Test Bank Medical Surgical Nursing Patient Centered Collaborative Care 8th Edition, Ignatavicius
Chapter 1: Introduction to Medical-Surgical Nursing Practice
1. A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor advises the student that which is the priority when working as a professional nurse?
a. Attending to holistic client needs
b. Ensuring client safety
c. Not making medication errors
d. Providing client-focused care
2. A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide to help the client promote his or her own safety?
a. Encourage the client and family to be active partners.
b. Have the client monitor hand hygiene in caregivers.
c. Offer the family the opportunity to stay with the client.
d. Tell the client to always wear his or her armband.
3. A nurse is caring for a postoperative client on the surgical unit. The client’s blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?
a. Call the Rapid Response Team.
b. Document and continue to monitor.
c. Notify the primary care provider.
d. Repeat blood pressure measurement in 15 minutes.
4. A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best demonstrates this concept?
a. Assesses for cultural influences affecting health care
b. Ensures that all the clients’ basic needs are met
c. Tells the client and family about all upcoming tests
d. Thoroughly orients the client and family to the room
5. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors?
a. Bring a list of all medications and what they are for.
b. Keep the doctor’s phone number by the telephone.
c. Make sure all providers wash hands before entering the room.
d. Write down the name of each caregiver who comes in the room.
6. Which action by the nurse working with a client best demonstrates respect for autonomy?
a. Asks if the client has questions before signing a consent
b. Gives the client accurate information when questioned
c. Keeps the promises made to the client and family
d. Treats the client fairly compared to other clients
7. A student nurse asks the faculty to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What answer by the faculty is most accurate?
a. Avoid embarrassing the client by asking questions.
b. Don’t make assumptions about their health needs.
c. Most LGBTQ people do not want to share information.
d. No differences exist in communicating with this population.
8. A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed narcotic pain medication. Which statement is part of the SBAR format for communication?
a. A: “I would like you to order a different pain medication.”
b. B: “This client has allergies to morphine and codeine.”
c. R: “Dr. Smith doesn’t like nonsteroidal anti-inflammatory meds.”
d. S: “This client had a vaginal hysterectomy 2 days ago.”
9. A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client’s blood pressure is much higher than previous readings, and the client’s mental status has changed. What action by the nurse would most likely have prevented this negative outcome?
a. Determining if the UAP knew how to take blood pressure
b. Double-checking the UAP by taking another blood pressure
c. Providing more appropriate supervision of the UAP
d. Taking the blood pressure instead of delegating the task
10. A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality improvement (QI) projects. What response by the precepting nurse is best?
a. “All staff nurses are required to participate in quality improvement here.”
b. “Even being new, you can implement activities designed to improve care.”
c. “It’s easy to identify what indicators should be used to measure quality.”
d. “You should ask to be assigned to the research and quality committee.”
Chapter 2: Common Health Problems of Older Adults
1. A nursing faculty member working with students explains that the fastest growing subset of the older population is which group?
a. Elite old
b. Middle old
c. Old old
d. Young old
2. A nurse working with older adults in the community plans programming to improve morale and emotional health in this population. What activity would best meet this goal?
a. Exercise program to improve physical function
b. Financial planning seminar series for older adults
c. Social events such as dances and group dinners
d. Workshop on prevention from becoming an abuse victim
3. A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse perform first?
a. Auscultate bowel sounds.
b. Check skin turgor.
c. Perform an oral assessment.
d. Weigh the client.
4. A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the client demonstrates a need for further review?
a. Barley soup
b. Black beans
c. White rice
d. Whole wheat bread
5. A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue?
a. “Cut some sodium out of your diet.”
b. “Dehydration can cause incontinence.”
c. “Have something to drink every 1 to 2 hours.”
d. “Take your diuretic in the morning.”
6. A home health care nurse is planning an exercise program with an older client who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult?
a. Building strength and flexibility
b. Improving exercise endurance
c. Increasing aerobic capacity
d. Providing personal training
7. An older adult recently retired and reports “being depressed and lonely.” What information should the nurse assess as a priority?
a. History of previous depression
b. Previous stressful events
c. Role of work in the adult’s life
d. Usual leisure time activities
8. A nurse is assessing coping in older women in a support group for recent widows. Which statement by a participant best indicates potential for successful coping?
a. “I have had the same best friend for decades.”
b. “I think I am coping very well on my own.”
c. “My kids come to see me every weekend.”
d. “Oh, I have lots of friends at the senior center.”
9. A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps?
a. Have the client use a walker or cane on the steps.
b. Install contrasting color strips at the edge of each step.
c. Instruct the client to use the garage door instead.
d. Tell the client to use a two-footed gait on the steps.
10. An older adult is brought to the emergency department because of sudden onset of confusion. After the client is stabilized and comfortable, what assessment by the nurse is most important?
a. Assess for orthostatic hypotension.
b. Determine if there are new medications.
c. Evaluate the client for gait abnormalities.
d. Perform a delirium screening test.
Chapter 3: Assessment and Care of Patients with Pain
1. A student asks the nurse what is the best way to assess a client’s pain. Which response by the nurse is best?
a. Numeric pain scale
b. Behavioral assessment
c. Objective observation
d. Client’s self-report
2. A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. What response by the experienced nurse is best?
a. “Being able to sleep doesn’t mean pain doesn’t exist.”
b. “Have you ever experienced any type of pain?”
c. “The client should be assessed for drug addiction.”
d. “You’re right; I would put the medication back.”
3. The nurse in the surgery clinic is discussing an upcoming surgical procedure with a client. What information provided by the nurse is most appropriate for the client’s long-term outcome?
a. “At least you know that the pain after surgery will diminish quickly.”
b. “Discuss acceptable pain control after your operation with the surgeon.”
c. “Opioids often cause nausea but you won’t have to take them for long.”
d. “The nursing staff will give you pain medication when you ask them for it.”
4. A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What pain assessment tool would the nurse choose for this assessment?
a. Numeric rating scale
b. Verbal Descriptor Scale
c. FACES Pain Scale-Revised
d. Wong-Baker FACES Pain Scale
5. The nurse is assessing a client’s pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. What question by the nurse would be best to ask the client for completing a comprehensive pain assessment?
a. “Are you worried about addiction to pain pills?”
b. “Do you attach any spiritual meaning to pain?”
c. “How high would you say your pain tolerance is?”
d. “What pain rating would be acceptable to you?”
6. A nurse is assessing pain in an older adult. What action by the nurse is best?
a. Ask only “yes-or-no” questions so the client doesn’t get too tired.
b. Give the client a picture of the pain scale and come back later.
c. Question the client about new pain only, not normal pain from aging.
d. Sit down, ask one question at a time, and allow the client to answer.
7. The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny changes in physical condition and is “on the light constantly” asking for more pain medication. When assessing this client’s pain, what statement or question by the nurse is most appropriate?
a. “Help me understand how pain is affecting you right now.”
b. “I wish I could do more; is there anything I can get for you?”
c. “You cannot have more pain medication for 3 hours.”
d. “Why do you think the medication is not helping your pain?”
8. A nurse on the medical-surgical unit has received a hand-off report. Which client should the nurse see first?
a. Client being discharged later on a complicated analgesia regimen
b. Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale
c. Postoperative client who received oral opioid analgesia 45 minutes ago
d. Client who has returned from physical therapy and is resting in the recliner
9. A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia. The client scores a zero. What action by the nurse is best?
a. Assess physiologic indicators and vital signs.
b. Do not give pain medication as no pain is indicated.
c. Document the findings and continue to monitor.
d. Try a small dose of analgesic medication for pain.
10. A student nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. What response by the registered nurse is best?
a. “A multimodal approach is the preferred method of control.”
b. “Doctors are much more liberal with pain medications now.”
c. “Pain is so complex it takes different approaches to control it.”
d. “Clients are consumers and they demand lots of pain medicine.”
Chapter 4: Genetic and Genomic Concepts for Medical-Surgical Nursing
1. A nurse is educating a client about genetic screening. The client asks why red-green color blindness, an X-linked recessive disorder noted in some of her family members, is expressed more frequently in males than females. How should the nurse respond?
a. “Females have a decreased penetrance rate for this gene mutation and are therefore less likely to express the trait.”
b. “Females have two X chromosomes and one is always inactive. This inactivity decreases the effect of the gene.”
c. “The incidence of X-linked recessive disorders is higher in males because they do not have a second X chromosome to balance expression of the gene.”
d. “Males have only one X chromosome, which allows the X-linked recessive disorder to be transmitted from father to son.”
2. A client is typed and crossmatched for a unit of blood. Which statement by the nurse indicates a need for further genetic education?
a. “Blood type is formed from three gene alleles: A, B, and O.”
b. “Each blood type allele is inherited from the mother or the father.”
c. “If the client’s blood type is AB, then the client is homozygous for that trait.”
d. “If the client has a dominant and a recessive blood type allele, only the dominant will be expressed.”
3. A nurse cares for a client of Asian descent who is prescribed warfarin (Coumadin). What action should the nurse perform first?
a. Schedule an international normalized ratio (INR) test to be completed each day.
b. Initiate fall precautions and strict activity limitations.
c. Teach the client about bleeding precautions, including frequent checks for any bruising.
d. Confirm the prescription starts warfarin at a lower-than-normal dose.
4. A nurse obtains health histories when admitting clients to a medical-surgical unit. With which client should the nurse discuss predisposition genetic testing?
a. Middle-aged woman whose mother died at age 48 of breast cancer
b. Young man who has all the symptoms of rheumatoid arthritis
c. Pregnant woman whose father has sickle cell disease
d. Middle-aged man of Eastern European Jewish ancestry
5. A client who tests positive for a mutation in the BRCA1 gene allele asks a nurse to be present when she discloses this information to her adult daughter. How should the nurse respond?
a. “I will request a genetic counselor who is more qualified to be present for this conversation.”
b. “The test results can be confusing; I will help you interpret them for your daughter.”
c. “Are you sure you want to share this information with your daughter, who may not test positive for this gene mutation?”
d. “This conversation may be difficult for both of you; I will be there to provide support.”
6. A nurse consults a genetic counselor for a client whose mother has Huntington disease and is considering genetic testing. The client states, “I know I want this test. Why do I need to see a counselor?” How should the nurse respond?
a. “The advanced practice nurse will advise you on whether you should have children or adopt.”
b. “Genetic testing can be a stressful experience. Counseling can provide support and education throughout the process.”
c. “There is no cure for this disease. The counselor will determine if there is any benefit to genetic testing.”
d. “Genetic testing is expensive. The counselor will advocate for you and help you obtain financial support.”
7. A health care provider prescribes genetic testing for a client who has a family history of colorectal cancer. Which action should the nurse take before scheduling the client for the procedure?
a. Confirm that informed consent was obtained and placed on the client’s chart.
b. Provide genetic counseling to the client and the client’s family members.
c. Assess if the client is prepared for the risk of psychological side effects.
d. Respect the client’s right not to share the results of the genetic test.
8. A nurse cares for an adult client who has received genetic testing. The client’s mother asks to receive the results of her daughter’s genetic tests. Which action should the nurse take?
a. Obtain a signed consent from the client allowing test results to be released to the mother.
b. Invite the mother and other family members to participate in genetic counseling with the client.
c. Encourage the mother to undergo genetic testing to determine if she has the same risks as her child.
d. Direct the mother to speak with the client and support the client’s decision to share or not share the results.
9. A nurse cares for a client who has a genetic mutation that increases the risk for colon cancer. The client states that he does not want any family to know about this result. How should the nurse respond?
a. “It is required by law that you inform your siblings and children about this result so that they also can be tested and monitored for colon cancer.”
b. “It is not necessary to tell your siblings because they are adults, but you should tell your children so that they can be tested before they decide to have children of their own.”
c. “It is not required that you tell anyone about this result. However, your siblings and children may also be at risk for colon cancer and this information might help them.”
d. “It is your decision to determine with whom, if anyone, you discuss this test result. However, you may be held liable if you withhold this information and a family member gets colon cancer.”
10. A nurse cares for a client who has a specific mutation in the a1AT (alpha1-antitrypsin) gene. Which action should the nurse take?
a. Teach the client to perform monthly breast self-examinations and schedule an annual mammogram.
b. Support the client when she shares test results and encourages family members to be screened for cancer.
c. Advise the client to limit exposure to secondhand smoke and other respiratory irritants.
d. Obtain a complete health history to identify other genetic problems associated with this gene mutation.
Chapter 5: Evidence-Based Practice in Medical-Surgical Nursing
1. A nurse identifies clinical practice problems on a cardiac unit. Which question is a background question?
a. “How should a client experiencing chest pain be prioritized?”
b. “What is the experience of a cardiac catheterization like for middle-aged men?”
c. “How are a client’s vital signs affected by anxiety?”
d. “What is the best treatment for a myocardial infarction?”
2. A nurse researcher is evaluating clinical questions. Which is a quantitative question?
a. “What are the effects of hourly rounding on client fall rates?”
b. “How do middle-aged men respond to premature balding?”
c. “What are the lived experiences of postoperative clients with pain?”
d. “What is the experience of having breast cancer like for young women?”
3. A nurse is looking for the best interventions for postoperative pain control. When are the facility’s policies and procedures an appropriate source of evidence?
a. When policies are based on high-quality clinical practice guidelines
b. When evidence is derived from a valid and reliable quantitative research study
c. When procedures originated from opinions of the facility’s chief surgeon
d. When evidence is founded on recommendations from experienced nurses
4. A medical-surgical nurse asks the nurse researcher, “What is the difference between qualitative and quantitative questions?” How should the nurse researcher respond?
a. “Quantitative questions analyze the content of what a person says or does.”
b. “Qualitative questions utilize a strict statistical analysis of information.”
c. “Quantitative questions identify relationships between measurable concepts.”
d. “Qualitative questions ask about associations among defined phenomena.”
5. A nurse is searching for evidence related to a qualitative PICOT question. Which type of evidence should the nurse search first?
a. Meta-analyses with credible synthesized findings
b. Systematic reviews
c. Multi-site randomized clinical trials
6. A nurse assesses this PICOT question: “In the adult hospitalized client, does a COX-2 inhibitor decrease the risk of gastrointestinal bleeding compared with other NSAIDs?” What is the outcome component in this question?
a. Adult hospitalized client
b. Cyclooxygenase-2 (COX-2) inhibitor
c. Decreased risk of gastrointestinal bleeding
d. Other nonsteroidal anti-inflammatory drugs (NSAIDs)
7. A health care facility is implementing a new evidence-based nursing protocol. Which action is necessary to ensure successful implementation?
a. Develop evaluation processes to validate the protocol.
b. Ask for recommendations from senior nursing administration.
c. Assess cost-effectiveness of the evidence-based protocol.
d. Attain support from nurses who are implementing the protocol.
8. A research nurse meets with the nurse manager to discuss plans for the development of evidence-based practice (EBP) guidelines using the Reavy and Tavernier model. Which statement should the nurse include in the discussion?
a. “Our efforts should focus on forming a team to develop an EBP initiative.”
b. “I will assist staff nurses with literature reviews and the synthesis of evidence.”
c. “You should identify barriers to evidence-based implementation.”
d. “I will develop a PICOT question and share it with the staff nurses.”
9. A nurse who wants to incorporate evidence-based practices into client care on a medical unit is meeting resistance. Which barrier does the nurse identify as preventing nurses from engaging in evidence-based practices?
a. Difficulty accessing research materials
b. Lack of value for client preferences
c. Trouble understanding client needs
d. Inadequate nurse-client ratios
10. A nurse wants to explore why clients who receive patient-controlled analgesia (PCA) after abdominal surgery ambulate sooner than clients who receive nurse-administered pain medications. Which action should the nurse take first?
a. Contact the medical center’s clinical pharmacist.
b. Search the medical library for the best evidence.
c. Recommend PCA for all clients.
d. Appraise data obtained through client chart audits.
Chapter 6: Rehabilitation Concepts for Chronic and Disabling Health Problems
1. A nurse assesses a client recovering from coronary artery bypass graft surgery. Which assessment should the nurse complete to evaluate the client’s activity tolerance?
a. Vital signs before, during, and after activity
b. Body image and self-care abilities
c. Ability to use assistive or adaptive devices
d. Client’s electrocardiography readings
2. A nurse teaches a client with a past history of angina who has had a total knee replacement. Which statement should the nurse include in this client’s teaching prior to beginning rehabilitation activities?
a. “Use analgesics before and after activity, even if you are not experiencing pain.”
b. “Let me know if you start to experience shortness of breath, chest pain, or fatigue.”
c. “Do not take your prescribed beta blocker until after you exercise with physical therapy.”
d. “If you experience knee pain, ask the physical therapist to reschedule your therapy.”
3. A rehabilitation nurse prepares to move a client who has new bilateral leg amputations. Which is the best approach?
a. Use the bear-hug method to transfer the client safely.
b. Ask several members of the health care team to carry the client.
c. Utilize the facility’s mechanical lift to move the client.
d. Consult physical therapy before performing all transfers.
4. A nurse performs passive range-of-motion exercises on a semiconscious client and meets resistance while attempting to extend the right elbow more than 45 degrees. Which action should the nurse take next?
a. Splint the joint and continue passive range of motion to the shoulder only.
b. Progressively increase joint motion 5 degrees beyond resistance each day.
c. Apply weights to the right distal extremity before initiating any joint exercise.
d. Continue to move the joint only to the point at which resistance is met.
5. A nurse cares for a client with decreased mobility. Which intervention should the nurse implement to decrease this client’s risk of fracture?
a. Apply shoes to improve foot support.
b. Perform weight-bearing activities.
c. Increase calcium-rich foods in the diet.
d. Use pressure-relieving devices.
6. A rehabilitation nurse cares for a client who has generalized weakness and needs assistance with activities of daily living. Which exercise should the nurse implement?
a. Passive range of motion
b. Active range of motion
c. Resistive range of motion
d. Aerobic exercise
7. A nurse plans care for a client who is bedridden. Which assessment should the nurse complete to ensure to prevent pressure ulcer formation?
a. Nutritional intake and serum albumin levels
b. Pressure ulcer diameter and depth
c. Wound drainage, including color, odor, and consistency
d. Dressing site and antibiotic ointment application
8. A nurse teaches a client about performing intermittent self-catheterization. The client states, “I am not sure if I will be able to afford these catheters.” How should the nurse respond?
a. “I will try to find out whether you qualify for money to purchase these necessary supplies.”
b. “Even though it is expensive, the cost of taking care of urinary tract infections would be even higher.”
c. “Instead of purchasing new catheters, you can boil the catheters and reuse them up to 10 times each.”
d. “You can reuse the catheters at home. Clean technique, rather than sterile technique, is acceptable.”
9. A nurse delegates the ambulation of an older adult client to an unlicensed nursing assistant (UAP). Which statement should the nurse include when delegating this task?
a. “The client has skid-proof socks, so there is no need to use your gait belt.”
b. “Teach the client how to use the walker while you are ambulating up the hall.”
c. “Sit the client on the edge of the bed with legs dangling before ambulating.”
d. “Ask the client if pain medication is needed before you walk the client in the hall.”
10. A nurse assesses a client who is admitted with hip problems. The client asks, “Why are you asking about my bowels and bladder?” How should the nurse respond?
a. “To plan your care based on your normal elimination routine.”
b. “So we can help prevent side effects of your medications.”
c. “We need to evaluate your ability to function independently.”
d. “To schedule your activities around your elimination pattern.”
Chapter 7: End-of-Life Care
1. A nurse cares for a dying client. Which manifestation of dying should the nurse treat first?
d. Hair loss
2. A nurse plans care for a client who is nearing end of life. Which question should the nurse ask when developing this client’s plan of care?
a. “Is your advance directive up to date and notarized?”
b. “Do you want to be at home at the end of your life?”
c. “Would you like a physical therapist to assist you with range-of-motion activities?”
d. “Have your children discussed resuscitation with your health care provider?”
3. A nurse is caring for a client who has lung cancer and is dying. Which prescription should the nurse question?
a. Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5
b. Albuterol (Proventil) metered dose inhaler every 4 hours PRN for wheezes
c. Atropine solution 1% sublingual every 4 hours PRN for excessive oral secretions
d. Sodium biphosphate (Fleet) enema once a day PRN for impacted stool
4. A client tells the nurse that, even though it has been 4 months since her sister’s death, she frequently finds herself crying uncontrollably. How should the nurse respond?
a. “Most people move on within a few months. You should see a grief counselor.”
b. “Whenever you start to cry, distract yourself from thoughts of your sister.”
c. “You should try not to cry. I’m sure your sister is in a better place now.”
d. “Your feelings are completely normal and may continue for a long time.”
5. After teaching a client about advance directives, a nurse assesses the client’s understanding. Which statement indicates the client correctly understands the teaching?
a. “An advance directive will keep my children from selling my home when I’m old.”
b. “An advance directive will be completed as soon as I’m incapacitated and can’t think for myself.”
c. “An advance directive will specify what I want done when I can no longer make decisions about health care.”
d. “An advance directive will allow me to keep my money out of the reach of my family.”
6. A nurse teaches a client who is considering being admitted to hospice. Which statement should the nurse include in this client’s teaching?
a. “Hospice admission has specific criteria. You may not be a viable candidate, so we will look at alternative plans for your discharge.”
b. “Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms.”
c. “Hospice care will not help with your symptoms of depression. I will refer you to the facility’s counseling services instead.”
d. “You seem to be experiencing some difficulty with this stage of the grieving process. Let’s talk about your feelings.”
7. A nurse is caring for a dying client. The client’s spouse states, “I think he is choking to death.” How should the nurse respond?
a. “Do not worry. The choking sound is normal during the dying process.”
b. “I will administer more morphine to keep your husband comfortable.”
c. “I can ask the respiratory therapist to suction secretions out through his nose.”
d. “I will have another nurse assist me to turn your husband on his side.”
8. The nurse is teaching a family member about various types of complementary therapies that might be effective for relieving the dying client’s anxiety and restlessness. Which statement made by the family member indicates understanding of the nurse’s teaching?
a. “Maybe we should just hire an around-the-clock sitter to stay with Grandmother.”
b. “I have some of her favorite hymns on a CD that I could bring for music therapy.”
c. “I don’t think that she’ll need pain medication along with her herbal treatments.”
d. “I will burn therapeutic incense in the room so we can stop the anxiety pills.”
9. A nurse is caring for a terminally ill client who has just died in a hospital setting with family members at the bedside. Which action should the nurse take first?
a. Call for emergency assistance so that resuscitation procedures can begin.
b. Ask family members if they would like to spend time alone with the client.
c. Ensure that a death certificate has been completed by the physician.
d. Request family members to prepare the client’s body for the funeral home.
10. A nurse assesses a client who is dying. Which manifestation of a dying client should the nurse assess to determine whether the client is near death?
a. Level of consciousness
b. Respiratory rate
c. Bowel sounds
d. Pain level on a 0-to-10 scale
Chapter 8: Concepts of Emergency and Trauma Nursing
1. An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this client’s care?
a. Emergency medicine physician
b. Case manager
c. Forensic nurse examiner
d. Psychiatric crisis nurse
2. The emergency department team is performing cardiopulmonary resuscitation on a client when the client’s spouse arrives at the emergency department. Which action should the nurse take first?
a. Request that the client’s spouse sit in the waiting room.
b. Ask the spouse if he wishes to be present during the resuscitation.
c. Suggest that the spouse begin to pray for the client.
d. Refer the client’s spouse to the hospital’s crisis team.
3. An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first?
a. A 30-year-old distraught mother holding her crying child
b. A 65-year-old conscious male with a head laceration
c. A 26-year-old male who has pale, cool, clammy skin
d. A 48-year-old with a simple fracture of the lower leg
4. While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first?
a. Apply oxygen via nasal cannula.
b. Administer intravenous 0.9% saline solution.
c. Transfer the client to a negative-pressure room.
d. Obtain a sputum culture and sensitivity.
5. A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first?
a. A 22-year-old with a painful and swollen right wrist
b. A 45-year-old reporting chest pain and diaphoresis
c. A 60-year-old reporting difficulty swallowing and nausea
d. An 81-year-old with a respiratory rate of 28 breaths/min and a temperature of 101° F
6. A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?
a. Level I – Located within remote areas and provides advanced life support within resource capabilities
b. Level II – Located within community hospitals and provides care to most injured clients
c. Level III – Located in rural communities and provides only basic care to clients
d. Level IV – Located in large teaching hospitals and provides a full continuum of trauma care for all clients
7. Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first?
a. Assess that the client is breathing adequately.
b. Insert a large-bore intravenous line.
c. Place the client on a cardiac monitor.
d. Assess for the best neurologic response.
8. A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support?
a. Contact the on-call orthopedic surgeon.
b. Don personal protective equipment.
c. Notify the Rapid Response Team.
d. Obtain a complete history from the paramedic.
9. A nurse is triaging clients in the emergency department. Which client should be considered “urgent”?
a. A 20-year-old female with a chest stab wound and tachycardia
b. A 45-year-old homeless man with a skin rash and sore throat
c. A 75-year-old female with a cough and a temperature of 102° F
d. A 50-year-old male with new-onset confusion and slurred speech
10. An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take?
a. Remove all tubes and wires in preparation for the medical examiner.
b. Limit the number of visitors to minimize the family’s trauma.
c. Consult the bereavement committee to follow up with the grieving family.
d. Communicate the client’s death to the family in a simple and concrete manner.
Chapter 9: Care of Patients with Common Environmental Emergencies
1. On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1° F (40.1° C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take?
a. Encourage the client to drink cool water or sports drinks.
b. Start an intravenous line and infuse 0.9% saline solution.
c. Administer acetaminophen (Tylenol) 650 mg orally.
d. Encourage rest and re-assess in 15 minutes.
2. While at a public park, a nurse encounters a person immediately after a bee sting. The person’s lips are swollen, and wheezes are audible. Which action should the nurse take first?
a. Elevate the site and notify the person’s next of kin.
b. Remove the stinger with tweezers and encourage rest.
c. Administer diphenhydramine (Benadryl) and apply ice.
d. Administer an EpiPen from the first aid kit and call 911.
3. A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take first?
a. Reposition the client into a prone position.
b. Administer warmed intravenous fluids to the client.
c. Wrap the client’s extremities in warm blankets.
d. Initiate extracorporeal rewarming via hemodialysis.
4. An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement?
a. Administer dexamethasone (Decadron).
b. Complete a mini–mental state examination.
c. Prepare the client for computed tomography of the brain.
d. Request a psychiatric consult.
5. An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first?
a. Electrocardiogram (ECG)
b. Wound inspection
c. Creatinine kinase
d. Computed tomography of head
6. A nurse teaches a community health class about water safety. Which statement by a participant indicates that additional teaching is needed?
a. “I can go swimming all by myself because I am a certified lifeguard.”
b. “I cannot leave my toddler alone in the bathtub for even a minute.”
c. “I will appoint one adult to supervise the pool at all times during a party.”
d. “I will make sure that there is a phone near my pool in case of an emergency.”
7. A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should the nurse take prior to starting this treatment?
a. Administer intravenous morphine.
b. Wrap the limb with a compression dressing.
c. Massage the frostbitten areas.
d. Assess the limb for compartment syndrome.
8. A nurse assesses a client recently bitten by a coral snake. Which assessment should the nurse complete first?
a. Unilateral peripheral swelling
b. Clotting times
c. Cardiopulmonary status
d. Electrocardiogram rhythm
9. A nurse plans care for a client admitted with a snakebite to the right leg. With whom should the nurse collaborate?
a. The facility’s neurologist
b. The poison control center
c. The physical therapy department
d. A herpetologist (snake specialist)
10. While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first?
a. Deliver rescue breaths.
b. Wrap the client in dry blankets.
c. Assess for signs of bleeding.
d. Check for a carotid pulse.
Chapter 10: Concepts of Emergency and Disaster Preparedness
1. A hospital responds to a local mass casualty event. Which action should the nurse supervisor take to prevent staff post-traumatic stress disorder during a mass casualty event?
a. Provide water and healthy snacks for energy throughout the event.
b. Schedule 16-hour shifts to allow for greater rest between shifts.
c. Encourage counseling upon deactivation of the emergency response plan.
d. Assign staff to different roles and units within the medical facility.
2. A client who is hospitalized with burns after losing the family home in a fire becomes angry and screams at a nurse when dinner is served late. How should the nurse respond?
a. “Do you need something for pain right now?”
b. “Please stop yelling. I brought dinner as soon as I could.”
c. “I suggest that you get control of yourself.”
d. “You seem upset. I have time to talk if you’d like.”
3. A nurse is field-triaging clients after an industrial accident. Which client condition should the nurse triage with a red tag?
a. Dislocated right hip and an open fracture of the right lower leg
b. Large contusion to the forehead and a bloody nose
c. Closed fracture of the right clavicle and arm numbness
d. Multiple fractured ribs and shortness of breath
4. An emergency department (ED) charge nurse prepares to receive clients from a mass casualty within the community. What is the role of this nurse during the event?
a. Ask ED staff to discharge clients from the medical-surgical units in order to make room for critically injured victims.
b. Call additional medical-surgical and critical care nursing staff to come to the hospital to assist when victims are brought in.
c. Inform the incident commander at the mass casualty scene about how many victims may be handled by the ED.
d. Direct medical-surgical and critical care nurses to assist with clients currently in the ED while emergency staff prepare to receive the mass casualty victims.
5. The hospital administration arranges for critical incident stress debriefing for the staff after a mass casualty incident. Which statement by the debriefing team leader is most appropriate for this situation?
a. “You are free to express your feelings; whatever is said here stays here.”
b. “Let’s evaluate what went wrong and develop policies for future incidents.”
c. “This session is only for nursing and medical staff, not for ancillary personnel.”
d. “Let’s pass around the written policy compliance form for everyone.”
6. A nurse is caring for a client whose wife died in a recent mass casualty accident. The client says, “I can’t believe that my wife is gone and I am left to raise my children all by myself.” How should the nurse respond?
a. “Please accept my sympathies for your loss.”
b. “I can call the hospital chaplain if you wish.”
c. “You sound anxious about being a single parent.”
d. “At least your children still have you in their lives.”
7. A nurse cares for clients during a community-wide disaster drill. Once of the clients asks, “Why are the individuals with black tags not receiving any care?” How should the nurse respond?
a. “To do the greatest good for the greatest number of people, it is necessary to sacrifice some.”
b. “Not everyone will survive a disaster, so it is best to identify those people early and move on.”
c. “In a disaster, extensive resources are not used for one person at the expense of many others.”
d. “With black tags, volunteers can identify those who are dying and can give them comfort care.”
8. A nurse wants to become involved in community disaster preparedness and is interested in helping set up and staff first aid stations or community acute care centers in the event of a disaster. Which organization is the best fit for this nurse’s interests?
a. The Medical Reserve Corps
b. The National Guard
c. The health department
d. A Disaster Medical Assistance Team
9. A nurse wants to become part of a Disaster Medical Assistance Team (DMAT) but is concerned about maintaining licensure in several different states. Which statement best addresses these concerns?
a. “Deployed DMAT providers are federal employees, so their licenses are good in all 50 states.”
b. “The government has a program for quick licensure activation wherever you are deployed.”
c. “During a time of crisis, licensure issues would not be the government’s priority concern.”
d. “If you are deployed, you will be issued a temporary license in the state in which you are working.”
10. After a hospital’s emergency department (ED) has efficiently triaged, treated, and transferred clients from a community disaster to appropriate units, the hospital incident command officer wants to “stand down” from the emergency plan. Which question should the nursing supervisor ask at this time?
a. “Are you sure no more victims are coming into the ED?”
b. “Do all areas of the hospital have the supplies and personnel they need?”
c. “Have all ED staff had the chance to eat and rest recently?”
d. “Does the Chief Medical Officer agree this disaster is under control?”
Chapter 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances
1. A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration?
a. A 36-year-old who is prescribed long-term steroid therapy
b. A 55-year-old receiving hypertonic intravenous fluids
c. A 76-year-old who is cognitively impaired
d. An 83-year-old with congestive heart failure
2. A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?
a. Measure intake and output every 4 hours.
b. Apply oxygen by mask or nasal cannula.
c. Increase the IV flow rate to 250 mL/hr.
d. Place the client in a high-Fowler’s position.
3. After teaching a client who is being treated for dehydration, a nurse assesses the client’s understanding. Which statement indicates the client correctly understood the teaching?
a. “I must drink a quart of water or other liquid each day.”
b. “I will weigh myself each morning before I eat or drink.”
c. “I will use a salt substitute when making and eating my meals.”
d. “I will not drink liquids after 6 PM so I won’t have to get up at night.”
4. A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess?
a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
b. Daily weight increase from 55 kg to 57 kg
c. Heart rate decrease from 100 beats/min to 82 beats/min
d. Respiratory rate increase from 12 breaths/min to 15 breaths/min
5. A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss?
a. Client taking furosemide (Lasix)
b. Anxious client who has tachypnea
c. Client who is on fluid restrictions
d. Client who is constipated with abdominal pain
6. A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan?
a. Increased respiratory rate from 12 breaths/min to 22 breaths/min
b. Decreased skin turgor on the client’s posterior hand and forehead
c. Increased urine specific gravity from 1.012 to 1.030 g/mL
d. Decreased orthostatic light-headedness and dizziness
7. After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client’s understanding. Which food choice for lunch indicates the client correctly understood the teaching?
a. Slices of smoked ham with potato salad
b. Bowl of tomato soup with a grilled cheese sandwich
c. Salami and cheese on whole wheat crackers
d. Grilled chicken breast with glazed carrots
8. A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?
a. A 34-year-old on NPO status who is receiving intravenous D5W
b. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic
c. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin)
d. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)
9. A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this client’s teaching?
a. “Weigh yourself every morning and every night.”
b. “Check your radial pulse twice a day.”
c. “Read food labels to determine sodium content.”
d. “Bake or grill the meat rather than frying it.”
10. A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
a. Depth of respirations
b. Bowel sounds
c. Grip strength
Chapter 12: Assessment and Care of Patients with Acid-Base Imbalances
1. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client’s arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3– 18 mEq/L. Which manifestation should the nurse identify as an example of the client’s compensation mechanism?
a. Increased rate and depth of respirations
b. Increased urinary output
c. Increased thirst and hunger
d. Increased release of acids from the kidneys
2. A nurse assesses a client who is experiencing an acid-base imbalance. The client’s arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3– 19 mEq/L. Which assessment should the nurse perform first?
a. Cardiac rate and rhythm
b. Skin and mucous membranes
c. Musculoskeletal strength
d. Level of orientation
3. A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
4. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?
a. Monitor daily hemoglobin and hematocrit values.
b. Administer furosemide (Lasix) intravenously.
c. Encourage the client to take deep breaths.
d. Teach the client fall prevention measures.
5. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess?
b. Kussmaul respirations
d. Positive Chvostek’s sign
6. A nurse assesses a client who is admitted with an acid-base imbalance. The client’s arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3– 16 mEq/L. What action should the nurse take next?
a. Assess client’s rate, rhythm, and depth of respiration.
b. Measure the client’s pulse and blood pressure.
c. Document the findings and continue to monitor.
d. Notify the physician as soon as possible.
7. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3– 22 mEq/L. Which clinical situation should the nurse correlate with these values?
a. Diabetic ketoacidosis in a person with emphysema
b. Bronchial obstruction related to aspiration of a hot dog
c. Anxiety-induced hyperventilation in an adolescent
d. Diarrhea for 36 hours in an older, frail woman
8. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The client’s arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3– 22 mEq/L. Which action should the nurse take first?
a. Apply oxygen by mask or nasal cannula.
b. Apply a paper bag over the client’s nose and mouth.
c. Administer 50 mL of sodium bicarbonate intravenously.
d. Administer 50 mL of 20% glucose and 20 units of regular insulin.
9. After teaching a client who was malnourished and is being discharged, a nurse assesses the client’s understanding. Which statement indicates the client correctly understood teaching to decrease risk for the development of metabolic acidosis?
a. “I will drink at least three glasses of milk each day.”
b. “I will eat three well-balanced meals and a snack daily.”
c. “I will not take pain medication and antihistamines together.”
d. “I will avoid salting my food when cooking or during meals.”
10. A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3– 22 mEq/L. Which client condition should the nurse correlate with these results?
a. Diarrhea and vomiting for 36 hours
b. Anxiety-induced hyperventilation
c. Chronic obstructive pulmonary disease (COPD)
d. Diabetic ketoacidosis and emphysema
Chapter 13: Infusion Therapy
1.A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next?
a. Begin the prescribed infusion via the new access.
b. Ensure an x-ray is completed to confirm placement.
c. Check medication calculations with a second RN.
d. Make sure the solution is appropriate for a central line.
2.A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?
a. Amount of pressure in fluid container
b. Date of catheter tubing change
c. Percent of heparin in infusion container
d. Presence of an ulnar pulse
3.A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this client’s teaching?
a. “Avoid carrying your grandchild with the arm that has the central catheter.”
b. “Be sure to place the arm with the central catheter in a sling during the day.”
c. “Flush the peripherally inserted central catheter line with normal saline daily.”
d. “You can use the arm with the central catheter for most activities of daily living.”
4.A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?
a. Administer a sublingual nitroglycerin tablet.
b. Prepare to assist with chest tube insertion.
c. Place a sterile dressing over the IV site.
d. Re-position the client into the Trendelenburg position.
5.A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
a. Redness at the catheter insertion site
b. Report of headache and stiff neck
c. Temperature of 100.1° F (37.8° C)
d. Pain rating of 8 on a scale of 0 to 10
6.A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?
a. The catheter has been in place for 20 hours.
b. The client has poor vascular access in the upper extremities.
c. The catheter is placed in the proximal tibia.
d. The client’s left lower extremity is cool to the touch.
7.A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?
a. The initial site dressing is 3 days old.
b. The PICC was inserted 4 weeks ago.
c. A securement device is absent.
d. Upper extremity swelling is noted.
8.A nurse assesses a client’s peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
a. Apply cold compresses to the IV site.
b. Elevate the extremity on a pillow.
c. Flush the catheter with normal saline.
d. Stop the infusion of intravenous fluids.
9.While assessing a client’s peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?
a. “Grade 3 phlebitis at IV site”
b. “Infection at IV site”
c. “Thrombosed area at IV site”
d. “Infiltration at IV site”
10.A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first?
a. Check for kinking of the catheter.
b. Flush the catheter with a thrombolytic enzyme.
c. Get a new infusion pump.
d. Remove the IV catheter.
Chapter 14: Care of Preoperative Patients
1. An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment?
a. Change in behavior
b. Daily white blood cell count
c. Presence of fever and chills
d. Tolerance of increasing activity
2. A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team?
a. Allergy to bee and wasp stings
b. History of lactose intolerance
c. No previous experience with surgery
d. Use of multiple herbs and supplements
3. A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care?
a. Married young adult who is the primary caregiver for children
b. Middle-aged client who is post knee replacement, needs physical therapy
c. Older adult who lives at home despite some memory loss
d. Young client who lives alone, has family and friends nearby
4. A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?
a. Assess the client for anxiety.
b. Break the information into smaller bits.
c. Give the client written information.
d. Review the information again.
5. A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team?
a. Creatinine: 1.2 mg/dL
b. Hemoglobin: 14.8 mg/dL
c. Potassium: 2.9 mEq/L
d. Sodium: 134 mEq/L
6. An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best?
a. Answer the questions and document that teaching was done.
b. Do not have the client sign the consent and call the surgeon.
c. Have the client sign the consent, then call the surgeon.
d. Remind the client of what teaching the surgeon has done.
7. A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best?
a. Call the provider to request more analgesia.
b. Demonstrate how to splint the incision.
c. Have the client take shallower breaths.
d. Tell the client a little pain is expected.
8. A nurse is giving a client instructions for showering with special antimicrobial soap the night before surgery. What instruction is most appropriate?
a. “After you wash the surgical site, shave that area with your own razor.”
b. “Be sure to wash the area where you will have surgery very thoroughly.”
c. “Use a washcloth to wash the surgical site; do not take a full shower or bath.”
d. “Wash the surgical site first, then shampoo and wash the rest of your body.”
9. A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met?
a. Drainage from the surgical site is 30 mL less than yesterday.
b. There is no redness, warmth, or drainage at the insertion site.
c. The client reports adequate pain control with medications.
d. Urine is clear yellow and urine output is greater than 40 mL/hr.
10. A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)?
a. Assess the client’s anxiety.
b. Give the client a back rub.
c. Remind the client to turn.
d. Teach about postoperative care.
Chapter 15: Care of Intraoperative Patients
1. The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best?
a. Call maintenance for repair.
b. Check the machine before using.
c. Get another piece of equipment.
d. Notify the charge nurse.
2. The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority?
a. Allergies noted and allergy band on
b. Consent for MIS procedure only
c. No prior anesthesia exposure
d. NPO status for the last 8 hours
3. A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to “break scrub” when going to the console and sitting down. What action by the nurse is best?
a. Call a “time-out” to discuss sterile procedure and scrub technique.
b. Document the time the robotic portion of the procedure begins.
c. Inform the surgeon that the scrub preparation has been compromised.
d. Report the surgeon’s actions to the charge nurse and unit manager.
4. The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate?
a. Ask the surgeon to change the sterile gown.
b. Do nothing; this is acceptable sterile procedure.
c. Inform the surgeon that the sterile field has been broken.
d. Obtain a new pair of sterile gloves for the surgeon to put on.
5. A client is in stage 2 of general anesthesia. What action by the nurse is most important?
a. Keeping the room quiet and calm
b. Being prepared to suction the airway
c. Positioning the client correctly
d. Warming the client with blankets
6. A client is having surgery. The circulating nurse notes the client’s oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best?
a. Assess the client’s end-tidal carbon dioxide level.
b. Document the findings in the client’s chart.
c. Inform the anesthesia provider of these values.
d. Prepare to administer dantrolene sodium (Dantrium).
7. A nurse is monitoring a client after moderate sedation. The nurse documents the client’s Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best?
a. Assess the client’s gag reflex.
b. Begin providing discharge instructions.
c. Document findings and continue to monitor.
d. Increase oxygen and notify the provider.
8. A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate?
a. Facilitate marking the site with the client and surgeon.
b. Have the client mark the operative site.
c. Mark the operative site with a waterproof marker.
d. Tell the surgeon it is time to mark the surgical site.
9. A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important?
a. Assist with administering muscle relaxants to the client.
b. Place the client on a cardiac monitor and pulse oximeter.
c. Prepare to administer intravenous antiemetics to the client.
d. Prevent the client from experiencing postoperative shivering.
10. A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client?
a. Allow the client to keep hearing aids in until anesthesia begins.
b. Pad the table as appropriate for the surgical procedure.
c. Position the client for maximum visualization of the site.
d. Stay with the client, providing emotional comfort and support.
Chapter 16: Care of Postoperative Patients
1. A client has arrived in the postoperative unit. What action by the circulating nurse takes priority?
a. Assessing fluid and blood output
b. Checking the surgical dressings
c. Ensuring the client is warm
d. Participating in hand-off report
2. The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first?
a. Client with a blood pressure of 100/50 mm Hg
b. Client with a pulse of 118 beats/min
c. Client with a respiratory rate of 6 breaths/min
d. Client with a temperature of 96° F (35.6° C)
3. A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate?
a. Assess other indicators of oxygenation.
b. Call the Rapid Response Team.
c. Notify the anesthesia provider.
d. Prepare to intubate the client.
4. Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best?
a. “Let me call the surgeon to see if you really need them.”
b. “No, you have to use those for 24 hours after surgery.”
c. “OK, we can remove them since you are stable now.”
d. “To prevent blood clots you need them a few more hours.”
5. A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the client’s bed. The client’s blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best?
a. Call the Rapid Response Team.
b. Increase the IV fluid rate.
c. Lower the head of the bed.
d. Nothing; this is expected.
6. A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important?
a. Allow the client to rest.
b. Auscultate lung sounds.
c. Document the episode.
d. Encourage the client to eat dry toast.
7. A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority?
d. Cardiac rhythm
8. A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer?
a. Flumazenil (Romazicon) 0.2 to 1 mg
b. Flumazenil (Romazicon) 2 to 10 mg
c. Naloxone (Narcan) 0.4 to 2 mg
d. Naloxone (Narcan) 4 to 20 mg
9. A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort?
a. Assess the client’s pain on a 0-to-10 scale.
b. Assist the client into a position of comfort.
c. Have the client sit up in a recliner.
d. Tell the client when pain medication is due.
10. A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?
a. “Be sure you keep all your postoperative appointments.”
b. “Call your surgeon if you have any questions at home.”
c. “Eat a diet high in protein, iron, zinc, and vitamin C.”
d. “Wash your hands before touching the drain or dressing.”
Chapter 17: Inflammation and Immunity
1. The student nurse learns that the most important function of inflammation and immunity is which purpose?
a. Destroying bacteria before damage occurs
b. Preventing any entry of foreign material
c. Providing protection against invading organisms
d. Regulating the process of self-tolerance
2. A nurse is assessing an older client for the presence of infection. The client’s temperature is 97.6° F (36.4° C). What response by the nurse is best?
a. Assess the client for more specific signs.
b. Conclude that an infection is not present.
c. Document findings and continue to monitor.
d. Request that the provider order blood cultures.
3. A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important?
a. “Avoid large crowds and people who are ill.”
b. “Check over-the-counter meds for acetaminophen.”
c. “Take this medicine exactly as prescribed.”
d. “You have a higher risk of developing cancer.”
4. A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client?
a. Assessing vaccination records for booster shot needs
b. Encouraging the client to eat a nutritious diet
c. Instructing the client to wash minor wounds carefully
d. Teaching hand hygiene to prevent the spread of microbes
5. A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess?
a. Noticeable rubor
b. Purulent drainage
c. Swelling and pain
d. Warmth at the site
6. A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ?
a. Bone marrow
7. The nurse understands that which type of immunity is the longest acting?
a. Artificial active
c. Natural active
d. Natural passive
8. The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem?
a. CD4+ cells
b. Cytotoxic T cells
c. Natural killer cells
d. Suppressor T cells
9. A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyperacute rejection. What treatment does the nurse prepare to facilitate?
b. High-dose steroid administration
c. Monoclonal antibody therapy
10. A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider?
a. Blood urea nitrogen (BUN) of 18 mg/dL
b. Cloudy, foul-smelling urine
c. Creatinine of 3.9 mg/dL
d. Urine output of 340 mL/8 hr
Chapter 18: Care of Patients with Arthritis and Other Connective Tissue Diseases
1. A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)?
a. Avoid contact sports.
b. Get plenty of calcium.
c. Lose weight if needed.
d. Engage in weight-bearing exercise.
2. A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching?
a. Acetaminophen (Tylenol)
b. Cyclobenzaprine hydrochloride (Flexeril)
c. Hyaluronate (Hyalgan)
d. Ibuprofen (Motrin)
3. The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the client’s blood glucose readings have been elevated. What question by the nurse is most appropriate?
a. “Are you compliant with following the diabetic diet?”
b. “Have you been taking glucosamine supplements?”
c. “How much exercise do you really get each week?”
d. “You’re still taking your diabetic medication, right?”
4. The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement?
a. Needs multiple dental fillings
b. Over age 85
c. Severe osteoporosis
d. Urinary tract infection
5. An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury?
a. Administer mild sedation.
b. Keep all four siderails up.
c. Restrain the client’s hands.
d. Use an abduction pillow.
6. What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement?
a. Administer preoperative antibiotic as ordered.
b. Assess the client’s white blood cell count.
c. Instruct the client to shower the night before.
d. Monitor the client’s temperature postoperatively.
7. The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The client’s surgical leg is visibly shorter than the other one and the client reports extreme pain. While a co-worker calls the surgeon, what action by the nurse is best?
a. Assess neurovascular status in both legs.
b. Elevate the affected leg and apply ice.
c. Prepare to administer pain medication.
d. Try to place the affected leg in abduction.
8. A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed?
a. Assess the distal circulation in 30 minutes.
b. Change the settings based on range of motion.
c. Raise the lower siderail on the affected side.
d. Remind the client to do quad-setting exercises.
9. After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the client’s pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next?
a. Document the findings and monitor as prescribed.
b. Increase the frequency of monitoring the client.
c. Notify the surgeon or anesthesia provider immediately.
d. Palpate the client’s bladder or perform a bladder scan.
10. A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important?
a. Administering pain medication before transport
b. Answering any last-minute questions by the client
c. Ensuring the family has directions to the facility
d. Providing a verbal hand-off report to the facility
Chapter 19: Care of Patients with HIV Disease and Other Immune Deficiencies
1. The nurse is caring for a client diagnosed with human immune deficiency virus. The client’s CD4+ cell count is 399/mm3. What action by the nurse is best?
a. Counsel the client on safer sex practices/abstinence.
b. Encourage the client to abstain from alcohol.
c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors.
d. Help the client plan high-protein/iron meals.
2. The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest?
a. Anal intercourse
c. Oral sex
d. Vaginal intercourse
3. The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective?
a. Consistent use of Standard Precautions
b. Double-gloving before body fluid exposure
c. Labeling charts and armbands “HIV+”
d. Wearing a mask within 3 feet of the client
4. A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first?
a. Initiate Droplet Precautions for the client.
b. Notify the provider about the CD4+ results.
c. Place the client under Airborne Precautions.
d. Use Standard Precautions to provide care.
5. A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states “Whew! I was really worried about that result.” What action by the nurse is most important?
a. Assess the client’s sexual activity and patterns.
b. Express happiness over the test result.
c. Remind the client about safer sex practices.
d. Tell the client to be retested in 3 months.
6. A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first?
a. Ask the client about travel to any foreign countries.
b. Assess the client for adherence to the drug regimen.
c. Determine if the client has any new sexual partners.
d. Request information about new living quarters or pets.
7. A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort?
a. Administer sleeping medication.
b. Perform most activities for the client.
c. Increase the client’s oxygen during activity.
d. Pace activities, allowing for adequate rest.
8. A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem?
a. Chooses high-protein food
b. Has decreased oral discomfort
c. Eats 90% of meals and snacks
d. Has a weight gain of 2 pounds/1 month
9. A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi’s sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important?
a. Adhering to Standard Precautions
b. Assessing tolerance to dressing changes
c. Performing hand hygiene before and after care
d. Disposing of soiled dressings properly
10. A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self-management by teaching what principle of medical management?
a. “Infusions will be scheduled every 3 to 4 weeks.”
b. “Treatment is aimed at treating specific infections.”
c. “Unfortunately, there is no effective treatment.”
d. “You will need many immunoglobulin A infusions.”
Chapter 20: Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity
1. A nurse works in an allergy clinic. What task performed by the nurse takes priority?
a. Checking emergency equipment each morning
b. Ensuring informed consent is obtained as needed
c. Providing educational materials in several languages
d. Teaching clients how to manage their allergies
2. A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best?
a. Assess that the client has been NPO as directed.
b. Communicate this information with dietary staff.
c. Document the information in the client’s chart.
d. Ensure the information is relayed to the surgical team.
3. The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction?
a. Administering steroids for severe serum sickness
b. Correctly identifying the client prior to a blood transfusion
c. Keeping the client free of the offending agent
d. Providing a latex-free environment for the client
4. A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition?
a. Blood urea nitrogen: 12 mg/dL
b. Creatinine: 3.2 mg/dL
c. Hemoglobin: 8.2 mg/dL
d. White blood cell count: 12,000/mm3
5. A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate?
a. “Antihistamines do not help poison ivy.”
b. “There are different antihistamines to try.”
c. “You should be seen in the clinic right away.”
d. “You will need to take some IV steroids.”
6. A client with Sjögren’s syndrome reports dry skin, eyes, mouth, and vagina. What nonpharmacologic comfort measure does the nurse suggest?
a. Frequent eyedrops
b. Home humidifier
c. Strong moisturizer
d. Tear duct plugs
7. A client is receiving plasmapheresis as treatment for Goodpasture’s syndrome. When planning care, the nurse places highest priority on interventions for which client problem?
a. Reduced physical activity related to the disease’s effects on the lungs
b. Inadequate family coping related to the client’s hospitalization
c. Inadequate knowledge related to the plasmapheresis process
d. Potential for infection related to the site for organism invasion
8. A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed?
a. “I don’t need to go to the hospital after using it.”
b. “I must carry two EpiPens with me at all times.”
c. “I will write the expiration date on my calendar.”
d. “This can be injected right through my clothes.”
9. A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important?
a. Assess the client’s bedside glucose reading.
b. Instruct the client not to get up without help.
c. Monitor the client frequently for tachycardia.
d. Record the client’s intake, output, and weight.
10. A client is in the hospital and receiving IV antibiotics. When the nurse answers the client’s call light, the client presents an appearance as shown below:
What action by the nurse takes priority?
a. Administer epinephrine 1:1000, 0.3 mg IV push immediately.
b. Apply oxygen by facemask at 100% and a pulse oximeter.
c. Ensure a patent airway while calling the Rapid Response Team.
d. Reassure the client that these manifestations will go away.
AND MUCH MORE