Test Bank Medical Surgical Nursing Assessment Management Clinical Problems 8th Edition, Lewis
Chapter 1: Contemporary Nursing Practice
1. The nurse has admitted a patient with a new diagnosis of pneumonia and explained to the patient that together they will plan the patient’s care and set goals for discharge. The patient says, “How is that different from what the doctor does?” Which response by the nurse is most appropriate?
a. “The role of the nurse is to administer medications and other treatments prescribed by your doctor.”
b. “The nurse’s job is to help the doctor by collecting data and communicating when there are problems.”
c. “Nurses perform many of the procedures done by physicians, but nurses are here in the hospital for a longer time than doctors.”
d. “In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health.”
2. When providing patient care using evidence-based practice, the nurse uses
a. clinical judgment based on experience.
b. evidence from a clinical research study.
c. evidence-based guidelines in addition to clinical expertise.
d. evaluation of data showing that the patient outcomes are met.
3. The nurse primarily uses the nursing process in the care of patients
a. to explain nursing interventions to other health care professionals
b. as a problem-solving tool to identify and treat patients’ health care needs
c. as a scientific-based process of diagnosing the patient’s health care problems
d. to establish nursing theory that incorporates the biopsychosocial nature of humans
4. The nurse plans an every 2-hour turning schedule to prevent skin breakdown for a critically ill patient in the intensive care unit. In this case, the nursing action is considered to be
5. A patient who has been admitted to the hospital for surgery tells the nurse, “I do not feel right about leaving my children with my neighbor.” Which action should the nurse take next?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Call the neighbor to determine whether adequate childcare is being provided.
d. Gather more data about the patient’s feelings about the childcare arrangements.
6. A patient with a stroke is paralyzed on the left side of the body and has developed a pressure ulcer on the left hip. The best nursing diagnosis for this patient is
a. impaired physical mobility related to left-sided paralysis.
b. risk for impaired tissue integrity related to left-sided weakness.
c. impaired skin integrity related to altered circulation and pressure.
d. ineffective tissue perfusion related to inability to move independently.
7. A patient with an infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis. An appropriate patient outcome identified by the nurse is that the
a. patient has a balanced intake and output.
b. patient’s bedding is changed when it becomes damp.
c. patient understands the need for increased fluid intake.
d. patient’s skin remains cool and dry throughout hospitalization.
8. A nursing activity that is carried out during the evaluation phase of the nursing process is
a. determining if interventions have been effective in meeting patient outcomes.
b. documenting the nursing care plan in the progress notes in the medical record.
c. deciding whether the patient’s health problems have been completely resolved.
d. asking the patient to evaluate whether the nursing care provided was satisfactory.
9. During the assessment phase of the nursing process, the nurse
a. obtains data with which to diagnose patient problems.
b. uses patient data to develop priority nursing diagnoses.
c. teaches interventions to relieve patient health problems.
d. helps the patient identify realistic outcomes to health problems.
10. An example of a correctly written nursing diagnosis statement is
a. altered tissue perfusion related to heart failure.
b. risk for impaired tissue integrity related to sacral redness.
c. ineffective coping related to response to biopsy test results.
d. altered urinary elimination related to urinary tract infection.
Chapter 2: Health Disparities and Culturally Competent Care
1. The nurse obtains information about all these areas during the health interview for a new patient. Which area will be the focus of patient teaching?
a. Age and gender
b. Hispanic/Latino ethnicity
c. Family history of diabetes
d. Refined carbohydrate intake
2. When developing strategies to decrease health care disparities, the nurse working in a clinic located in a neighborhood with many Vietnamese individuals will include
a. improving public transportation.
b. obtaining low-cost medications.
c. updating equipment and supplies for the clinic.
d. educating staff about Vietnamese health beliefs.
3. Which information will the nurse need to collect when assessing the health status of a community?
a. Average income of community members
b. Morning traffic patterns in the community
c. Median life expectancy for the community
d. Occupations of individuals in the community
4. A family member of an elderly Hispanic patient admitted to the hospital tells the nurse that the patient has traditional beliefs about health and illness. The best action by the nurse is to
a. avoid asking any questions unless the patient initiates conversation.
b. ask the patient whether it is important that cultural healers are contacted.
c. explain the usual hospital routines for meal times, care, and family visits.
d. obtain further information about the patient’s cultural beliefs from the daughter.
5. When caring for a patient who is Native American, the best initial action by the nurse is to
a. avoid all eye contact with the patient.
b. observe the patient’s use of eye contact.
c. look directly at the patient when interacting.
d. ask the family about the patient’s cultural beliefs.
6. A new RN graduate is assessing a newly admitted non–English-speaking Chinese patient who complains of severe headaches. The charge nurse should intervene if the new RN’s first action is to
a. sit down at the bedside.
b. palpate the patient’s scalp.
c. call for a medical interpreter.
d. avoid eye contact with the patient.
7. If an interpreter is not available when a patient speaks a language different from the nurse’s language, it is appropriate for the nurse to
a. use specific medical terms in the Latin form.
b. talk slowly so that each word is clearly heard.
c. repeat important words so that the patient recognizes their importance.
d. use simple gestures to demonstrate meaning while talking to the patient.
8. When planning care for a hospitalized patient who uses culturally based treatments, the most appropriate action by the nurse is to
a. coordinate the use of folk treatments with ordered medical therapies.
b. discourage the use of culturally based treatments for Western diseases.
c. teach the patient that folk remedies will interfere with Western treatments.
d. ask the patient to discontinue the cultural treatments during hospitalization.
9. The best example of culturally appropriate nursing care when caring for a newly admitted patient is
a. having family members provide most of the patient’s personal care.
b. maintaining a personal space of at least 2 feet when assessing the patient.
c. asking permission before touching a patient during the physical assessment.
d. considering the patient’s ethnicity as the most important factor in planning care.
10. While talking with the nursing supervisor, a staff nurse expresses frustration that a Native American patient always has several family members at the bedside. The most appropriate action by the nursing supervisor is to
a. remind the nurse that family support is important to this family and patient.
b. have the nurse explain to the family that too many visitors will tire the patient.
c. suggest that the nurse ask family members to leave the room during patient care.
d. ask about the nurse’s personal beliefs about family support during hospitalization.
Chapter 3: Health History and Physical Examination
1. A patient who is having difficulty breathing is admitted to the hospital. The best approach for the nurse to use to obtain a complete health history is to
a. obtain subjective data about the patient from family members.
b. omit subjective data collection and obtain the physical examination.
c. use the health care provider’s medical history to obtain subjective data.
d. schedule several short sessions with the patient to gather subjective data.
2. Immediate surgery is planned for a patient with acute abdominal pain. The question used by the nurse that will elicit the most complete information about the patient’s coping-stress tolerance pattern is
a. “Can you tell me how intense your pain is now?”
b. “What do you think caused this abdominal pain?”
c. “How do you feel about yourself and your hospitalization?”
d. “Are there other major problems that are a concern right now?”
3. During the health history interview, a patient tells the nurse about periodic fainting spells. Which question by the nurse will be most helpful in determining the setting in which the fainting spells occur?
a. “How frequently do you have the fainting spells?”
b. “Where are you when you have the fainting spells?”
c. “Do the spells tend to occur at any special time of day?”
d. “Do you have any other symptoms along with the spells?”
4. The nurse records the following general survey of a patient: “The patient is a 68-year-old male Asian attended by his wife and two daughters. Alert and oriented. Does not make eye contact with the nurse and responds slowly, but appropriately, to questions. No apparent disabilities or distinguishing features.” Additional information that should be added to this general survey includes
a. nutritional status.
b. intake and output.
c. reasons for contact with the health care system.
d. comments of family members about his condition.
5. A nurse is performing a health history and physical examination for a patient with right-sided rib fractures. The pertinent negative finding is that the patient
a. states that there have been no other health problems recently.
b. denies having pain when the area over the fractures is palpated.
c. has several bruised and swollen areas on the right anterior chest.
d. refuses to take a deep breath because of the associated chest pain.
6. As the nurse assesses the patient’s neck, the patient says, “My neck is so stiff I can hardly move it.” This finding indicates the nurse should perform a(n)
a. focused assessment.
b. screening assessment.
c. emergency assessment.
d. comprehensive assessment.
7. The nurse is preparing to perform a focused abdominal assessment for a patient who has high-pitched bowel sounds. Which equipment will be needed?
c. Tongue blades
d. Percussion hammer
8. When the nurse is planning for the physical examination of an alert 86-year-old patient, adaptations to the examination technique should include
a. speaking slowly when directing the patient.
b. avoiding the use of touch as much as possible.
c. using slightly more pressure for palpation of the liver.
d. organizing the sequence to minimize position changes.
9. While the nurse is taking the health history, a patient states, “My father and grandfather both had heart attacks and were unable to be very active afterwards.” This statement is related to the functional health pattern of
c. coping-stress tolerance.
d. health perception–health management.
10. A patient is seen in the emergency department with chest pain and hypotension. Which type of assessment should the nurse do at this time?
a. Focused assessment
b. Subjective assessment
c. Emergency assessment
d. Comprehensive assessment
Chapter 4: Patient and Caregiver Teaching
1. A patient with newly diagnosed breast cancer has a nursing diagnosis of deficient knowledge about breast cancer. When the nurse is planning teaching for the patient, which is the most important initial learning goal?
a. The patient will select the most appropriate breast cancer therapy.
b. The patient will state ways of preventing the recurrence of the tumor.
c. The patient will demonstrate coping skills needed to manage the disease.
d. The patient will choose methods to minimize adverse effects of treatment.
2. After the nurse implements diet instruction for a patient with heart disease, the patient can explain the information but fails to make the recommended dietary changes. The nurse’s evaluation is that
a. learning did not occur because the patient’s behavior did not change.
b. choosing not to follow the diet is the behavior that resulted from learning.
c. the nursing responsibility for helping the patient make dietary changes has been fulfilled.
d. the teaching methods were ineffective in helping the patient learn the dietary information.
3. A 43-year-old is diagnosed with type 2 diabetes mellitus after being admitted to the hospital with an infected foot wound. When applying principles of adult learning, which teaching strategy by the nurse is most likely to be effective?
a. Discuss the importance of blood glucose control in maintenance of long-term health.
b. Demonstrate the correct method for cleaning and redressing the wound to the patient.
c. Assure the patient that the nurse is an expert on management of diabetes complications.
d. Wait until after discharge and have a home health nurse teach about foot care and diabetes management.
4. A patient admitted to the hospital with hyperglycemia and newly diagnosed diabetes mellitus is scheduled for discharge the second day after admission. When implementing patient teaching, which is the best action for the nurse to take?
a. Instruct about the increased risk for cardiovascular disease.
b. Provide detailed information about dietary control of glucose.
c. Teach glucose self-monitoring and medication administration.
d. Give information about the effects of exercise on glucose control.
5. When using the Transtheoretical Model of Health Behavior Change during patient teaching, the nurse identifies that the patient who states, “I told my wife that I was going to start exercising, and I think I will join a fitness club,” is in the stage of
6. While admitting a patient to the medical unit, the nurse learns that the patient does not read well. This information will guide the nurse in determining
a. the degree of patient motivation and readiness to learn.
b. what information the patient will be able to understand.
c. that the family must be included in the teaching process.
d. which instructional strategies should be used in teaching.
7. When assessing the learning needs for a patient who has coronary heart disease, the nurse finds that the patient has recently made dietary changes to decrease fat intake and has stopped smoking. The best initial statement by the nurse at this time is
a. “Although those are important, it is essential that you make other changes, too.”
b. “Are you having any difficulty in maintaining the changes you have already made?”
c. “You have already accomplished some changes that are important in heart health.”
d. “Which additional changes in your lifestyle would you like to implement at this time?”
8. To assess a patient’s readiness to learn before planning teaching activities, which question should the nurse ask?
a. “What kind of work and leisure activities do you do?”
b. “What information do you think you need right now?”
c. “Do you have any religious beliefs that are inconsistent with the treatment?”
d. “Can you describe the types of activities that help you learn new information?”
9. The nurse develops a nursing diagnosis of ineffective health maintenance related to low motivation based on the finding that the diabetic patient
a. does not perform capillary blood glucose tests as directed.
b. occasionally forgets to take the daily prescribed medication.
c. says that dietary intake does not seem to impact fatigue level.
d. cannot identify signs or symptoms of high and low blood glucose.
10. A patient with poor circulation to the feet requires teaching about foot care. Which learning goal should the nurse include in the teaching plan?
a. The nurse will demonstrate the proper technique for trimming toenails.
b. The patient will list three ways to protect the feet from injury by discharge.
c. The nurse will instruct the patient on appropriate foot care before discharge.
d. The patient will understand the rationale for proper foot care after instruction.
Chapter 5: Chronic Illness and Older Adults
1. When caring for a patient with type 2 diabetes who has been hospitalized with severe hyperglycemia, which topic will be most important to include in discharge teaching?
a. Effect of endogenous insulin on transportation of glucose into cells
b. Function of the liver in formation of glycogen and gluconeogenesis
c. Impact of the patient’s family history on likelihood of developing diabetes
d. Symptoms indicating that the patient should contact the health care provider
2. Which question will provide the most useful information when the nurse is performing a comprehensive geriatric assessment of an older adult who is being assessed for admission to an assisted-living facility?
a. “Have you had any recent infections?”
b. “How frequently do you see a doctor?”
c. “Do you have a history of heart disease?”
d. “Are you able to prepare your own meals?”
3. The nurse is planning care for an alert and active 85-year-old patient who takes multiple medications for chronic cardiac and respiratory disease and lives with a daughter who works during the day. Which nursing diagnosis is most appropriate?
a. Risk for injury related to drug-drug interactions
b. Social isolation related to weakness and fatigue
c. Compromised family coping related to the patient’s many care needs
d. Caregiver role strain related to need to adjust family employment schedule
4. To obtain the most complete information when doing an assessment for an 81-year-old patient, the nurse will
a. interview both the patient and the primary patient caregiver.
b. use a geriatric assessment instrument to evaluate the patient.
c. review the patient’s chart for the history of medical problems.
d. ask the patient to write down medical problems and medications.
5. When developing the plan of care for an older adult who is hospitalized for an acute illness, the nurse should
a. use a standardized geriatric nursing care plan.
b. minimize activity level during hospitalization.
c. plan for transfer to a long-term care facility after the hospitalization.
d. consider the preadmission functional abilities when setting patient goals.
6. When caring for an older adult who lives in a rural area, the nurse will plan to
a. assess the patient for chronic diseases that are unique to rural areas.
b. ensure transportation to appointments with the health care provider.
c. suggest that the patient move to an urban area for better health care.
d. obtain adequate medications for the patient to last for 4 to 6 months.
7. When the nurse is working in the outpatient clinic, which nursing action will be most helpful in decreasing the risk for drug-drug interactions in an older adult patient?
a. Teach the patient to have all prescriptions filled at the same pharmacy
b. Instruct the patient to avoid taking over-the-counter (OTC) medications.
c. Make a medication schedule for the patient as a reminder about when to take each medication.
d. Have the patient bring all the medications, supplements, and herbs to every health care appointment.
8. Which action will the nurse take when planning for discharge of a 68-year-old patient who will need daily assistance with activities such as shopping and transportation?
a. Write to the state Medicaid office.
b. Contact the Area Agency on Aging.
c. Provide documentation to Medicare.
d. Communicate with the patient’s insurer.
9. A 78-year-old patient with multiple health problems complains of having “no energy” and feeling increasingly weak. The patient has had an 11-pound weight loss over the last year. The nurse should initially
a. ask the patient about daily dietary intake.
b. schedule regular range-of-motion exercise.
c. discuss long-term care placement with the patient.
d. describe normal changes with aging to the patient.
10. When admitting an 88-year-old patient to the hospital, the nurse should plan to
a. speak slowly and loudly while facing the patient.
b. obtain a detailed medical history from the patient.
c. interview the patient before the physical assessment.
d. determine whether the patient uses glasses or hearing aids.
Chapter 6: Community-Based Nursing and Home Care
1. A family caregiver tells the home health nurse, “I feel like I can never get away to do anything for myself.” Which action will be best for the nurse to take?
a. Assist the caregiver in finding respite services.
b. Assure the caregiver that the work is appreciated.
c. Teach the caregiver that family members provide excellent patient care.
d. Encourage the caregiver to discuss feelings openly with the nurse as needed.
2. A patient who was in an automobile accident is assigned a nurse as a case manager. The responsibilities of the nurse in this role are to
a. care for the patient during hospitalization for the injuries.
b. assist the patient with home care activities during recovery.
c. coordinate the services that the patient receives in the hospital and at home.
d. determine the types of medical care the patient needs for optimal rehabilitation.
3. A patient who has just moved to a long-term care facility has a nursing diagnosis of relocation stress syndrome. Which action should the nurse include in the plan of care?
a. Remind the patient that making changes is usually stressful.
b. Discuss the reason for the move to the facility with the patient.
c. Restrict family visits until the patient is accustomed to the facility.
d. Have staff members write notes welcoming the patient to the facility.
4. A 78-year-old patient hospitalized for a fractured hip has recovered from the surgery but needs to work with physical therapy to improve mobility before returning home. The nurse will anticipate transferring the patient to
a. an acute care setting.
b. a transitional care setting.
c. a residential care facility.
d. an intermediate care facility.
5. In describing home care services to a patient requiring extended care, the nurse tells the patient that
a. technologically complex therapies must be managed in the hospital.
b. the patient’s family will be included in planning and the patient’s care.
c. home care services are limited to visits by registered nurses or home health aides.
d. in order for insurance to cover the home care, the patient must be confined to bed.
6. Which of these patients being discharged by the acute care nurse meets the requirements for Medicare reimbursement for home health services?
a. A 71-year-old who needs weekly blood sampling for monitoring of clotting times
b. A 70-year-old who receives daily intravenous antibiotics for an infected leg wound
c. A 68-year-old diabetic patient who needs teaching about a diabetic diet and lifestyle
d. A 65-year-old patient with a spinal cord injury and paralysis who needs dressing changes
7. When the home health nurse is caring for a patient who needs to relearn self-care skills such as dressing and self-feeding, which referral will be best?
b. Speech therapist
c. Physical therapist
d. Occupational therapist
8. When making an initial home visit, the most appropriate approach by the nurse is to
a. ask the patient and family what their expectations are.
b. tell the patient and family all of the planned interventions.
c. instruct the family members that they will need to participate in care.
d. discuss the importance of following through with health care provider orders.
9. Which of these patients should the nurse refer for Medicare-reimbursed home health services?
a. A 71-year-old with dementia who needs 24-hour care to prevent injury
b. An 82-year-old whose family has asked for respite care for a few days a month
c. A 67-year-old who requires assistance with shopping, housework, and cooking
d. A 79-year-old who needs to have medications placed in a marked pillbox weekly
10. The family of an 85-year-old with chronic health problems and increasing weakness is considering placing the patient in a long-term care (LTC) facility. Which action by the nurse will be most helpful in assisting the patient to make the transition?
a. Have the family select an LTC facility that is relatively new.
b. Obtain the patient’s input about the choice of LTC facility.
c. Ask that the patient be placed in a private room at the facility.
d. Explain the reasons for the need to live in LTC to the patient.
Chapter 7: Complementary and Alternative Therapies
1. After the charge nurse has completed orienting a new staff nurse, which action by the staff nurse indicates that further education about complementary and alternative therapy may be needed?
a. The new nurse massages the legs of a patient who has a left foot stasis ulcer.
b. The new nurse does a capillary blood glucose check for a patient taking aloe.
c. The new nurse suggests the use of acupressure to a patient with tension headaches.
d. The new nurse shows family members how to provide a hand massage to a patient.
2. A patient with fibromyalgia has back pain and stiffness. The nurse suggests that a therapy that might be appropriate for this patient is
c. St. John’s wort.
d. magnetic therapy.
3. Which of these complementary and alternative therapies should the nurse suggest to a patient who has elevated triglyceride levels?
a. Fish oil
b. Milk thistle
c. Saw palmetto
d. Ginkgo biloba
4. Which information obtained by the nurse when admitting a patient with osteoarthritis may indicate a need for patient teaching?
a. The patient obtains information about herbal therapies online.
b. The patient takes glucosamine daily to prevent knee and hip pain.
c. The patient attends a weekly yoga class to improve flexibility and balance.
d. The patient states that prayer helps to improve the knee pain and function.
5. A patient with chronic headaches seeks treatment from a nurse trained in Healing Touch (HT). During the HT session, the nurse will
a. realign the patient’s energy flow.
b. manipulate muscles and soft tissues.
c. apply pressure to body points where energy is obstructed.
d. passively move stressed joints through the range of motion.
6. A patient who has nausea associated with chemotherapy asks the nurse whether there are any complementary and alternative therapies that might be effective. The nurse should discuss the use of
a. green tea.
c. black cohosh.
d. chiropractic therapy.
7. A patient who develops frequent upper respiratory infections (URIs) asks the nurse whether any herbal therapies might help. The nurse suggests that the patient try
c. ginkgo biloba.
d. St. John’s wort.
8. Which information will the nurse include when discussing the use of herbal remedies with a patient who uses a variety of herbs for health maintenance?
a. Herbs should be purchased only from manufacturers with a history of quality control.
b. Most herbs are toxic and carcinogenic and should be used only when proven effective.
c. Herbs are no better than conventional drugs in maintaining health and may be less safe.
d. Frequent medical evaluation is required during the use of herbs to avoid adverse effects.
9. Which information obtained by the nurse during the preoperative assessment of a patient is most important to assess further?
a. The patient uses several herbal remedies routinely.
b. The patient recently visited a chiropractor for back pain.
c. The patient has used acupressure to relieve postoperative nausea in the past.
d. The patient expresses a wish to use acupuncture for postoperative pain control.
10. A patient who has a chronic foot wound tells the nurse about using herbal therapies to boost immune function rather than taking antibiotics. Which action should the nurse take first?
a. Instruct the patient about the rationale for antibiotic use to treat infection.
b. Remind the patient that the infection has not cleared with herbal treatment.
c. Determine how the patient would feel about using antibiotics in addition to herbal products.
d. Tell the patient that studies of herbal products indicate that they are not effective in treating infection.
Chapter 8: Stress and Stress Management
1. A 22-year-old patient arrives in the emergency department (ED) with multiple abrasions after a motor vehicle accident and has an initial blood pressure (BP) of 180/98. The nurse will plan to
a. discuss the need for hospital admission to control blood pressure.
b. treat the abrasions and discuss the risks associated with hypertension.
c. recheck the blood pressure before the patient’s discharge from the ED.
d. start an intravenous (IV) line to administer antihypertensive medications.
2. A hospitalized patient who is usually well organized and calm is receiving diabetic teaching after being newly diagnosed with diabetes. The patient is forgetful, irritable, and has poor concentration. Which action should the nurse take?
a. Ask the health care provider for a psychiatric referral.
b. Administer the PRN sedative medication every 4 hours.
c. Suggest the use of a home caregiver to the patient’s family.
d. Plan to reinforce and repeat teaching about diabetes management.
3. A patient who has been hospitalized for a heart attack tells the nurse, “I didn’t sleep last night because I worried about missing work and losing my insurance coverage.” Which nursing diagnosis is appropriate to include in the plan of care?
b. Defensive coping
c. Ineffective denial
d. Risk prone health behavior
4. The nurse is assisting with a breast biopsy for an alert patient who has a lump in the right breast. Which relaxation technique will be best to use at this time?
c. Guided imagery
d. Relaxation breathing
5. A patient who has fibromyalgia tells the nurse, “My life feels very chaotic and out of my control. I will not be able to manage if anything else happens.” Which response should the nurse make initially?
a. “Regular massages may help reduce muscle pain.”
b. “Guided imagery can be helpful in regaining control.”
c. “Tell me more about how your life has been recently.”
d. “Your previous coping mechanism can help you now.”
6. When choosing music to help relax a patient who is having a painful dressing change, which action is best for the nurse to take?
a. Use music composed by Mozart.
b. Ask the patient about music preferences.
c. Select music that has 60 to 80 beats/minute.
d. Encourage the patient to use music without words.
7. The nurse is teaching a hospitalized patient to use imagery as a relaxation technique. Which statement by the nurse is appropriate?
a. “Place your stress in the image of a form you can destroy.”
b. “Think of a place where you feel peaceful and comfortable.”
c. “Bring what you hear and sense in your present environment into your image of the scene.”
d. “If your scene is stressful to you, continue visualizing until you can overcome the distress.”
8. An overweight patient who enjoys active outdoor activities develops arthritis in the knees. Which action by the nurse will be best to assist the patient in coping with the diagnosis?
a. Ask the patient to discuss feelings about the diagnosis.
b. Have the patient practice frequent relaxation breathing.
c. Educate the patient on the use of imagery to decrease pain and decrease stress.
d. Encourage the patient to think about how weight loss might improve symptoms.
9. A diabetic patient who is hospitalized tells the nurse, “I don’t understand why I can keep my blood sugar under control at home with diet alone, but when I get sick, my blood sugar goes up.” Which response by the nurse is appropriate?
a. “It is probably just coincidental that your blood sugars are high when you are ill.”
b. “Stressors such as illness cause the release of hormones that increase blood sugar.”
c. “Increased blood sugar occurs because the kidneys are not able to metabolize glucose as well during stressful times.”
d. “Your diet is different here in the hospital than at home and that is the most likely cause of the increased glucose level.”
Chapter 9: Sleep and Sleep Disorders
1. To assist in determining whether a patient seen in the ambulatory care setting has chronic insomnia, the nurse will initially
a. schedule a polysomnography (PSG) study.
b. arrange for the patient to have a sleep study.
c. ask the patient to keep a 2-week sleep diary.
d. teach the patient about the use of an actigraph.
2. Which instruction will the nurse include when teaching a patient with chronic insomnia about ways to improve sleep quality?
a. Avoid aerobic exercise during the day.
b. Read in bed for a few minutes each night.
c. Keep the bedroom temperature slightly warm.
d. Try to go to bed at the same time every evening.
3. After the nurse has taught a patient about the use of extended-release zolpidem (Ambien CR) for insomnia, which patient statement indicates a need for further teaching?
a. “I will take the medication an hour before bedtime.”
b. “I should take the medication on an empty stomach.”
c. “I should not take this medication unless I can sleep for at least 6 hours.”
d. “I will schedule activities that require mental alertness for later in the day.”
4. Which action is best for the nurse to include in the plan of care in order to improve sleep quality for a critically ill patient in the intensive care unit (ICU)?
a. Ask all visitors to leave the ICU for the night.
b. Lower the level of light from 8:00 PM until 7:00 AM.
c. Avoid the use of opioids for pain relief during the evening hours.
d. Schedule assessments to allow at least 4 hours of uninterrupted sleep.
5. Which information will the nurse plan to include when teaching a patient with narcolepsy about management of the disorder?
a. Stimulant drugs should be used for only a short time because of the risk for abuse.
b. Driving an automobile may be possible with appropriate treatment of narcolepsy.
c. Changes in sleep hygiene are ineffective in improving sleep quality in narcolepsy.
d. Antidepressant drugs are prescribed to treat the depression caused by the disorder.
6. Which action by the nurse manager of an acute care unit will improve the alertness of nurses who must work the night shift?
a. Arrange for older staff members to work most night shifts.
b. Provide a sleeping area for staff to use for napping at night.
c. Post reminders about the relationship of sleep and alertness.
d. Schedule nursing staff to rotate day and night shifts monthly.
7. The nurse takes the health history for four patients in the clinic. Which information regarding the patients’ sleep is most important to communicate to the health care provider?
a. A 21-year-old student takes melatonin to assist in sleeping when traveling from the United States to Europe.
b. A 32-year-old who is experiencing a stressful week uses diphenhydramine (Benadryl) for several nights.
c. A 41-year-old with a body mass index (BMI) of 42 kg/m2 says that the spouse complains about the patient’s snoring.
d. A 64-year-old nurse who works the night shift reports drinking hot chocolate before going to bed in the morning.
8. Which of these actions should the nurse take first for a patient in the clinic who is complaining of insomnia and daytime fatigue?
a. Question the patient about the use of over-the-counter (OTC) sleep aids.
b. Suggest that the patient decrease intake of caffeine-containing beverages.
c. Advise the patient to get out of bed if unable to fall asleep in 10 to 20 minutes.
d. Recommend that the patient use any prescribed sleep aids for only 2 to 3 weeks.
9. A patient with sleep apnea who received a new prescription for a continuous positive airway pressure (CPAP) device a week ago returns to the clinic and says that severe daytime fatigue is still a problem. Which action should the nurse take first?
a. Teach about radiofrequency ablation.
b. Plan to schedule a night time PSG study.
c. Ask the patient whether the CPAP is being used every night.
d. Discuss the possible surgical approaches used for sleep apnea.
Chapter 10: Pain
1. When doing a pain assessment for a patient who has been admitted with metastatic breast cancer, which question asked by the nurse will give the most information about the patient’s pain?
a. “How long have you had this pain?”
b. “How would you describe your pain?”
c. “How much medication do you take for the pain?”
d. “How many times a day do you medicate for pain?”
2. A patient who uses a fentanyl (Duragesic) patch for chronic cancer pain complains to the nurse of the rapid onset of pain at a level 9 (0 to 10 scale) and requests “something for pain that will work quickly.” The nurse will document this as
a. somatic pain.
b. referred pain.
c. neuropathic pain.
d. breakthrough pain.
3. A postoperative patient asks the nurse how the prescribed ibuprofen (Motrin) will control the incisional pain. The nurse will teach the patient that ibuprofen interferes with the pain process by decreasing the
a. modulating effect of descending nerves.
b. sensitivity of the brain to painful stimuli.
c. production of pain-sensitizing chemicals.
d. spinal cord transmission of pain impulses.
4. A patient with chronic cancer pain is receiving imipramine (Tofranil) in addition to long-acting morphine for pain control. Which information is the best indicator that the imipramine is effective?
a. The patient sleeps 8 hours every night.
b. The patient has no symptoms of anxiety.
c. The patient states, “I feel much less depressed since I’ve been taking the imipramine.”
d. The patient states, “The pain is manageable, and I can accomplish my desired activities.
5. A patient with chronic abdominal pain has learned to control the pain with the use of imagery and hypnosis. A family member asks the nurse how these techniques work. The nurse’s reply is based on the information that these strategies
a. impact the cognitive and affective components of pain.
b. increase the modulating effect of the efferent pathways.
c. prevent transmission of nociceptive stimuli to the cortex.
d. slow the release of transmitter chemicals in the dorsal horn.
6. A patient who is receiving sustained-release morphine sulfate (MS Contin) every 12 hours for chronic pain experiences level 9 (0 to 10 scale) breakthrough pain and anxiety. Which of these prescribed medications will be best for the nurse to administer?
a. lorazepam (Ativan) 1 mg orally
b. amitriptyline (Elavil) 10 mg orally
c. ibuprofen (Motrin) 400 to 800 mg orally
d. immediate-release morphine 30 mg orally
7. A patient with chronic back pain is seen in the pain clinic for follow-up. In order to evaluate whether the pain management is effective, which question is best for the nurse to ask?
a. “Can you describe the quality of your pain?”
b. “Has there been a change in the pain location?”
c. “How would you rate your pain on a 0 to 10 scale?”
d. “Does the pain keep you from doing things you enjoy?”
8. A patient with second-degree burns has been receiving morphine through patient-controlled analgesia (PCA) for a week. The patient wakes up frequently during the night complaining of pain. The most appropriate action by the nurse is to
a. administer a dose of morphine every 1 to 2 hours from the PCA machine while the patient is sleeping.
b. consult with the health care provider about using a different treatment protocol to control the patient’s pain.
c. request that the health care provider order a bolus dose of morphine to be given when the patient awakens with pain.
d. teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal.
9. When caring for a patient who is receiving epidural morphine, which information obtained by the nurse indicates that the patient may be experiencing a side effect of the medication?
a. The patient has cramping abdominal pain.
b. The patient becomes restless and agitated.
c. The patient has not voided for over 10 hours.
d. The patient complains of a “pounding” headache.
10. When the nurse visits a hospice patient, the patient has a respiratory rate of 8 breaths/minute and complains of severe pain. Which action is best for the nurse to take?
a. Inform the patient that increasing the morphine will cause the respiratory drive to fail.
b. Administer a nonopioid analgesic, such as a nonsteroidal anti-inflammatory drug (NSAID), to improve patient pain control.
c. Tell the patient that additional morphine can be administered when the respirations are 12.
d. Titrate the prescribed morphine dose upward until the patient indicates adequate pain relief.
Chapter 11: Palliative Care at End of Life
1. The nurse is caring for a terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. The nurse documents this finding as
a. agonal breathing.
b. apneustic breathing.
c. death-rattle respirations.
d. Cheyne-Stokes respirations.
2. A 21-year-old is dying after an automobile accident. The family members want to donate the patient’s organs and ask the nurse how the decision about brain death is made. The nurse explains that the patient will be considered brain dead when
a. the patient is flaccid and unresponsive.
b. CPR is ineffective in restoring heartbeat.
c. the patient is apneic and without brainstem reflexes.
d. respiratory efforts cease and no apical pulse is audible.
3. A hospice patient is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. The nurse explains to the family that these symptoms
a. will continue to increase until death finally occurs.
b. are a normal response before these functions decrease.
c. indicate a reflex response to the slowing of other body systems.
d. may be associated with an improvement in the patient’s condition.
4. A patient who has been diagnosed with metastatic cancer and has a poor prognosis plans a trip across the country “to settle some issues with my sisters and brothers.” The nurse recognizes that the patient is manifesting the psychosocial response of
b. yearning and protest.
c. anxiety about unfinished business.
d. fear of the meaninglessness of one’s life.
5. The spouse of a patient with terminal lung cancer visits daily and cheerfully talks with the patient about vacation plans for the next year. When the nurse asks about any concerns, the spouse says, “I’m busy at work, but otherwise things are fine.” An appropriate nursing diagnosis is
a. ineffective coping related to lack of grieving.
b. anxiety related to complicated grieving process.
c. caregiver role strain related to feeling overwhelmed.
d. hopelessness related to knowledge deficit about cancer.
6. As the nurse admits a patient with severe heart failure to the hospital, the patient tells the nurse, “If my heart or breathing stop, I do not want to be resuscitated.” Which action is best for the nurse to take?
a. Ask if these wishes have been discussed with the health care provider.
b. Place a “Do Not Resuscitate” (DNR) notation in the patient’s care plan.
c. Inform the patient that a notarized advance directive must be included in the record or resuscitation must be performed.
d. Advise the patient to designate a person to make health care decisions when the patient is not able to make them independently.
7. A patient who is very close to death is very restless and keeps repeating, “I am not ready to die.” Which action is best for the nurse to take?
a. Remind the patient that no one feels ready for death.
b. Sit at the bedside and ask if there is anything the patient needs.
c. Insist that family members remain at the bedside with the patient.
d. Tell the patient that everything possible is being done to delay death.
8. A patient in a hospice program is experiencing continuous, increasing amounts of pain. The nurse caring for the patient plans the scheduling of opioid pain medications to provide
a. around-the-clock routine administration of analgesics.
b. PRN doses of medication whenever the patient requests.
c. enough pain medication to keep the patient sedated and unaware of stimuli.
d. analgesic doses that provide pain control without decreasing respiratory rate.
9. When caring for a patient with lung cancer in a home hospice program, it is important for the nurse to
a. discuss cancer risk factors and appropriate lifestyle modifications.
b. encourage the patient to discuss past life events and their meaning.
c. accomplish a thorough head-to-toe assessment several times a week.
d. educate the patient about the purpose of chemotherapy and radiation.
10. A hospice nurse who has become very close to a terminally ill patient and family is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time?
a. Contact a grief counselor as soon as possible.
b. Cry along with the patient’s family members.
c. Leave the home as quickly as possible to allow the family to grieve privately.
d. Consider whether working in hospice is desirable since patient losses are common.
Chapter 12: Addictive Behaviors
1. When assessing a patient who has a history of alcohol abuse, the nurse will plan to assess for
a. low blood pressure.
b. decreased heart rate.
c. elevated temperature.
d. abdominal tenderness.
2. A patient who smokes a pack of cigarettes daily is admitted to the hospital for surgery. When planning postoperative care, the nurse should include measures to
a. improve sleep.
b. enhance appetite.
c. decrease diarrhea.
d. prevent sore throat.
3. A new 21-year-old patient who is scheduled for an annual physical examination arrives in the clinic smelling of cigarette smoke and carrying a pack of cigarettes. Which action will the nurse plan to take?
a. Urge the patient to quit smoking as soon as possible.
b. Avoid confronting the patient about smoking at this time.
c. Wait for the patient to start the discussion about quitting smoking.
d. Explain that the “cold turkey” method is most effective in stopping smoking.
4. A patient admitted to the hospital after an automobile accident has a blood alcohol concentration (BAC) of 220 mg/dl (0.22 mg%). The patient is alert and does not appear highly intoxicated. An appropriate nursing action is to
a. maintain the patient on NPO status.
b. avoid the use of intravenous (IV) fluids.
c. administer acetaminophen for headache.
d. monitor frequently for anxiety, hyperreflexia, and sweating.
5. A patient who is alcohol-intoxicated must undergo emergency surgery for abdominal trauma. The nurse anticipates that during the perioperative period, the patient
a. will require an increased dose of the general anesthetic medication.
b. will need frequent monitoring for bleeding and respiratory complications.
c. is likely to develop withdrawal symptoms within a few hours after surgery.
d. should be stimulated every hour to prevent prolonged postoperative sedation.
6. A patient with alcohol dependence is admitted to the hospital with chest pain. Twenty-four hours after admission, the patient becomes very tremulous and anxious. An appropriate intervention by the nurse is to
a. insert an IV line and infuse fluids.
b. promote oral intake to 3000 ml/day.
c. provide a quiet, well-lit environment.
d. administer opioids to provide sedation.
7. A patient with a history of heavy alcohol use is seen at the clinic with acute gastritis. Which statement by the patient indicates that the patient is in the contemplation stage of change?
a. “I am older and wiser now, and I know I can change my drinking behavior.”
b. “Alcohol has never bothered my stomach. I think it’s likely that I have the flu.”
c. “I think my drinking is affecting my stomach, but maybe some drugs will help.”
d. “People say that I drink too much, but I really feel pretty good most of the time.”
8. A patient who smokes a pack of cigarettes daily develops tachycardia and irritability on the second day after abdominal surgery. Which action is best for the nurse to take at this time?
a. Escort the patient outside where smoking is allowed.
b. Request a prescription for a nicotine replacement agent.
c. Move the patient to a private room and allow smoking.
d. Tell the patient that this is a good time to quit smoking.
9. A patient who is admitted to the hospital for treatment of an abscess on the left thigh admits to using fentanyl (Sublimaze) illegally. The nurse will monitor the patient for manifestations of withdrawal such as
a. nausea and diarrhea.
b. tremors and seizures.
c. lethargy and disorientation.
d. delusions and hallucinations.
10. A patient in the outpatient clinic who is using a nicotine patch (Nicoderm CQ) tells the nurse about waking frequently during the night. Which action is best for the nurse to take?
a. Question the patient about use of the patch at night.
b. Suggest that the patient go to bed earlier in the evening.
c. Ask the health care provider about prescribing a sedative drug for nighttime use.
d. Remind the patient that the benefits of the patch outweigh the short-term insomnia.
Chapter 13: Inflammation and Wound Healing
1. The nurse assesses a surgical patient the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate?
a. Obtain wound cultures.
b. Document the assessment.
c. Notify the health care provider.
d. Assess the wound every 2 hours.
2. A patient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. The nurse anticipates that the next action will be to
a. obtain wound cultures.
b. start antibiotic therapy.
c. redress the wound with wet-to-dry dressings.
d. continue to monitor the wound for purulent drainage.
3. A patient with a systemic bacterial infection has “goose pimples,” feels cold, and has a shaking chill. At this stage of the febrile response, the nurse will plan to monitor for
a. skin flushing.
b. muscle cramps.
c. rising body temperature.
d. decreasing blood pressure.
4. A 24-year-old patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). Which action by the nurse is most appropriate?
a. Apply a cooling blanket.
b. Notify the health care provider.
c. Give the prescribed PRN aspirin (Ascriptin) 650 mg.
d. Check the patient’s oral temperature again in 4 hours.
5. A patient’s 6 ´ 3-cm leg wound has a 2-mm black area surrounded by yellow-green semiliquid material. Which dressing will the nurse use for wound care?
a. Dry gauze dressing (Kerlix)
b. Nonadherent dressing (Xeroform)
c. Hydrocolloid dressing (DuoDerm)
d. Transparent film dressing (Tegaderm)
6. A 76-year-old patient has an open surgical wound on the abdomen that contains a creamy exudate and small areas of deep pink granulation tissue. The nurse documents the wound as a
a. red wound.
b. yellow wound.
c. full-thickness wound.
d. stage III pressure wound.
7. Which nursing action is most likely to detect early signs of infection in a patient who is taking immunosuppressive medications?
a. Monitor white blood cell count.
b. Check the skin for areas of redness.
c. Check the temperature every 2 hours.
d. Ask about fatigue or feelings of malaise.
8. The nurse will plan to use wet-to-dry dressings when providing care for a patient with a
a pressure ulcer with pink granulation tissue.
a. surgical incision with pink, approximated edges.
b. full-thickness burn filled with dry, black material.
c. wound with purulent drainage and dry brown areas.
9. A patient is admitted to the hospital with a pressure ulcer on the left buttock. The base of the wound is yellow and involves subcutaneous tissue. The nurse classifies the pressure ulcer as stage
10. A patient who is confined to bed and who has a stage II pressure ulcer is being cared for in the home by family members. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to
a. change the patient’s bedding frequently.
b. use a hydrocolloid dressing over the ulcer.
c. record the size and appearance of the ulcer weekly.
d. change the patient’s position at least every 2 hours.
Chapter 14: Genetics, Altered Immune Responses, and Transplantation
1. A patient whose mother has been diagnosed with BRCA gene–related breast cancer asks the nurse, “Do you think I should be tested for the gene?” Which response by the nurse is most appropriate?
a. “In most cases, breast cancer is not caused by the BRCA gene.”
b. “It depends on how you will feel if the test is positive for the BRCA gene.”
c. “There are many things to consider before deciding to have genetic testing.”
d. “You should decide first whether you are willing to have a double mastectomy.”
2. A patient seen in the outpatient clinic has an immune deficiency involving the T-lymphocytes. The nurse should teach the patient about the need for more frequent screening for
c. antibody deficiency.
d. autoimmune disorders.
3. In counseling a couple in which the man has an autosomal recessive disorder, and the woman has no gene for the disorder, the nurse uses Punnett squares to show the couple that the probability of their having a child with the disorder is
4. The nurse encourages a new mother to breastfeed her infant, even for a short time, because colostrum will provide the infant with
a. innate immunity.
b. active immunity.
c. passive immunity.
d. cell-mediated immunity.
5. A patient is being evaluated for possible atopic dermatitis. The nurse will review the patient’s laboratory values for the level of
6. A 62-year-old patient who is having an annual check-up tells the nurse, “I don’t understand why I need to have so many cancer screening tests now. I feel just fine!” The nurse will plan to teach the patient about the
a. consequences of aging on cell-mediated immunity.
b. decrease in antibody production associated with aging.
c. impact of poor nutrition on immune function in older people.
d. incidence of cancer-stimulating infections in older individuals.
7. The nurse discusses the prevention and management of allergic reactions with a beekeeper who has developed a hypersensitivity to bee stings. The nurse identifies a need for additional teaching when the patient states,
a. “I will plan to take oral antihistamines daily before going to work.”
b. “I will get a prescription for epinephrine and learn to self-inject it.”
c. “I should wear a Medic Alert bracelet indicating my allergy to bee stings.”
d. “I am going to need job retraining so that I can work in a different occupation.”
8. Which instruction will be included when teaching a patient with possible allergies about intradermal skin testing?
a. “Do not eat anything for about 6 hours before the testing.”
b. “Take an oral antihistamine about an hour before the testing.”
c. “Plan to wait in the clinic for 20 to 30 minutes after the testing.”
d. “Reaction to the testing will take about 48 to 72 hours to occur.”
9. A patient who receives weekly immunotherapy at a clinic missed the previous appointment. When the patient comes for the next injection, the nurse should
a. schedule an additional dose that week.
b. administer the usual dosage of the allergen.
c. consult with the health care provider about giving a lower allergen dose.
d. re-evaluate the patient’s sensitivity to the allergen with a repeat skin test.
10. While obtaining a health history from the patient who works as a laboratory technician, the nurse learns that the patient has a history of allergic rhinitis, asthma, and multiple food allergies. It is important that the nurse
a. encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops.
b. advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves.
c. document the patient’s allergy history and be alert for any clinical manifestations of a type I latex allergy.
d. recommend that the patient use vinyl gloves instead of latex gloves in preventing blood-borne pathogen contact.
Chapter 15: Infection and Human Immunodeficiency Virus Infection
1. A patient who has vague symptoms of fatigue and headaches is found to have a positive enzyme immunoassay (EIA) for human immunodeficiency virus (HIV) antibodies. In discussing the test results with the patient, the nurse informs the patient that
a. the EIA test will need to be repeated to verify the results.
b. a viral culture will be done to determine the progress of the disease.
c. it will probably be 10 or more years before the patient develops acquired immunodeficiency syndrome (AIDS).
d. the Western blot test will be done to determine whether AIDS has developed.
2. A patient is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP) and HIV testing is positive. Based on diagnostic criteria established by the Centers for Disease Control and Prevention (CDC), the patient is diagnosed as having
a. acute infection.
b. early chronic infection.
c. intermediate chronic infection.
d. late chronic infection or AIDS.
3. After having a positive rapid-antibody test for HIV, a patient is anxious and does not appear to hear what the nurse is saying. At this time, it is most important that the nurse
a. teach the patient about the medications available for treatment.
b. inform the patient how to protect sexual and needle-sharing partners.
c. remind the patient about the need to return for retesting to verify the results.
d. ask the patient to notify individuals who have had risky contact with the patient.
4. A patient who is diagnosed with AIDS tells the nurse, “I have lots of thoughts about dying. Do you think I am just being morbid?” Which response by the nurse is best?
a. “Thinking about dying will not improve the course of AIDS.”
b. “It is important to focus on the good things about your life now.”
c. “Do you think that taking an antidepressant might be helpful to you?”
d. “Can you tell me more about the kind of thoughts that you are having?”
5. A pregnant woman with a history of early chronic HIV infection is seen at the clinic. Which information will the nurse include when teaching the patient?
a. The antiretroviral medications used to treat HIV infection are teratogenic.
b. Most infants born to HIV-positive mothers are not infected with the virus.
c. Since she is at an early stage of HIV infection, the infant will not contract HIV.
d. It is likely that her newborn will become infected with HIV unless she uses antiretroviral drug therapy (ART).
6. When the nurse is caring for a patient whose HIV status in unknown, which of these patient exposures is most likely to require postexposure prophylaxis?
a. Needle stick with a needle and syringe used to draw blood
b. Splash into the eyes when emptying a bedpan containing stool
c. Contamination of open skin lesions with patient vaginal secretions
d. Needle stick injury with a suture needle during a surgical procedure
7. A 20-year-old female patient who is HIV-positive has a new prescription for efavirenz (Sustiva). Which information about the patient is most important to communicate to the prescribing physician before administering the efavirenz?
a. The patient’s CD4+ T cell count is 800 cells/μL.
b. The patient already has etravirine (Intelence) prescribed.
c. The patient states that the antiretroviral therapy (ART) frequently cause nausea.
d. The patient is sexually active and does not use any contraception.
8. Antiretroviral therapy (ART) is being considered for an HIV-infected patient who has a CD4+ cell count of 400/µl. Which factor is most important to consider when determining whether ART will be started for this patient?
a. Patient social support system
b. HIV genotype and phenotype
c. Potential medication side effects
d. Patient ability to comply with ART schedule
9. Which of these patients will the nurse working in an HIV testing and treatment clinic anticipate teaching about antiretroviral therapy (ART)?
a. A patient who is currently HIV negative but has unprotected sex with multiple partners
b. A patient who was infected with HIV 15 years ago and now has a CD4+ count of 840/µl
c. An HIV-positive patient with a CD4+ count of 120/µl who drinks a fifth of whiskey daily
d. A patient who tested positive for HIV 2 years ago and has cytomegalovirus (CMV) retinitis
10. When assessing an individual who has been diagnosed with early chronic HIV infection and has a normal CD4+ count, the nurse will
a. check neurologic orientation.
b. ask about problems with diarrhea.
c. palpate the regional lymph nodes.
d. examine the oral mucosa for lesions.
Chapter 16: Cancer
1. While being prepared for a biopsy of a lump in the right breast, the patient asks the nurse about the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct?
a. “Benign tumors do not cause damage to other tissues.”
b. “Benign tumors are likely to recur in the same location.”
c. “Malignant tumors may spread to other tissues or organs.”
d. “Malignant cells reproduce more rapidly than normal cells.”
2. A patient is receiving intravesical bladder chemotherapy. The nurse will monitor for
3. The nurse in the outpatient clinic is caring for a 50-year-old who smokes heavily. To reduce the patient’s risk of dying from lung cancer, which action will be best for the nurse to take?
a. Educate the patient about the seven warning signs of cancer.
b. Plan to monitor the patient’s carcinoembryonic antigen (CEA) level.
c. Discuss the risks associated with cigarettes during every patient encounter.
d. Teach the patient about the use of annual chest x-rays for lung cancer screening.
4. After the nurse has finished teaching a patient who is scheduled to receive external beam radiation for abdominal cancer about appropriate diet, which dietary selection by the patient indicates that the teaching has been effective?
a. Fresh fruit salad
b. Roasted chicken
c. Whole wheat toast
d. Cream of potato soup
5. During a routine health examination, a 30-year-old patient tells the nurse about a family history of colon cancer. Which action should the nurse take next?
a. Educate the patient about the need for a colonoscopy at age 50.
b. Teach the patient how to do home testing for fecal occult blood.
c. Obtain more information from the patient about the family history.
d. Schedule a sigmoidoscopy to provide baseline data about the patient.
6. When reviewing the chart for a patient with cervical cancer, the nurse notes that the cancer is staged as Tis, N0, M0. The nurse will teach the patient that
a. the cancer is localized to the cervix.
b. the cancer cells are well-differentiated.
c. further testing is needed to determine the spread of the cancer.
d. it is difficult to determine the original site of the cervical cancer.
7. Which statement by a patient who is scheduled for a needle biopsy of the prostate indicates that the nurse’s teaching about the purpose of the biopsy has been effective?
a. “The biopsy will remove the cancer in my prostate gland.”
b. “The biopsy will determine how much longer I have to live.”
c. “The biopsy will help decide the treatment for my enlarged prostate.”
d. “The biopsy will indicate whether the cancer has spread to other organs.”
8. The nurse is teaching a postmenopausal patient with stage III breast cancer about the expected outcomes of her cancer treatment. Which patient statement indicates that the teaching has been effective?
a. “After cancer has not recurred for 5 years, it is considered cured.”
b. “The cancer will be cured if the entire tumor is surgically removed.”
c. “Cancer is never considered cured, but the tumor can be controlled with surgery, chemotherapy, and radiation.”
d. “I will need to have follow-up examinations for many years after I have treatment before I can be considered cured.”
9. A patient with a large stomach tumor that is attached to the liver is scheduled to have a debulking procedure. The nurse explains that the expected outcome of this surgery is
a. relief of pain by cutting sensory nerves in the stomach.
b. control of the tumor growth by removal of malignant tissue.
c. decrease in tumor size to improve the effects of other therapy.
d. promotion of better nutrition by relieving the pressure in the stomach.
10. External-beam radiation is planned for a patient with endometrial cancer. The nurse teaches the patient that an important measure to prevent complications from the effects of the radiation is to
a. test all stools for the presence of blood.
b. maintain a high-residue, high-fiber diet.
c. clean the perianal area carefully after every bowel movement.
d. inspect the mouth and throat daily for the appearance of thrush.
Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances
1. The nurse obtains all of the following assessment data about a patient with deficient fluid volume caused by a massive burn injury. Which of the following assessment data will be of greatest concern?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 ml over the last hour.
c. Oral fluid intake is 100 ml for the last 8 hours.
d. There is prolonged skin tenting over the sternum.
2. A recently admitted patient has a small cell carcinoma of the lung, which is causing the syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully for
a. increased total urinary output.
b. elevation of serum hematocrit.
c. decreased serum sodium level.
d. rapid and unexpected weight loss.
3. When the nurse is evaluating the fluid balance for a patient admitted for hypovolemia associated with multiple draining wounds, the most accurate assessment to include is
a. skin turgor.
b. daily weight.
c. presence of edema.
d. hourly urine output.
4. When caring for an alert and oriented elderly patient with a history of dehydration, the home health nurse will teach the patient to increase fluid intake
a. in the late evening hours.
b. if the oral mucosa feels dry.
c. when the patient feels thirsty.
d. as soon as changes in level of consciousness (LOC) occur.
5. A patient is taking a potassium-wasting diuretic for treatment of hypertension. The nurse will teach the patient to report symptoms of adverse effects such as
a. personality changes.
b. frequent loose stools.
c. facial muscle spasms.
d. generalized weakness.
6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic. Which statement by the patient indicates that the teaching about this medication has been effective?
a. “I will try to drink at least 8 glasses of water every day.”
b. “I will use a salt substitute to decrease my sodium intake.”
c. “I will increase my intake of potassium-containing foods.”
d. “I will drink apple juice instead of orange juice for breakfast.”
7. When caring for a patient admitted with hyponatremia, which actions will the nurse anticipate taking?
a. Restrict patient’s oral free water intake.
b. Avoid use of electrolyte-containing drinks.
c. Infuse a solution of 5% dextrose in 0.45% saline.
d. Administer vasopressin (antidiuretic hormone, [ADH]).
8. Intravenous potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 20 mEq/hour.
c. Give the KCl only through a central venous line.
d. Add no more than 40 mEq/L to a liter of IV fluid.
9. A postoperative patient who has been receiving nasogastric suction for 3 days has a serum sodium level of 125 mEq/L (125 mmol/L). Which of these prescribed therapies that the patient has been receiving should the nurse question?
a. Infuse 5% dextrose in water at 125 ml/hr.
b. Administer IV morphine sulfate 4 mg every 2 hours PRN.
c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
d. Administer 3% saline if serum sodium drops to less than 128 mEq/L.
10. A patient who has required prolonged mechanical ventilation has the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse interprets these results as
a. metabolic acidosis.
b. metabolic alkalosis.
c. respiratory acidosis.
d. respiratory alkalosis.
Chapter 18: Nursing Management: Preoperative Care
1. During the preoperative interview, a patient scheduled for an elective hysterectomy tells the nurse, “I am afraid that I will die in surgery like my mother did!” Which response by the nurse is most appropriate?
a. “Tell me more about what happened to your mother.”
b. “You will receive medications to reduce your anxiety.”
c. “You should talk to the doctor again about the surgery.”
d. “Surgical techniques have improved a lot in recent years.”
2. A patient arrives at the ambulatory surgery center for a scheduled outpatient surgery. Which information is of most concern to the nurse?
a. The patient has not had outpatient surgery before.
b. The patient is planning to drive home after surgery.
c. The patient’s insurance does not cover outpatient surgery.
d. The patient had a glass of water a few hours before arriving.
3. A 36-year-old woman is admitted for an outpatient surgery. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery?
a. The patient’s lack of knowledge about postoperative pain control measures
b. The patient’s statement that her last menstrual period was 8 weeks previously
c. The patient’s history of a postoperative infection following a prior cholecystectomy
d. The patient’s concern that she will be unable to care for her children postoperatively
4. A patient who is scheduled for surgery in a week tells the nurse doing the preoperative assessment about an allergy to bananas, kiwifruit, and latex products. Which action is most important for the nurse to take?
a. Notify the dietitian about the food allergies.
b. Alert the surgery center about the latex allergy.
c. Reassure the patient that all allergies are noted on the medical record.
d. Ask whether the patient uses antihistamines to reduce allergic reactions.
5. Any patient guilt about having a therapeutic abortion may be identified when the nurse assesses the functional health pattern of
d. coping-stress tolerance.
6. During the preoperative assessment of a patient scheduled for a colon resection, the patient tells the nurse about using St. John’s wort to prevent depression. The nurse should alert the staff in the postanesthesia recovery area that the patient may
a. experience increased pain.
b. have hypertensive episodes.
c. take longer to recover from the anesthesia.
d. have more postoperative bleeding than expected.
7. On the day of surgery, the nurse is admitting a patient with a history of cigarette smoking. Which action is most important at this time?
a. Auscultate for adventitious breath sounds.
b. Ask whether the patient has smoked recently.
c. Remind the patient about harmful effects of smoking.
d. Calculate the cigarette smoking history in pack-years.
8. A patient is seen at the health care provider’s office several weeks before hip surgery for preoperative assessment. The patient reports use of echinacea, saw palmetto, and glucosamine/chondroitin. The nurse should
a. ascertain that there will be no interactions with anesthetic agents.
b. discuss the supplement use with the patient’s health care provider.
c. teach the patient that these products may be continued preoperatively.
d. advise the patient to stop the use of all herbs and supplements at this time.
9. Before the administration of preoperative medications, the nurse is preparing to witness the patient signing the operative consent form when the patient says, “I do not really understand what the doctor said.” Which action is best for the nurse to take?
a. Provide an explanation of the planned surgical procedure.
b. Notify the surgeon that the informed consent process is not complete.
c. Administer the prescribed preoperative antibiotics and withhold any ordered sedative medications.
d. Notify the operating room staff that the surgeon needs to give a more complete explanation of the procedure.
10. Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for a colon resection?
a. Care for the surgical incision
b. Medications used during surgery
c. Deep breathing and coughing techniques
d. Oral antibiotic therapy after discharge home
Chapter 19: Nursing Management: Intraoperative Care
1. The perioperative nurse encourages a family member or a friend to remain with a patient in the preoperative holding area until the patient is taken into the operating room primarily to
a. ensure the proper identification of the patient before surgery.
b. protect the patient from cross-contamination with other patients.
c. assist the perioperative nurse to obtain a complete patient history.
d. help relieve the stress of separation for the patient and significant others.
2. Which description best defines the role of the nurse anesthetist as a member of the surgical team?
a. Functions independently in the administration of anesthetics
b. Has the same credentials and responsibilities as an anesthesiologist
c. Is responsible for intraoperative administration of anesthetics ordered by the anesthesiologist
d. Requires supervision by the anesthesiologist or surgeon while administering anesthesia to a patient
3. Which outcome measure will be best for the operating room (OR) nurse manager to use in determining the effectiveness of the physical environment and traffic control measures in the operating room?
a. Smooth functioning of the OR team
b. Effective protection of patient privacy
c. Rapid completion of surgical procedure
d. Low incidence of perioperative infection
4. Which action will the scrub nurse use to maintain aseptic technique during surgery?
a. Use waterproof shoe covers.
b. Wear personal protective equipment.
c. Insist that all operating room (OR) staff perform a surgical scrub.
d. Change gloves after touching the upper arm of the surgeon’s gown.
5. After orienting a new staff member to the scrub nurse role, the nurse preceptor will know that the teaching was effective if the new staff member
a. documents all patient care accurately.
b. labels all specimens to send to the lab.
c. keeps both hands above the operating table level.
d. takes the patient to the postanesthesia recovery area.
6. Data that were obtained during the perioperative nurse’s assessment of a patient in the preoperative holding area that would indicate a need for special protection techniques during surgery include
a. a stated allergy to cats and dogs.
b. a history of spinal and hip arthritis.
c. verbalization of anxiety by the patient.
d. having a sip of water 2 hours previously.
7. The nurse from the general surgical unit is asked to bring the patient’s hearing aid to the surgical suite. The nurse will take the hearing aid to the
a. clean core.
b. scrub sink areas.
c. nursing station or information desk.
d. corridors of the operating room area.
8. A preoperative patient in the holding area asks the nurse, “Will the doctor put me to sleep with a mask over my face?” The most appropriate response by the nurse is,
a. “A drug will be given to you through your IV line, which will cause you to go to sleep almost immediately.”
b. “Only your surgeon can tell you for sure what method of anesthesia will be used. Should I ask your surgeon?”
c. “General anesthesia is now given by injecting medication into your veins, so you will not need a mask over your face.”
d. “Masks are not used anymore for anesthesia. A tube will be inserted into your throat to deliver a gas that will put you to sleep.”
9. A surgical patient received a volatile liquid as an inhalation anesthetic during surgery. Postoperatively the nurse should monitor the patient for
d. incisional pain.
10. When the nurse caring for a patient before surgery has a question about a sedative medication to be given before sending the patient to the surgical suite, the nurse will communicate with the
c. circulating nurse.
d. registered nurse first assistant (RNFA).
Chapter 20: Nursing Management: Postoperative Care
1. A 42-year-old patient is recovering from anesthesia in the postanesthesia care unit (PACU). On admission to the PACU, the blood pressure (BP) is 124/70. Thirty minutes after admission, the blood pressure falls to 112/60, with a pulse of 72 and warm, dry skin. The most appropriate action by the nurse at this time is to
a. increase the rate of the IV fluid replacement.
b. continue to take vital signs every 15 minutes.
c. administer oxygen therapy at 100% per mask.
d. notify the anesthesia care provider (ACP) immediately.
2. During recovery from anesthesia in the postanesthesia care unit (PACU), a patient’s vital signs are blood pressure 118/72, pulse 76, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action should the nurse take at this time?
a. Place the patient in a side-lying position.
b. Encourage the patient to take deep breaths.
c. Prepare to transfer the patient from the PACU.
d. Increase the rate of the postoperative IV fluids.
3. After a new nurse has been oriented to the postanesthesia care unit (PACU), the charge nurse will evaluate that the orientation has been successful when the new nurse
a. places a patient in the Trendelenburg position when the blood pressure (BP) drops.
b. assists a patient to the prone position when the patient is nauseated.
c. turns an unconscious patient to the side when the patient arrives in the PACU.
d. positions a newly admitted unconscious patient supine with the head elevated.
4. A 75-year-old is to be discharged from the ambulatory surgical unit following left eye surgery. The patient tells the nurse, “I do not know if I can take care of myself with this patch over my eye.” The most appropriate nursing action is to
a. refer the patient for home health care services.
b. discuss the specific concerns regarding self-care.
c. give the patient written instructions regarding care.
d. assess the patient’s support system for care at home.
5. After removal of the nasogastric (NG) tube on the second postoperative day, the patient is placed on a clear liquid diet. Four hours later, the patient complains of sharp, cramping gas pains. Which action should the nurse take?
a. Reinsert the NG tube.
b. Give the PRN IV opioid.
c. Assist the patient to ambulate.
d. Place the patient on NPO status.
6. Following gallbladder surgery, a patient’s T-tube is draining dark green fluid. Which action should the nurse take?
a. Place the patient on bed rest.
b. Notify the patient’s surgeon.
c. Document the color and amount of drainage.
d. Irrigate the T-tube with sterile normal saline.
7. In intervening to promote ambulation, coughing, deep breathing, and turning by a postoperative patient on the first postoperative day, which action by the nurse is most helpful?
a. Discuss the complications of immobility and poor cough effort.
b. Teach the patient the purpose of respiratory care and ambulation.
c. Administer ordered analgesic medications before these activities.
d. Give the patient positive reinforcement for accomplishing these activities.
8. The nurse evaluates that the interventions for the nursing diagnosis of ineffective airway clearance in a postoperative patient have been successful when the
a. patient drinks 2 to 3 L of fluid in 24 hours.
b. patient uses the spirometer 10 times every hour.
c. patient’s breath sounds are clear to auscultation.
d. patient’s temperature is less than 100.4° F orally.
9. A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. The patient’s oxygen saturation is 99%, and recent lab results are all normal. Which action by the nurse is most appropriate?
a. Insert an oral or nasal airway.
b. Notify the anesthesia care provider.
c. Orient the patient to time, place, and person.
d. Be sure that the patient’s IV lines are secure.
10. Which action should the postanesthesia care unit (PACU) nurse delegate to nursing assistive personnel (NAP) who help with the transfer of a patient to the surgical unit?
a. Help with the transfer of the patient onto a stretcher.
b. Give a verbal report to the surgical unit charge nurse.
c. Document the appearance of the patient’s incision in the chart.
d. Ensure that the receiving nurse understands the postoperative orders.
AND MUCH MORE