Download 1. Chapter 04-03 (1.0 point) A registered nurse was accused of

1. Chapter 04-03 (1.0 point)
A registered nurse was accused of patient abandonment when she became angry, quit her
job, and left the hospital before the end of her shift. This is an example of violating
guidelines set by which of the following?
a. State Department of Health
b. The Joint Commission
*c. State Board of Nursing
d. National League of Nursing
General Feedback:
Nurse Practice Acts permit the State Board of Nursing to set rules,
regulations, and guidelines that specifically define the standard of care in nursing
practice. An example is the guidelines that define patient abandonment.
2. Chapter 04-04 (1.0 point)
A RN suffers from chronic back pain that was the result of an injury she suffered when
pulling a patient up in bed. She is addicted to pain medication and has recently been
accused of stealing narcotics. This is an example of which of the following violations of
the law?
a. Misdemeanor
b. Tort
c. Malpractice
*d. Felony
General Feedback:
A felony is a serious offense that results in significant harm to another person
or to society in general. Felony crimes may carry penalties of monetary restitution,
imprisonment for greater than 1 year, or death. Examples of Nurse Practice Act violations
that may carry criminal penalties include practicing nursing without a license and misuse
of controlled substances.
3. Chapter 04-05 (1.0 point)
A registered nurse was pulled from her normal unit to fill in for a pediatric unit. She is
caring for a 16-year-old patient who refuses to cooperate for a dressing change. The nurse
tells the patient that she will tie the patient down if she does not hold still. This threat is
an example of which of the following?
*a. Assault
b. Unintentional tort
c. Battery
d. Felony
General Feedback:
Assault is an intentional threat toward another person that gives that person a
reasonable fear of harmful contact. No actual contact is required for an assault to occur.
An example of an assault in nursing practice is to threaten to restrain a patient for an xray procedure when the patient has refused consent.
4. Chapter 04-06 (1.0 point)
A wrong-site surgery is considered a sentinel event for a health care organization. In
addition to the hospital being at fault for this situation, the health care provider could also
be considered guilty of committing which of the following?
a. Negligence
*b. Battery
c. Felony
d. Misdemeanor
General Feedback:
An example of a battery in health care is when the patient has consented to a
right knee surgery and the surgeon performs surgery on the patient’s left knee. An
example of an assault and battery is to threaten to restrain a competent patient for an xray procedure to which the patient has not consented and then to actually restrain the
patient.
5. Chapter 04-08 (1.0 point)
Which of the following is the best way for a nurse to avoid being liable for malpractice?
a. Purchasing quality malpractice insurance coverage
*b. Practicing nursing that meets the generally accepted standard of care
c. Not sharing his or her last name with patients and families
d. Not delegating any tasks to unlicensed assistive personnel
General Feedback:
The best way to avoid being liable for malpractice is to give nursing care that
meets the generally accepted standard of care. In a malpractice lawsuit the law uses
nursing standards of care to measure nursing conduct and to determine whether the nurse
acted as any reasonably prudent nurse would act under the same or similar circumstances.
6. Chapter 04-11 (1.0 point)
A registered nurse is caring for a 45-year-old patient 2 days after a colon resection. The
patient called for assistance to go to the bathroom. Instead of waiting for help, the patient
decided to get up on her own. She fell but did not injure herself. After contacting the
patient’s health care provider, which of the following is most important for the nurse to
do?
a. Nothing; the patient wasn’t injured.
b. Call the Risk Management Department.
*c. Submit an incident report.
d. Insist that the patient have a radiograph done.
General Feedback:
When there is a deviation from the standard of care, such as a patient or
visitor falls or an error is made, a nurse makes specific documentation of the event or
incident in the form of an occurrence report/incident report. The nurse should complete
an occurrence report when anything unusual happens that could potentially cause harm to
a patient, visitor, or employee.
7. Chapter 04-12 (1.0 point)
After witnessing a patient fall, a nurse fills out an occurrence report. Which of the
following is the best way for the nurse to document this occurrence?
*a. “Patient found lying on right side on floor. No noted injuries, patient stated, ‘I
slipped on a wet spot on the floor. I don’t think I am injured.’”
b. “Patient slipped on a wet spot on the floor. No noted injuries, physician
notified.”
c. “Patient in too much of a hurry and was walking too fast and fell. Was not
injured. Patient instructed to slow down and not be in such a hurry. Health care
provider notified.”
d. “Patient fell while going outside to smoke. Patient denied any injuries. Health
care provider notified. Patient counseled.”
General Feedback:
Objectively record the details of the event and any statements the patient
makes. An example is as follows: “Patient found lying on floor on right side. Abrasion on
right forehead. Patient stated, ‘I fell and hit my head.’” At the time of the event, always
contact the health care provider to examine the patient.
8. Chapter 04-13 (1.0 point)
A new registered nurse who recently passed board examinations was on his way home
from the STD clinic where he was working since graduating from nursing school. He
stopped at an automobile accident to see if he could assist. There was one victim who
was not breathing. The nurse provided CPR at the scene, but the victim died. The
victim’s family sued the nurse. Which of the following provides the best protection to the
nurse in this case?
a. STD clinic’s malpractice insurance policy
*b. Good Samaritan Law
c. The State Board of Nursing
d. Institute of Medicine
General Feedback:
Although Good Samaritan Laws provide immunity to the nurse who does
what is reasonable to save a person’s life, if a nurse performs a procedure for which a
nurse has no training, the nurse will be liable for any injury resulting from that act.
Therefore, provide only care that is consistent with your level of expertise.
9. Chapter 04-14 (1.0 point)
A registered nurse has recently started working as a surgical nurse. Within his orientation
he was instructed that he would be responsibility for verifying that the Consent for
Surgery form was signed. He understands that the person signing the form must be
competent. Which of the following patients would be considered competent to give
informed consent?
a. 27-year-old unconscious patient
*b. 16-year-old emancipated minor
c. 43-year-old patient who has been drinking alcohol
d. 33-year-old patient who has received preanesthesia medication
General Feedback:
Informed consent requires that a nurse gives the patient all relevant
information required to make a decision, that the patient is capable of understanding the
relevant information, and that the patient actually gives consent.
10. Chapter 04-15 (1.0 point)
A nurse works for a unit caring for patients after open heart surgery. A patient is
confused and is attempting to get out of bed. The nurse is tired after working for more
than 10 hours and is concerned for the patient’s safety. What is the best action that the
nurse should take to prevent the patient from harm?
a. Restrain the patient with wrist restraints.
b. Restrain the patient with a belt restraint in a chair.
c. Sedate the patient with medication.
*d. Ask a family member to sit with the patient.
General Feedback:
The Joint Commission has set guidelines for the use of restraints. These
regulations set the standard that all patients have the right to be free from seclusion and
physical or chemical restraints except to ensure the patient’s safety in emergency
situations. The standards specifically prohibit restraining patients for staff convenience,
punishment, or retaliation.
11. Chapter 04-16 (1.0 point)
A registered nurse is admitting a 65-year-old patient into the hospital for acute
pancreatitis. As part of the admission process she asks if the patient has an advance
directive. The patient states that he is not sure. Which of the following is considered an
advance directive?
a. Power of attorney
*b. Living will
c. Legal will
d. Organ donation card
General Feedback:
Many times the decision regarding lifesaving treatment is in writing in the
patient’s living will or advance directive. Living wills are documents instructing the
physician or health care provider to withhold or withdraw life-sustaining procedures in a
patient who is terminally ill. If the patient has executed a durable power of attorney for
health care, the document will designate an individual who is able to give consent for
health care treatment when the patient is no longer able.
12. Chapter 04-17 (1.0 point)
Which of the following examples demonstrates a breach of confidentiality and a violation
of HIPAA?
a. Giving a report to the oncoming nurse in a conference room
b. Discussing a patient’s diagnosis with the patient’s health care provider
c. Providing patient information to the nursing assistant caring for the patient
*d. Sharing with other nurses on the unit that a patient is HIV-positive
General Feedback:
Issues of disclosure, privacy, and confidentiality are an important concern
when working with patients or peers infected with blood-borne illnesses such as human
immunodeficiency virus (HIV) or acquired immunodeficiency virus (AIDS), hepatitis,
and sexually transmitted illnesses. A nurse will care for patients with these illnesses in
every segment of nursing practice. A nurse should always use standard precautions as a
standard of care when caring for all patients. The 1995 American Disabilities Act (ADA)
applies to persons with AIDS. This federal law protects the rights of disabled people and
HIV-infected patients.
13. Chapter 04-18 (1.0 point)
Crystal, a RN, has been caring for a patient of Dr. Hoover. Crystal received an illegible
order for a medication. Dr. Hoover has a reputation for impatience and irritability.
Knowing Dr. Hoover’s surly nature, which of the following would be the most
appropriate action by Crystal?
a. Clarify the order with the pharmacy.
b. Clarify the order with the nursing supervisor.
*c. Clarify the order with Dr. Hoover.
d. Ask another nurse to look at the order to try to clarify it.
General Feedback:
A nurse will assess all physician or health care provider orders, and if the
nurse determines they are erroneous or harmful—or illegible—obtain clarification from
that physician or health care provider.
14. Chapter 04-19 (1.0 point)
During an evening shift, Clara, a senior student nurse, was working as a nursing assistant
in the local hospital where she does her school clinical rotations. One of the nurses she
was working with was extremely busy and asked Clara to assist her. The nurse knew that
Clara would be graduating soon and had good clinical skills. Which of the following
tasks would be appropriate for Clara to independently perform?
a. Distributing medications to patients
b. Administering insulin injections
*c. Collecting intake and output data
d. Assessing patients
General Feedback:
During the time when a student nurse works as an employee of a health care
facility, perform only tasks that appear in a job description for a nurse’s aide or nursing
assistant. For example, even if a student nurse has learned how to administer
intramuscular medications, a nurse’s aide does not perform this task.
15. Chapter 04-20 (1.0 point)
Only one nurse was scheduled to care for 12 postsurgical patients with a nursing
assistant. He is concerned for the safety of the patients and his nursing license. What is
the most appropriate first step in this situation?
*a. Contacting the nursing supervisor and documenting the action
b. Refusing to care for the patients without appropriate help and leaving
c. Contacting the State Board of Nursing and documenting the action
d. Contacting the hospital administrator on call to complain and documenting the
action
General Feedback:
If a nurse is assigned to care for more patients than is reasonable for safe care,
he or she should notify the nursing supervisor. If the nurse is required to accept the
assignment, he or she must document this information in writing and provide the
document to nursing administrators. Although documentation does not relieve a nurse of
responsibility if patients suffer harm because of inattention, it shows that the nurse
attempted to act appropriately.
16. Chapter 04-21 (1.0 point)
A nurse administered the wrong medication to a patient. As a result, the patient received
a large cash settlement. What did the nurse commit?
*a. Tort
b. Misdemeanor
c. Negligence
d. Violation of criminal law
General Feedback:
A misdemeanor is a less serious crime that has a penalty of a fine or
imprisonment for less than 1 year. An example is misuse of a controlled substance by a
nurse. Negligence is conduct that falls below a standard of care. Violation of a criminal
law is either a felony or misdemeanor.
17. Chapter 04-22 (1.0 point)
If a patient falls out of bed because the side rails were not raised, this action would
constitute:
a. a felony.
b. assault.
c. battery.
*d. negligence.
General Feedback:
A felony is a serious offense that has a penalty of imprisonment for greater
than a year or possibly even death. Assault is any intentional threat to bring about
harmful or offensive contact with another individual. Battery is any intentional touching
without consent.
18. Chapter 04-23 (1.0 point)
Nurses may place a patient in restraint devices to:
a. ensure staff convenience.
b. retaliate against poor behavior.
c. punish a patient.
*d. ensure the patient’s safety.
General Feedback:
Medicaid statute (1988), Department of Health and Human Services (1992),
and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (2005)
regulate the use of physical or chemical restraints. The regulations set the standards that
patients have the right to be free from seclusion and physical or chemical restraints
except to ensure a patient’s safety in emergency situations. A nurse can be liable for
improper or unlawful restraint.
19. Chapter 04-25 (1.0 point)
A state with abuse legislation requires a nurse who suspects child abuse or neglect to:
*a. report it to the proper legal authority.
b. inform the parents that their actions are illegal.
c. call the security department to handle the problem.
d. prevent the parents from seeing the child during hospitalization.
General Feedback:
Health care providers are required to report incidents such as child, spousal,
or elder abuse; rape; gunshot wounds; attempted suicide; and certain communicable
diseases.
Health care providers are provided legal immunity if the report is made in good faith.
Not reporting suspected child abuse or neglect can cause a nurse to be liable in civil or
criminal legal actions.
20. Chapter 04-26 (1.0 point)
A student nurse employed as a personal care assistant may perform patient care:
a. learned in school.
b. expected of a nurse at that level.
*c. identified in the position’s job description.
d. requiring technical rather than professional skills.
General Feedback:
During the time a student nurse works as an employee of a health care
facility, he or she must only perform tasks that appear in a job description for a nurse’s
aide or nursing assistant. Even if a student nurse has previously learned a task or
procedure in nursing school, he or she must not perform this task as a nursing assistant
because it is outside the scope of the nursing assistant job description.
21. Chapter 05-05 (1.0 point)
A registered nurse is working on a pediatric oncology unit and caring for four children
undergoing chemotherapy. Today she has a new nursing assistive personnel (NAP)
assigned to assist her. Although she has never worked with this person, she understands
that the NAP had to pass a basic competency examination before he was allowed to work
on the unit with patients. She will delegate a portion of the fundamental nursing tasks to
the NAP during the shift. This is an example of demonstrating which of the following?
a. Ethical dilemma
*b. Code of ethics
c. Bioethics
d. Feminist ethics
General Feedback:
The code of ethics reflects underlying principles that include responsibility,
accountability, respect for confidentiality, competency, judgment, and advocacy.
22. Chapter 05-06 (1.0 point)
The mother of a 45-year-old patient is a retired physician and requests to discuss her
daughter’s plan of care with the nurse caring for the patient. What is the nurse’s best
response to this request?
a. “I will need to ask permission from my supervisor before I can share that
information.”
b. “I cannot share that information with you. I would suggest you ask your
daughter.”
c. “I would suggest that you discuss that with your daughter’s physician.”
*d. “I will have to get your daughter’s permission before I can share that
information.”
General Feedback:
The concept of confidentiality in health care has widespread acceptance in the
United States. Federal legislation known as HIPAA (Health Insurance Portability and
Accountability Act of 1996) requires that those with access to personal health
information not disclose the information to a third party without patient consent.
23. Chapter 05-10 (1.0 point)
Although a registered nurse has been working for several years as a staff nurse on an
adult oncology unit, he recently transferred to a pediatric unit in the hospital. He will be
in orientation for several days to learn about the different systems, and he will need to
demonstrate proficiency in various pediatric areas such as medication administration.
This is because he will need to demonstrate which of the following?
*a. Competency
b. Judgment
c. Advocacy
d. Utilitarianism
General Feedback:
Competence refers to specific knowledge and skills necessary to perform a
task. In the practice of nursing, competence ensures the provision of safe nursing care.
Regulations that guide the documentation of competence vary from state to state, but the
agreement to practice with competence is a common denominator for all states and is in
the nursing code of ethics.
24. Chapter 07-01 (1.0 point)
A registered nurse is caring for a 68-year-old patient in the trauma unit who had been
involved in a motor vehicle accident. Although the patient denied pain, during the nurse’s
assessment, she observed that he groaned when moving and was protective of his right
arm. She believed the patient had pain and reported it to the health care provider who
ordered a radiograph of his right arm. The radiograph revealed a fractured humerus. This
is best described as which of the following?
a. Intuition
*b. Critical thinking
c. Nursing process
d. Reflection
General Feedback:
Critical thinking is the active, organized, cognitive process used to carefully
examine one’s thinking and the thinking of others. It involves recognizing that an issue
(e.g., patient problem) exists, analyzing information related to the issue (e.g., clinical data
about a patient), evaluating information (including assumptions and evidence), and
drawing conclusions.
25. Chapter 07-02 (1.0 point)
A registered nurse is caring for a postoperative patient whose systolic blood pressure has
dropped 10 points during his shift. He remembers that this was similar to a situation that
happened in the past when the patient developed an internal bleed. The nurse’s thoughts
are best described as which of the following?
a. Intuition
b. Critical thinking
c. Nursing process
*d. Reflection
General Feedback:
Reflection is a part of critical thinking that involves the process of
purposefully thinking about or recalling a situation to discover its purpose or meaning.
26. Chapter 07-03 (1.0 point)
Blair, a student nurse, is assisting a nurse with admitting a 73-year-old woman with a
fractured ulna and radius to the trauma unit of the hospital. The patient’s daughter and
son-in-law are with her. Blair notices that the patient does not make eye contact when
answering questions and she feels that something is not right about the situation. This can
best be explained by which of the following?
*a. Intuition
b. Critical thinking
c. Nursing process
d. Reflection
General Feedback:
Intuition is the inner sensing or “gut feeling” that something is so. For
example, a nurse walks into a patient’s room and, by looking at the patient’s appearance
without the benefit of a thorough assessment, senses that he or she has worsened
physically. Intuition is a common experience that many people have when interacting
with their environments.
27. Chapter 07-04 (1.0 point)
A student nurse is with a medical unit during this clinical rotation. She is administering
an enema with her instructor in the room. The patient states that they can no longer hold
the enema solution. The student nurse acknowledges the patient’s request and begins to
tell the patient that he can go to the bathroom to expel the enema. The instructor suggests
that the patient wait a few minutes to give the enema solution time to be absorbed into the
bowel. In this situation the student nurse follows the suggestion of the instructor, which
demonstrates what level of critical thinking according to Kataoka-Yahiro and Saylor’s
model?
*a. Level 1: Basic
b. Level 2: Complex
c. Level 3: Commitment
d. The student nurse is not demonstrating critical thinking.
General Feedback:
At the basic level of critical thinking a learner trusts that experts have the
right answers for every problem. Thinking is concrete and based on a set of rules or
principles.
28. Chapter 07-05 (1.0 point)
A novice nursing student will most likely practice nursing at level _____ of critical
thinking according to Kataoka-Yahiro and Saylor's model.
*a. 1
b. 2
c. 3
d. 4
General Feedback:
At the basic level of critical thinking a learner trusts that experts have the
right answers for every problem. Thinking is concrete and based on a set of rules or
principles.
29. Chapter 07-06 (1.0 point)
A nursing student learning about the critical thinking process begins with which of the
following?
a. Collecting data
*b. Identifying a problem
c. Formulating a question
d. Evaluating the results
General Feedback:
The steps of the scientific method are as follows: Problem identification;
Collection of data; Formulation of a question or hypothesis; Testing the question or
hypothesis; Evaluating results of the study.
30. Chapter 07-08 (1.0 point)
A 56-year-old patient receiving blood after an abdominal surgery notified the nurse that
her IV pump was alarming. The nurse checked the pump and determined that the tubing
was kinked. The tubing was straightened out and the nurse left the room. Five minutes
later the IV pump again alarmed. The nurse returned to find the tubing was again kinked.
On further investigation, the nurse discovered that the IV tubing had become twisted.
This is an example of which of the following on the part of the nurse?
*a. Effective problem solving
b. Diagnostic reasoning
c. Scientific method
d. Commitment level of critical thinking
General Feedback:
Effective problem solving involves evaluating the solution over time to be
sure that it is still effective.
31. Chapter 07-09 (1.0 point)
A 16-year-old patient on a pediatric unit who underwent an appendectomy for a ruptured
appendix 3 days ago complains of acute pain and has a high fever. The nurse is
concerned that she may have an infection and notifies the health care provider of the
change in her condition. This concern is based on the nurse’s experience as a pediatric
nurse. Her ability to make a tentative conclusion regarding this patient’s situation based
on observed data is known as what?
a. Scientific method
*b. Clinical inference
c. Effective problem solving
d. Data collection
General Feedback:
Clinical inference is a critical thinking skill in which a nurse makes tentative
conclusions based on observed data or cues existing in patient situations.
32. Chapter 07-10 (1.0 point)
Roger, a 34-year-old patient with cancer, is undergoing outpatient chemotherapy. Nancy,
the nurse caring for him at the clinic where he goes for his treatments notes that Roger’s
white blood cell count is very low. Roger’s plan of care is based upon the nursing
diagnosis Risk for infection. Nancy provides patient teaching in order to reduce Roger’s
risk for infection. Nancy is using which skill in this situation?
a. Medical diagnosis
b. Scientific method
*c. Diagnostic reasoning
d. Data collection
General Feedback:
Diagnostic reasoning involves the use of cognitive thinking, metacognition
(thinking about thinking), and assessment skills to structure situations so a nurse can
apply knowledge. Expert nurses make diagnostic conclusions in the form of nursing
diagnoses.
33. Chapter 07-11 (1.0 point)
Stacie, a nursing student, is caring for Mrs. Thames, an elderly lady who recently
experienced a stroke. Stacie notices that Mrs. Thames coughs after she eats or drinks.
Stacie knew that Mrs. Thames was at risk for aspiration because of the stroke that she had
experienced and was concerned that Mrs. Thames may have impaired swallowing. Stacie
develops a care plan for Mrs. Thames based on the nursing diagnosis Impaired
swallowing. Which of the following is Stacie using to make this nursing diagnosis?
a. Medical diagnosis
b. Scientific method
*c. Diagnostic reasoning
d. Data collection
General Feedback:
In nursing, diagnostic reasoning is a process of using gathered data, forming
inferences, and then logically explaining a clinical judgment.
34. Chapter 07-12 (1.0 point)
A nurse who is demonstrating clinical decision-making is:
a. collecting information about a patient and coming to a conclusion about his or
her health problems.
b. clarifying the problem and analyze possible causes.
c. developing a new idea based on experience and knowledge over time.
*d. selecting appropriate treatment after forming a nursing diagnosis.
General Feedback:
Clinical decision-making is a problem-solving activity that focuses on
selecting appropriate treatment after forming diagnostic conclusions. Clinical decisionmaking requires careful reasoning so that a nurse chooses the option for the best patient
outcome on the basis of the patient’s condition and priority of the problem.
35. Chapter 07-13 (1.0 point)
A new registered nurse working for a busy unit of an acute care teaching hospital begins
her shift with four patients. She needs to prioritize care. Which of the following patients
should she attend to first?
a. Patient who needs assistance in ambulating the hall
*b. Patient whose blood pressure suddenly drops and who passes out
c. Recovering surgical patient whose family has just arrived
d. Patient who was just diagnosed with cancer and is alone
General Feedback:
When a nurse provides care for several patients at one time, he or she will
need to use decision-making criteria. These criteria include the clinical conditions of the
patients, Maslow’s hierarchy of needs, risks involved in treatment delays, and the
patients’ expectations of care to determine what patients have the greatest priorities for
care.
36. Chapter 07-15 (1.0 point)
A new nurse is working for a surgical unit. One of the postoperative patients has been
experiencing a great deal of pain. She notified the surgeon who wrote an order for pain
medication. Upon checking the order, she noticed that the dosage was more than three
times the normal range for this medication. She called the surgeon to question the order.
This is primarily an example of which of the following critical thinking attitudes?
a. Confidence
b. Risk-taking
c. Fairness
*d. Thinking independently
General Feedback:
A critical thinker does not accept another person’s ideas without question.
When thinking independently, a person challenges the ways in which others think and
looks for rational and logical answers to problems.
37. Chapter 07-16 (1.0 point)
A nurse for 6 years has always worked for the oncology unit of a hospital. Recently,
however, there were cutbacks because more patients are being treated on an outpatient
basis, so the nurse transferred to an orthopedic unit where he is caring for a patient who
underwent an above-the-knee amputation, something for which he has never provided
care. He is to do a dressing change for the amputated leg, so he asks another nurse to help
him. He is demonstrating which of the following critical thinking attitudes?
*a. Humility
b. Confidence
c. Risk-taking
d. Fairness
General Feedback:
Critical thinkers admit what they do not know and try to find the knowledge
they need to make a proper decision. Humility is recognizing when one needs more
information to make a decision. When a nurse is new to a clinical division and unfamiliar
with the patients, he or she should ask for an orientation to the area and ask nurses
regularly assigned to the area for assistance. Nurses should also read professional
journals regularly to keep updated on new approaches to care.
38. Chapter 07-17 (1.0 point)
A student nurse in her last semester of nursing school found that keeping a journal of her
experiences helped her to understand why she took a certain action and to evaluate
whether there was a better way of approaching the task. She has found that this has
helped her to grow into the role of a nurse. Which of the following critical thinking
attitudes is she demonstrating?
a. Humility
b. Confidence
c. Risk-taking
*d. Reflection
General Feedback:
Reflection is an important aspect of critical thinking. Purposeful reflection
leads to a deeper understanding of issues and to the development of judgment and skill.
One activity that will help a nurse develop into a critical thinker is reflective journaling.
39. Chapter 07-19 (1.0 point)
A nurse walks into a room and finds a patient to be incoherent. As the nurse examines
and observes the patient closely, searches for ideas, and considers scientific principles to
plan the patient’s care, the nurse is using:
*a. inferences.
b. reflection.
c. intuition.
d. accountability.
General Feedback:
When reflecting, one thinks about or recalls a situation to discover purpose or
meaning. Intuition is an inner sensing or “gut feeling” about something. Accountability
refers to being answerable for one’s actions.
40. Chapter 07-20 (1.0 point)
Last night a nurse spent time instructing a patient on how to monitor his pulse while
taking digoxin. The next day the nurse asks the patient to recount the details of this skill.
The nurse is using:
*a. reflection.
b. evaluation.
c. perseverance.
d. assessment.
General Feedback:
When a nurse evaluates, he or she is determining if a patient goal has been
met. When a nurse perseveres, he or she seeks resources until a successful approach has
been found. Assessment involves the act of collecting pertinent patient data.
41. Chapter 07-21 (1.0 point)
A patient is admitted with dependent edema. As a nurse assesses the patient for the
presence of jugular vein distention, the nurse is using the process of:
a. evaluation.
*b. data collection.
c. problem identification.
d. testing the hypothesis.
General Feedback:
When a nurse evaluates, he or she is determining if a patient goal has been
met. Problem identification and testing the hypothesis are two steps used in the scientific
process.
42. Chapter 09-02 (1.0 point)
Sadie, a registered nurse was caring for Mr. Harris, an older adult patient with lung
cancer. His daughter, a nurse, asked Sadie to let her look at Mr. Harris’ chart. Sadie’s
best reply should be:
a. “I’m sorry; you will have to wait until I am done with my documentation to
look at the chart.”
*b. “I’m sorry; this information is confidential.”
c. “Let me ask my supervisor if it is okay.”
d. “You should know better than to ask me that.”
General Feedback:
Do not disclose information about patients’ status to other patients, family
members (unless granted by the patient), or to health care staff not involved in their care.
Legal and ethical obligations require nurses to keep information about patients strictly
confidential.
43. Chapter 09-03 (1.0 point)
A nursing student is working on his clinical assignment. He knows that he must maintain
patient confidentiality. Which of the following is acceptable for him to write on the
clinical care plan that he will give to his instructor?
a. Patient room number
b. Patient date of birth
c. Patient medical record number
*d. Patient nursing diagnosis
General Feedback:
To further maintain confidentiality and protect patient privacy, make sure
written materials used in student clinical practice do not have patient identifiers, such as
room number, date of birth, medical record number, or other identifiable demographic
information.
44. Chapter 09-05 (1.0 point)
Practitioners from many disciplines use the medical record to document data. The most
important purpose of the medical record is to:
a. invoice the patient or insurance company for reimbursement.
b. protect the clinician in case of a malpractice suit.
*c. ensure everyone is working toward a common goal of providing safe care.
d. contribute to a databank for medical and nursing research.
General Feedback:
The overall purpose of the medical record is to ensure all health team
members are working toward a common goal of providing safe, effective, continuity of
care.
45. Chapter 09-06 (1.0 point)
A nurse is frustrated about what she feels is a lack of staff on her shift. When one of the
patients fell and broke his hip, she documented the incident in the patient’s chart. Which
of the following is the best way that she should document what happened?
*a. “Fell while going to the bathroom. Physician notified.”
b. “Nobody available to answer call bell; patient got up on own and fell.”
c. “Patient fell due to unsafe staffing levels on unit.”
d. “Patient waited as long as he could; nobody there to help him and he fell.”
General Feedback:
Never use the record for complaining, finger-pointing, or commenting on
other nonpatient care issues. Only information relevant to patient care belongs in the
record.
46. Chapter 09-07 (1.0 point)
A registered nurse is documenting her patient assessment. Which of the following
examples of documentation is most clear?
a. “Seems comfortable at this time.”
b. “Is asleep, appears not to be experiencing pain.”
c. “Apparently is not in pain because he didn’t rate it high on the scale.”
*d. “States pain is a 2 on a 0 to 10 scale.”
General Feedback:
To be factual, avoid words such as appears, seems, or apparently because
they are vague and lead to conclusions that cannot be supported by objective information.
47. Chapter 09-08 (1.0 point)
A patient states that she is experiencing pain in her lower back. What is the best way for
the nurse to document this subjective information?
a. “States her back is hurting.”
*b. “States ‘My lower back hurts.‘”
c. “Grimaces when moving; I believe she has lower back pain.”
d. “Appears to be uncomfortable with lower back pain.”
General Feedback:
The only subjective data included in a record are what the patient says. Write
subjective information with quotation marks, using the patient’s own words. For
example, a patient’s statement of “My lower back hurts” is subjective and acceptable
documentation.
48. Chapter 09-11 (1.0 point)
Which of the following documentation samples is most appropriate?
a. “The patient states he would except moving to a semi-private room.”
b. “Patient stated he developed aspiration pneumonia due to dysphasia.”
c. “Bruise noted on right side over fractured ileum.”
*d. “Right jugular vein distended.”
General Feedback:
Correct spelling demonstrates competency and attention to detail. Misspelled
words lead to confusion. For example, often words sound the same but have different
meanings.
49. Chapter 09-15 (1.0 point)
A student nurse as been scheduled to do her clinical rotation this semester for a busy
medical unit in an acute care hospital. This is the first time she has been at this hospital,
and she is told during orientation that the organization is very patient focused and that it
uses a documentation system with the acronym PIE. What does PIE stands for?
*a. Problem, Intervention, Evaluation
b. Patient, Intervention, Evaluation
c. Population, Intervention, Evaluation
d. Plan, Intervention, Evaluation
General Feedback:
PIE is an acronym for problem, interventions, evaluation as follows (see
Table 9-3):
P: Problem or nursing diagnosis applicable to patient
I:
Interventions or actions taken
E: Evaluation of the outcomes of nursing
interventions
The PIE format simplifies documentation by unifying the care plan and progress notes
into a complete record.
50. Chapter 09-16 (1.0 point)
A new registered nurse is working on a pediatric unit in a large teaching hospital that uses
focus charting with the acronym DAR. What does this stand for?
a. Data, Assessment, Reaction
b. Data, Assessment, Response
*c. Data, Actions, Response
d. Data, Actions, Reaction
General Feedback:
Focus charting is a unique narrative format in that it places less emphasis on
patient problems and instead focuses on patient concerns such as a sign or symptom, a
condition, a behavior, or a significant event. Each entry includes data, actions, and patient
response (DAR) for the particular patient situation.
51. Chapter 09-17 (1.0 point)
A registered nurse recently changed jobs and is now working in home health. She
understood that the reason for accurate documentation in the acute care setting where she
had previously worked was to provide an accurate record for safe patient care. Working
in home health, she now has learned that in addition to providing an accurate record for
safe patient care, this documentation is also used by Medicare, Medicaid, and private
insurance companies for which of the following?
a. Justification for prescribed medications
b. Data for nursing research
*c. Justification for home care reimbursement
d. Data to support social security benefits for the disabled
General Feedback:
Medicare has specific guidelines for establishing eligibility for home care
reimbursement. When nurses provide home care, documentation must specifically
address the category of care and the patients’ responses to care. Documentation in the
home care system has different implications than in other areas of nursing. The
documentation is both the quality control and the justification for reimbursement from
Medicare, Medicaid, or private insurance companies.
52. Chapter 09-19 (1.0 point)
When a student nurse began working at a local hospital this past summer, she learned that
the hospital had just instituted a “hand-off” protocol. Which of the following is the best
example of a hand-off report?
*a. Transfer report
b. IV fluid flow sheet
c. Documentation in the nurse’s notes of the patient chart
d. Laboratory report
General Feedback:
A hand-off report happens any time one health care provider transfers care of
a patient to another health care provider. The purpose of hand-off reports is to provide
better continuity and individualized care for patients.
53. Chapter 09-21 (1.0 point)
A nurse records that a patient states his abdominal pain is worse now than last night. Of
what is this an example?
a. PIE documentation
b. SOAP documentation
*c. Narrative charting
d. Charting by exception
General Feedback:
PIE charting focuses on problem, intervention, and evaluation. SOAP
documentation addresses subjective data, objective data, assessment, and the plan period.
Charting by exception reduces the time required to compete documentation, using a flow
sheet to indicate normal findings or routine interventions.
54. Chapter 09-22 (1.0 point)
A nurse completes an incident report on a patient who fell while walking in the hallway.
The purpose of this documentation is to:
a. exchange information among health care members.
b. provide information about patients on one unit to another.
c. ensure proper care for the patient.
*d. aid in the hospital’s quality improvement program.
General Feedback:
A report is an exchange of information between health care members.
Transfer reports involve communication of information about patients from one nurse on
the sending unit to the nurse on the receiving unit.
55. Chapter 09-23 (1.0 point)
After a nurse receives a medication telephone order for a patient, what is the proper
action?
a. Withholding the medication until the physician or health care provider is able to
write the prescription in person
b. Verifying the physician’s or health care provider’s order with the pharmacy
*c. Documenting the new medication order in the patient’s chart
d. Clarifying the new medication order with another registered nurse
General Feedback:
The purpose of a telephone order (TO) is to begin a therapy before the
physician or health care provider can arrive at the hospital. The nurse reads back to the
physician or health care provider the order. The read-back is a Joint Commission
requirement. The nurse reads back the order to the physician or health care provider, and
then the physician or health care provider has 24 hours to sign the order.
56. Chapter 09-24 (1.0 point)
During a change-of-shift report the nurse who is going off duty is expected to:
a. exchange judgments made about the patient’s attitudes.
b. include a description of how to perform procedures.
*c. provide a concise and organized description of the patient’s status and needs.
d. make walking rounds with the nurse coming on duty to review the patient’s
plan of care.
General Feedback:
Describing interactions in subjective terms will contribute to prejudiced
opinions about patients. A change-of-shift report provides information to ensure
continuity and individualized care for patients. Walking rounds allow the nurse to obtain
immediate feedback when questions arise about a patient’s plan of care. Walking rounds
are one type of shift report used by health care facilities.
57. Chapter 09-25 (1.0 point)
Multidisciplinary team members use a critical pathway to monitor the patient’s progress.
This is an example of using a critical pathway as a:
*a. documentation tool.
b. method to track changes.
c. way to format the nursing process.
d. substitute for a Kardex form.
General Feedback:
Variances track patient outcomes when the patient deviates from the critical
path plan.
Critical pathways summarize the standardized plan of care. A critical path includes plans
to address patient problems, key interventions, and expected outcomes for the patient
with a specific disease or condition.
58. Chapter 09-26 (1.0 point)
The discharge summary deals with important elements pertaining to the patient’s
problems and health care after discharge. When preparing the summary, the nurse needs
to include:
*a. the specific teaching plan.
b. deviations from the plan of care.
c. the standardized nursing care plan.
d. a detailed description of nursing procedures.
General Feedback:
Deviations from the plan of care are tracked as variances. Standardized
nursing care plans are based on the institution’s standards of nursing practice. Detailed
descriptions of nursing procedures are shared in change-of-shift reports.
59. Chapter 09-27 (1.0 point)
Information about a patient’s status may not be disclosed to non–health care team
members because:
*a. legal and ethical obligations require health care team members to keep
information strictly confidential.
b. regulations require health care institutions to document evidence of physical
and emotional well-being.
c. reimbursement issues relating to patient care and procedures may be of
concern.
d. a fragmentation of nursing and medical care procedures may be identified.
General Feedback:
The Joint Commission requirements require documentation of physical and
emotional well-being; however, HIPAA regulations must be strictly enforced.
Reimbursement is linked to documentation; however, only authorized hospital personnel
can view a patient care record. An audit may discover fragmentation between nursing and
medical care.
60. Chapter 09-28 (1.0 point)
A nursing unit is conducting a trial on a computerized documentation system. The nurse
is anxious to implement this type of system because it:
a. maximizes the need to duplicate records.
*b. can be used to document all aspects of care.
c. alters the need to document on a regular basis.
d. has a much narrower scope than current charting systems.
General Feedback:
Computerized documentation is designed to minimize repetitive clerical and
monitoring tasks. When used properly, computerized documentation improves
documentation accuracy, timeliness, completeness, and communication. Computerized
documentation is virtually unlimited.
61. Chapter 09-29 (1.0 point)
A nurse has just admitted a patient with a medical diagnosis of Rule out myocardial
infarction. When completing the paperwork the nurse needs to record:
a. an interpretation of patient behavior.
*b. objective data that are observed.
c. lengthy entries using lay terminology.
d. abbreviations familiar to the nurse.
General Feedback:
Nurses should only include descriptive, objective information about what
they see, hear, feel, and smell. Entries should be precise and accurate. Nurses must only
use acceptable abbreviations identified by their institution. The Joint Commission has
strict regulations regarding the use of abbreviations.
62. Chapter 19-01 (1.0 point)
Martha is a student nurse who is caring for Ileana, a 25-year-old Mexican American
woman who has learned that she has cervical cancer. Martha has learned that in the
Mexican-American culture, decisions about healthcare are often made by the family
group. Martha would like to help Ileana as she makes a decision about her treatment
options. The most appropriate way for her to assist in this situation is to do which of the
following?
a. Suggest the health care provider meet with Ileana privately.
*b. Let Ileana know what time the health care provider will make rounds so that
she can invite her family to be present.
c. Explain to Ileana what the treatment options are.
d. Have an interpreter present to answer any questions.
General Feedback:
A worldview is the way a particular cultural group thinks. Professional
worldviews about health and illness are often different from those of patients.
63. Chapter 19-09 (1.0 point)
A nurse working in an ambulatory care center is caring for a patient who requires
dressing changes every other day. The family caregiver indicates that the patient does not
value adhering to a time schedule. What is the most appropriate action?
a. Continue to schedule the appointments.
b. Ask the patient to call the ambulatory care center to cancel appointments.
c. Call every other day to remind the patient of the scheduled appoint.
*d. Explain to the patient and family members the importance of wound dressing
changes and explore anticipated barriers to time adherence.
General Feedback:
Present time orientation is in conflict with the dominant organizational norm
in health care emphasizing punctuality and adherence to appointments. Nurses should
expect conflicts and make adjustments when dealing with other ethnic groups. Improving
the accessibility of health services so time schedules accommodate cultural patterns may
assist patients with making appointments and referrals.
64. Chapter 21-01 (1.0 point)
A student nurse who works in a pediatric clinic is assisting with an assessment on a
young child who is not yet walking. She knows that it is considered a delayed gross
motor ability if the child does not walk by _____ months.
a. 16
b. 18
*c. 20
d. 22
General Feedback:
A critical period of development refers to a specific phase or period when the
presence of a function or reasoning has its greatest effect on a specific aspect of
development. For example, if a child does not walk by the age of 20 months, there is
delayed gross motor ability, which slows exploration and manipulation of the
environment. The success or failure experienced within a phase affects the child’s ability
to complete the next phases.
65. Chapter 21-06 (1.0 point)
Margaret has just found out she is pregnant. The nurse at the clinic told her that she
should stop smoking, avoid alcohol, and avoid eating king mackerel because of the high
mercury content in the fish. Although this advice should be followed during the entire
pregnancy, the fetus is most vulnerable to adverse affects in the _____ trimester.
*a. first
b. second
c. third
d. final
General Feedback:
Exposure to potential teratogens can affect fetal development during any of
the trimesters; however, vulnerability is increased during the first trimester when fetal
cells are differentiating and organs are forming.
66. Chapter 21-07 (1.0 point)
A student nurse is in her community health clinical rotation. She is visiting a family with
a new baby. Which of the following statements made by the mother of a 1-month-old
infant indicates the need for client education?
a. “My baby should double his birth weight by the time he is 6 months old.”
b. “I shouldn’t give my baby any cow’s milk until he is at least a year old.”
*c. “My baby has been fussy lately; I believe he is probably cutting his teeth.”
d. “I shouldn’t put my baby on a fluffy pillow to sleep.”
General Feedback:
The first tooth to erupt is usually one of the lower central incisors at the
average age of 7 months. Most babies have six teeth by their first birthday.
67. Chapter 21-08 (1.0 point)
The mother of a toddler is concerned that her son is not eating enough, although he has
not lost any weight. She tells the nurse that her son used to have a very good appetite, but
now does not eat as much as he did a couple of months ago. What is the best response for
the nurse to provide?
a. “You should try to get him to eat, even if it is only cereal.”
b. “He needs a lot of protein for growth during his toddler years.”
*c. “Toddlers have periods when they aren’t growing as fast and they don’t need
to eat as much.”
d. “Why don’t you let him eat off of your plate instead of making him his own
plate.”
General Feedback:
Slower growth rates often occur with a decrease in caloric needs and a
smaller food intake. Confirming the child’s pattern of growth with standard growth charts
is reassuring to parents concerned about their toddler’s decreased appetite (physiological
anorexia). Encourage parents to offer a variety of nutritious foods, in reasonable servings,
for mealtime and snacks.
68. Chapter 21-09 (1.0 point)
Kevin is the father of 11-year-old Harry, who is being seen at the clinic for his annual
check-up. As part of anticipatory guidance, you instruct Kevin that accidents and injuries
are major health problems affecting school age children. Kevin asks what the number one
cause of death is in this age group and your response is:
a. drowning.
*b. motor vehicle accidents.
c. fire.
d. firearms.
General Feedback:
Accidents and injuries are major health problems affecting school-age
children and are the causative factor in a large number of deaths in this age group. Motor
vehicle accidents, followed by drowning, fires, burns, and firearms are the most frequent
fatal accidents.
69. Chapter 21-10 (1.0 point)
Margery is the mother of 8-year-old Bonnie. Margery has brought Bonnie in to the health
clinic for her annual check-up. She is concerned about the high blood pressure in her
family and asks the nurse if there is some way to know if Bonnie is at risk for
hypertension. What is the nurse’s best response?
*a. “Blood pressure elevation in childhood is the single best predictor of adult
hypertension.”
b. “There is no way of knowing because there are so many variables involved.”
c. “If you are concerned about hypertension, you need to keep Bonnie on a low
sodium diet.”
d. “Childhood obesity is the single best predictor of adult hypertension.”
General Feedback:
Blood pressure elevation in childhood is the single best predictor of adult
hypertension. This recognition has reinforced the significance of making blood pressure
measurement a part of every annual assessment of the child.
70. Chapter 21-12 (1.0 point)
A nurse is caring for a 5-year-old child who is hospitalized for stabilization of asthma. To
provide age-specific care, which of the following is the most appropriate action by the
nurse?
*a. Allowing the child to handle medical equipment
b. Responding immediately to the child’s every need
c. Telling the child he has to be good while in the hospital
d. Rationalizing the child’s complaints as part of the developmental process
General Feedback:
These strategies can be used to reduce preschooler’s fears when they are
hospitalized: allowing children to sit up when performing assessments and procedures;
allowing the child to see and handle equipment; allowing the child to assist with the
procedure if appropriate; giving simple and factual information to these children because
they have a great sense of imagination.
71. Chapter 21-14 (1.0 point)
A patient is experiencing incisional pain after an operation. When using Maslow’s
hierarchy of needs, the nurse realizes that for the patient to return to a prehospitalized
status, the patient needs to progress beyond:
a. belonging.
b. self-esteem.
c. self actualization.
*d. safety and security.
General Feedback:
Individuals need to satisfy each level before moving on to the next.
Belonging occupies the third stage, where threats to relationships create anticipatory
loneliness and alienation. Self-esteem occupies the fourth stage, and threats create
alienation. Self actualization is the highest level that one can achieve—the realization that
one has reached their highest potential. Safety and security occupies the second stage,
and threats to security (such as pain) produce feelings of insecurity.
72. Chapter 21-15 (1.0 point)
A pregnant teenager asks the clinic nurse why she cannot smoke during the first
trimester. Remembering growth and development, what is the nurse’s best response?
a. “The distribution of body hair can be altered.”
*b. “The organ systems are beginning to develop.”
c. “Development of fingers and toes can be affected.”
d. “The sex of the baby is determined in the first 3 months.”
General Feedback:
During the first trimester, fetal cells differentiate and develop into essential
organ systems. During the second trimester most organs are complete and able to
function. During the third trimester, skin thickens, lanugo disappears, and central nervous
system is established.
73. Chapter 21-16 (1.0 point)
A nurse is conducting a community-based education class. A strategy for positive health
habits is:
a. daily monitoring of blood pressure.
*b. adhering to a regular exercise regimen.
c. adhering to a daily exercise regimen and abstaining from alcohol consumption.
d. following the most popular diet to control the effects of weight gain.
General Feedback:
Community health programs are designed to prevent illness, promote health,
and detect diseases. Actively plan screening sessions that lend themselves to health
teaching and counseling. Regular exercise, a healthy diet, and periodic blood pressure
monitoring contribute to a healthy lifestyle.
74. Chapter 21-17 (1.0 point)
A patient asks about strategies that can be used to aid in weight reduction. The nurse can
inform the patient to follow a well-balanced diet, including selections of low-fat foods
such as:
*a. grilled chicken.
b. hot dog with relish.
c. hamburger and French fries.
d. baked potato with bacon and cheese.
General Feedback:
Refer to the food guide pyramid for healthy choices. Young, middle age, and
older adults are interested and want to be informed about health practices.
75. Chapter 22-01 (1.0 point)
Kate is caring for Nancy, a 34-year-old abused woman, who was admitted to the hospital
with multiple rib fractures that she received from her partner. Nancy states, “I don’t
blame Mike for what he did to me; I can be so stupid sometimes.” Kate recognizes this
statement as a manifestation of which of the following?
a. Body image disturbance
*b. Low self-esteem
c. Cultural differences
d. Sexual orientation
General Feedback:
Self-concept is your view of who you are. It is a combination of unconscious
and conscious thoughts, attitudes, and perceptions. Self-concept, or how you think about
yourself, directly affects your self-esteem, or how you feel about yourself.
76. Chapter 22-02 (1.0 point)
Lilly is a 66-year-old patient who has been admitted to the hospital for a stroke. Her
health care provider has told her that she should consider retiring from her high-stress
position as a hospital administrator. Lilly is distraught over this suggestion. The nurse
caring for her recognizes the most likely cause of distress is due to:
a. body image.
*b. role performance.
c. self-esteem.
d. self evaluation.
General Feedback:
Role performance is the way in which a person views his or her ability to
carry out significant roles. Common roles include mother or father, wife or husband,
daughter or son, sister or brother, employee or employer, and nurse or patient.
77. Chapter 22-03 (1.0 point)
Frank is a nurse who works at a pediatric clinic. Elliott is a 16-year-old patient who is in
the clinic for his annual check-up. During the assessment, Frank asks Elliott about his use
of tobacco. Although he denies smoking, he tells Frank that he dips snuff. He tells him
that he started last year because all his friends do it. Frank recognized this as a stressor of:
a. body image.
*b. identity.
c. role performance.
d. sexuality.
General Feedback:
An adolescent who wants to be identified as part of the popular crowd at
school develops a poor self-concept if not included in that group. Family and cultural
factors sometimes influence negative health practices, such as cigarette smoking.
78. Chapter 22-04 (1.0 point)
Robert is a 47-year-old patient who has recently undergone surgery to remove a tumor
from his colon. As a result of his surgery he has a colostomy. Robert’s nurse is planning
his care and would like to incorporate measures to support the adaptation to stress. Which
of the following is least likely to support Robert’s adaptation to stress?
a. Adequate sleep
b. Regular exercise
c. Appropriate nutrition
*d. Beginning smoking cessation classes
General Feedback:
Measures that support adaptation to stress, such as proper nutrition, regular
exercise within the patient’s capabilities, adequate sleep and rest, and stress reducing
practices contribute to a healthy self-concept.
79. Chapter 22-05 (1.0 point)
A 35-year-old new mother returned to the clinic for her 6 week postpartum check. As the
nurse, you plan to discuss any questions that she might have regarding her sexual health.
When is the best time to initiate this discussion?
a. As soon as the health care provider completes her pelvic exam
b. As the patient is preparing for the examination
*c. After the examination is over and the patient is dressed
d. In the waiting area
General Feedback:
Exploring a person’s sexuality and providing useful sex education require
good communication skills. Make sure the environment and timing provide privacy,
uninterrupted time, and patient comfort.
80. Chapter 22-06 (1.0 point)
Kathy is assessing a 27-year-old woman who confides to her in the clinic that she has
three sex partners and none of them are aware of the others. Which of the following
would be the most appropriate statement that Kathy should make?
a. “Don’t you think that is risky behavior?”
*b. “Are you practicing safe sex and using condoms?”
c. “Do you think that you are being responsible in your behavior?”
d. “What do you think they would say if they found out about each other?”
General Feedback:
Individuals need to learn more about safe sex practices when they have more
than one sex partner or when their partner had other sexual experiences. Provide
information on sexually transmitted infections, including their symptoms, use of
condoms, and high-risk sexual activities.
81. Chapter 22-07 (1.0 point)
Bill is a 17-year-old patient who was admitted to the hospital after a motorcycle accident.
He has become a paraplegic as a result of his injuries. The nurse recognizes that Bill is
ready to have another paraplegic visit him when he says:
a. “I am going to spend the remainder of the school year at home.”
b. “I don’t want to go back to school.”
*c. “I’m not sure how I will manage going back to school in a wheelchair.”
d. “I don’t want the kids at school to feel sorry for me.”
General Feedback:
You will care for patients who are faced with the need to adapt to an altered
body image as a result of surgery or other physical change. Often a visit by someone who
has experienced similar changes and adapted to them is helpful. Signs that a person is
receptive to such a visit include the patient’s asking questions related to how to manage a
particular aspect of what has happened or looking at the changed area.
82. Chapter 22-08 (1.0 point)
Leigh is a 45-year-old mother of three who recently underwent bladder surgery. She has a
Hemovac drain in her abdomen and a urinary catheter in place. The nurse needs to
ambulate her, but Leigh doesn’t want to walk down the hall of her hospital unit. She tells
the nurse, “I don’t want anyone to see the tubes and the gross drainage bags.” This
indicates to the nurse that Leigh is at risk for:
a. infection.
*b. low self-concept.
c. deep vein thrombosis.
d. decreased self-awareness.
General Feedback:
In the acute care setting you are likely to encounter patients who are
experiencing potential threats to their self-concept because of the nature of the treatment
and diagnostic procedures. Threats to a patient’s self-concept result in anxiety and/or
fear.
83. Chapter 22-09 (1.0 point)
Faith, a student nurse, is discussing a 4-year-old patient, Mike, with her nursing
instructor. The instructor asks Faith about how Erikson’s Developmental Tasks have an
impact on a 4-year-old child’s self-concept and sexuality. What is the best response?
*a. “Mike says he wants to be a mechanic like his dad when he grows up.”
b. “Mike likes to go to the park to play.”
c. “Mike’s favorite food is hot dogs.”
d. “Mike likes to play video games with his older sister.”
General Feedback:
Initiative Versus Guilt (3 to 6 Years): Takes initiative; identifies with a
gender; enhances self-awareness; increases language skills, including identification of
feelings
84. Chapter 22-10 (1.0 point)
The mother of a 7-year-old boy asked the nurse what factors tended to increase selfesteem in boys. According to research, which of the following is the nurse’s best
response?
*a. Positive family communication
b. Parents who have at least 4 years of college
c. Boys with older siblings
d. Boys from two-parent households
General Feedback:
One group of researchers found that family income above the federal poverty
level, positive family communication, and involvement in a religious community are
associated with high self-esteem in boys.
85. Chapter 22-11 (1.0 point)
As a nurse caring for a patient with a colostomy that resulted from the treatment of a
benign tumor of the bowel, you most appropriately classify this self-concept component
as:
a. role performance stressor.
b. sexuality stressor.
c. identity stressor.
*d. body image stressor.
General Feedback:
A role performance stressor occurs when acute and chronic illness alters a
person’s ability to carry out his or her roles. Alterations in sexual health occur from a
variety of situations such as illness, infertility, trauma, or abuse. Identity stressors affect
an individual’s identity, but identity is particularly vulnerable during adolescence.
86. Chapter 22-12 (1.0 point)
A nurse is caring for an adult patient who retired last year. While rendering care, the
nurse identifies that the patient is struggling emotionally with this change. This situation
is most likely associated with what self-concept component?
*a. Role
b. Identity
c. Self-esteem
d. Body image disturbance
General Feedback:
Identity stressors affect an individual’s identity, but identity is particularly
vulnerable during adolescence. Self-esteem stressors vary with developmental stages.
Potential self-esteem stressors in older adults include health problems, declining
socioeconomic status, spousal loss or bereavement, loss of social support. Body image
stressors involve attitudes related to the body, including appearance, femininity and
masculinity, youthfulness, health, and strength.
87. Chapter 22-13 (1.0 point)
After a large weight loss a patient tells the nurse, “There still is a fat person inside of
me.” This type of statement illustrates a flaw in what self-concept component?
a. Role
b. Identity
c. Self-esteem
*d. Body image
General Feedback:
Role is the way in which a person views his or her ability to carry out
significant roles. Identity stressors affect an individual’s identity, but identity is
particularly vulnerable during adolescence. Self-esteem stressors vary with
developmental stages. Potential self-esteem stressors in older adults include health
problems, declining socioeconomic status, spousal loss or bereavement, and loss of social
support.
88. Chapter 22-14 (1.0 point)
An older adult patient who recently lost her husband is admitted for surgery. The nurse
notices that the patient is experiencing an alteration in psychosocial development when
the patient:
a. accepts her own limits.
b. voices concerns about the upcoming surgery.
c. expresses her opinions about the quality of care.
*d. demands unnecessary assistance from her daughter.
General Feedback:
Knowledge regarding developmental stage will help the nurse to determine
responses that are important to the patient. A change in behavior suggests an alteration in
self-concept.
89. Chapter 22-15 (1.0 point)
To devise a plan of care, when taking a patient’s health history the nurse should always:
a. focus only on physical factors that affect sexual functioning.
b. discuss sexual concerns only if the patient raises questions or concerns.
c. use emotionally laden terms when discussing sexual concepts.
*d. routinely include a few questions related to sexual functioning.
General Feedback:
Every nursing history needs to include a few questions related to sexual
functioning. In gathering the sexual history, consider physical, functional, relationship,
lifestyle, and self-esteem factors that influence sexual functioning.
90. Chapter 23-03 (1.0 point)
Gene and Jackie are parents of twins. As their daughters have entered high school they
have gradually become more independent and the family boundaries have become more
flexible. This family is in what developmental stage?
a. Unattached young adults
b. Family with young children
*c. Family with adolescents
d. Family with young adults
General Feedback:
Family with adolescents experience changes in family status that are needed
to proceed developmentally; these include shifting of parent-child relationships to permit
adolescents to move into and out of system; refocusing on midlife marital and career
issues; beginning to shift toward concerns for older generations.
91. Chapter 23-07 (1.0 point)
Mark is the nurse admitting Mr. Kern to the neurology unit of the hospital. Mr. Kern is an
82-year-old man who lives at home with his wife of 60 years. His daughter and her
family live next door to the Kerns and help care for them. Mrs. Kern has diabetes and
hypertension, which are both controlled with medication and diet. As Mark develops a
plan of care for Mr. Kern, he should consider which of the following nursing diagnoses?
*a. Risk for caregiver role strain
b. Disabled family coping
c. Impaired parenting
d. Ineffective role performance
General Feedback:
During times of acute illness a family becomes distressed and focuses solely
on the ill member, neglecting the needs of the other family members. For example, you
will always consider the diagnosis of Risk for caregiver role strain a possibility when
extended care of a family member is necessary.
92. Chapter 23-08 (1.0 point)
Sarah is a nurse who works in home care. She is caring for Mr. Jenkins, a 78-year-old
patient with liver cancer. Mr. Jenkins lives at home with his wife of 53 years. In addition
to caring for Mr. Jenkins, Sarah also assesses caregiver stress in Mrs. Jenkins. Which of
the following indicates caregiver stress in Mrs. Jenkins?
a. Increased visits from church members
b. Mrs. Jenkins asking her daughter for help with shopping
c. Mrs. Jenkins arranging for Meals-on-Wheels three days a week
*d. Mrs. Jenkins contracting pneumonia
General Feedback:
Assess for caregiver stress, such as tension in relationships with family and
care recipient, changes in level of health, changes in mood, and anxiety and depression.
93. Chapter 23-09 (1.0 point)
When evaluating patient expectations of family-centered nursing, it is most important to
obtain which of the following?
a. Patient outcome information
*b. Family’s perspective of nursing care
c. Physician’s perspective of nursing care
d. Health care goals of the patient
General Feedback:
It is important to obtain the family’s perspective of nursing care: how you
planned and delivered the care with them, whether it was satisfactory, whether it met the
family’s goals, and if not, what they think was needed instead. This evaluation needs to
be ongoing so that care delivery techniques can be modified or adjusted as needed.
94. Chapter 23-15 (1.0 point)
A husband and wife are having a loud discussion regarding acceptable health care
practices. The nurse uses therapeutic communication to deal with this situation. The nurse
understands that effective communication within the family promotes:
a. increased financial opportunities for the family.
b. socialization among individual family members.
c. role development of each individual family member.
*d. problem solving and emotional support of the family members.
General Feedback:
Economic factors are always a concern for families, especially for those at the
lower end of the economic scale and single-income families. The family is the primary
social context in which health promotion and disease prevention take place. Families, just
like individuals, change and grow over time. Each developmental stage has challenges,
needs, and resources.
95. Chapter 23-18 (1.0 point)
An older adult patient is returning home after a total knee replacement. The patient lives
within an alternative pattern relationship. The patient is unable to perform the
postoperative exercises. What is the most appropriate action the nurse should take?
a. Referring the patient to an outpatient exercise group
b. Arranging for a private duty nurse to help perform exercises three times a week
c. Informing the patient that if he cannot do the exercises, he will have to go to an
extended care facility
*d. Investigating whether or not someone else in the home will be able to assist
with the knee exercises
General Feedback:
When assessing a patient, it is important to include family form, structure,
and function, including developmental stage. Identifying the family form and system will
assist you in determining if support is available within the family form.
96. Chapter 23-19 (1.0 point)
The family of a patient attends a patient care conference. When planning family goals the
nurse should:
a. view the family as a system.
b. make the goals as broad as possible.
*c. assess the availability of family members.
d. not recognize developmental stages of family members.
General Feedback:
Family is viewed as context, family, and system. When goals are made broad,
they are less measurable and less practical. Each individual, as well as the family,
changes and grows over time. Each stage has challenges and needs.
97. Chapter 25-01 (1.0 point)
Harold is a 45-year-old man who recently lost his job as a result of downsizing at his
company. Harold was employed at this company since graduating from college and
identifies himself by the work that he did. He is currently grieving as a result of which
type of loss in his life?
a. Maturational
b. Situational
*c. Actual
d. Perceived
General Feedback:
People experience an actual loss when they can no longer touch, hear, see, or
have near them valued people or objects. Examples include the loss of a body part, pet,
friend, life partner, or role at work.
98. Chapter 25-02 (1.0 point)
Kelly is a nursing student who has maintained a 4.0 GPA since she has been in nursing
school. The past semester she has started working, is planning a wedding, and has moved
into a new home. Kelly has not been able to maintain the 4.0 GPA this semester and as a
result, Kelly is feeling like a failure. How is this loss best described?
a. Maturational
b. Situational
c. Actual
*d. Perceived
General Feedback:
Perceived losses are uniquely experienced by a grieving person and are often
less obvious to others. A perceived loss is “real” to the person who feels the loss. A
person may perceive that she is less loved by her parents, for example, and experiences a
loss of self-esteem. Others often overlook or misunderstand perceived losses.
99. Chapter 25-03 (1.0 point)
Jenny is the young mother of three children. Her oldest child has started school this year,
and she cried as she left him at kindergarten on the first day. How is the loss that Jenny is
experiencing best described?
*a. Maturational
b. Situational
c. Actual
d. Perceived
General Feedback:
People experience maturational losses as they go through a lifetime of normal
developmental processes. When a child goes to school for the first time, she will spend
less time with her parent and the parent-child relationship changes. Acknowledging and
grieving maturational losses help a person cope with the change.
100. Chapter 25-04 (1.0 point)
Denise is a recently widowed mother of two. Her late husband was starting his own
business, and she was managing the accounting paperwork. The family had no life or
health insurance. When her husband suddenly died, Denise was left with a large hospital
bill, funeral expenses, unemployment, and no means of support. How are the multiple
losses that Denise is experiencing best described?
a. Maturational
*b. Situational
c. Actual
d. Perceived
General Feedback:
Situational loss occurs as a result of a sudden, unpredictable life event. A
situational loss often involves multiple losses. A divorce, for example, begins with the
loss of a life companion, but often leads to financial strain, changes in living
arrangements, less contact with one’s children, and loss of friends who were part of the
couple’s married life.
101. Chapter 25-10 (1.0 point)
Mrs. Unger, a 76-year-old patient, has been suffering from liver cancer for more than a
year. The family has requested hospice services. The family members are taking turns
staying with Mrs. Unger. They have been reminiscing with Mrs. Unger about her life and
are now saying their good-byes. The type of grief that this family is experiencing is best
described as which of the following?
a. Normal
*b. Anticipatory
c. Complicated
d. Disenfranchised
General Feedback:
The process of “letting go” that occurs before an actual loss or death has
occurred is called anticipatory grief.
102. Chapter 25-12 (1.0 point)
Eleanor is a 45-year-old widow who is being seen in a mental health clinic for clinical
depression and alcohol dependency. She lost her husband and her son in a boating
accident 10 months ago and has become increasingly despondent and withdrawn. She
verbalizes that she feels overwhelmed by her loss. Her daughter urged her mother to seek
help. Which type of complicated grief best explains Eleanor’s behavior?
a. Chronic
b. Delayed
*c. Exaggerated
d. Masked
General Feedback:
Persons overwhelmed by their loss cannot function or display significant
behavioral dysfunction in an exaggerated grief response. Evidence of exaggerated grief
includes severe phobias, deep depression, or self-destructive behaviors such as
alcoholism, substance abuse, or suicide.
103. Chapter 25-13 (1.0 point)
Hannah is a 34-year-old single mother of three who had been involved in a secret
relationship with her boss, a married man who was 24 years her senior. When her boss
suddenly died as the result of a heart attack, Hannah had difficulty expressing the extent
of her loss. The grief that Hannah was experiencing could best be described as which of
the following?
*a. Disenfranchised
b. Complicated
c. Normal
d. Anticipatory
General Feedback:
Individuals experience disenfranchised grief when they cannot openly
acknowledge a loss and experience full social support from others. Disenfranchised grief
happens most often in situations in which others regard the person’s loss as less
significant or “legitimate.”
104. Chapter 25-14 (1.0 point)
Mary, a student nurse, is caring for a 3-year-old niece whose mother has recently died of
cancer. Because of the child’s stage of development, Mary expects that the child will
most likely see the loss of her mother as which of the following?
a. Permanent
b. A threat to her self-concept
*c. Temporary
d. A challenge to her emerging identity
General Feedback:
A person’s age and stage of development partly determine his or her ability to
understand loss and what it means for his or her future and well-being.
105. Chapter 25-15 (1.0 point)
Last year Margaret, a student nurse, became very involved in her church’s youth group
when she lost her father to cancer. Currently Margaret is facing another challenge in her
life because her dog has become terminally ill and is not expected to live. How will
Margaret most likely cope with the death of her beloved pet?
a. Dropping out of school
*b. Staying busy with her student nurse organization
c. Turning to alcohol
d. Becoming obsessive compulsive about her personal hygiene
General Feedback:
Individuals first respond to loss by using coping mechanisms that worked for
them in the past.
106. Chapter 25-16 (1.0 point)
Robert is a businessman who has been diagnosed with multiple sclerosis. His health care
provider has not given him a very positive prognosis because his disease is progressing
very quickly. What is the most important thing for Robert to maintain at this point in his
illness for his sense of well-being?
*a. Hope
b. Skin integrity
c. Individuality
d. Socioeconomic status
General Feedback:
People facing life-changing experiences need to maintain hope. Hope is the
anticipation of a continued good or an improvement or lessening of something
unpleasant. Hope energizes and comforts people as they face personal challenges and
enhances their coping skills.
107. Chapter 25-18 (1.0 point)
Wendy is a nursing student who is admitting Mrs. Williams, a 75-year-old patient into the
gastrointestinal laboratory for a routine colonoscopy. During the assessment, Wendy
learns that Mrs. Williams lost her husband 4 months ago to stomach cancer and has not
been sleeping well. Which of the following is the best question to obtain more data
regarding Mrs. Williams’ sleeping pattern?
a. “Are you taking medication to help you sleep?”
*b. “How long have you had difficulty sleeping?”
c. “What time do you go to bed at night?”
d. “Are you taking a nap in the afternoon?”
General Feedback:
A patient who complains of loneliness and difficulty falling asleep may be in
a yearning or searching phase. To gather more data, ask questions such as, “When did the
loss occur?” or “How long have you been feeling this way?”
108. Chapter 25-19 (1.0 point)
Denise is attending a grief support group that you are facilitating. She lost her son in Iraq
18 months ago. She confides in you that she went to her son’s grave yesterday and broke
down. She told you that she hurt as deeply as the day she found out that he had been
killed and feels that she would never get through this feeling of intense grief. On listening
to her you discover that yesterday would have been her son’s twenty-first birthday. What
is the best response to Denise?
a. “It would be best to avoid the cemetery on dates that might trigger this type of
reaction.”
*b. “What happened to you yesterday is understandable and common in people
who have lost loved ones.”
c. “Next time you go to the cemetery you should take someone with you.”
d. “Why don’t you go home and take a bubble bath instead of attending the
support group this evening.”
General Feedback:
Allow time to grieve. Some people have “anniversary reactions” (heightened
or renewed feelings of loss or grief) months or years after a loss. They worry that they are
losing ground when signs of grief reappear after a period of relative calm. Offer
reassurance that anniversary reactions are common, and encourage pleasant
reminiscence.
109. Chapter 25-24 (1.0 point)
Mrs. Cherewski is a 78-year-old patient from Poland who has been admitted to the
hospital with advanced colon cancer. She is receiving palliative care at this time. Which
of the following questions would be best for the nurse to ask to obtain information about
cultural factors that influence grieving?
a. “How have you coped with other hospitalizations?”
b. “Tell me about the family that is available to help you.”
c. “What do you expect will happen to you?”
*d. “What do you believe about death?”
General Feedback:
Factors to assess regarding cultural and spiritual beliefs include the following
areas/questions to explore: What do you believe about death? Who makes health care
decisions in your family/culture? Tell me about your family’s/culture’s funeral practices.
110. Chapter 25-25 (1.0 point)
A nurse is caring for a patient who has become depressed because her children have gone
away to college. The nurse assesses this type of depression as __________ loss.
a. actual
b. perceived
c. situational
*d. maturational
General Feedback:
An actual loss is any loss of a person or object that an individual can no
longer feel, hear, know, or experience. Perceived loss is any loss that is uniquely defined
by the grieving patient. Situational loss includes any sudden, unpredictable external
event.
111. Chapter 25-27 (1.0 point)
A middle-age patient with a terminal disease is speaking harshly to the nurse every time
the call light is answered. The nurse identifies that this dying patient is experiencing the
second stage of Kübler-Ross’s stages of dying. What is the second stage?
*a. Anger
b. Denial
c. Bargaining
d. Acceptance
e. Depression
General Feedback:
The order is denial, anger, bargaining, depression, and acceptance.
112. Chapter 25-29 (1.0 point)
A patient suffering from lung cancer experiences nausea and vomiting. When rendering
palliative care, what is the best action for the nurse to take?
a. Reducing fatigue
b. Offering high-protein food
*c. Administering analgesics
d. Increasing patient’s fluid intake of milk and fruit juice
General Feedback:
Palliative care is a philosophy of total care. A palliative care approach
ensures that a patient experiences a good death, free of avoidable pain and suffering, in
accord with the patient’s and family’s wishes.
113. Chapter 25-34 (1.0 point)
A hospitalized husband and father of two children just learned that his wife was killed in
a motor vehicle accident. The method in which this patient manifests loss will be
influenced by:
a. personal attitude.
b. maturational loss.
c. emotional well-being.
*d. the stage of human development.
General Feedback:
A maturational loss is any change in the developmental process that is
normally expected during a lifetime. Emotional well-being examines a person’s state of
mind and presence.
114. Chapter 26-02 (1.0 point)
Marge is a nursing student who is completing her clinical rotation on a geriatric unit. She
cares for patients with fragile skin on this unit and looks for ways to reduce the friction
caused when repositioning a patient in bed. Which of the following causes the most
friction when repositioning a patient?
a. Lifting the patient
b. Using a drawsheet
*c. Pushing the patient
d. Using a transfer board
General Feedback:
You reduce friction by lifting rather than pushing a patient. Lifting has an
upward component and decreases the pressure between the patient and the bed or the
chair. The use of a drawsheet reduces friction because you are able to move the patient
more easily along the bed’s surface. However, there are several commercially available
products to assist in the task of positioning and moving patients in bed such as transfer
boards and Maxi Slides.
115. Chapter 26-08 (1.0 point)
Esther, a devout Muslim, is a 46-year-old client who is being evaluated for weight-loss
surgery. One aspect of the comprehensive bariatric program is that clients begin an
exercise program. Esther is self-conscious about her weight and concerned about
maintaining her modesty. Which of the following exercise programs would be the best
choice for the nurse to suggest to Esther?
a. A private trainer at a local fitness center
b. An aerobics class at the local YMCA
c. The evening yoga class at a local country club
*d. Walking 30 minutes a day at the mall with a friend
General Feedback:
Exercise and physical fitness is beneficial to all people. When developing a
physical fitness program for culturally diverse populations, consider what motivates
individuals to exercise and what activities will be appropriate and enjoyable.
116. Chapter 26-11 (1.0 point)
Mr. Kelly is a 56-year-old patient with COPD. He does not tolerate a supine position for
sleeping. What is the best position for the nurse to suggest for him?
a. Lateral
b. Prone
*c. Semi-Fowler’s
d. Sims’
General Feedback:
In semi-Fowler’s position the head of the bed is at a 30-degree angle; you will
use this position for patients who will not tolerate a supine position, such as those with
cardiac and respiratory problems.
117. Chapter 26-14 (1.0 point)
Mr. Stephens, a 46-year-old patient, has been hospitalized for 5 days after pancreatic
surgery. Jillian, the student nurse caring for him, is preparing him to ambulate for the first
time. What is the best thing that Jillian can do to prevent Mr. Stephens from suffering
orthostatic hypotension when helping him stand up?
a. Having him sit up in bed for a few minutes before standing
*b. Having him sit up with his legs dangling over the side of his bed for a few
minutes before standing
c. Placing him in a high-Fowler’s position for a few minutes before standing
d. Placing him in a low-Fowler’s position for a few minutes before standing
General Feedback:
When preparing a patient for ambulation, dangling is an important technique.
You assist the patient to a sitting position with the legs dangling off the side of the bed
and have the patient rest for 1 to 2 minutes before standing. When the patient has been
flat for extended periods, blood pressure drops when the patient stands. Dangling helps to
prevent this.
118. Chapter 26-15 (1.0 point)
Paul is a student nurse assisting Mr. Jenkins with his new walker. Which of the following
is appropriate information for Paul to provide to Mr. Jenkins?
a. “The top of the walker should line up with the crease on the inside of your
elbows.”
b. “You should walk behind the walker to maintain balance.”
c. “You should lean forward over the walker to maintain balance.”
*d. “When walking, you should take a step, move the walker forward, and take
another step.”
General Feedback:
When the person relaxes the arms at the side of their body, the top of the
walker should line up with the crease on the inside of the wrist. When walking, the
patient holds the handgrips on the upper bars, takes a step, moves the walker forward, and
takes another step. The patient should not lean over the walker or walk behind it;
otherwise he or she might lose balance and fall.
119. Chapter 26-16 (1.0 point)
Brittney is a student nurse caring for Mrs. Flowers, a 67-year-old patient who recently
had a stroke that left her with left-sided weakness. Brittney is providing patient teaching
regarding the use of a quad-cane for ambulation. Which of the following statements is
correct?
*a. “You should use the cane on the stronger side of the body.”
b. “Move the stronger leg with the cane.”
c. “When walking, advance the weaker leg past the cane.”
d. “Your body weight should be supported by the cane and stronger leg.”
General Feedback:
Make sure the patient keeps the cane on the stronger side of the body. The
patient moves the weaker leg to the cane, which divides body weight between the cane
and the stronger leg. The patient then advances the stronger leg past the cane so the
weaker leg and the body weight is supported by the cane and weaker leg.
120. Chapter 26-18 (1.0 point)
A nurse is educating a patient who needs stability about how to use the crutches that have
been ordered. The use of the technique the nurse is teaching requires weight bearing on
both legs. Each leg is moved alternately with each opposing crutch so that three points of
support are on the floor at all times. The term for this gait is the __________ gait.
*a. four-point
b. three-point
c. two-point
d. two-point alternating
General Feedback:
Four-point alternating or four-point gait gives stability to the patient but
requires weight bearing on both legs. Each leg is moved alternately with each opposing
crutch so that three points of support are on the floor at all times.
121. Chapter 26-19 (1.0 point)
Theresa is a nurse caring for five orthopedic patients on her shift. Kate is a nursing
assistive personnel who is assisting Theresa. Which of the following tasks is most
appropriate for Theresa to delegate to Kate?
*a. Moving a 45-year-old patient who had a CVA toward the head of the bed
b. Repositioning a confused 87-year-old patient with contractures
c. Providing discharge teaching for a 49-year-old patient who had a stroke
d. Preparing a 77-year-old patient for hip replacement surgery
General Feedback:
The skill of moving and positioning patients in bed can be delegated to
nursing assistive personnel.
122. Chapter 26-20 (1.0 point)
A nurse and another staff member are preparing to reposition a patient in bed. To prevent
back strain, these two health care providers must:
a. keep their knees stiff to enhance their lifting strength potential.
*b. keep the weight of the patient as close to their bodies as possible.
c. loosen their stomach muscles to keep from injuring the pelvic region.
d. twist their upper torsos to enhance the use and strength of their upper
extremities.
1.
2.
3.
4.
General Feedback:
To prevent lifting-related injuries, always follow these steps:
Keep weight as close to the body as possible.
Bend at the knees.
Tighten abdominal muscles, and tuck pelvis.
Maintain the trunk erect and knees bent.
123. Chapter 26-22 (1.0 point)
A patient presents to the emergency department with a fractured leg that requires a full
leg cast. The nurse needs to teach the patient to ambulate with crutches using the:
a. two-point gait.
*b. three-point gait.
c. four-point gait.
d. tripod alternating position.
General Feedback:
A two-point gait requires at least partial weight bearing on each foot. A fourpoint gait gives stability to the patient but requires weight bearing on both legs. The
tripod position is the basic crutch stance.
124. Chapter 26-25 (1.0 point)
A patient with arthritis is complaining of sensitivity and warmth in the elbow and wrist
joints. To determine the degree of limitation or injury, the nurse can assess:
a. posture.
b. activity tolerance.
c. body mechanics.
*d. joint range of motion.
General Feedback:
The term posture means maintaining optimal body position. Activity
tolerance assesses the patient’s ability to become fatigued, lightheaded, dizzy, or short of
breath related to activity. Body mechanics require knowledge of proper walking, turning,
and lifting and carrying objects in a way to prevent injury.
125. Chapter 27-01 (1.0 point)
The Martin family has recently moved into a newly renovated home in the inner city. The
house is the dream home that they have been saving for years to purchase. Mrs. Martin
has been to the clinic with her 12-year-old daughter. She complains that they have been
having headaches and nausea since the first of the year, shortly after moving into the new
home. As the nurse gathers information, what other question would be most appropriate
to ask Mrs. Martin?
a. “When was your last period?”
b. “Have you changed your diet since moving?”
*c. “What type of furnace do you have?”
d. “Do you have a history of headaches?”
General Feedback:
A furnace, stove, or fireplace that is not properly vented introduces carbon
monoxide into the environment. Carbon monoxide is a colorless, odorless, poisonous gas
produced by the combustion of carbon or organic fuels. This gas binds strongly with
hemoglobin, preventing the formation of oxyhemoglobin and thus reducing the supply of
oxygen delivered to the tissues (see Chapter 29). Low concentrations cause nausea,
dizziness, headache, and fatigue.
126. Chapter 27-02 (1.0 point)
Sally is a registered nurse who works for a home health agency. She has been asked to
admit Mr. Kelly, a 72-year-old patient who was released from a rehabilitation hospital
following therapy after he fell at home and broke his hip. As Sally surveys the home
environment, which of the following situations is most dangerous to Mr. Kelly?
a. Bedside lamp with an extension cord
b. Handrail on one side of stairs only
*c. Throw rugs in the bedroom
d. No handrail near toilet
General Feedback:
Common physical hazards in the home include inadequate lighting, barriers
along normal walking paths and stairways, and a lack of safety devices.
127. Chapter 27-03 (1.0 point)
Of the following, who is most at risk for accidental poisoning?
a. Supervised 16-month-old toddler in the kitchen
*b. Unsupervised 2-month-old infant left near a closed bottle of prescription
medication
c. Unsupervised 4-year-old child playing dress-up with mother’s makeup
d. Supervised 6-year-old child playing with watercolor paints
General Feedback:
In the home, accidental poisoning is a greater risk for the toddler,
preschooler, and young school-age child, who often ingest household cleaning solutions,
medications, or personal hygiene products.
128. Chapter 27-04 (1.0 point)
A nursing student is volunteering with a local agency to help prepare his community for a
potential bioterrorist attack. On which of the following threats should he focus?
a. Hurricane
b. Earthquake
*c. Anthrax
d. Tornado
General Feedback:
A new potential environmental health threat is the possibility of a bioterrorist
attack. Threats of this type come in the form of biological, chemical, and radiological
attacks.
129. Chapter 27-05 (1.0 point)
A student nurse is working on her senior project for school. She is concerned about the
safety of patients in the hospital, especially regarding the transmission of pathogens. She
knows that the most common means of transmission of pathogens in this environment is
caused by which of the following?
a. Contaminated blood products
b. Enteric transmission
*c. Insufficient hand hygiene
d. Aerosols
General Feedback:
Pathogens and parasites pose a threat to patient safety. A pathogen is any
microorganism capable of producing an illness. The most common means of transmission
of pathogens is by the hands.
130. Chapter 27-08 (1.0 point)
The father of a 13-year-old boy is concerned because his son wants to hang out with
friends all the time and has asked his father for permission to get his ear pierced because
all his friends have earrings. What is the best response from the nurse?
a. “I think you need to seek counseling for your son.”
b. “This is just a phase that will quickly pass.”
c. “Your son needs to find new friends.”
*d. “Your son’s behavior is normal; he is trying to assert his independence.”
General Feedback:
As children enter adolescence, they develop greater independence and a sense
of identity. The adolescent begins to separate emotionally from the family, and the peer
group begins to have a stronger influence.
131. Chapter 27-09 (1.0 point)
Edith is the mother of a 16-year-old who is being seen in the emergency department for a
minor injury when he was involved in a motor vehicle accident. Edith told the nurse
assessing her son that during the past 3 months he has been increasingly difficult to get
along with and has been spending most of his time in his room. Which of the following
topics is most important for the nurse to discuss with Edith?
a. Accident prevention measures
b. Enrolling her son in a defensive driving course
*c. The possibility of substance abuse
d. The importance of automobile insurance
General Feedback:
To assess for possible substance abuse, have parents look for environmental
and psychosocial clues. Environmental clues include the presence of drug-oriented
magazines, beer and liquor bottles, drug paraphernalia, blood spots on clothing, and the
continual wearing of long-sleeved shirts in hot weather and dark glasses indoors.
Psychosocial clues include failing grades, change in dress, increased absenteeism from
school, isolation, increased aggressiveness, and changes in interpersonal relationships.
132. Chapter 27-10 (1.0 point)
Mrs. Unger is a 36-year-old bank executive who was recently promoted to vice president.
She and her husband have two school-age children. Recently Mrs. Unger has been
experiencing abdominal pain and diarrhea. She is currently at a clinic where Thomas, a
registered nurse, has worked since graduating from nursing school. As Thomas is
assessing Mrs. Unger, she tells him that her family will be moving to another state
because of her promotion and that her children are upset about leaving their friends.
Thomas is planning care for Mrs. Unger and decides that which of the following is a
priority for patient teaching?
a. Providing growth and development information about the school-age child
b. Recommending a gastroenterologist
c. Discussing potential fluid volume deficit related to diarrhea
*d. Discussing how a high level of stress can cause illness
General Feedback:
An adult experiencing a high level of stress is also at a greater risk for
accidents and certain stress-related illnesses such as headaches, depression,
gastrointestinal disorders, and infections.
133. Chapter 27-11 (1.0 point)
Dr. Martin is an 85-year-old retired physician who has recently been prescribed a new
medication by his health care provider for a complication related to diabetes. He now
takes 13 different mediations daily. A student nurse who is seeing Dr. Martin during her
community health clinical rotation prioritizes her assessment. Which of the following is
most important to assess?
a. Altered mental status
*b. Potential for falls
c. Skin breakdown
d. Medication side effects
General Feedback:
The physiological changes associated with aging, effects of multiple
medications, psychological factors, and acute or chronic disease increase the older adult’s
risk for falls and other types of accidents.
134. Chapter 27-12 (1.0 point)
A senior nursing student is undergoing her community health clinical rotation. One of the
clients who she will see is a 53-year-old grandmother who has recently assumed custody
of her daughter’s two young children. Regarding the children’s welfare, which of the
following is most important for the nursing student to assess on this visit?
a. The patient’s financial ability to care for two young children
*b. The patient’s knowledge of safety precautions for young children
c. The patient’s emotional stability
d. The patient’s feelings regarding taking on this responsibility
General Feedback:
Some patients are unaware of safety precautions, such as keeping medicine,
poisonous plants, or other poisons away from children or reading the expiration date on
food products. A nursing assessment will identify the patient’s level of knowledge
regarding home safety so that safety problems can be corrected with an individualized
care plan.
135. Chapter 27-14 (1.0 point)
A student nurse is concerned because a patient is weak after abdominal surgery. Which of
the following should she do to ensure that one of the eight preventable conditions
identified by the Center for Medicare and Medicaid does not occur?
a. Use the “rights” of medication administration.
*b. Provide frequent opportunities to use the bathroom.
c. Complete thorough documentation.
d. Complete discharge teaching as quickly as possible.
General Feedback:
The Hospital-Acquired Conditions and Present on Admission Indicator
Reporting Act identifies eight conditions that are preventable through the application of
evidence-based guidelines: object left in surgery, air embolism, blood incompatibility,
catheter-associated urinary tract infection, pressure ulcers, vascular catheter-associated
infection, surgical site infection after coronary artery bypass graft surgery, and falls and
trauma. Gait or lower extremity problems, urinary/stool frequency or incontinence, and
use of certain medications increase the likelihood of patient falls in an acute care hospital.
136. Chapter 27-15 (1.0 point)
A 5-year-old child was admitted to the pediatric unit of the hospital with a high fever of
unknown origin. Because of his illness, his nurse is concerned about a patient-inherent
accident. Which of the following is the best way to prevent this from happening?
a. Keep all electric receptacles covered in the patient’s room.
b. Clean up patient spills as they occur.
*c. Pad all bed side rails.
d. Do not allow the child in the playroom.
General Feedback:
One of the more common precipitating factors for a patient-inherent accident
is a seizure. Place patients with a seizure disorder on seizure precautions, which are
designed to protect patients when seizures occur.
137. Chapter 27-16 (1.0 point)
Stanley is a nurse who works in busy outpatient surgery center. He works in the patient
admissions area and starts multiple IVs each day. One of the surgeons who works at the
center orders a different type of IV fluid than the rest of the surgeons. What should
Stanley be most concerned about in this situation?
*a. Procedure-related accident
b. Potential patient fluid overload
c. Wrong-site surgery
d. Potential electrolyte imbalance
General Feedback:
Procedure-related accidents are caused by health care providers and include
medication and fluid administration errors, improper application of external devices, and
improper performance of procedures such as dressing changes. Following an
organization’s policies and procedures and standards of nursing practice helps prevent
procedure-related accidents.
138. Chapter 27-17 (1.0 point)
A student nurse is working for the medical unit of her local hospital. One of the IV
pumps on the unit has been malfunctioning and was placed outside a patient room until it
could be repaired. To prevent an equipment-related accident from occurring, which of the
following should be done?
*a. Tag the pump and remove it from the area.
b. Initiate a work order on the pump.
c. Clean the pump and put it in the equipment closet.
d. Call the pump manufacturer.
General Feedback:
Accidents that are equipment related result from the malfunction, disrepair, or
misuse of equipment or from an electrical hazard.
139. Chapter 27-18 (1.0 point)
Aaron is a registered nurse who works on the surgical unit of a large urban hospital. He is
responsible for the care of six postoperative patients on his shift. Kaleigh is a nursing
assistive personnel who is working with Aaron. One of the patients that Aaron is
responsible for, Mr. Johnson, is a 56-year-old patient who underwent surgery for a bowel
obstruction yesterday. Mr. Johnson is confused this shift and has tried to climb out of bed
on his own several times. Aaron is considering options to prevent Mr. Johnson from
harming himself. Assuming it is within his organization’s policy, which of the following
is most appropriate for Aaron to delegate to Kaleigh?
a. Assessing Mr. Johnson for appropriateness of restraints
b. Calling the physician for an order for a restraint alternative
c. Discussing the need for restraints with Mr. Johnson
*d. Applying restraint
General Feedback:
The skill of applying a restraint can be delegated to trained nursing assistive
personnel. However, the nurse is responsible for assessment of patient’s behavior, need
for restraint, type of restraint to use, and patient assessments while restraint is in place.
140. Chapter 27-19 (1.0 point)
A student nurse has been asked by the registered nurse with whom she is working to
apply wrist restraints to a patient who is confused and is trying to remove her
endotracheal tube. The student nurse knows that it is important to tie the restraints to
which part of the bed?
a. Bed frame
*b. Part that moves up and down with the patient
c. Footboard
d. Headboard
General Feedback:
Attach restraint straps to portion of bed frame that moves when raising or
lowering head of bed. Do not attach to side rails.
141. Chapter 27-20 (1.0 point)
A nursing student is in her senior year of nursing school. She is caring for three patients
for a busy surgical unit. One of the patients is confused and has been restrained to prevent
him from injuring himself. Which of the following is a priority as she plans her care for
the shift?
a. Calling the physician for an order for a chemical restraint
b. Requesting restraint alternatives from the physician for her patient who is
restrained
*c. Removing the restraints on the patient at least every 2 hours
d. Checking on the restrained patient last because he cannot get out of bed
General Feedback:
Assess proper placement of restraint, skin integrity, pulses, temperature,
color, and sensation of the restrained body part. Remove restraints at least every 2 hours
or more frequently as determined by agency policy. If patient is violent or noncompliant,
remove one restraint at a time and/or have other staff present while removing restraints.
142. Chapter 27-21 (1.0 point)
A nurse for a busy medical unit mistakenly administers a wrong medication to a patient.
After assessing this error, the nurse classifies the error as a(n):
a. poisoning accident.
b. equipment-related accident.
*c. procedure-related accident.
d. accident related to time management.
General Feedback:
A poisoning accident is related to inhaled or ingested substances. An
equipment-related accident results from misuse, disrepair, malfunction, or electrical
hazard. An accident related to time management deals with the nurse’s inability to follow
an organization’s policy and procedures.
143. Chapter 27-22 (1.0 point)
A newly admitted older adult patient was found wandering in the hallways in the past two
nights. What is the most appropriate nursing intervention to prevent a fall by this patient?
a. Reassigning the patient to a room closer to the nursing station
*b. Using an electronic monitor that sounds an alarm when the patient reaches a
near-vertical position
c. Having the night shift raise two or four side rails
d. Placing a loose vest type of restraint on the patient during the nighttime hours
of sleep
General Feedback:
Moving the patient to a room closer to the nursing station does not solve the
problem.
Raising side rails has the potential to trap parts of the patient’s body, producing a hazard.
Restraints are not a solution to a patient problem, but a temporary means to patient safety.
144. Chapter 27-23 (1.0 point)
A 3-year-old child is ready to be discharged home to a young single parent. When
conducting a home safety assessment with the child’s mother, the most important safety
issue for the nurse to identify includes information about the:
a. stability of the neighborhood.
b. reasons for outbursts in behavior.
*c. storage of cleaning supplies in the house.
d. child’s use of safety equipment when riding or skating.
General Feedback:
Physical hazards such as inadequate lighting can create a hazard; uncontrolled
mosquitoes and rodent populations increase risk of diseases. Outbursts in behavior are
related to developmental changes. Children need to follow safety regulations in outdoor
activities.
145. Chapter 27-24 (1.0 point)
A pediatric nurse is caring for the fourth of five children in one family. The nurse
identifies that the parents need additional safety teaching when the mother mentions that:
*a. a 2-year-old can safely sit in the front seat of a car.
b. teenagers need to practice safe sex.
c. children need to wear a helmet and safety pads when in-line skating.
d. children need to learn to swim even if parents do not have a swimming pool.
General Feedback:
Educating parents or guardians about reducing risks of injuries to children
and teaching ways to prevent accidents include the use of safety seats, as well as ageappropriate toys and placement of covers on electrical outlets.
146. Chapter 27-25 (1.0 point)
A fire erupts after a patient drops a cigarette in a hospital waste receptacle in the
bathroom. The nurse’s first response is to:
a. report the fire.
b. attempt to extinguish the fire.
*c. assist the patient to a safe area.
d. close the door to contain the fire.
General Feedback:
If a fire occurs, the first priority is to protect the patient in immediate danger.
Next, report the fire. Try to contain the fire by closing any doors, and/or extinguish the
fire.
147. Chapter 27-26 (1.0 point)
A physician or health care provider orders that a confused and disoriented patient be
placed in a full hand restraint because of excessive scratching of skin. The nurse
acknowledges that:
a. restraints are used on an as-needed basis.
b. no orders or patient consents are needed.
*c. restraints must be removed on a regular basis to allow for skin assessment,
toileting, and nutrition.
d. an order for restraints may be used indefinitely until the patient no longer needs
to be restrained.
General Feedback:
Restraints are only used when other less restrictive measures fail to prevent
interruption of therapies. The physician’s or health care provider’s orders are necessary.
The need for restraints must be reevaluated every 24 hours.
148. Chapter 27-27 (1.0 point)
A patient in the intensive care unit requires mechanical ventilation, a wound V.A.C.
system, patient-controlled analgesia, and an intravenous infusion device. Safety
precautions a nurse must use in the health care setting include:
a. using two-pronged plugs.
*b. never operating equipment without previous instruction.
c. always unplugging equipment when moving the patient.
d. never using equipment without having another nurse assist.
General Feedback:
Decrease the incidence of electrical hazards by using a three-pronged
grounded plug. Many types of equipment have both electric outlet and battery power
sources. Never use equipment unless properly trained.
149. Chapter 27-28 (1.0 point)
A nurse is giving injections at an immunization clinic. A patient asks why immunizations
are necessary. The nurse informs the patient that after getting an immunization, resistance
to an infectious disease is:
*a. produced.
b. decreased.
c. weakened.
d. eliminated.
General Feedback:
Immunizations often reduce or prevent the transmission of disease from
person to person. Immunization is the process by which resistance to an infectious
disease is produced or increased. The body acquires active immunity by injection of a
small amount of weakened or dead organisms and modified toxins from the organism
(toxoids) into the body.
150. Chapter 33-03 (1.0 point)
Mrs. Thornton is a 56-year-old patient who has recently become postmenopausal. She
told the nurse that ever since she had gone through menopause she noticed that she was
getting more urinary tract infections. What is the best response from the nurse?
*a. “As we go through menopause, the lining of the urethra becomes more
susceptible to infections.”
b. “Why don’t you ask your health care provider for some antibiotics to keep on
hand.”
c. “That must be frustrating.”
d. “I’m not looking forward to going through menopause.”
General Feedback:
Decreased levels of estrogen tend to cause the urethral mucosa to become
thinner and more fragile and consequently more easily traumatized and infected.
151. Chapter 33-05 (1.0 point)
Laura is a student nurse who is working on a rehabilitation unit in the hospital. She is
caring for Mrs. Cruse, a 77-year-old patient who had undergone knee replacement
surgery. Since Mrs. Cruse had surgery, she has had several instances of urinary
incontinence. The nurse caring for Mrs. Cruse has told Laura that she will be calling the
health care provider for an order to anchor a Foley catheter. What is Laura’s best
response to this suggestion?
a. “Would it be better to request a straight catheter instead?”
b. “I think it would be better to put a disposable undergarment on her.”
*c. “Could we try a toileting schedule before you request the Foley?”
d. “I think that is a good idea; it will prevent skin breakdown.”
General Feedback:
You are in a key position to serve as a patient advocate by suggesting
noninvasive alternatives to catheterization use. For example, you may decrease the risk
for UTI by suggesting the use of a bladder scanner to evaluate bladder urine volume
without invasive instrumentation or implement a toileting schedule for the incontinent
patient.
152. Chapter 33-07 (1.0 point)
Peter is a student nurse who is caring for Mr. Grey, a patient who has been admitted to
the medical unit of the hospital with a fever and malaise. The health care provider has
ordered a urinalysis on Mr. Grey. To collect the urine specimen, Peter should:
a. obtain the specimen from a straight catheter.
b. use sterile gloves to cleanse the penis and collect the specimen in a sterile cup.
*c. ask Mr. Grey to void into a cup.
d. instruct Mr. Grey to cleanse his penis, begin his stream, and then void into a
sterile cup.
General Feedback:
A simple urinalysis does not require a sterile urine specimen or sample. The
laboratory performs urinalysis on a routine or clean-voided specimen or on a specimen
obtained from a catheter.
153. Chapter 33-12 (1.0 point)
A patient has just been diagnosed with diabetes mellitus. The patient voices concerns
about possible kidney disease in the future. The patient asks the nurse, “Where is urine
formed in the kidney?” The nurse’s response is that urine is formed in the:
a. ureter.
b. kidney.
c. nephron.
*d. glomerulus.
General Feedback:
The ureter is attached to the kidney pelvis and carries urinary wastes into the
bladder. The kidneys are reddish-brown, bean-shaped organs that filter the blood waste
products. The nephrons remove waste products from the blood and regulate water and
electrolyte concentrations in body fluids.
154. Chapter 33-13 (1.0 point)
A nurse suspects that a patient may be experiencing urinary retention. When assessing
this patient, the nurse’s first suspicion is when the patient has:
a. spasms and difficulty urinating.
b. pain in the suprapubic region.
c. large amounts of voided cloudy urine.
*d. small amounts of urine voided 2 to 3 times per hour.
General Feedback:
The patient is only able to partially empty the bladder. Because of a distended
bladder, the patient experiences pressure, discomfort, and tenderness over the suprapubic
area. The patient voids only 25 to 60 mL of urine at a time.
155. Chapter 33-14 (1.0 point)
A patient with congestive heart failure is taking a diuretic. The patient asks why she has
to urinate so often. The nurse’s best response is that the medication:
*a. increases urinary output.
b. causes the bladder to relax.
c. relaxes inhibition to void.
d. strengthens the pelvic floor muscles.
General Feedback:
Some medications affect the ability to relax and empty the bladder. Exercises
strengthen the pelvic floor muscles.
156. Chapter 33-15 (1.0 point)
A patient is taking warfarin (Coumadin), which is making his urine orange. The patient
wants to know what normal urine should look like. The nurse informs the patient that
normal urine is:
a. red to pink.
b. amber to orange.
c. yellow to dark yellow.
*d. pale straw to amber in color.
General Feedback:
Red to pink urine may be related to cystoscopy. At times medications also
turn urine red or orange. The darker the urine, the more concentrated it is.
157. Chapter 33-16 (1.0 point)
A female adolescent who suffers from frequent UTI visits the student health clinic. The
student wants to know what she can do to stop these occurrences. What is the nurse’s
most appropriate response?
*a. “Drink at least 2 L of fluid daily.”
b. “Wait to void until the bladder is full.”
c. “Cleanse the perineal area from anus to meatus.”
d. “Take an over-the-counter urinary tract cleanser.”
General Feedback:
Normally the body flushes out organisms during voiding; therefore it is
important to avoid bladder distention. To avoid UTI and contamination, women should
cleanse themselves from the meatus towards the rectum. Proper hand washing and
perineal care will greatly reduce the incidence of UTI.
158. Chapter 33-17 (1.0 point)
One day after surgery a 4-year-old patient is having difficulty urinating. The nurse
realizes that children often are unable to void:
a. in a urinal.
b. lying in bed.
c. in bathrooms other than their own.
*d. in the presence of persons other than their parents.
General Feedback:
Anxiety and stress prevent urination because tension makes it difficult to
relax abdominal muscles.
159. Chapter 33-18 (1.0 point)
A patient is scheduled for an intravenous pyelogram (IVP). For this diagnostic
examination the nurse needs to:
a. make no special preparations before the examination.
b. push oral fluids before the examination.
c. have the patient fast after the procedure.
*d. assess the patient for an allergy to iodine before the examination.
General Feedback:
Before an IVP procedure, bowel preparation is required. The patient is NPO
after midnight. After the procedure the patient is encouraged to push fluids to reduce the
nephrotoxic effects of the contrast material.
160. Chapter 34-02 (1.0 point)
Kelly is a student nurse who is caring for Mrs. Mermann, a 33-year-old who is in labor
with her first child. Mrs. Mermann has complained to Kelly about the hemorrhoids that
she has experienced during the last month of her pregnancy. She asks Kelly what she can
do to prevent future problems with hemorrhoids. What is Kelly’s best response?
a. “Hemorrhoids are caused by straining.”
*b. “You need to soften your stools by drinking plenty of fluids.”
c. “You should eat less carbohydrates.”
d. “There is nothing that you can do to prevent hemorrhoids.”
General Feedback:
The rectum contains vertical and transverse folds of tissue that help to
temporarily hold fecal contents during defecation. Each fold contains an artery and veins
that can become distended from pressure during straining. This distention results in
hemorrhoid formation.
161. Chapter 34-03 (1.0 point)
William is a nurse caring for several patients on the surgical unit of the hospital. He
knows that constipation can be a significant health hazard and encourages his
postoperative patients to drink fluids. Which of the following patients that he is caring for
are most at risk from complications of constipation?
a. 35-year-old man with back surgery
*b. 47-year-old woman with abdominal hysterectomy
c. 29-year-old women with carpal tunnel surgery
d. 77-year-old man with hip surgery
General Feedback:
Constipation is a significant health hazard. Straining during defecation causes
problems for patients with recent abdominal, gynecological, or rectal surgery. An effort
to pass a stool can cause sutures to separate, reopening a wound. In addition, patients
with cardiovascular disease, diseases causing elevated intraocular pressure (glaucoma),
and increased intracranial pressure need to prevent constipation and avoid using the
Valsalva maneuver.
162. Chapter 34-04 (1.0 point)
Mrs. Julian will be undergoing abdominal surgery, which will most likely result in an
ostomy. She asks the nurse what the consistency of the stool from her ostomy will be.
What is the best answer?
a. “Your stools won’t change from what they currently are.”
b. “The consistency will be very soft.”
c. “The consistency will be liquid.”
*d. “It depends on the location of the intestine where the ostomy is.”
General Feedback:
The location of an ostomy determines stool consistency. The more intestine
remaining, the more formed and normal the stool.
163. Chapter 34-05 (1.0 point)
Mrs. White was involved in a motor vehicle accident and underwent a loop colostomy.
She asks the nurse about the colostomy and asks what is draining out of each side. What
is the nurse’s best response?
a. “There is stool draining out of both sides.”
*b. “Stool is draining out the right side and mucus is draining out the left side.”
c. “There is mucus and stool draining from both sides.”
d. “Stool is draining out the left side and mucus is draining out the right side.”
General Feedback:
Loop colostomies are frequently performed on an emergency basis and are
temporary large stomas constructed in the transverse colon. The loop ostomy has two
openings through the stoma. The proximal end drains stool, and the distal portion drains
mucus.
164. Chapter 34-06 (1.0 point)
Mrs. Chavez is a 45-year-old Catholic Hispanic American patient who was admitted to
the hospital with pneumonia. On admission, Mrs. Chavez didn’t indicate that she had any
food preferences or food allergies. Her nurse notes that she has requested that her family
bring in her meals. The nurse suspects it is most likely related to which of the following?
a. Food preferences
*b. Hispanic cultural traditions
c. Religious preferences
d. Food sensitivities
General Feedback:
The intake of certain foods also reflects the patient’s culture or beliefs. Foods
in various cultures have different status relating to religion, availability, cost, and
tradition. For example, some Hispanic Americans use certain hot foods (e.g., chocolate,
cheese, and eggs) for conditions producing fever and cold foods (e.g., fresh vegetables,
dairy foods, and honey) for disorders such as cancer or headaches. Understand the
patient’s cultural heritage and the role diet plays in health promotion and maintenance.
165. Chapter 34-07 (1.0 point)
Mrs. Greene is a 67-year-old widow who lives at home by herself. Lisa is a nursing
student who visits Mrs. Greene every week as part of her community health rotation.
Mrs. Greene is concerned about constipation. What is the best way for Lisa to approach
Mrs. Greene’s concern?
*a. “Tell me why you think you are constipated.”
b. “Are your stools hard?”
c. “How frequently are you having a bowel movement?”
d. “What color is your stool?”
General Feedback:
Determine your patient’s usual pattern of bowel elimination. Usual frequency
and time of day are important, but also determine if any changes in elimination patterns
have occurred. Ask the patient to make suggestions about the reason for any change.
166. Chapter 34-08 (1.0 point)
Mr. Barnes is a 56-year-old patient who was admitted with diabetic ketoacidosis to the
medical unit of the hospital where Maggie works as a registered nurse. As she reviews his
labs, which of the following would she expect to be elevated?
a. Total bilirubin
b. Alkaline phosphatase
*c. Amylase
d. Carcinoembryonic antigen
General Feedback:
Amylase is an enzyme secreted by the pancreas that is elevated in conditions
of the pancreas, such as inflammation or tumors. It is also elevated in cholecystitis,
necrotic bowel, and diabetic ketoacidosis.
167. Chapter 34-09 (1.0 point)
Mr. Hawes is a 56-year-old patient who was admitted to the hospital with abdominal
pain. Tony is the nurse caring for Mr. Hawes, and he has an order from the health care
provider for a stool specimen for occult blood. Tony notices that the stool specimen that
Mr. Hawes produces is black. Tony knows that this is a sign of melena and indicates that
Mr. Hawes has lost at least how much blood?
a. 20 mL
b. 30 mL
c. 40 mL
*d. 50 mL
General Feedback:
Blood loss more than 50 mL causes stool to turn black, the sign of melena. To
detect quantities less than 50 mL of blood, you will need a laboratory analysis.
168. Chapter 34-11 (1.0 point)
Mrs. Grant is a patient with colon cancer who recently underwent surgery to remove a
portion of her colon. She has a colonostomy and needs patient teaching regarding diet.
Which of the following is a food that she needs to avoid to prevent blockages?
*a. Oranges
b. Bananas
c. Beef
d. Rice
General Feedback:
When a patient has an ostomy, the location of the ostomy determines the type
of diet needed for regular evacuation. Initially place ostomy patients on low-fiber diets to
avoid stoma obstruction. Slowly add high-fiber foods one at a time over a period of
several weeks. Maintain a high fluid intake. Teach the patient to avoid foods that cause
blockage, such as oranges, apples with tough skins, corn, and popcorn.
169. Chapter 34-13 (1.0 point)
A patient is immobilized after surgery. The nurse observes a continual oozing of stool
from the patient’s rectum. The nurse recognizes that this condition most likely represents:
a. diarrhea.
b. incontinence.
*c. fecal impaction.
d. the Valsalva maneuver.
General Feedback:
Diarrhea is an increased frequency in the passage of loose stools.
Incontinence is the inability to control the passage of urine. The Valsalva maneuver
occurs when pressure is exerted to expel feces through a voluntary contraction of the
abdominal muscles while maintaining forced expiration against a closed airway.
170. Chapter 34-14 (1.0 point)
A patient with an ileostomy is losing weight. The patient asks the nurse why. The nurse’s
best response is to tell the patient that most enzymes and nutrients are absorbed in the:
a. stomach.
b. duodenum.
*c. small intestine.
d. large intestine.
General Feedback:
The stomach performs three tasks: storage of swallowed food and liquid;
mixing of food, liquid, and digestive juices; and emptying of contents into small intestine.
The duodenum is approximately 2 feet long and continues to process chyme from the
stomach. The large intestine is the primary organ of bowel elimination.
171. Chapter 34-15 (1.0 point)
To maintain normal elimination patterns in a hospitalized patient, the nurse should
encourage the patient to take time to defecate 1 hour after meals because:
a. the presence of food stimulates peristalsis.
*b. mass colonic peristalsis occurs at this time.
c. irregularity helps to develop a habitual pattern.
d. neglecting the urge to defecate can cause diarrhea.
General Feedback:
When stool reaches the rectum, distension causes relaxation of the internal
sphincter and awareness of the need to defecate. Establishing a consistent time for bowel
hygiene is one evidenced-based practice to avoid constipation. Ignoring the urge to
defecate and not taking time to defecate completely are common causes of constipation.
172. Chapter 34-16 (1.0 point)
A physician or health care provider orders a patient to have a fecal occult blood test. To
receive a correct result, the nurse instructs the patient to:
a. submit only one sample for analysis.
b. take extra amounts of iron supplements.
c. drink at least 1 L of fluid before the examination.
*d. refrain from ingesting foods and medications that can cause a false-positive
result.
General Feedback:
Ingesting certain foods and medications will cause a false positive. Foods and
medications to avoid include red meat, poultry, fish, some vegetables, vitamin C, and
aspirin.
173. Chapter 34-17 (1.0 point)
A nurse is taking a history on a newly admitted patient. The patient states that he recently
had a change in diet and medication. When asked about bowel elimination the patient
reports that stools are dry and hard to pass. The nurse realizes that this bowel pattern is
best identified as:
*a. constipation.
b. fecal impaction.
c. fecal incontinence.
d. abnormal defecation.
General Feedback:
Fecal impaction results from unrelieved constipation. Fecal incontinence is
the inability to control the passage of feces and gas from the anus. Normal defecation
begins with movement in the left colon, moving stool towards the anus.
174. Chapter 34-18 (1.0 point)
A patient in balanced suspension traction can have the head of the bed raised only 30
degrees. To promote normal elimination, patients need to assume a sitting position to:
a. stimulate the peristaltic movement.
b. contract the thigh muscles used to defecate.
c. strengthen the internal and external sphincters.
*d. exert intra-abdominal pressure, which aids in defecation.
General Feedback:
Physiological factors critical to bowel function and defecation include normal
GI tract function, sensory awareness of rectal distention and rectal contents, voluntary
sphincter control, and adequate rectal capacity and compliance. Contraction of abdominal
muscles at times aids in defecation. When stool reaches the rectum, the internal sphincter
relaxes.
175. Chapter 35-01 (1.0 point)
Mr. Elliott is a 76-year-old patient who was admitted to the hospital after falling in the
nursing home. He had broken his right femur and is awaiting surgery. His health care
provider told him that his activity would be limited to bed rest. He asks the nurse what
this means. What is the best explanation?
a. “You are to be immobile.”
b. “You cannot move.”
c. “Your activity is restricted.”
*d. “You have to remain in bed.”
General Feedback:
Immobility occurs when a patient is unable to move independently or is
restricted for therapeutic reasons, such as bed rest.
176. Chapter 35-02 (1.0 point)
Mr. Gregory was involved in a motor vehicle accident. He has a fractured right hip and is
on bed rest in Buck’s traction. Which of the following systems is least likely to be
impaired as a result of his immobility?
a. Musculoskeletal
*b. Lymphatic
c. Respiratory
d. Cardiovascular
General Feedback:
Despite a patient’s age, impairment as a result of immobility affects the
respiratory system, metabolism, fluid and electrolyte balance, gastrointestinal tract,
cardiovascular system, musculoskeletal system, integument, and urinary elimination.
177. Chapter 35-03 (1.0 point)
Morgan is a student nurse who is caring for a 24-year-old patient who is immobile with a
back injury. On auscultation, Morgan heard rhonchi in his lower lobes. Morgan is most
concerned that the patient may have developed which of the following?
a. A collapsed lung
*b. Hypostatic pneumonia
c. Aspiration pneumonia
d. Tension pneumothorax
General Feedback:
Decreased lung expansion, generalized respiratory muscle weakness, and
stasis of secretions occur with immobility. These conditions often contribute to the
development of atelectasis (collapse of alveoli) and hypostatic pneumonia (inflammation
of the lung from stasis or pooling of secretions).
178. Chapter 35-04 (1.0 point)
Michael is a 23-year-old patient who was involved in a motorcycle accident. He was in
the intensive care unit of the hospital for 2 months and was just discharged to a
rehabilitation hospital. He tells his nurse that he doesn’t understand why he is so weak.
What is the best response from the nurse?
*a. “When you are in bed for a long time, your body begins to break down its own
protein.”
b. “When you don’t use it, you lose it.”
c. “You haven’t eaten much for the past couple of months.”
d. “Your body has spent energy trying to heal itself.”
General Feedback:
Prolonged bed rest decreases the body’s ability to produce insulin and
metabolize glucose. When the body is unable to metabolize glucose, it begins to break
down its protein stores for energy.
179. Chapter 35-05 (1.0 point)
Patients on prolonged bed rest are at risk for a deep vein thrombosis. Which of the
following factors is not included in Virchow’s triad?
a. Loss of integrity of the vessel wall
b. Abnormalities of blood flow
c. Alterations in blood constituents
*d. Increased muscle atrophy
General Feedback:
Three factors contribute to venous thrombus formation: (1) loss of integrity of
the vessel wall (e.g., injury), (2) abnormalities of blood flow (e.g., slow blood flow in calf
veins associated with bed rest), and (3) alterations in blood constituents (e.g., a change in
clotting factors or increased platelet activity). These three factors are referred to as
Virchow’s triad.
180. Chapter 35-06 (1.0 point)
Mildred is a 92-year-old nursing home resident. She fell 2 weeks ago and has been on
bed rest. She has become increasingly fatigued when her caregivers bathe her. Mildred’s
family is concerned about her declining condition. The best explanation that the nurse can
give the family is that Mildred’s fatigue is caused by which of the following?
*a. Decreased muscle endurance caused by immobility
b. Her advanced age
c. That she is not eating as much
d. Increased oxygen demands of the healing process
General Feedback:
Muscle endurance decreases as a result of the inability of the
cardiopulmonary system to meet the oxygen needs of the body. Reduced metabolism
leads to a loss of muscle and body mass, causing fatigue with prolonged activity.
181. Chapter 35-07 (1.0 point)
Which of the following patients is at greatest risk for developing a pressure ulcer?
*a. 26-year-old man paraplegic with pneumonia
b. 64-year-old woman in Buck’s traction
c. 14-year-old boy on a ventilator
d. 56-year-old woman with breast cancer
General Feedback:
The direct effect of pressure on the skin by immobility is compounded by
metabolic changes. Older adult patients and patients with paralysis have a greater risk for
developing pressure ulcers.
182. Chapter 35-08 (1.0 point)
Which of the following patients is most at risk for developing a urinary tract infection?
*a. 12-year-old comatose boy on a ventilator
b. 48-year-old woman after abdominal surgery
c. 67-year-old man with Alzheimer disease
d. 58-year-old man postcardiac catheterization
General Feedback:
Because the peristaltic contractions of the ureters are not strong enough to
overcome gravity when the patient is reclining, the renal pelvis fills before urine enters
the ureters, which increases the patient’s risk for urinary tract infection (UTI) and renal
calculi. Renal calculi are calcium stones that lodge in the renal pelvis and pass through
the ureters. Immobilized patients are at risk for calculi because of altered calcium
metabolism and the resulting hypercalcemia.
183. Chapter 35-10 (1.0 point)
Which of the following patients is most likely to have developmental effects due to
prolonged immobility?
*a. 18-month-old patient in Buck’s traction for a fractured femur
b. 7-year-old patient with third degree burns to lower extremities
c. 16-year-old patient with chest trauma on a ventilator
d. 53-year-old patient with bilateral fractured ankles
General Feedback:
Developmental effects of immobility more commonly affect the very young
and the older adult. The immobilized young or middle-age adult experiences few, if any,
developmental changes.
184. Chapter 35-11 (1.0 point)
Which of the following major musculoskeletal changes would you not expect to see
during an assessment of an immobilized patient?
a. Loss of muscle tone
b. Decreased muscle strength
c. Contractures
*d. Increased muscle mass
General Feedback:
The major musculoskeletal changes expected during assessment of an
immobilized patient include decreased muscle strength, loss of muscle tone and mass,
and contractures.
185. Chapter 35-12 (1.0 point)
Gina is a nursing student who works for a postsurgical unit of the hospital. She wants to
do everything possible to prevent her patients from developing a thrombus. Which of the
following is the best thing she can do to prevent thrombus formation in postsurgical
patients?
a. Maintaining light pressure on the posterior knee when positioning patients
b. Putting pillows under the knees of patients when positioning them in bed
c. Massaging patient’s legs after a bath
*d. Avoiding putting patients in tight clothing that constricts the waist
General Feedback:
Proper positioning used with other therapies (e.g., anticoagulants and
antiembolic stockings) helps reduce thrombus formation. When positioning patients, use
caution to prevent pressure on the posterior knee and deep veins in the lower extremities.
Teach patients to avoid crossing the legs, sitting for prolonged periods of time, wearing
tight clothing that constricts the legs or waist, putting pillows under the knees, and
massaging the legs.
186. Chapter 35-13 (1.0 point)
A nurse is caring for an immobile patient. The most appropriate nursing intervention to
implement is:
a. turning the patient every 4 hours.
b. applying an abdominal binder while the patient is lying in bed.
*c. encouraging the use of incentive spirometry hourly.
d. maintaining the patient’s maximum fluid intake of 1000 mL daily.
General Feedback:
Patients need to be repositioned every 2 hours to reduce stagnation of
secretions. An application of an abdominal binder will restrict chest expansion. Patients
need a minimum of 2000 mL every day to adequately hydrate and keep pulmonary
secretions thin, watery, and clear.
187. Chapter 35-14 (1.0 point)
A nurse notes a cardiovascular change on an immobilized postoperative patient. One such
change the nurse could have noticed is consistent with:
a. atelectasis.
b. hypertension.
*c. orthostatic hypotension.
d. increased coagulation of blood.
General Feedback:
Decreased lung expansion, generalized muscle weakness, and stasis of
secretions occur with immobility. These conditions are consistent with the development
of atelectasis. The immobilized patient experiences a decreased circulating fluid, pooling
of blood in lower extremities, and a drop in systolic blood pressure. Three factors
contribute to thrombus formation, which include loss of integrity of vessel wall,
abnormalities of blood flow, and changes in clotting factors/increased platelet activity.
188. Chapter 35-15 (1.0 point)
A nurse is caring for a patient in Buck’s traction for a compound comminuted fracture of
the femur. An appropriate action the nurse must take in order to help preserve skin
integrity is to:
*a. provide meticulous skin care.
b. use analgesia to prevent excessive movement.
c. limit range of joint motion so the traction apparatus is not disturbed.
d. limit the amount of protein intake so renal function can be preserved.
General Feedback:
Immobility leads to loss of strength and endurance, decreased muscle, and
deep vein thrombosis formation. A patient needs adequate protein intake to ensure wound
healing and tissue growth and to prevent a negative nitrogen balance.
189. Chapter 35-16 (1.0 point)
Keeping a patient immobilized creates benefits for the patient. Nurses implement
therapeutic immobilization as a means to:
*a. limit the movement of the body.
b. restrain a unstable patient in bed.
c. increase active range of joint motion.
d. strengthen joints and muscles in preparation for ambulation.
General Feedback:
Bed rest is an intervention in which a patient is restricted to bed for
therapeutic reasons. Advantages of bed rest include decreasing the body’s oxygen needs,
reducing pain, and allowing a debilitated or ill patient to rest. The duration of bed rest
depends on the type and nature of the illness or injury and the patient’s previous state of
health.
190. Chapter 35-17 (1.0 point)
Immobilized patients are affected by changes in their metabolic rate. Therefore nurses
need to monitor:
*a. increased serum glucose levels.
b. decreased serum calcium levels.
c. positive nitrogen balance.
d. increases in serum potassium levels.
General Feedback:
In the immobilized patient, a major shift in blood volume occurs, which
causes diuresis. Diuresis causes the body to lose electrolytes, such as potassium and
sodium. Diuresis also affects serum calcium levels, which results in an increase in
calcium loss from the bones, causing a release of excess calcium into circulation
(hypercalcemia). When the body is unable to metabolize glucose, it begins to break down
protein stores for energy. Nitrogen balance provides a reliable indicator of protein use by
the body. Negative nitrogen balance exists when the excretion of nitrogen from the
breakdown of protein exceeds intake.
191. Chapter 35-18 (1.0 point)
The length of immobilization can adversely affect a patient. When assessing patients,
nurses need to assess muscle mass for:
a. increased fat.
b. increases in strength.
*c. decreases in strength.
d. increases in lean muscle.
General Feedback:
Examining metabolic functioning, the nurse uses anthropometric
measurements. Immobilized patients will lose skin fat, thus indicating a decrease in
nutritional status. The major musculoskeletal changes identified during assessment of the
immobilized patient include decreased muscle strength, loss of muscle tone and mass,
and contractures. Because immobilized patients are weakened, determine if difficulty in
moving joints is the result of fatigue or decreased range of joint motion.
192. Chapter 35-19 (1.0 point)
A patient is recovering from an abdominal aortic bypass graft. To reduce the effects of
orthostatic hypotension, the most appropriate action for the nurse to encourage is:
*a. slowly sitting up in a chair.
b. performing isometric exercises.
c. decreasing the number of ankle pumps.
d. participating in chest physiotherapy.
General Feedback:
Isometric exercises, which are activities that involve muscle tension without
muscle shortening, do not have any effect on preventing orthostatic hypotension but
improve activity tolerance. Ankle pumps help to prevent deep vein thrombosis.
Participating in chest physiotherapy assists patients with decreasing effects of pulmonary
complications.
193. Chapter 37-01 (1.0 point)
Kirby is a 63-year-old welder who has gone to the clinic for his annual check-up. He
shares with the nurse that he has been having difficulty hearing conversations at the
coffee shop in the mornings. After looking in his ears to determine if there is a build-up
of cerumen, the nurse tells Kirby that his hearing loss needs to be checked further, but
that it may be associated with aging. What is the best term to describe this?
a. Tinnitus
b. Accommodation
*c. Presbycusis
d. Presbyopia
General Feedback:
Hearing changes often associated with aging include decreased hearing
acuity, speech intelligibility, and pitch discrimination, which is referred to as presbycusis.
Low-pitched sounds are easiest to hear, but it is difficult to hear conversation over
background noise. A decrease in active sebaceous glands causes the cerumen to become
dry and completely obstruct the external auditory canal.
194. Chapter 37-02 (1.0 point)
Mr. Barnes is a 64-year-old house painter who is seeing his health care provider for his
annual check-up. When the nurse asks him if he has had any problems, he tells her that he
doesn’t think his vision is as good as it used to be. He states that “things look more
yellow than they used to.” She knows that this is a visual change in older adults because
the:
a. iris yellows.
*b. lens yellows.
c. pupils take longer to dilate.
d. pupils take longer to constrict.
General Feedback:
Visual changes often include reduced visual fields, increased glare sensitivity,
impaired night vision, reduced accommodation, reduced depth perception, and reduced
color discrimination. Many of these symptoms occur because the pupils in the older adult
take longer to dilate and constrict secondary to weaker iris muscles. Color vision
decreases because the retina is duller and the lens yellows.
195. Chapter 37-03 (1.0 point)
Omar is a 47-year-old divorced man who recently moved back in with his elderly mother
after she had been hospitalized several times with gastrointestinal problems. He is
concerned because as he was going through her refrigerator, he noticed food that had
turned rancid. His mother hadn’t seemed to notice the spoiled food and was going to heat
up some rancid soup for lunch. What is the most likely physiologic reason that Omar’s
mother does not realize that the food is spoiled?
a. She has early Alzheimer disease.
*b. She has a diminished sense of smell.
c. She is frugal and does not want to throw things out.
d. She has a limited vision.
General Feedback:
Olfactory changes begin around age 50 and include a loss of cells in the
olfactory bulb of the brain and a decrease in the number of sensory cells in the nasal
lining. Reduced sensitivity to odors is common.
196. Chapter 37-05 (1.0 point)
Bernice is a 76-year-old retired secretary with diabetes who is seeing her health care
provider because she is having visual changes. She explains to the nurse that she is
experiencing distortion that makes the edges of objects appear wavy. The nurse knows
that this is an early sign of:
a. cataracts.
b. glaucoma.
c. diabetic retinopathy.
*d. age-related macular degeneration.
General Feedback:
Age-related macular degeneration occurs when the macula (specialized
portion of the retina responsible for central vision) degenerates as a result of aging and
loses its ability to function efficiently. An early sign includes distortion that causes edges
or lines to appear wavy. In later stages, patients may see dark or empty spaces that block
the center of vision.
197. Chapter 37-06 (1.0 point)
Jane is a nursing student who has completed transferring Mrs. Ennis, who is blind, to the
orthopedic unit after right knee replacement surgery. The best position for Jane to assume
when ambulating Mrs. Ennis is standing on her _____ side and walking a half step _____
her.
*a. left; ahead
b. right; ahead
c. left; behind
d. right; behind
General Feedback:
You will need to assist patients with acute visual impairments with walking.
Stand on the patient’s dominant, stronger, or uninjured side. The patient grasps your
elbow or upper arm. You then walk one half step ahead and slightly to the patient’s side.
The patient’s shoulder is directly behind your shoulder. Relax and walk at a comfortable
pace.
198. Chapter 37-07 (1.0 point)
Macie is a nursing student who has been concerned about sensory deprivation with
patients in the nursing home where she works. Which of the following can be caused by
sensory deprivation?
a. Confusion
b. Anxiety
c. Disorientation
*d. Increased pain
General Feedback:
Sensory deprivation occurs when inadequate quality or quantity of stimuli
impairs perception. These effects sometimes produce cognitive changes, such as the
inability to solve problems, poor task performance, and disorientation. Affective changes,
which include boredom, restlessness, increased anxiety, or emotional ability, can occur.
199. Chapter 37-08 (1.0 point)
Ellen is a student nurse who is visiting Sydney, a 16-year-old mother and her newborn as
part of her community health clinical rotation. Sydney tells Ellen that she is concerned
that her baby could be deaf because her uncle lost his hearing at a young age. The best
way for Ellen to assure Sydney that her baby can hear is by telling her that her baby:
a. was discharged from the hospital without any known problems.
b. looks completely normal.
*c. responds to loud noises.
d. does not have excessive cerumen in his auditory canal.
General Feedback:
Neonates without hearing impairments respond to loud noises.
200. Chapter 37-09 (1.0 point)
Mrs. Beeson asks Robert, a visiting nurse, why her older adult mother seems to prefer
eating ice cream and other sweets to any other foods. What is Robert’s best response?
a. “Maybe she has a ‘sweet tooth.’”
*b. “Older adults seem to be able to taste sweet foods best.”
c. “I wouldn’t worry about it as long as she is eating something.”
d. “She is probably getting all the nutrients that she needs.”
General Feedback:
A small decrease in the number of taste cells occurs with aging, beginning
around age 60. Reduced sour, salty, and bitter taste discrimination is common. The ability
to detect sweet tastes seems to remain intact.
201. Chapter 37-10 (1.0 point)
A visually impaired patient has been hospitalized with pyelonephritis. Because this
patient will be making frequent visits to the bathroom, a way for the nurse to maintain a
safe environment includes:
*a. supplying a night light to provide better vision.
b. keeping the bed side rails down so the patient will not fall.
c. assisting the patient by standing on his or her dominant side.
d. keeping necessary objects in a bedside drawer to decrease clutter.
General Feedback:
Side rails should be kept up to prevent patients from falling out of bed. When
assisting with ambulation, the nurse should be positioned at the patient’s nondominant
side. Always place necessary objects in front of the patient to prevent falls caused by
reaching for objects.
202. Chapter 37-12 (1.0 point)
An older adult patient has been admitted to a busy medical unit. To control
environmental stimuli a nurse should:
a. leave the hospital room lights on.
*b. coordinate patient care activities.
c. leave the widow curtains closed at all times.
d. turn up pump and bed alarms so the patient can hear them.
General Feedback:
Open drapes and close door if indicated. Control extraneous noise in and
around room such as television volume and visitors. Turn off bedside equipment not in
use.
203. Chapter 37-13 (1.0 point)
An older adult patient visits the clinic for an annual physical. As the nurse reviews the
health assessment sheet, the nurse notes that the patient has experienced a distortion or
loss of central vision. The nurse can best identify this sensory change as:
a. glaucoma.
b. cataract formation.
c. diabetic retinopathy.
*d. senile macular degeneration.
General Feedback:
Glaucoma is a slowly progressing increase in intraocular pressure that causes
pressure against the optic nerve, resulting in peripheral visual loss, decreased visual
acuity with difficulty adapting to darkness, and a halo effect around lights if untreated. A
cataract is a cloudy or opaque area in part of the lens or the entire lens that causes
problems with glare and blurred vision. Diabetic retinopathy occurs when pathological
changes occur in the retina, causing a decrease in vision.
204. Chapter 37-14 (1.0 point)
A school nurse performs a routine screening on a newly transferred school-age child.
This nurse is especially interested in discovering the child’s medical history regarding
middle ear infections. The nurse knows that chronic ear infections are a major
contributing factor to:
a. tonsillitis.
b. strep throat.
c. high fevers.
*d. hearing impairment.
General Feedback:
In the United States hearing impairment is common. At risk children include
those with a family history of childhood hearing impairment, perinatal infection (rubella,
herpes, or cytomegalovirus), low birth weight, chronic ear infections, and Down
syndrome. Children need periodic auditory testing.
205. Chapter 37-15 (1.0 point)
An older adult patient residing at an adult assisted living facility complains of hearing
and visual disturbances. A nurse must be alert to the effects of sensory deprivation that
are associated with:
a. stable affect.
*b. altered perception.
c. improved task completion.
d. increased need for social interaction.
General Feedback:
A change demonstrated by fear, anger, and feelings of hopelessness can be
attributed to a sensory loss resulting from injury or medication usage. Patients may
withdraw from social situations because of their inability to handle stimuli.
206. Chapter 37-17 (1.0 point)
A home care nurse visits a new patient. The family asks how the home can be made safer.
The nurse’s best advice includes:
a. using throw rugs to prevent tripping.
*b. installing extra incandescent lighting.
c. painting the floor black and white to add perception.
d. installing handrails painted the same color as the walls.
General Feedback:
Throw rugs, footstools, and electrical cords present tripping hazards. Good
lighting at front and back entrances and light switches at the top and bottom of stairwells
and long hallways add an additional safety element. The use of color contrasts, such as
tape, paint, or nail enamel, add highlights.
207. Chapter 02-10 (1.0 point)
The nurse is teaching the client about weight management, and the client wants to know
how the nurse manages to stay “so thin.” Which response should the nurse use to
maintain therapeutic communication?
a. State that nurses cannot discuss personal information with clients
b. Describe a daily routine of walking the family’s dog to the local park
*c. Recognize the question and redirect the discussion to weight management
d. Explain the client needs a background in health care to use the nurse’s plan
General Feedback:
3. After acknowledging the client’s question, the nurse
redirects the conversation to weight management because
therapeutic communication is client centered and goal
oriented; however, the communication and the goal do
not involve personal details about nurse because
therapeutic communication is not social conversation.
1. To convey respect and consideration, the nurse avoids
a blunt statement about professional boundaries; besides,
stating the nurse cannot divulge personal information
keeps the focus on the nurse.
2. Describing a daily routine reveals personal information
that belies the nurse-client relationship.
4. Telling the client a health care background is needed to
implement the nurse’s plan is condescending and conveys
a lack of respect.
208. Chapter 02-12 (1.0 point)
The male client whose parents died of heart disease early in life is waiting for diagnostic
testing results. He is biting his nails and pacing around the room. Which statement should
the nurse use to clarify client information?
a. “I can see that you are anxious about dying.”
*b. “Tell me more about your family’s history.”
c. “Do you have your parents’ medical records?”
d. “I’m not sure that I understand what you mean.”
General Feedback:
2. Asking for more information about the family’s history
directs the client to expand on a specific, pertinent topic
and to relate pertinent details before moving to another
topic. “Early in life” and “heart disease” need to be
defined by the client; “early in life” can indicate a wide
range of ages depending on the definition of “early” and
“heart disease” can mean heart failure, coronary artery
disease, valve disease, arrhythmias, and so forth.
1. The nurse concludes that the client is anxious about
dying because his parents died early in life, to clarify the
nurse’s perception of the client’s nonverbal cues.
3. Objective information is always valuable and reading
the parents’ medical records provides the best
information available about their histories, but asking for
the records can display a lack of respect by implying the
client is an unreliable source for information.
4. Stating that the nurse is not sure about the client’s
meaning is a vague statement leaving the client to guess
what the nurse wants to know.
209. Chapter 02-14 (1.0 point)
The client tells the nurse, “I must be really sick because so many tests are being
performed on me.” Which statement does the nurse use to reflect the client’s message?
a. “I sense that you are very worried.”
b. “You mention this so frequently.”
c. “We should talk about this more.”
*d. “You think you must be very sick.”
General Feedback:
4. The nurse reflects the client’s message by focusing on
the feelings the client identifies, including nonverbal cues
and then, clarifying the nurse’s perception with the client.
The nurse follows this statement by encouraging the
client to confirm the perception.
1. Stating the nurse feels the client is worried is a suitable
response but does not reflect what the client actually said.
2. Pointing out the client has stated this before can be
misinterpreted to mean the client is forgetful or annoying.
3. Exploring the topic with the client is a suitable
response but does not reflect the client’s statement and
message.
210. Chapter 03-01 (1.0 point)
The nurse is caring for a 79-year-old man who has a non-weight-bearing cast on the left
lower extremity. The client ambulates without using a walker despite repeated instruction
from the nurse. Which response by the nurse is most likely to keep the client from
falling?
a. Apply a vest restraint and offer frequent toileting.
*b. Plan fall prevention with client, family, and provider.
c. Inform family that the client needs physical restraints.
d. Document that the client has a high potential for falling.
General Feedback:
2. Planning an individualized fall prevention program
with the help of the client, family, and provider is more
likely to reduce this client’s risk of falls because the client
gains some control over the plan of care and still benefits
from the input of the provider, family, and nurse and the
fall prevention program. Including the client in planning
also gives the client ownership of the plan, making it less
likely that the client will disregard a plan he helped to
design.
1. Vest restraints are associated with serious injuries and
are not recommended for use.
3. The nurse informs the family before applying restraints
to comply with nursing and legal standards; however,
applying restraints may increase the risk of falls and
thereby justifying the nurse’s attempts to exhaust
alternative methods of engaging the client in the plan
before resorting to restraints.
4. Documenting the client’s risk is important because it
communicates the information and records the nurse’s
acknowledgment of the risk, but it is not as effective as
engaging the client in planning care as a prevention
technique because it is indirect.
211. Chapter 03-17 (1.0 point)
The nurse plans a safety program for clients on a medical-surgical unit and reviews the
admission diagnoses of clients over the past year. Which client diagnosis represents the
greatest likelihood of falling on the unit?
a. Pacemaker battery replacement
*b. Heart failure with pulmonary edema
c. Arthroscopy after a college football injury
d. Right salpingectomy for ectopic pregnancy
General Feedback:
2. The client with heart failure and pulmonary edema is
most likely to fall because this client is likely to be older,
have decreased exercise tolerance, and taking diuretics to
reduce total body fluid. Clients with heart failure take
other medications, including antihypertensive agents that
increase the risk of falls due to confusion, dizziness,
orthostatic hypotension, or getting to the bathroom.
1. This client is likely to be older but has a history of a
permanent pacemaker; battery replacement is usually a
low-risk, routine procedure.
3. This client is most likely to be a muscular, young adult
who is stable while ambulating.
4. This client is of childbearing age and likely to be
ambulatory.
212. Chapter 03-19 (1.0 point)
The female client wearing bilateral wrist restraints complains that her hands are numb
and the nurse assesses pale, cool fingers. Which is the nurse’s priority intervention?
a. Notify the provider quickly.
*b. Remove the wrist restraints.
c. Try another type of restraint.
d. Increase the restraint padding.
General Feedback:
2. The client displays clinical indicators of neurovascular
impairment and a delay in resolving the problem can
result in tissue damage, so the nurse removes the
restraint, thoroughly assesses the extremities, and plans
nursing care.
1. The nurse notifies the provider after assessing the
client.
3. Before another type of restraint is applied, the nurse
completes the assessment and notifies the provider as
necessary. A physical restraint is contraindicated if the
client has impaired perfusion or tissue damage in an area
restricted by the restraint.
4. Increasing the padding is a reasonable intervention
after the nurse’s assessment and provider notification.
213. Chapter 04-14 2 (1.0 point)
The nurse assists the provider during a colonoscopy. Which does the nurse implement to
prevent transmission of potential pathogens during the procedure?
a. Sterilize working surfaces.
b. Close the procedure room door.
*c. Sterilize the endoscope with gas.
d. Follow surgical aseptic principles.
General Feedback:
3. A colonoscopy is a clean procedure, but the endoscope
must be sterilized between procedures to prevent
transmission of potential pathogens to another client from
the endoscope.
1. Because a colonoscopy is a clean procedure, a sterile
field is not indicated. Nevertheless, working surfaces are
cleaned with an agency-approved agent between
procedures.
2. The procedure room door is closed during a
colonoscopy to maintain client privacy and to provide a
quiet environment while the client is medicated with
conscious sedation.
4. The nurse follows principles of medical asepsis during
a colonoscopy. The bowel cannot be sterilized for the
procedure; besides, removing the intestinal flora is
undesirable for client health and well-being.
214. Chapter 06-01 (1.0 point)
The client’s nursing diagnosis is “Impaired physical mobility manifested by paralysis of
both lower extremities.” Which is the best intervention for the nurse to use to place the
client in semi-Fowler’s position?
a. Help the client push up in bed by bending the client’s knees.
b. Raise head of the bed to 45 degrees and pull client to head of bed.
c. Roll the client to one side using pillows to support the client’s back.
*d. Pull the client to head of the bed and then, raise the head of the bed.
General Feedback:
4. With the assistance of another staff member and using
a draw sheet, the nurse bends the client’s knees to
unweight the legs, pulls the client to the head of the bed
(HOB), elevates the HOB to 45 degrees, and removes
wrinkles from the draw sheet. The client cannot assist
with repositioning, so the nurse uses the help of another
person, the draw sheet, synchronized movements, proper
body mechanics, and unweighting the legs to reduce the
amount of force needed to move the client. Using these
techniques, the nurse moves and repositions the client
correctly to prevent skin breakdown and injury. If it is
available, the client can assist positioning using an
overhead trapeze to unweight the torso.
1. The client is unable to push up to the HOB because the
client is paralyzed below the waist.
2. Elevating the HOB follows moving the client up in bed
and minimizes the force needed to move the client uphill
and decreases the risk of injury.
3. Rolling the client to the side achieves Sims’ or lateral
position, or assists with logrolling; however, rolling the
client is usually necessary to place the draw sheet under
the client before moving the client up in bed.
215. Chapter 06-08 (1.0 point)
Which is the best outcome statement for a client with generalized postoperative
weakness?
a. Client transfers self safely from the bed to the chair three times daily
b. Altered physical mobility related to the effects of surgery and anxiety
c. At risk for falls related to client’s postoperative weakness and anxiety
*d. Client transfers safely from bed to chair four times daily within 2 days
General Feedback:
4. The best goal for a client with postoperative weakness
is the client transfers safely four times a day within 2
days because it is specific, client oriented, measurable,
and time limited; any nurse who reads this outcome
knows the specific expectations for the client. In addition,
the outcome focuses on improving the client’s ability and
strength.
1. Transferring three times daily is a reasonable outcome
but lacks a time limit.
2 and 3. Altered physical mobility and at risk for falls are
nursing diagnoses; the nurse lacks specific data to support
these diagnoses.
216. Chapter 06-12 (1.0 point)
The nurse wants to transfer the client from the bed to the chair by using a mechanical lift
and cannot find help. Which is the most important action for the nurse to implement?
a. Assure the client that the lift is safe.
b. Use two safety chains on canvas sling.
*c. Find help to assist with the transfer.
d. Double check the wheel locks on lift.
General Feedback:
3. To maneuver the client safely with a mechanical lift,
the nurse must find an assistant to assist on the opposite
side of the bed and to help hold the chair as the nurse
lowers the client onto the chair.
1. Assuring the client about the safety of the lift is proper
but is less important than ensuring the client’s safety on
the lift.
2. The chains attach to the sling, providing a strong bond
between the lift and the sling, but the chains are not
specifically designated as safety devices.
4. The nurse and the assistant check the wheel locks on
the lift to prevent unintentional movement and,
potentially, increasing the risk of injury to the client.
217. Chapter 06-15 (1.0 point)
The client remains unconscious in the operating room while the nurse assesses the fivemember team of people to move the client from the surgical table to a stretcher. Which is
a suitable action for the nurse before the moving the client?
*a. Assign a specific role to each person for the transfer.
b. Instruct the surgeon to stand at the head of the client.
c. Suspend the IVs and Foley catheter from the stretcher.
d. Wrap client in a sheet to prevent injury to arms and legs
General Feedback:
1. The nurse effectively manages client safety by
assigning specific roles to each person assisting with the
client’s transfer. Assigning roles increases the likelihood
that participants receive clear expectations and fulfill
critical tasks; if the client is not breathing spontaneously,
airway maintenance is one of the critical responsibilities
during the transfer in addition to successfully handling
equipment, drains, and IV fluids and protecting the
surgical site.
2. The nurse anesthetist or anesthesiologist stands at the
head of the bed to maintain the client’s airway and direct
medical care to the postanesthesia recovery room.
3. Suspending the Foley catheter from the stretcher is fine
but, if the IVs are hung from the stretcher, blood will
back up into the IV tubing and fluid will not infuse. This
becomes a problem if the client needs the extra fluid
volume.
4. The client needs close observation during the transfer;
wrapping the client in a sheet obscures critical
observations that can prevent accidents and injury to the
client.
218. Chapter 06-16 (1.0 point)
Which outcome statement for client ambulation after surgery should the nurse use in a
plan of care?
a. Client receives instruction about safe ambulation techniques.
b. Client ambulates without difficulties within 48 hours of surgery.
c. Client ambulates according to the provider’s activity prescription.
*d. Client ambulates to the nurses’ station four times daily within 2 days.
General Feedback:
4. The nurse uses “client ambulates to the nurses’ station
four times daily within 2 days” because it is client
centered, specific, measurable, and time limited.
1. Receiving instruction is a suitable client intervention as
a part of client teaching.
2. The nurse does not use the statement, “…ambulates
without difficulties within 48 hours of surgery” because
“difficulties” is vague and the client’s action is not
measurable.
3. Client ambulation in accordance with the provider’s
prescription is an expectation of every nurse unless the
client’s safety is jeopardized by the prescription; then the
nurse clarifies the prescription with the provider. Besides,
the statement is too vague to use as an outcome.
219. Chapter 06-23 (1.0 point)
Which is the best method of assessing a client’s ability to ambulate?
a. Interview client’s visitors.
*b. Observe client ambulating.
c. Review client progress notes.
d. Measure distances ambulated.
General Feedback:
2. The best method of assessing a client’s ability to
ambulate is to observe the client during ambulation,
gather data, draw conclusions, and document the data and
conclusions. This method provides the nurse with
objective data on which to base the plan of care and
fulfills the nurse’s duty to the client by taking
responsibility for assessment; the nurse breaches the duty
owed to the client if actions are based on another person’s
assessment.
1. Even if the client’s visitors are health care
professionals, the nurse must assess the client before
taking action.
3. Reviewing progress notes provides valuable baseline
data for comparison to the nurse’s assessment; however,
the nurse assesses the client to determine the nurse’s
future care.
4. Measuring the distance covered by the client is
valuable information and is one part of the data the nurse
gathers for the nursing assessment.
220. Chapter 06-26 (1.0 point)
The nurse admits the client who prefers to ambulate with a wooden cane. Which action
should the nurse implement?
a. Explain that a wooden cane is dangerous for the client.
*b. Assess the client’s stability when ambulating with the cane.
c. Make the appropriate adjustments to the height of the cane.
d. State that the client must use a walker for adequate stability.
General Feedback:
2. The nurse is responsible for basing nursing
interventions on a nursing assessment, so the nurse
assesses the client’s ability to use a wooden cane for
ambulation focusing on the client’s stability, strength, and
vision.
1. The nurse does not know whether the cane is suitable
for the client; in addition, the nurse can frighten the client
by stating the cane is dangerous.
3. The nurse can alter a wooden cane by removing a
portion of the end and replacing the rubber tip, but the
nurse does not have the means to accomplish this.
Besides, the nurse does not want the responsibility of
permanently altering the cane, especially without an
assessment. If the cane is unsuitable for the client, the
nurse collaborates with other health care professionals to
fit the client with a suitable assistive device.
4. Walkers are not required for every client who needs an
assistive device for ambulation; often a cane provides
suitable stability for safe ambulation.
221. Chapter 06-32 (1.0 point)
The nurse teaches the caregiver to maintain the client’s body alignment when sitting in a
chair. Which teaching does the nurse include?
a. Instruct client to flex and extend feet.
b. Direct the client to tuck head to chest.
c. Reposition the client every 1 to 2 hours.
*d. Provide a footstool to prevent back pain.
General Feedback:
4. The nurse instructs the caregiver to provide the client
with a footstool to prevent client back pain because if the
client has to arch the back or lean forward to place the
feet on the floor, unnecessary stress strains back muscles,
potentially leading to back pain. In addition, the nurse
instructs the caregiver to place a small pillow behind the
client’s lower back for support.
1. Sitting in a chair flexes the client’s hips and knees,
impeding venous blood return to the heart and increasing
the risk of venous stasis in the legs and development of
deep venous thrombosis; thus the nurse instructs the
caregiver to encourage ankle exercises for the client to
facilitate venous blood return. Although hip and knee
flexion is related, instruction about ankle exercises is
unrelated to body alignment.
2. Tucking the head to the chest applies unnecessary
stress to the cervical spine, potentially leading to upper
back pain. The head and neck maintain body alignment
when the head aligns with the anterior spine in a straight
line, allowing the spine to assume its normal curves.
3. Repositioning a client in a chair is recommended every
20 to 30 minutes to maintain blood flow to the tissues and
adequate oxygenation. This is important but does not
apply to maintaining body alignment.
222. Chapter 06-33 (1.0 point)
The nurse reviews the diagnoses for assigned clients. Which client has the greatest
potential for injury during transfers?
a. Deep vein thrombosis
b. Type 1 diabetes mellitus
c. Upper extremity fracture
*d. Cerebrovascular accident
General Feedback:
4. The client who has a cerebrovascular accident (CVA)
has the greatest potential for injury during a transfer
because most CVAs result in a neurological deficit. The
deficit can involve communication, sensory, and muscle
function, decreasing the client’s ability to interact with
the environment, assist with movement, and, thus,
increase the risk for injury.
1. Although the client with a deep vein thrombosis
usually does not have impaired neurological or muscle
functioning, the client usually does receive
anticoagulation; if the client is injured during a transfer,
the risk for significant bleeding increases. These clients
usually retain the ability to interact with the environment
unless a comorbidity interferes.
2. Clients with type 1 diabetes mellitus have a risk for
injury due to decreased sensation in the extremities
caused by microvascular complications of hyperglycemia.
The clients usually retain the ability to interact with the
environment to minimize the risk for injury during a
transfer.
3. The client with an upper extremity fracture can have
significant pain, and the treatment for pain increases the
client’s risk of injury during a transfer because of
dizziness, decreased level of consciousness, and
hypotension. This client is also less stable with one
nonfunctional arm and can have difficulty assisting with
transfers using the other arm.
223. Chapter 07-07 (1.0 point)
The nurse bathes an unconscious client. Which does the nurse implement to maintain
infection control during a bed bath?
a. Uses long strokes and lotion to massage both legs
*b. Performs a complete assessment of the client’s skin
c. Washes each eye carefully, rinsing all traces of soap
d. Soaps the entire front of the client’s body and then rinses.
General Feedback:
2. The nurse assesses the client’s skin during a bed bath
because the skin is a major part of the body’s innate
defense against microorganisms. The nurse identifies
areas of the client’s skin with a potential for breakdown
and plans preventive or restorative nursing care.
1. Lower extremities are not massaged, to prevent
dislodging a potential thrombus.
3. Warm water is used to cleanse the eyes because soap is
likely to cause client discomfort if it seeps into the
client’s eyes.
4. The nurse washes and rinses smaller areas of the body
to complete a bed bath because wetting a large surface
area can cause vasoconstriction and shivering in the client
from the cooling effects of evaporation.
224. Chapter 08-02 (1.0 point)
A client has not eaten since admission to the long-term care facility 2 days ago. Which is
the best intervention for the nurse to prevent malnutrition in this client?
a. Make a diet request to the provider for full liquids.
b. Ask the client’s daughter why the client will not eat.
c. Remind the client that nutrition is essential to health.
*d. Assess the client for possible barriers to self-feeding.
General Feedback:
4. The nurse gathers additional information by using the
nursing process to prevent malnutrition for a new client in
the long-term care facility. Identifying barriers to selffeeding with objective and subjective data is the best
intervention because the nurse gathers valuable
nutritional information, including muscle function, teeth,
cognition, and client preferences.
1. Requesting a diet change is premature and not based on
assessment data.
2. Asking the daughter for information reveals the
daughter’s opinion, anecdotal information, and, possibly,
biased observations about the client.
3. Reminding the client about nutrition may be a useless
intervention if the client’s cognition is low, if the client
has a sensory or communication disorder, or the client is
depressed. In addition, the client can interpret this as an
insult to the client’s intelligence.
225. Chapter 08-03 (1.0 point)
A client with a neurological disease has difficulty swallowing. Which does the nurse
include in the plan of care?
a. Limit oral intake to clear liquids.
*b. Allow adequate time for the feeding.
c. Ask family members to coach the client.
d. Maintain low-Fowler’s position for meals.
General Feedback:
2. The nurse plans an adequate amount of time for client
feeding to prevent complications from impaired
swallowing. With nursing supervision and encouragement
and in a relaxed manner, the food is prepared properly,
and the client chews food thoroughly, swallows as
necessary, and takes short breaks while feeding.
1. Clear liquids can be contraindicated for the client.
3. Family coaching may pressure, misdirect, or shame the
client; increase the risk of aspiration or choking; and
decrease the client’s appetite. In addition, if the family is
present during feeding, the client lacks nursing
supervision.
4. Low-Fowler’s position is contraindicated for
swallowing difficulties and feeding because an upright
position facilitates swallowing.
226. Chapter 08-18 (1.0 point)
The nurse receives the report stating that the client, who is 5 feet tall, has a nutritional
deficit. Which physical clinical indicator consistent with a nutritional deficit does the
nurse expect to observe in the client?
a. Long, shiny hair
*b. Pale conjunctivae
c. Pink oral mucosa
d. Weight 99 pounds
General Feedback:
2. Pale conjunctivae are a clinical indicator of a
nutritional deficit consistent with a low serum
hemoglobin or hematocrit. The hematological
deficiencies result in a low oxygen-carrying capacity and
a deficient number of red blood cells in the blood. This
decreases the ability of the erythrocytes to oxygenate the
tissues adequately thereby resulting in pale mucous
membranes. Conjunctivae should appear reddish pink.
1, 3, and 4. The remaining options are clinical indicators
of a client who consumes an adequate diet. A female
client who is 5 feet tall should weigh 100 pounds.
227. Chapter 08-20 (1.0 point)
The nurse wants to know if the nursing plan of care is effective for a male client with
malnutrition. Which does the nurse use to determine whether the plan is effective?
a. Large, smooth tongue surface
b. 80% of food consumed at meals
c. 185 pounds at 5 feet 6 inches tall
*d. Reddish-pink mucous membranes
General Feedback:
4. Reddish-pink oral and conjunctival mucous
membranes are indications of a well-nourished person
because this color is consistent with well-oxygenated
tissue due to adequate amounts of hemoglobin and
erythrocytes. A malnourished person is likely to have
pale mucous membranes because the individual does not
receive adequate nutrition in the diet to provide the body
with the necessary iron to synthesize hemoglobin, amino
acids to manufacture protein, and other nutrients to
manufacture red blood cells in adequate amounts.
1. The tongue is a vivid pink or deep red with papillae
present in nourished individuals.
2. Consuming 80% of meals is an acceptable dietary
intake, generally; however, a malnourished person
usually needs to eat the entire meal on a consistent basis
to restore and maintain health and wellness.
3. A male who is 5 feet 6 inches tall weighing 185 pounds
is overweight because this client should weigh
approximately 136 pounds. Obese individuals are
frequently malnourished but gain weight by eating foods
that are high in fat and calories but low in nutrition.
228. Chapter 08-25 (1.0 point)
The nurse at a community center is preparing a program for older retired people at risk
for malnutrition who need community resources. Which is the best action for initiating
the nurse’s program?
*a. Review individual’s height, weight, and health history.
b. Teach low-cost menus and methods for a balanced diet.
c. Post flyers with instructions for obtaining free vitamins.
d. Provide telephone numbers of food banks and free meals.
General Feedback:
1. To start a community nutrition program, the nurse
applies the nursing process and implements the first step,
data gathering, to determine community needs. The nurse
gathers suitable data for planning the program by
screening older retired people for malnutrition and people
at risk for malnutrition using a nutritional screening tool.
The nurse analyzes the data including height, weight, and
health history to tailor the overall program, organizes
suitable resources, plans for individual nutritional
assistance, and matches people who are malnourished or
at risk with community resources such as food banks, free
meals, and Meals on Wheels. The remaining choices do
not help the nurse identify people at risk for malnutrition.
2, 3, and 4. Teaching about a balanced diet is a prevention
technique, and obtaining free vitamins and providing
contact information may help people find community
resources. The health care provider recommends vitamins
to supplement to a well-balanced diet but not to replace it.
229. Chapter 09-03 2 (1.0 point)
The nurse assesses the female client who has a bladder control problem and leaks small
amounts of urine occasionally. Which should the nurse implement to help restore the
client’s bladder control?
a. Recommend using commercial incontinence briefs.
*b. Instruct client to perform pelvic floor exercises daily.
c. Teach the client to apply an external urinary catheter.
d. Encourage client to limit daily fluid intake to 2000 ml.
General Feedback:
2. To increase bladder tone and urinary sphincter
function, the nurse instructs the client to perform pelvic
floor exercises daily; however, the nurse cautions the
client to avoid performing the exercises while on the
commode because it increases the risk of urinary
retention. An effective method of remembering to
perform the exercises is to associate exercising with
something such as television commercials, washing
dishes, or stopping at a traffic light.
1. Containing incontinent urine prevents leakage onto
clothing, does not improve bladder control, and does not
prevent urinary leakage from the bladder; it can increase
the risk of skin breakdown.
3 and 4. An external urinary catheter and fluid restriction
are not indicated.
230. Chapter 09-06 2 (1.0 point)
Four hours after applying an external urinary catheter to the client, the nurse observes no
urine output in the drainage bag. Which should the nurse implement first?
a. Check catheter tubing for an obstruction.
*b. Ask the client if he feels the urge to void.
c. Notify provider of inadequate urine output.
d. Increase client’s fluid intake over the next hour.
General Feedback:
2 and 1. The nurse asks the client if he senses the urge to
void because it can indicate a full bladder potentially
caused by obstructed tubing. The client can also have
urinary retention with an urge to void but no urine output.
If the client states he has no urge to void, the nurse can
scan the bladder to evaluate its contents.
3. It is premature to notify the provider because the nurse
has not assessed the client adequately.
4. Increasing the client’s intake can be contraindicated
but can be effective to increase urine output.
231. Chapter 09-09 (1.0 point)
The nurse instructs the client to record intake and output at home. Which should the nurse
include in client teaching?
a. Allow the client to exclude liquid medicine.
b. Ask the client to save all urine for a full day.
*c. Provide written list of food to record as intake.
d. Instruct client to estimate the amount of liquid.
General Feedback:
3. The nurse provides and explains a written list of food
to categorize as liquid and to record as intake; the client
learns to record food including ice cream, soup, and
prepackaged liquid meals as liquid intake.
1. Liquid medicine is considered fluid intake.
2. All urine is saved for 1 day to collect a 24-hour urine
specimen.
4. The nurse instructs the client to measure liquids
precisely using standardized measuring tools.
Prepackaged liquids are usually labeled with the volume
of the package.
232. Chapter 09-10 (1.0 point)
The female client has urinary incontinence and malnutrition. Which is the most important
information for the nurse to include in client teaching to maintain skin integrity?
a. Apply barrier protection to perineum.
*b. Keep the perineal skin clean and dry.
c. Visit community center to obtain food.
d. Adhere to well-balanced diet for meals.
General Feedback:
2. The most important information for the nurse to share
with the client who has malnutrition and is incontinent is
to keep the skin clean and dry. This is the priority because
a poorly nourished client is at high risk for skin
breakdown if the skin is exposed to urine regularly
because the body lacks adequate plasma proteins and,
thereby, the ability to repair damaged tissue.
1. One aspect of maintaining clean and dry skin can be to
apply a barrier ointment; however, the nurse reminds the
client to use the barrier only on intact skin.
3 and 4. The skin is more fragile and prone to breakdown
in a client who is malnourished; the nurse can provide
community resources for the client to obtain food and
instructs the client about planning and eating a wellbalanced diet as another part of a plan to maintain skin
integrity.
233. Chapter 09-11 2 (1.0 point)
The male client is weak, has diarrhea, and declines use of the bedside commode. Which
is the best nursing intervention to maintain client safety?
a. Keep the commode out of the client’s sight until it is needed.
b. Reassure the client that most people use the commode willingly.
c. Instruct the client that the only alternative for elimination is to use the bedpan.
*d. Explain to the client how the nurse ensures privacy and safety when using the
commode.
General Feedback:
4. The nurse increases the likelihood of the client using
the commode by explaining how the nurse ensures safety
and privacy while the client uses the commode. The nurse
places the call bell and other items that the client needs or
wants within easy reach, covers the client sufficiently for
privacy and warmth, pulls the privacy curtain, and
prevents other people from entering the room while the
client sits on the commode. Because the client is weak
and has diarrhea, the client is at risk for injury because he
can have difficulty supporting his weight and ambulating
to the bathroom safely. The nurse also explains how
ambulating to the bathroom in a hurry to have a bowel
movement increases the risk of client injury.
1. Hiding the commode is deceitful and defeats the
purpose of placing a commode at the bedside if the client
has a sudden stool.
2 Comparing the client to other clients to induce
cooperation shames the client and is improper; in
addition, it denies the client the right to information and
to informed consent.
3. Telling the client the only alternative is to use the
bedpan can be interpreted as coercion and a veiled threat.
The nurse can suggest using a bedpan instead of the
commode, but the commode is a better choice because it
helps to maintain client muscle strength and endurance.
234. Chapter 09-14 (1.0 point)
The male client is having difficulty using the urinal in bed. Which does the nurse
implement to facilitate voiding into the urinal?
a. Applies an external urinary catheter
*b. Assists client to the upright position
c. Encourages client to void every hour
d. Instructs client to increase fluid intake
General Feedback:
2. The nurse assists the client into an upright position to
facilitate voiding into a urinal because men are
accustomed to voiding in a standing position. If sitting
upright is ineffective and the client is hemodynamically
stable, the nurse assists the client to dangle or to stand for
urination into a urinal.
1. Applying an external catheter facilitates containing the
urine but not in a urinal.
3 and 4. Decreasing or increasing the volume of urine,
voiding hourly, or increasing fluid intake respectively,
can be ineffective strategies to facilitate using a urinal in
bed if the client must stand to initiate the flow of urine.
235. Chapter 09-15 2 (1.0 point)
The nurse removes the client’s indwelling urinary catheter but, 8 hours later, the client
has not voided. Which intervention should the nurse try first to facilitate client voiding?
a. Run a trickle of water in the bathroom.
b. Apply rolling motion over the bladder.
*c. Ask about voiding difficulties in the past.
d. Instruct client to run warm water on perineum.
General Feedback:
3. The nurse assesses the client for a history of voiding
difficulties, especially after removal of an indwelling
catheter, and asks the client about successful strategies
that facilitated voiding. The client difficulties often arise
from the physical distortion of the urinary meatus and
sphincters by the urinary catheter and, after the urethra
and sphincters return to normal and regional edema
improves several hours later, the client voids.
1, 2, and 4. Running water in the bathroom, running
warm water over the perineum, and applying gentle
pressure to the bladder are suitable techniques to
stimulate urination after assessing the client.
236. Chapter 09-18 (1.0 point)
At 7 AM, the nurse admits the client, who has a balanced fluid status. What is the client’s
fluid status at the end of the 7 AM to 3 PM period? Refer to the 24-hour intake and
output record for the client.
Ora IV Total Urine Ileostomy Surgical Total
l
Drain
7 AM–3 455 650
570
50
50
PM
3-11 PM 390 550
435
150
25
11 PM– 200 400
280
90
15
7 AM
24-hour
total
a. Fluid volume deficit
*b. Fluid volume excess
c. Excess intake 355 ml
d. Excess output 285 ml
General Feedback:
According to the intake and output record, the client has
fluid volume excess. Total intake for this period is
. Total output for this period is
. The client’s intake of 1055 ml exceeds the client’s
output of 670 ml by 385 ml.
237. Chapter 10-01 (1.0 point)
Which is the best justification for nursing interventions to promote optimal sleep and
rest?
a. Increases the client and family satisfaction with the agency
b. Promotes lengthy, uninterrupted periods of non-REM sleep
c. Decreases the need for pain control and relaxation therapies
*d. Helps client to learn and problem solve by enhancing REM sleep
General Feedback:
4. Facilitating learning and problem solving is the best
reason to promote optimal sleep and rest because it is the
most comprehensive result of optimal sleep and rest. The
client thinks and reasons with more clarity and has a
greater ability to function in society. If the client is
hospitalized, learning and problem solving are essential to
maintain health and well-being.
1. Increasing client and family satisfaction is important
for client recovery and the agency for public relations and
economic reasons but are secondary in importance to
increasing client health and well-being.
2. Non-REM sleep occurs between periods of REM sleep,
and each are important for restorative sleep. Rest is
mainly an energy conserving technique but does not help
to create energy.
3. Pain control and relaxation therapies promote optimal
sleep and rest.
238. Chapter 10-08 (1.0 point)
The client has hypotension, receives as much opioid analgesia as the prescription allows,
and continues to have difficulty sleeping at night from pain. Which should the nurse
implement to relieve pain and improve sleep?
*a. Encourage controlled breathing.
b. Provide a glass of wine at bedtime.
c. Give a sedative 1 hour before sleep.
d. Increase fluids and reposition client.
General Feedback:
1. The nurse encourages the client with controlled
breathing exercises serving as a distraction to increase
relaxation, decrease pain, and promote sleep. The nurse
applies a nonpharmacologic relaxation technique because
the client has hypotension and additional analgesia is
likely to lower the blood pressure further potentially
leading to serious complications including loss of
consciousness, decreased perfusion to vital organs, and
cardiopulmonary arrest.
2. Alcohol is contraindicated for use with opioids; in
addition, alcohol consumption is likely to lower the blood
pressure by vasodilation.
3. The nurse avoids administering a sedative because
hypotension is an adverse effect of most sedatives and
that will aggravate the client’s hypotension.
4. The nurse increases fluid if the client has a fluid
volume deficiency; however, restoring fluid balance is
unlikely to promote relaxation to relieve pain and
improve sleep. Until the client’s hypotension is resolved,
the nurse repositions the client in the supine position or
with the head slightly elevated to prevent increasing
venous return from the head to the heart.
239. Chapter 11-24 (1.0 point)
The primary care nurse measures the client’s blood pressure and obtains 145/90 mm Hg.
Which should the nurse implement?
a. Collaborate on antihypertensive therapy.
b. Ask client about caffeine and sodium intake.
c. Ask for date of initial hypertension diagnosis.
*d. Repeat the blood pressure after client relaxation.
General Feedback:
4. Hypertension is never diagnosed on the basis of one
reading. At a minimum, the nurse allows the client to
relax for a few minutes and then takes another blood
pressure measurement. The client is directed to return to
the clinic in 1 to 4 weeks to rule out hypertension.
1. Collaborating on antihypertensive therapy is premature
because hypertension has not been diagnosed.
2. Asking the client about sodium and caffeine intake is a
reasonable response after repeating the blood pressure
measurement and obtaining similar results. While
instructing the client to return to the clinic to reevaluate
the blood pressure, the provider can suggest lifestyle
changes to the client as initial antihypertensive therapy
including sodium and caffeine restrictions because
sodium retains water and caffeine vasoconstricts.
3. Asking for the date when hypertension was originally
diagnosed is premature; however, the nurse conducts a
thorough review of the systems by asking about medical
history and current medications because that information
will provide valuable data about the client’s blood
pressure.
240. Chapter 11-26 (1.0 point)
The nurse teaches the client about the pulse oximeter alarm to engage the client in selfcare. Which is the best client teaching the nurse provides about the pulse oximeter alarm?
a. The sensor becomes dislodged.
*b. The client needs to breathe deeply.
c. The nurse needs to measure vital signs.
d. Oxygen level falls below desired range.
General Feedback:
2. The best information to provide is to prompt the client
to take a deep breath to increase oxygen saturation The
nurse also teaches the client that the nurse responds to the
alarm knowing the client was briefly hypoxemic; if the
client is able to breathe deeply in response, the nurse
assesses the client’s ability to increase oxygenation. If the
client cannot take a deep breath or not increase the
oxygen saturation, if the nurse responds to the alarm, the
nurse will be at the bedside to care for the client.
1 and 4. The nurse includes client teaching about keeping
the sensor in place and about falling oxygen levels;
however, this information does little to affect the client
positively and engage the client is self-care.
3. The nurse potentially needs to measure vital signs
when the alarm sounds but does not rely on activation of
the alarm to measure vital signs.
241. Chapter 12-02 (1.0 point)
The nurse assesses the client with light skin and observes normally shaped nail beds
exhibiting pallor and slight bluishness. Which should the nurse implement?
a. Provide a warm heating pad.
b. Collaborate with the physician.
*c. Assess client oxygen saturation.
d. Check for restricted venous return.
General Feedback:
3. Nail beds in a client with light skin are a view of the
client’s capillary bed at the periphery. Pallor and
bluishness in the capillary bed indicate inadequate
oxygenation because oxygenated blood is dark red,
rendering the nail beds pink. Hypoxia in extremities can
be due to cold temperatures; vasoconstriction, peripheral
vascular, or vasospastic disease reducing the oxygenated
blood flow; hypoxemia; anemia; preparation for dying;
and respiratory failure.
1. Generally, heat and cold require a provider
prescription; moreover, the nurse needs to assess the
client and to gather related data before being able to
decide that warmth is indicated.
2. The nurse needs to complete the assessment, first, as
long as the client is in no immediate danger or
experiencing distress, and to think critically before
collaboration. If collaboration with the provider becomes
necessary, the nurse presents a complete client
assessment.
4. Restricted venous return usually leads to edema; severe
peripheral edema lead to pallor and cyanosis potentially
occurring but it is not common.
242. Chapter 12-20 (1.0 point)
Which does the nurse use to complete a general assessment of a toddler efficiently?
a. The nurse avoids waking the child.
*b. The child handles some equipment.
c. The parent or guardian is not present.
d. The nurse palpates and then observes.
General Feedback:
2. The nurse familiarizes the toddler with equipment that
is safe for the toddler to handle to begin a general
assessment to engage the child in the assessment and to
decrease fear of pain or injury from the equipment. If
fearful of pain or injury, the child is likely to be
uncooperative and impede the nurse’s assessment.
1 and 3. The nurse wants the child awake during the
assessment to observe toddler-parent (or guardian)
interaction.
4. The nurse performs inspection and then palpation for
an assessment except for the abdomen, when the nurse
inspects and then auscultates.
243. Chapter 12-21 (1.0 point)
The male client with back pain asks why the nurse needs so many details about his
history. What is the most effective response by the nurse?
a. “You seem reluctant to provide information.”
*b. “We need complete data to plan nursing care.”
c. “It will take a short time to answer all questions.”
d. “We need to determine contributors to your pain.”
General Feedback:
2. The nurse explains that comprehensive data facilitates
individualized client care, lowers client risks of injury,
and increases client safety.
1. The nurse interprets the client’s statement as hesitancy
about revealing details; the client wants to know why the
nurse needs so much specific information.
3. This response does not answer the client’s question.
4. Determining factors that contribute to the client’s pain
is part of a pain assessment and one of the details that
help the nurse plan individualized client care.
244. Chapter 12-28 (1.0 point)
The nurse assesses the client with altered musculoskeletal function. Which is the best
reason supporting the nurse’s reason to ask probing questions?
a. Explore how the client’s family reacts to the disability.
b. Evaluate client concerns about the problem at this time.
*c. Determine how the alteration affects the client’s lifestyle.
d. Validate the amount of physical rehabilitation completed.
General Feedback:
3, 1, 2, and 4. Determining how the altered
musculoskeletal function affects the client’s lifestyle is
the best reason the nurse asks probing questions; with
skillful follow-up questioning, the nurse reveals the most
comprehensive information about the client, including
family reactions, client concerns, and rehabilitation
issues. If the nurse justified asking probing questioning to
evaluate client concerns, family reactions, or
rehabilitation, any issues unrelated to client these
elements would not receive attention.
245. Chapter 12-33 (1.0 point)
The nurse documents the client’s swollen lower extremities and measures the depth of a
4-mm indentation made 1 minute ago. Which is the best description for the nurse to use
to describe the client’s lower extremities?
*a. 4+ pitting edema
b. Mild pitting edema
c. 4+ nonpitting edema
d. Severe nonpitting edema
General Feedback:
1. The best description of any clinical indicator is the
most precise one; for this client, 4+ pitting edema is the
best description of a lasting indentation of swollen legs at
a depth of 4 mm.
2. Mild is a subjective term open to interpretation.
3. 4+ is precise but the edema is pitting because the
indentation lingers for at least a minute.
4. Severe is a subjective term and the edema is pitting.
246. Chapter 12-44 (1.0 point)
Which does the nurse implement to begin the thoracic assessment of a client?
a. Percussion of the lateral thorax
b. Palpation of the anterior thorax
c. Measurement of respiratory rate
*d. Inspection of the posterior thorax
General Feedback:
4. The nurse begins a thoracic assessment by inspecting
the posterior thorax to identify any factors that can impair
chest expansion or respiratory distress.
1. Lateral percussion is not used in a respiratory
assessment because the biggest lung fields are across the
client’s back.
2. Palpation of the anterior thorax follows assessment of
the posterior thorax.
3. Measuring the respiratory rate follows the posterior
thoracic inspection.
247. Chapter 29-02 (1.0 point)
The nurse assesses arterial blood gas result from the 88-year-old client who receives
oxygen at 3 L/min by nasal cannula. The PaO2 at 8 AM was 84 mm Hg and at 10 AM it
was 82 mm Hg. Which does the nurse implement?
a. Collaborates with provider to use an oxygen mask
b. Plans follow-up nursing care for client hypoxemia
c. Requests the laboratory confirm the client’s results
*d. Continues with the current therapy and nursing care
General Feedback:
4. The nurse continues with the current therapy and
nursing care because the difference oxygen values have
an insignificant difference, probably representing a
normal variation in client PaO2 occurring from minute to
minute. The nurse continues to monitor the client closely
because the PaO2 is approaching the lower limit for an
acceptable arterial blood oxygen tension.
1. Collaborating for a mask is unnecessary because the
client's PaO2 is within normal limits.
2. The client’s oxygen tension is at the lower acceptable
range for arterial blood.
3. The most likely reason for the variation between the
blood gas results is normal minute-to-minute variation.
248. Chapter 29-03 (1.0 point)
The nurse admits the client with exacerbation of chronic obstructive pulmonary disease
(COPD). Which should the nurse implement after reading the prescription for oxygen at 7
L/min by simple facemask?
a. Suction the oropharynx before applying the mask.
*b. Check with provider about prescription for a mask.
c. Substitute a Venturi mask for the simple facemask.
d. Ask the nursing assistant to assemble equipment.
General Feedback:
2. The nurse checks with the provider before
implementing the prescription for a client with COPD
because a simple facemask is likely to aggravate carbon
dioxide retention. A simple facemask does not allow the
escape of carbon dioxide, a chronic problem for a client
with COPD. In addition, the nurse confirms that the
number 7 is correct because the provider can write a 7
that is similar in appearance to a 1 or a 2, depending on
the provider’s penmanship. Seven liters per minute are
excessive for the client because clients with COPD
stimulate breathing with hypoxemia compared with most
other people who breathe from hypercarbia.
1. The nurse avoids suctioning the client with COPD
without justification because it removes inspired oxygen
from a typically hypoxemic client. In addition, this client
is in distress, so the nurse optimizes oxygen tension of
inspired air for the client within limits.
3. The nurse cannot use a Venturi mask with the
prescription as written because it delivers oxygen by
FiO2.
4. The nurse is not sure which equipment the client needs,
so the nurse clarifies the prescription first and then
delegates to the assistant.
249. Chapter 29-04 (1.0 point)
A home care client receives oxygen by nonrebreather (NRB) mask. Which does the nurse
include when teaching the caregiver about the oxygen delivery system?
*a. Keep the plastic bag at the end of the mask inflated continually.
b. Adjust the oxygen flow rate with the valve in front of the mask.
c. Offer fluids frequently and apply moisturizer to prevent dry skin.
d. Remove the elastic head strap to prevent skin breakdown at ears.
General Feedback:
1. To prevent inhalation of carbon dioxide, the nurse
instructs the caregiver to maintain an inflated bag at the
end of the mask because it serves as an oxygen reservoir
for the client. If the bag deflates, the client is at risk to
inhale excessive levels of carbon dioxide.
2. The nurse regulates the oxygen flow rate by adjusting
the flow meter on the oxygen source; an NRB mask does
not have a mixing valve.
3. A NRB mask does not dehydrate the client.
4. The NRB mask requires a tight seal for effective
therapy, making it uncomfortable and difficult to
maintain.
250. Chapter 29-05 (1.0 point)
The nurse hears the client’s stridor from the hallway and notes that the client’s oxygen
saturation has decreased to 92%. Which nursing intervention does the nurse implement
first?
*a. Adjust client’s position.
b. Suction the oropharynx.
c. Insert an artificial airway.
d. Measure arterial blood gases.
General Feedback:
1. The nurse implements a noninvasive intervention to
enhance the client’s airway before instituting an invasive
measure because, although the client’s airway is
impaired, the client continues to oxygenate fairly well but
is working very hard to do so. By quickly adjusting the
client’s position to maximize gas exchange and chest
expansion, the nurse intervenes and gains additional
valuable data for planning additional nursing care.
2. Suctioning is contraindicated for stridor because it can
aggravate stridor to laryngospasm.
3. The nurse avoids inserting an airway because the client
has stridor, an airway impairment in the trachea. If the
client needs an artificial airway, the nurse needs to
provide an endotracheal tube or tracheostomy to restore
the client’s airway because the obstruction is beyond the
reach of an oral airway. In addition, the insertion of an
airway is likely to make the client gag and increase the
risk of airway collapse or aspiration.
4. The nurse avoids arterial blood gases (ABG) because
valuable data are already available for client assessment;
ABGs are not necessary yet.
251. Chapter 29-06 (1.0 point)
The client’s nursing diagnoses include Risk for ineffective airway clearance related to
decreased respiratory effort postoperatively. Which specific client assessment data
should the nurse monitor in the client’s plan of care?
a. Peak expiratory flow rate at 2% less than the client baseline
*b. Nasal flaring and intercostal retractions with each inspiration
c. Frequent coughing and large amounts of clear, watery sputum
d. Arterial blood gases reveal PaO2 97 mm Hg and PaCO2 37 mm Hg
General Feedback:
2. The nurse specifically monitors for nasal flaring and
accessory muscle use during inspiration because these
indicate the client needs additional oxygen and is working
very hard to breathe. Clients cannot breathe in this
manner for long periods because the muscles become
fatigued and respiratory failure develops. The nurse
addresses nasal flaring and use of accessory muscles
promptly to avoid client deterioration.
1. A peak expiratory flow rate within 2% of baseline is
acceptable because it indicates that the client is able to
exhale at a rate within 2% of the client’s normal rate.
3. Frequent coughing that produces thin, clear secretions
facilitates airway clearance and is highly desirable in the
postoperative period.
4. The ABGs are within normal limits and the nurse
expects blood gases within normal limits.
252. Chapter 29-08 (1.0 point)
The client uses continuous positive airway pressure (CPAP) at home and tells the home
care nurse that the mask fits too tightly. Which does the nurse implement?
a. Uses a simple facemask
*b. Maintains tight fit to face
c. Enlarges several air holes
d. Loosens the mask’s straps
General Feedback:
2. The nurse teaches the client that the mask of the CPAP
must fit tightly to prevent collapse of the upper airway
because the device is unable to establish positive airway
pressure without a tight seal.
1 and 4. Loosening the straps or using a simple facemask
allows so much air to leak from the system that positive
pressure never builds.
3. If the CPAP has holes, they are integrated into the
system; the nurse avoids enlarging the holes because it
alters the design and potentially alters the function.
253. Chapter 29-09 (1.0 point)
The client is lethargic and unable to clear oral secretions effectively. Which does the
nurse use to suction oropharyngeal secretions from the client?
*a. Delegate oral suctioning to the nursing assistant.
b. Loosen oral secretions with normal saline solution.
c. Suction the nose, mouth, and throat with catheter.
d. Use a clean catheter to suction the nose and mouth.
General Feedback:
1. The nurse delegates oropharyngeal suctioning to the
nursing assistant as necessary and retains responsibility
for client assessment. The nurse also remains responsible
for instructing and supervising the nursing assistant. The
nurse instructs the nursing assistant to report changes in
client’s oxygen saturation or respiratory rate during and
after suctioning.
2. The nurse avoids instilling saline solution into the
client’s oropharynx, to prevent aspiration.
3. Suctioning the nose and throat are not indicated.
4. The nurse uses a sterile catheter for nasopharyngeal
suctioning to prevent contamination of the nasal passages
or trachea.
254. Chapter 29-17 (1.0 point)
The nurse assesses the client’s water-seal drainage (WSD) system connected to two chest
tubes. Which is an unexpected finding for a properly functioning WSD system?
a. Fluid drains into the WSD collection chamber slowly.
b. Serosanguinous chest tube drainage postoperatively.
c. Fluid in water-seal chamber fluctuates with breathing.
*d. Tape covers WSD system vent and not the connections.
General Feedback:
4. The nurse should use tape to secure every connection
in the WSD system to prevent air leaks but not to cover
the vent because the vent allows expired air to escape into
the atmosphere. The water-seal in the drainage system
prevents expired air from returning to the lungs.
1 and 2. The nurse expects chest tube drainage to be
bloody because the client is postoperative after a
thoracotomy; however, the nurse expects the drainage to
dissipate after the first few hours of thoracic surgery and
to accumulate gradually in the collection device as
hemostasis and healing stop the blood flow.
3. The nurse expects to visualize fluctuations in the
water-seal chamber, indicating the system is closed.
255. Chapter 29-18 (1.0 point)
The nurse notes that the client’s chest tube pulled out by 2 inches during turning and
repositioning. Which does the nurse implement?
a. Instruct the nursing assistant to apply pressure for 5 minutes.
b. Replace the WSD system with a sterile waterless unit quickly.
*c. Hold a towel firmly over site and send for petrolatum gauze.
d. Push tube into place and apply an occlusive sterile dressing.
General Feedback:
3. The nurse secures the tube in place with a clean towel
and sends the nursing assistant for sterile petroleum
gauze. The nurse securely wraps the gauze around the
base of the chest tube insertion to recreate an airtight seal
so negative intrapleural pressure can be restored. The
nurse should collaborate with the provider for a chest xray to evaluate the lung’s status after the accident.
1. The nurse applies pressure to the site to prevent the
wound from drawing in room air because this
intervention requires clinical judgment and critical
thinking to seal the wound completely. The nursing
assistant receives training to procure the petroleum gauze
for the nurse.
2. A standard or a waterless system is suitable for the
client’s WSD; however, neither system is effective
therapy until the airtight insertion site is reestablished.
4. The nurse avoids pushing the chest tube into place
because the tubing pulled out by the accident is
contaminated; if reinserted into the chest, the client is at
high risk for a pulmonary infection.
256. Chapter 29-19 (1.0 point)
The nurse applies supplemental oxygen to the client who has emphysema. Which oxygen
delivery device does the nurse choose for the client?
*a. Nasal cannula
b. Simple facemask
c. Nonrebreather mask
d. Partial rebreather mask
General Feedback:
1. The nurse applies supplemental oxygen to the client
with a nasal cannula because the cannula delivers oxygen
at a suitably low flow rate for the client with emphysema,
maintaining hypoxemia as the client’s respiratory drive.
2. A facemask is unsuitable for the client with
emphysema because the mask can aggravate carbon
dioxide retention.
3 and 4. A nonrebreather mask and partial rebreather
mask are unsuitable for the client because each is suited
for delivery of high oxygen concentrations.
257. Chapter 29-28 (1.0 point)
The nurse suctions the client with pneumonia. Which client assessment data requires the
nurse to discontinue suctioning?
a. Pulmonary infiltrates are on chest x-ray.
b. Client coughing clear, watery secretions.
c. Oxygen saturation falls from 97% to 92%.
*d. Heart rate decreases from 84 to 59 beats/min.
General Feedback:
4. Bradycardia during suctioning is consistent with
clinical indicators of vasovagal stimulation and requires
the nurse to discontinue the suctioning. The nurse applies
oxygen quickly and hyperoxygenates as needed. The
nurse continues to monitor the heart rate and checks the
client’s blood pressure, level of consciousness, SaO2, and
respiratory rate for an assessment. If the heart rate does
not recover quickly to baseline levels, the nurse should
collaborate with the provider and prepare emergency
drugs and equipment.
1. The nurse expects to view pulmonary infiltrates on the
chest x-ray as evidence of the lung infection.
2. The nurse expects thin, clear secretions during
suctioning and the secretions indicate effective coughing.
3. An SaO2 of 92% from 97% is a transient drop in the
oxygen saturation from hypoxemia induced from
suctioning.
258. Chapter 29-35 (1.0 point)
The nurse admits a client who received a tracheostomy today. Which should the nurse
implement for tracheostomy care without assistance?
a. Cleanse the inside of the outer cannula with saline solution.
*b. Rinse inner cannula with hydrogen peroxide and saline solution.
c. Suction oropharynx after thoroughly cleaning the tracheostomy.
d. Remove the old tracheostomy ties prior to applying new ones.
General Feedback:
2. The nurse removes the inner cannula of the
tracheostomy tube, cleans it in hydrogen peroxide, and
rinses it in normal saline solution before reinserting it into
the outer cannula. Cleaning removes surface debris to
maintain patency and to reduce the transmission of
microorganisms into the lower respiratory tract because
the tracheostomy bypasses a normal, protecting, filtering
mechanism of the respiratory system.
1. The nurse cleans the outside of the outer cannula at the
stoma.
3. The nurse suctions the oropharynx before tracheostomy
care to prevent client coughing during the procedure
because secretions accumulate on the cuff. The nurse
wants to remove the secretions to prevent coughing and
to prevent client aspiration of secretions during accidental
dislodgement of the tracheostomy.
4. The nurse applies new tracheostomy ties before
removing the old ties when working unassisted. With
assistance, the nurse instructs the nurse assistant to hold
the tracheostomy in place while the nurse removes the old
tie and replaces it with fresh twill tape.
259. Chapter 29-39 (1.0 point)
The male client who receives continuous positive airway pressure (CPAP) tells the nurse
that he feels like he is suffocating during the treatments. Which does the nurse implement
to facilitate client therapy?
a. Try saline solution nasal spray.
b. Use oral breathing techniques.
c. Loosen the straps for the seal.
*d. Decrease the pressure settings.
General Feedback:
4. The nurse responds to the client complaint by setting
the pressure at a slightly lower setting and teaching the
client that the feeling of suffocation dissipates over time
with regular usage. If the client tolerates the new
pressure, the nurse provides the client an opportunity to
adjust to the setting and increases the pressure as
tolerated to comply with the prescription.
1. Nasal spray is ineffective therapy for feelings of
suffocation during CPAP therapy.
2. Oral breathing is ineffective during CPAP because the
device is fitted over the nose; if the client mouth breathes
during therapy, the high pressure cannot be achieved.
3. The CPAP requires a tight seal for effectiveness to
establish high pressure.
260. Chapter 29-40 (1.0 point)
The nurse suctions the client’s endotracheal tube and the client becomes hypoxic. Which
is the priority nursing intervention to increase client oxygenation?
a. Assess breath sounds
b. Discontinue suctioning.
c. Instruct client to cough.
*d. Ventilate client manually.
General Feedback:
4. If the client becomes hypoxic, the nurse ventilates the
client manually with supplemental oxygen to increase
client oxygenation. The nurse implements measures to
oxygenate the client quickly to avoid adverse and
potentially life-threatening complications, including
arrhythmias and cardiopulmonary arrest.
1. The nurse assesses the client after providing
supplemental oxygen and before seeking assistance
because the hypoxia is most likely transient.
2. The nurse discontinues suctioning to stop the decline in
client oxygen saturation; however, this action alone does
not increase oxygenation. This nursing intervention halts
the declining oxygen saturation but does not inherently
increase it.
3. Instructing the client to cough is a reasonable response
to hypoxia, especially if the client has pulmonary
secretions; however, manual ventilation provides
supplemental oxygen in addition to ventilation to increase
client oxygenation.