uncertain and unfamiliar experiences. This best describes the skill of
a.
Mindfulness.
b.
Focusing.
c.
Passivity.
d.
Receptivity.
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.
A patient asks about the new clinic in town that is staffed by allopathic and complementary practitioners. The nurse recognizes that the patient is most likely asking about which clinic?
a.
Integrative medical clinic
b.
Ayurvedic clinic
c.
Naturopathic medical clinic
d.
Healing intention clinic
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.
The group leader is overheard saying to the gathering of patients, “Focus on your breathing once again…notice how it is regular…Now focus on your left arm…Notice how relaxed your left arm feels…Notice the relaxation going down the left arm to the hand.” The nursing student asks the nursing preceptor what the unit group leader is doing. The best answer is which of the following?
a.
Group psychotherapy
b.
Progressive relaxation training
c.
Meditation
d.
Group biofeedback
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.
A therapeutic touch practitioner scans the patient’s body to identify what?
a.
Blocked chakra
b.
Accumulated tension
c.
The flow of Qi
d.
Structural and functional imbalance
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.
In a cardiac dysrhythmia clinic, a patient inquires about using acupuncture to help alleviate stress. The nurse’s best answer is which of the following?
a.
“It is acceptable, but do not use electro-acupuncture.”
b.
“It is very clearly contraindicated.”
c.
“Do not allow needles near the heart.”
d.
“You do not look like you have an infection, so it will be OK.”
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.
A basic foundational principle of chiropractic care is that
a.
Structure and function coexist.
b.
Chiropractic care is risk free.
c.
Human beings need external hands-on care to be healthiest.
d.
Subluxation will cause permanently restricted joint movement.
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.
A holistic nurse would be a nurse who
a.
Recommends a vegan diet for all patients.
b.
Recognizes the mind-body-spirit connection.
c.
Provides spiritual literature to patients.
d.
Knows about resources for fresh herbs.
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.
Drawbacks of complementary and alternative therapies would be all of the following except
a.
Lack of evidence-based guidelines.
b.
Minimal supportive research studies.
c.
Strong support by allopathic medical providers.
d.
Lack of a long tradition of therapies taught in health care education.
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.
Physiological symptoms of a stress response include all of the following except
a.
Constricted pupils.
b.
Tachycardia.
c.
Tachypnea.
d.
Elevated blood pressure.
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.
A long-term outcome for an individual who is learning relaxation therapy is
a.
Identifying tension in his body and consciously releasing the tension.
b.
Having no tension in his life.
c.
Increasing delta brain activity.
d.
Increasing the focus on himself.
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.
One benefit of meditation over other forms of behavioral therapy is that meditation
a.
Improves communication skills.
b.
Cures hypertension.
c.
Does not require memorization.
d.
Balances insulin and other body hormones.
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.
The 1994 Dietary Supplement Health and Education Act impacted herbal therapies in what way?
a.
Allowed for labeling of herbal medicines as safe
b.
Allowed herbs to be sold as dietary supplements
c.
Classified herbs as beneficial, harmful, or neutral
d.
Classified herbs as “natural” foods
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.
Which medication could cause an abnormal drug interaction in a patient taking an antidepressant medication?
a.
Digoxin
b.
Aspirin
c.
Chamomile
d.
Ginger
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.
The organization that facilitates the evaluation of alternative medical treatments is the
a.
National Center for Complementary and Alternative Medicine.
b.
American Holistic Nurses Association.
c.
Food and Drug Administration.
d.
U.S. Department of Health and Human Services.
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.
The complementary and alternative therapy that is known to alter immune function is which of the following?
a.
Biofeedback
b.
Imagery
c.
Breath work
d.
Acupuncture
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.
The nurse is precepting a student nurse and explains that perioperative nursing care occurs
a.
Before, during, and after surgery.
b.
In preadmission testing.
c.
During the surgical procedure.
d.
In the postanesthesia care unit.
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.
The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patient’s laboratory tests and allergies. In which perioperative nursing phase would this work be completed?
a.
Perioperative
b.
Preoperative
c.
Intraoperative
d.
Postoperative
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.
The nurse is caring for a patient in the postanesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. This procedure would be classified as
a.
Elective.
b.
Urgent.
c.
Emergency.
d.
Major.
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.
The nurse is caring for a patient in preadmission testing. The patient has been assigned a physical status classification by the American Society of Anesthesiologist of P3. Which of the following assessments would support this classification?
a.
Denial of any major illnesses or conditions
b.
Normal, healthy patient
c.
History of hypertension, 80 pounds overweight, history of asthma
d.
History of myocardial infarction that limits activity
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.
The patient has presented to the ambulatory surgery center to have a colonoscopy. The patient is scheduled to receive moderate sedation (conscious sedation) during the procedure. Moderate sedation is used routinely for procedures that require
a.
Performance on an outpatient basis.
b.
A depressed level of consciousness.
c.
Loss of sensation in an area of the body.
d.
The patient to be immobile.
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.
The nurse is caring for a patient in the postanesthesia care unit who has undergone a left total knee arthroplasty. The anesthesia provider has indicated that the patient received a left femoral peripheral nerve block. Which assessment would be an expected finding for a patient with this type of regional block?
a.
Decreased pulse at the left posterior tibia
b.
Left toes cool to touch and slightly cyanotic
c.
Sensation decreased in the left leg
d.
Patient report of pain in the left foot
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.
The nurse is preparing a patient for surgery. Aims of assessment before surgery include
a.
Establishing a patient’s baseline of normal function.
b.
Planning for care after the procedure.
c.
Educating the patient and family about the procedure.
d.
Gathering appropriate equipment for the patient’s needs.
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.
The nurse is completing a medication history for the surgical patient in preadmission testing. Which of the following medications should the nurse instruct the patient to hold in preparation for surgery?
a.
Ibuprofen
b.
Acetaminophen
c.
Vitamin C
d.
Miconazole
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.
The nurse is caring for a potential surgical patient in the preadmission testing unit. The medication history indicates that the patient is currently taking warfarin (Coumadin). Which of the following actions should the nurse take?
a.
Consult with the physician regarding a radiological examination of the chest.
b.
Consult with the physician regarding an international normalized ratio (INR).
c.
Consult with the physician regarding blood urea nitrogen (BUN).
d.
Consult with the physician regarding a complete blood count (CBC).
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.
The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Reasons for this intervention include
a.
Management of pain.
b.
Decreased healing time.
c.
Prevention of atelectasis.
d.
Decreased thrombus formation.
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.
The nurse is caring for a postoperative patient on the medical-surgical floor. To prevent venous stasis and the formation of thrombus after general anesthesia, the nurse encourages
a.
Coughing.
b.
Diaphragmatic breathing.
c.
Incentive spirometry.
d.
Leg exercises.
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.
The nurse is caring for a preoperative patient. The nurse teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurse’s best next step?
a.
Assess for the presence of anxiety, pain, or fatigue.
b.
Ask the patient why he does not want to do the exercises.
c.
Encourage the patient to practice at a later date.
d.
Assess the educational methods used to educate the patient.
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.
Which nursing assessment would indicate that the patient is performing diaphragmatic breathing correctly?
a.
Hands placed on border of rib cage with fingers extended will touch as chest wall contracts.
b.
Hands placed on chest wall with fingers extended will separate as chest wall contracts.
c.
The patient will feel upward movement of the diaphragm during inspiration.
d.
The patient will feel downward movement of the diaphragm during expiration.
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.
The nurse is caring for a postoperative patient with an abdominal incision. A pillow is used during coughing to provide
a.
Pain relief.
b.
Splinting.
c.
Distraction.
d.
Anxiety reduction.
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.
The nurse is encouraging a reluctant postoperative patient to deep breathe and cough. What explanation can the nurse provide that may encourage the patient to cough more effectively?
a.
“If you don’t deep breathe and cough, you will get pneumonia.”
b.
“Deep breathing and coughing will clear out the anesthesia.”
c.
“Coughing will not harm the incision if done correctly.”
d.
“You will need to cough only a few times during this shift.”
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.
The nurse and the nursing assistant are assisting a postoperative patient to turn in the bed. To assist in minimizing discomfort, which instruction should the nurse provide to the patient?
a.
“Close your eyes and think about something pleasant.”
b.
“Hold your breath and count to three.”
c.
“Hold my shoulders with your hands.”
d.
“Place your hand over your incision.”
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.
The nurse is preparing to assist the patient in using the incentive spirometer. Which nursing intervention should the nurse provide first?
a.
Perform hand hygiene.
b.
Place in reverse Trendelenburg position.
c.
Explain use of the mouthpiece.
d.
Instruct the patient to inhale slowly.
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.
The nurse and the nursing assistant are caring for a group of postoperative patients who need turning, coughing, deep breathing, incentive spirometer, and leg exercises. The nurse directs the nursing assistant to
a.
Teach and demonstrate postoperative exercises.
b.
Inform the nurse if the patient is unwilling to perform exercises.
c.
Document in the medical record when exercises are completed.
d.
Do nothing associated with postoperative exercises.
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.
The nurse is providing preoperative teaching for the ambulatory surgery patient who will be having a cyst removed from the right arm. Which would be the best explanation for diet progression after surgery?
a.
“Start with clear liquids, soup, and crackers. Advance to a normal diet as you tolerate.”
b.
“There is no limitation on your diet. You can have whatever you want.”
c.
“Stay on clear liquids for 24 hours. Then you can progress to a normal diet.”
d.
“Start with clear liquids for 2 hours, then full liquids for 2 hours. Then progress to a normal diet.”
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.
The nurse explains the pain relief measures available after surgery during preoperative teaching for a surgical patient. Which of the following comments from the patient indicates the need for additional education on this topic?
a.
“I will take the pain medication as the physician prescribes it.”
b.
“I will be asked to rate my pain on a pain scale.”
c.
“I will have minimal pain because of the anesthesia.”
d.
“I will take my pain medications before doing postoperative exercises.”
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.
The nurse is making a preoperative education appointment with a patient. The patient asks if he should bring family with him to the appointment. What is the best response by the nurse?
a.
“There is no need for an additional person at the appointment.”
b.
“Your family can come and wait with you in the waiting room.”
c.
“We recommend including family in this appoint to ease everyone’s anxiety.”
d.
“It is required that you have a family member at this appointment.”
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.
The nurse is reviewing the surgical consent with the patient during preoperative education. The patient indicates that he does not understand what procedure will be completed. What is the nurse’s best next step?
a.
Notify the physician about the patient’s question.
b.
Explain the procedure that will be completed.
c.
Ask the patient to sign the form.
d.
Continue with preoperative education.
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.
During preoperative assessment for a 7:30 case, the patient indicates to the nurse that he had a cup of coffee this morning. The nurse reports this information to the anesthesia provider anticipating
a.
A delay in or cancellation of surgery.
b.
Questions regarding components of the coffee.
c.
Additional questions about why the patient had coffee.
d.
Instructions to determine what education was provided in the preoperative visit.
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.
The nurse has administered an anxiolytic as a preoperative medication to the patient going to surgery. Which of the following is the best next step?
a.
Waste any unused medication according to policy.
b.
Notify the operating suite that the medication has been given.
c.
Instruct the patient to call for help to go to the restroom.
d.
Ask the patient to sign the consent for surgery.
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.
The nurse has completed a preoperative assessment for a patient going to surgery and gathers assessment data. Of the following, which would be the most important next step?
a.
Notify the operating suite that the patient has a latex allergy.
b.
Document that the patient had a bath at home this morning.
c.
Ask the nursing assistant to obtain vital signs.
d.
Administer the ordered preoperative intravenous antibiotic.
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.
The nurse is preparing a patient for a surgical procedure on the right great toe. Which of the following actions would be most important to include in this patient’s preparation?
a.
Ascertain that the surgical site has been correctly marked.
b.
Ascertain where the family will be located during the procedure.
c.
Place the patient in a clean surgical gown.
d.
Ask the patient to remove all hairpins and cosmetics.
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.
The nurse is caring for a patient intraoperatively. Primary roles of the circulating nurse include
a.
Establishing and implementing the plan of care.
b.
Maintaining a sterile field.
c.
Assisting with applying sterile drapes.
d.
Handing sterile instruments and supplies to the surgeon.
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.
The nurse is caring for a patient in the preoperative holding area of an ambulatory surgery center. Which nursing action would be most appropriate for this area?
a.
Monitor vital signs every 15 minutes.
b.
Empty the urinary drainage bag.
c.
Apply a warm blanket.
d.
Check the surgical dressing.
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.
The nurse is caring for a patient in the operating suite. Which of the following outcomes would be most appropriate for this patient?
a.
At the end of the intraoperative phase, the patient will be free of burns at the grounding pad.
b.
At the end of the intraoperative phase, the patient will be free of infection.
c.
At the end of the intraoperative phase, the patient will be free of nausea and vomiting.
d.
At the end of the intraoperative phase, the patient will be free of pain.
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.
The nurse is concerned about the skin integrity of the patient in the intraoperative phase of surgery. Which of the following actions helps to minimize skin breakdown?
a.
Encouraging the patient to bathe before surgery
b.
Securing attachments to the operating table with foam padding
c.
Periodically adjusting the patient during the surgical procedure
d.
Measuring the time a patient is in one position during surgery
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.
The nurse is caring for a postoperative patient with a history of obstructive sleep apnea. The nurse monitors for which of the following?
a.
Choking and noisy, irregular respirations
b.
Shallow respirations
c.
Moaning and reports of pain
d.
Disorientation
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.
The nurse is caring for a patient in the operating suite who is experiencing hypercarbia, tachypnea, tachycardia, premature ventricular contractions, and muscle rigidity. The nurse suspects that this patient may be experiencing
a.
Hypoxia.
b.
Malignant hyperthermia.
c.
Fluid imbalance.
d.
Hemorrhage.
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).
The nurse is caring for a postoperative patient who has had a carpel tunnel repair. The patient has a temperature of 97° F and is shivering. Which of the following is the best reason for this condition?
a.
The patient is dressed only in a gown.
b.
Anesthesia lowers metabolism.
c.
The surgical suite has laminar flow.
d.
The open body cavity contributed to heat loss.
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.
The nurse is monitoring a patient in the postanesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which of the following actions would be most appropriate for this patient?
a.
Encourage copious amounts of water.
b.
Weigh the patient and compare with preoperative weight.
c.
Measure and record all intake and output.
d.
Start an additional intravenous (IV) line.
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.
The nurse is caring for a patient in the postanesthesia care unit. The patient asks for a bedpan and states to the nurse, “I feel like I need to go to the bathroom, but I can’t.” Which of the following nursing interventions would be most appropriate?
a.
Encourage the patient to wait a minute and try again.
b.
Call the physician and obtain an order for catheterization.
c.
Assess the patient’s intake and the patient for bladder distention.
d.
Inform the patient that everyone feels this way after surgery.
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.
The postanesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgical floor. Before leaving the floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this nursing action?
a.
The first action in a head-to-toe assessment is vital signs.
b.
This is done to compare and monitor for vital sign variation during transport.
c.
This is done to ensure that the medical-surgical nurse checks on the postoperative patient.
d.
This is done to follow hospital policy and procedure for care of the surgical patient.
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.
The nurse is caring for a patient who will undergo a coronary artery bypass graft procedure. What level of care will the patient require immediately post procedure?
a.
Acute care—medical-surgical unit
b.
Acute care—intensive care unit
c.
Ambulatory surgery
d.
Ambulatory surgery—extended stay
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.
The ambulatory surgical nurse calls to check on the patient at home the morning after surgery. The patient is reporting continued nausea and vomiting. Which of the following discharge education points should be reviewed with the patient?
a.
Instruct the patient to take deep breaths.
b.
Instruct the patient to drink ginger ale and eat crackers.
c.
Instruct and attempt to connect the patient with the physician.
d.
Instruct the patient to go to the emergency department.
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.
The nurse is precepting a new nurse in the perioperative area. The nurse explains that perioperative nursing is based on certain principles and includes (Select all that apply.)
a.
Purchasing the correct equipment.
b.
Providing high-quality and patient safety–focused care.
c.
Scheduling the right types of patients.
d.
Conducting multidisciplinary teamwork.
e.
Ensuring effective therapeutic communication.
f.
Providing advocacy for the patient.
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.
The nurse is caring for an ambulatory surgery patient. To be discharged home, what criteria must the patient meet? (Select all that apply.)
a.
Able to drink fluids
b.
Able to eat crackers
c.
Manageable pain
d.
Able to void
e.
Dry and intact dressing
f.
Able to dress self
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.
The nurse is caring for a postoperative patient with an incision. Which of the following nursing interventions have been found to decrease wound infections? (Select all that apply.)
a.
Perform hand hygiene before and after contact with the patient.
b.
Maintain normoglycemia.
c.
Use hair clippers to remove hair.
d.
Administer antibiotics within 30 to 60 minutes of incision time.
e.
Provide bath and linen change daily.
f.
Perform first dressing change 1 week postoperatively.
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.
The nurse is preparing for a patient who will be going to surgery. The nurse screens for risk factors that can increase a person’s risks in surgery. What risk factors are included in the nurse’s screening? (Select all that apply.)
a.
Age
b.
Nutrition
c.
Race
d.
Obesity
e.
Pregnancy
f.
Ambulatory surgery
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.
The nurse is providing preoperative education and reviews with the patient what it will be like to be in the surgical environment. What points should the nurse include? (Select all that apply.)
a.
The surgical area is cold but warm blankets will be provided.
b.
The surgical staff will be dressed in special clothing with hats and masks.
c.
The operative suite will be very dark.
d.
Families are not allowed in the operating suite.
e.
The operating table or bed will be comfortable and soft.
f.
The nurses will be there to assist you through this process.
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.
The nurse is using a preoperative checklist to assist in preparing a patient on the day of surgery. What will the checklist include? (Select all that apply.)
a.
Vital signs
b.
Laboratory data
c.
Living will
d.
NPO
e.
Identification (ID) band on
f.
Family location
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.
The nurse is caring for a patient in the operating suite. The nurse assists in positioning the patient to (Select all that apply.)
a.
Gain access to the operative site.
b.
Sustain adequate circulatory and respiratory function.
c.
Ensure patient safety and skin integrity.
d.
Support the use of equipment.
e.
Maintain neuromuscular structures.
f.
Provide warmth and comfort.
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.
A nurse encounters a family that experienced the death of their adult child last year. The parents are talking about the upcoming anniversary of their child’s death. The nurse spends time with them discussing their child’s life and death. The nurse’s action best demonstrates which nursing principle?
a.
Pain management technique
b.
Facilitating normal mourning
c.
Grief evaluation
d.
Palliative care
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.
A cancer patient asks the nurse what the criteria are for hospice care. What should the nurse answer?
a.
Having a terminal illness, such as cancer
b.
Needing assistance with pain management
c.
Expected to live less than 6 to 12 more months
d.
Completion of an advance directive
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.
terminally ill patient is experiencing constipation secondary to pain medication. What is the best way for the nurse to improve the patient’s constipation problem?
a.
Massage the patient’s abdomen.
b.
Contact the provider to discontinue pain medication.
c.
Administer enemas twice daily for 7 days.
d.
Use a stimulant laxative and increase fluid intake.
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.
A severely depressed patient cannot state any positive attributes to his or her life. The nurse patiently sits with this patient and assists the patient to identify several activities the patient is actually looking forward to in life. The nurse is helping the patient to demonstrate which spiritual concept?
a.
Time management
b.
Hope
c.
Charity
d.
Faith
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.
In preparation for the eventual death of a female hospice patient of the Muslim faith, the nurse organizes a meeting of all hospice caregivers. A plan of care to be followed when this patient dies is prepared. This plan of care would include
a.
Male health care workers care for the body after death has occurred.
b.
Body preparation for autopsy.
c.
Body preparation for cremation.
d.
Female health care workers care for the body after death has occurred.
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.
Family members gather in the emergency department after learning that a family member was involved in a motor vehicle accident. After learning of the family member’s unexpected death, the surviving family members begin to cry and scream in despair. The nurse recognizes this as the Bowlby Attachment Theory stage of
a.
Numbing.
b.
Disorganization and despair.
c.
Bargaining.
d.
Yearning and searching.
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.
After the anticipated demise of a chronically ill patient, the unit nurse is found crying in the staff lounge. The best response to her crying colleague would be
a.
“It is normal to feel this way. Give yourself some time to mourn.”
b.
“Your other patients still need you, so hurry back to them.”
c.
“You’re being a bad role model to the unit’s nursing students.”
d.
“Why don’t you take a sedative to cope?”
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.
A family is grieving after learning of a family member’s accidental death. The transplant coordinator requests to talk with the family about possible organ and tissue donation. The nurse recognizes that
a.
All religions allow for organ donation.
b.
Life support must be removed before organ and tissue retrieval occurs.
c.
The best time for organ and tissue donation is immediately after the autopsy.
d.
The transplant coordinator is working in accordance with federal law.
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.
An Orthodox Jewish Rabbi has been pronounced dead. The nursing assistant respectfully asks family members to leave the room and go home as postmortem care is provided. Which of the following statements from the supervising nurse reflects correct knowledge of Jewish culture?
a.
“I wish they would go home because we have work to do here.”
b.
“Family members stay with the body until burial the next day.”
c.
“I should have called a male colleague to handle the body.”
d.
“I thought they would quietly leave after praying and touching the Rabbi’s head.”
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.
The palliative team’s primary obligation to a patient in severe pain includes which of the following?
a.
Supporting the patient’s nurse in her grief
b.
Providing postmortem care for the patient
c.
Teaching the patient the stages of grief
d.
Enhancing the patient’s quality of life
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.
A man is hospitalized after surgery that amputated both lower extremities owing to injuries sustained during military service. The nurse should recognize his need to grieve for what type of loss?
a.
Maturational loss
b.
Situational loss
c.
Perceived loss
d.
Uncomplicated loss
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.
“I know it seems strange, but I feel guilty being pregnant after the death of my son last year,” said a woman during her routine obstetrical examination. The nurse spends extra time with this woman, helping her to better bond with her unborn child. This demonstrates which nursing technique?
a.
Facilitating mourning
b.
Providing curative therapy
c.
Promoting spirituality
d.
Eradicating grief
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.
The nurse has had three patients die during the past 2 days. Which approach is most appropriate to manage the nurse’s sadness?
a.
Telling the next patients why the nurse is sad
b.
Talking with a colleague or writing in a journal
c.
Exercising vigorously rather than sleeping
d.
Avoiding friends until the nurse feels better
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.
A woman is called into her supervisor’s office regarding her deteriorating work performance since the loss of her husband 2 years ago. The woman begins sobbing and saying that she is “falling apart” at home as well. The woman is escorted to the nurse’s office, where the nurse recognizes the woman’s symptoms as which of the following?
a.
Normal grief
b.
Complicated grief
c.
Disenfranchised grief
d.
Perceived grief
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.
The father has recently begun to attend his children’s school functions since the death of his wife. This would best be described as which task in the Worden Grief Tasks Model?
a.
Task I
b.
Task II
c.
Task III
d.
Task IV
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.
The mother of a recently murdered child keeps the child’s room intact. Family members are encouraging her to redecorate and move forward in life. The visiting nurse recognizes this behavior as _____ grief.
a.
Normal
b.
End-of-life
c.
Abnormal
d.
Complicated
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.
Validation of a dying person’s life would be demonstrated by which nursing action?
a.
Taking pictures of visitors
b.
Calling the organ donation coordinator
c.
Listening to family stories about the person
d.
Providing quiet visiting time
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.
A couple is informed that their fetus’ condition is incompatible with life after birth. Nurses can best help the couple with their end-of-life decision making by offering them which of the following?
a.
An advance directive to complete
b.
Brief discussion and funeral guidance
c.
Time and careful explanations
d.
Instructions on how to proceed
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.
A correctional facility nurse is called to the scene of a deceased inmate. The correction officer wants to quickly move the body to the funeral home because he is not comfortable with death. The inmate’s body will need to be transported where?
a.
Coroner’s office for an autopsy
b.
Police department for an investigation
c.
Directly to the inmate’s family
d.
Warden for inspection
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.
A dying patient with liver and renal failure requires pain medication. The nurse anticipates that the medication dose will be
a.
Given at appropriate milligrams per kilogram medication levels.
b.
A decreased dose from milligrams per kilogram levels.
c.
An increased dose from milligrams per kilogram levels.
d.
Given at midrange for dosing at recommended levels.
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.
A patient cancels a scheduled appointment because she will be attending a Shiva for a family member. Recognizing the importance of this cultural ritual, the nurse’s best comment would be which of the following?
a.
“Congratulations, what’s the baby’s name?”
b.
“I’m so sorry for your loss.”
c.
“Missionary church outreach is so important.”
d.
“Can I buy a ticket to this fundraiser?”
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.
During a follow-up visit, a woman is describing new onset of marital discord with her terminally ill spouse. Using the Kübler-Ross behavioral theory, the nurse recognizes that the spouse is in which stage of dying?
a.
Denial
b.
Bargaining
c.
Anger
d.
Depression
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.
Enuresis is reported in a previously toilet trained toddler. While gathering a health history from the grandparent, the nurse asks about which factor as the most likely cause?
a.
Lack of outside playtime
b.
Having too many toys
c.
Dietary changes
d.
Recent parental death
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.
Mrs. Harrison’s father died a week ago. Mr. Harrison is experiencing headaches and fatigue, and keeps shouting at his wife to turn down the television, although he has not done so in the past. Mrs. Harrison is having trouble sleeping, has no appetite, and says she feels like she is choking all the time. How should the nurse interpret these assessment findings as the basis for a follow-up assessment?
a.
Mrs. Harrison is grieving and Mr. Harrison is angry.
b.
Mrs. Harrison is ill and Mr. Harrison is grieving.
c.
Both Mr. and Mrs. Harrison likely are in denial.
d.
Both Mr. and Mr. Harrison likely are grieving.
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.
A client is ordered to receive an NSAID for a disorder. The client states that she is aware that NSAIDs are frequently taken to decrease inflammation. The nurse clarifies that these agents may also be taken to:
a.
decrease pulse rate.
b.
reduce body temperature.
c.
decrease blood pressure.
d.
increase platelet aggregation.
ANS: B
One of the functions of NSAIDs is to reduce body temperature.
A nurse is teaching a client who has been prescribed NSAIDs for osteoarthritis. The nurse instructs the client that the best time to take the medication will be:
a.
upon rising.
b.
with meals.
c.
on an empty stomach.
d.
at bedtime.
ANS: B
GI upset is a classic side effect of the NSAIDs; therefore the medication should be taken with meals.
A client is ordered to receive aspirin after an acute heart attack. The nurse is evaluating use of this medication with other medications. The nurse is aware that aspirin can cause which drug interaction?
a.
Increased risk of bleeding with anticoagulants
b.
Decreased risk of hypoglycemia with oral hypoglycemic drugs
c.
Decreased ulcerogenic effect with glucocorticoids
d.
Increased risk of infection with amoxicillin
ANS: A
ASA is an anticoagulant that may increase the bleeding time when used with other anticoagulants.
A group of clients cared for by the nurse is ordered to take NSAIDs. Which client instruction would the nurse question?
a.
Instruct the client not to take aspirin and other NSAIDs together.
b.
Instruct the client to take NSAIDs with meals or 8 ounces of fluid.
c.
Instruct women to take NSAIDs during heavy menstrual flow for pain.
d.
Instruct the client to avoid alcohol when taking NSAIDs.
ANS: C
NSAIDs may increase the client’s bleeding time, which may increase bleeding time during menstrual periods.
Clients with which disorders are most often responsive to the NSAID groups of medications?
a.
Rheumatoid arthritis and osteoarthritis
b.
Postoperative pain and discomfort
c.
Infections and incisional pain
d.
Gastrointestinal discomfort and bleeding
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.
A client is ordered to receive gold therapy. The client asks how long it will take for him to feel the effects of this medication. The nurse teaches the client that gold medications:
a.
achieve the desired effect in 1 to 2 months.
b.
achieve the desired effect in 3 to 4 months.
c.
alleviate symptoms immediately.
d.
are effective within 7 days of therapy.
ANS: B
Gold therapy, or chrysotherapy, takes 3 to 4 months to reach effective levels.
A client is receiving auranofin (Ridaura). Which instruction takes priority?
a.
“You may have a salty taste in your mouth.”
b.
“You may experience constipation.”
c.
“You may experience visual changes.”
d.
“You’ll need frequent blood counts drawn.”
ANS: D
Agranulocytosis and thrombocytopenia are potentially life-threatening adverse reactions to the medication.
Client teaching related to colchicine (Novocolchine) includes which instruction?
a.
“Take the drug on an empty stomach.”
b.
“Keep fluid intake to no more than 1000 mL daily.”
c.
“Take a laxative daily to prevent constipation.”
d.
“Take the drug with food.”
ANS: D
The drug should be taken with food to avoid gastric upset.
A client with rheumatoid arthritis is ordered to receive tumor necrosis factor (TNF) as treatment for symptoms. Which manifestations are of most concern to the nurse?
a.
Elevated temperature and a sore throat
b.
Decreased range of motion and crepitation
c.
Constipation and abdominal pain
d.
Poor skin turgor and increased urine specific gravity
ANS: A
TNF may cause immunosuppression and increased risk for infection.
Indomethacin (Indocin) is highly protein bound and is ordered as a new medication for the client. The client is taking another medication that is moderately protein bound. Upon administration of both medications, the nurse should be most concerned with:
a.
indomethacin toxicity.
b.
indomethacin levels below the therapeutic level.
c.
an increase in medication side effects.
d.
toxic levels of the first drug.
ANS: D
The indomethacin would replace the first drug, allowing more of the first medication free for active drug levels.
In teaching a client about NSAIDs, the nurse is careful to teach about how to monitor for side effects. What side effect is of special concern?
a.
Tachycardia
b.
Polyuria
c.
Elevated temperature
d.
Gastrointestinal upset or distress
ANS: D
NSAIDs commonly cause gastrointestinal lining breakdown that may lead to ulceration.
A client diagnosed with acute gout is prescribed allopurinol (Zyloprim). The nurse is reviewing the client’s medication history and will contact the healthcare provider if the client is taking:
a.
diphenhydramine (Benadryl).
b.
metoclopramide (Reglan).
c.
propranolol (Inderal).
d.
warfarin (Coumadin).
ANS: D
Allopurinol (Zyloprim) increases the effects of warfarin (Coumadin). Allopurinol does not interact with diphenhydramine, metoclopramide, and propranolol.
A client is ordered to receive celecoxib (Celebrex) for chronic pain caused by osteoarthritis. The nurse anticipates that the client will exhibit:
a.
an increase in pain level.
b.
an increase in bleeding time.
c.
erosion of the stomach lining.
d.
a decrease in inflammation.
ANS: D
A decrease in inflammation is the anticipated function of this medication.
A client is ordered to receive a medication to relieve inflammation. The nurse determines that the medication is needed quickly. The nurse anticipates that which drug form will be ordered so that the medication can be released rapidly?
a.
Tablet
b.
Enteric-coated pill
c.
Capsule
d.
Liquid suspension
ANS: D
This medication does not need to go through the dissolution phase, so it is more rapidly absorbed.
A client is ordered to receive an NSAID for osteoarthritis. Which nursing intervention will treat the side effect most commonly associated with the NSAIDs?
a.
Taking the medication with meals
b.
Using sunscreen
c.
Avoiding crowds
d.
Encouraging deep breathing
ANS: A
The most common side effect is gastric upset, so taking the medication with meals will alleviate/assist with these symptoms.
The client has been ordered to be treated with Benemid. What is the highest priority instruction to give the client?
a.
“Take on an empty stomach.”
b.
“Increase fluid intake.”
c.
“Take with food.”
d.
“Limit fluid intake.”
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.
The client has been ordered to be treated with Ridaura. The nurse anticipates seeing an increased _____ in the client’s laboratory results.
a.
fasting blood glucose
b.
liver enzyme tests
c.
potassium level
d.
calcium level
ANS: B
The client who is being treated with Ridaura may exhibit a slight increase in liver enzyme tests.
The client is an older adult who has been diagnosed with cardiac arrhythmias. She has been ordered to be treated with Remicade. What should the nurse do?
a.
Administer the medication as ordered by the physician.
b.
Administer the drug after clarifying the dose with the pharmacist.
c.
Hold the drug and conduct the physician; the dosage should be decreased.
d.
Hold the drug and contact the physician; the drug is contraindicated.
ANS: D
Remicade is contraindicated when the client is elderly and is experiencing cardiac arrhythmias.
The client has been ordered to be treated with allopurinol. He complains to the nurse that he has noted changes in his vision. What is the most appropriate nursing intervention?
a.
Explain to the client that this is an expected response to the drug.
b.
Call the physician; this is a life-threatening response to the drug.
c.
Explain to the client that this is a normal side effect of the drug.
d.
Call the physician; this is an adverse reaction to the drug.
ANS: D
An adverse reaction to allopurinol is the development of cataracts and retinopathy.
A nurse is working on a pediatric unit. Which clients on the unit will be candidates for treatment with aspirin? (Select all that apply.)
a.
Child who is experiencing pain from an injury
b.
Child who has influenza-like symptoms
c.
Child who is exhibiting fever
d.
Child who has inflammation from an injury
ANS: A, B, D
Use of ASA following a viral infection has been related to Reye’s syndrome and is therefore contraindicated in children.
A client is ordered to receive a nonopioid analgesic. The nurse knows that the client is experiencing _____ pain.
a.
acute severe
b.
visceral (deep)
c.
acute mild
d.
superficial moderate to severe
ANS: C
Nonopioid analgesics are used for mild to moderate pain and may be available over the counter.
The client is complaining of severe pain. The nurse anticipates that the client will be ordered treatment with:
a.
aspirin.
b.
acetaminophen.
c.
diflunisal.
d.
morphine sulfate.
ANS: D
Morphine sulfate should be used for severe pain.
A 5-year-old client has an elevated temperature as a result of a viral respiratory tract infection. What nonopioid drug should be given to decrease the child’s body temperature?
a.
Aspirin
b.
Acetaminophen
c.
Diflunisal
d.
Sodium salicylate
ANS: B
Medications containing salicylates are not recommended because of the possibility of developing Reye’s syndrome.
An adolescent client tells the nurse that she takes acetaminophen (Tylenol) a few times every day because of “stress headaches.” The nurse advises her to see a primary healthcare provider because overuse of the medication may result in:
a.
nausea and anorexia.
b.
gastrointestinal irritation.
c.
hepatotoxicity.
d.
diaphoresis and fluid loss.
ANS: C
Tylenol is metabolized by the liver and, with extended use, may be toxic to liver tissue.
A client takes aspirin regularly to deal with the pain of arthritis. Which symptom may be indicative of a serious side effect of the medication?
a.
Intense abdominal pain
b.
Frequent constipation
c.
Excessive perspiration
d.
Excessive fatigue
ANS: A
ASA may cause gastric irritation and lead to ulceration. Abdominal pain may indicate this and may be a medical emergency.
A client is ordered to receive ibuprofen (Motrin) for dysmenorrhea. The highest priority instruction that the nurse should give the client is to take the drug:
a.
with fluid or food.
b.
on an empty stomach.
c.
upon arising.
d.
nightly before sleep.
ANS: A
Ibuprofen may cause gastric irritation, so food or fluid will decrease this effect.
A client is prescribed morphine sulfate for management of severe pain. The client tells the nurse that he takes several herbal preparations. Which herbal preparation will be of most concern to the nurse?
a.
Garlic
b.
Ginger
c.
St. John’s wort
d.
Saw palmetto
ANS: C
Opioids such as morphine sulfate may increase sedation when taken with St. John’s wort.
A nurse is planning the care of a client receiving opioid analgesia. What is considered a priority in planning this care?
a.
Monitoring respiratory rate
b.
Listening for adventitious breath sounds
c.
Assessing for speed of pupillary reaction
d.
Increasing the IV fluid flow rate
ANS: A
Assessing respiratory rate is a priority with medications that may cause respiratory depression.
A client requires an opioid antagonist after receiving an overdose of an opioid agent. The nurse anticipates that the client will be ordered:
a.
pentazocine.
b.
ibuprofen.
c.
naloxone.
d.
probenecid.
ANS: C
Narcan is a opioid antagonist used with overdose or oversedation caused by opioids.
The client is ordered methadone. The client is most likely experiencing:
a.
opioid overdose.
b.
acute or chronic pain.
c.
opioid addiction.
d.
sleep apnea.
ANS: C
Methadone is used to assist in detoxification and monitoring of people with drug addiction.
A nurse is assessing a postoperative client who received morphine sulfate for severe pain 1 hour ago. What common side effects are associated with this medication?
a.
Constipation and pruritus
b.
Diarrhea and lethargy
c.
Tachycardia and hypertension
d.
Coughing and wheezing
ANS: A
Constipation and pruritus are known to occur with morphine use and should be assessed in patients.
A patient receives nalbuphine (Nubain) for intense pain related to a fracture. Which nursing intervention is an important part of the plan of care 1 hour after administration of this medication?
a.
Strain all urine.
b.
Elevate the head of the bed.
c.
Monitor vital signs when getting out of bed.
d.
Infuse IV fluid at a rapid rate.
ANS: C
This medication may cause hypotension, so the nurse should assess vital signs with position changes.
An adult client with a head injury complains of severe pain. The nurse notes that the dose of opioid is half the normal adult dose. What is the reason for this?
a.
Head injury patients do not experience severe pain but are disoriented.
b.
Respiratory depression can lead to cerebral hemorrhage.
c.
Opioids decrease heart rate such that the brain becomes hypoxic.
d.
Respiratory depression allows for a buildup of CO2, a vasodilator.
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.
A client receives hydromorphone (Dilaudid) following an operative procedure. The nurse assesses the client’s urine output in order to monitor for which side effect of this medication?
a.
Urinary tract infections
b.
Incontinence
c.
Urinary retention
d.
Renal failure
ANS: C
A common side effect of opioid agents is urinary retention.
An adult client has just received morphine sulfate for severe pain. What would indicate that the pain medication was effective?
a.
Client lies very still in bed
b.
Reduction of the respiratory rate to 8 breaths per minute
c.
Facial grimacing and verbalization of relief of pain
d.
Lowering of tachycardia to within normal limits
ANS: D
A lowering of the heart rate to within normal limits indicates relief of pain.
The client is prescribed Imitrex for migraine headaches. She is nauseated and cannot take the medication by mouth. The nurse anticipates that the client will receive the medication via:
a.
subcutaneous injection.
b.
intramuscular injection.
c.
intravenous infusion.
d.
sublingual route.
ANS: A
Imitrex can be administered by mouth, by subcutaneous injection, or by intranasal route.
The client receiving Imitrex complains of dizziness. The nurse’s highest priority intervention is to recognize that this is a(n) ________ and notify the physician.
a.
adverse reaction to the medication
b.
food-drug interaction
c.
side effect of the medication
d.
life-threatening reaction to the drug
ANS: C
Dizziness is a side effect of treatment with Imitrex but is not life threatening.
The client is ordered Nubain intravenously for treatment of severe pain. The client anxiously asks when she can expect to have relief from the pain. The nurse anticipates that the client will have relief within _____ minutes.
a.
2 to 3
b.
5 to 6
c.
10 to 11
d.
15 to 16
ANS: A
Intravenous administration of Nubain should result in relief from pain within 2 to 3 minutes.
The client is taking acetaminophen on a regular basis as well as oral contraceptives. The nurse tells the client that this drug interaction will result in a(n) _____ in the effectiveness of the _____.
a.
decrease; oral contraceptives
b.
increase; oral contraceptives
c.
decrease; acetaminophen
d.
increase; acetaminophen
ANS: C
When acetaminophen is combined with oral contraceptives, the result is a decrease in the effectiveness of the acetaminophen.
A nurse has administered 8.0 mg morphine sulfate to an adult client in severe pain. What would the nurse evaluate as positive outcomes of this intervention? (Select all that apply.)
a.
Respiratory rate of 6 breaths/min
b.
Heart rate of 80 beats/minute
c.
Blood pressure 180/110 mm Hg
d.
Restlessness
e.
Absence of facial grimacing
f.
Verbalization of pain relief
g.
Ability to take deep breaths
ANS: B, E, F, G
These indicate relief of pain and represent normal vital and objective signs.
