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Brunner & Suddarth’s Textbook of Medical Surgical Nursing 13th Edition – Test Bank
 

 

1. A nurse has been offered a position on an obstetric unit and has learned that the unit offers therapeutic abortions, a procedure which contradicts the nurse’s personal beliefs. What is the nurse’s ethical obligation to these patients?
A) The nurse should adhere to professional standards of practice and offer service to these patients.
B) The nurse should make the choice to decline this position and pursue a different nursing role.
C) The nurse should decline to care for the patients considering abortion.
D) The nurse should express alternatives to women considering terminating their pregnancy.
Ans: B
Feedback:
To avoid facing ethical dilemmas, nurses can follow certain strategies. For example, when applying for a job, a nurse should ask questions regarding the patient population. If a nurse is uncomfortable with a particular situation, then not accepting the position would be the best option. The nurse is only required by law (and practice standards) to provide care to the patients the clinic accepts; the nurse may not discriminate between patients and the nurse expressing his or her own opinion and providing another option is inappropriate.

 

 

2. A terminally ill patient you are caring for is complaining of pain. The physician has ordered a large dose of intravenous opioids by continuous infusion. You know that one of the adverse effects of this medicine is respiratory depression. When you assess your patient’s respiratory status, you find that the rate has decreased from 16 breaths per minute to 10 breaths per minute. What action should you take?
A) Decrease the rate of IV infusion.
B) Stimulate the patient in order to increase respiratory rate.
C) Report the decreased respiratory rate to the physician.
D) Allow the patient to rest comfortably.
Ans: C
Feedback:
End-of life issues that often involve ethical dilemmas include pain control, “do not resuscitate” orders, life-support measures, and administration of food and fluids. The risk of respiratory depression is not the intent of the action of pain control. Respiratory depression should not be used as an excuse to withhold pain medication for a terminally ill patient. The patient’s respiratory status should be carefully monitored and any changes should be reported to the physician.

 

 

3. An adult patient has requested a “do not resuscitate” (DNR) order in light of his recent diagnosis with late stage pancreatic cancer. The patient’s son and daughter-in-law are strongly opposed to the patient’s request. What is the primary responsibility of the nurse in this situation?
A) Perform a “slow code” until a decision is made.
B) Honor the request of the patient.
C) Contact a social worker or mediator to intervene.
D) Temporarily withhold nursing care until the physician talks to the family.
Ans: B
Feedback:
The nurse must honor the patient’s wishes and continue to provide required nursing care. Discussing the matter with the physician may lead to further communication with the family, during which the family may reconsider their decision. It is not normally appropriate for the nurse to seek the assistance of a social worker or mediator. A “slow code” is considered unethical.

 

 

4. An elderly patient is admitted to your unit with a diagnosis of community-acquired pneumonia. During admission the patient states, “I have a living will.” What implication of this should the nurse recognize?
A) This document is always honored, regardless of circumstances.
B) This document specifies the patient’s wishes before hospitalization.
C) This document that is binding for the duration of the patient’s life.
D) This document has been drawn up by the patient’s family to determine DNR status.
Ans: B
Feedback:
A living will is one type of advance directive. In most situations, living wills are limited to situations in which the patient’s medical condition is deemed terminal. The other answers are incorrect because living wills are not always honored, they are not binding for the duration of the patient’s life, and they are not drawn up by the patient’s family.

 

 

5. A nurse has been providing ethical care for many years and is aware of the need to maintain the ethical principle of nonmaleficence. Which of the following actions would be considered a contradiction of this principle?
A) Discussing a DNR order with a terminally ill patient
B) Assisting a semi-independent patient with ADLs
C) Refusing to administer pain medication as ordered
D) Providing more care for one patient than for another
Ans: C
Feedback:
The duty not to inflict as well as prevent and remove harm is termed nonmaleficence. Discussing a DNR order with a terminally ill patient and assisting a patient with ADLs would not be considered contradictions to the nurse’s duty of nonmaleficence. Some patients justifiably require more care than others.

 

 

6. You have just taken report for your shift and you are doing your initial assessment of your patients. One of your patients asks you if  an error has been made in her medication. You know that an incident report was filed yesterday after a nurse inadvertently missed a scheduled dose of the patient’s antibiotic. Which of the following principles would apply if you give an accurate response?
A) Veracity
B) Confidentiality
C) Respect
D) Justice
Ans: A
Feedback:
The obligation to tell the truth and not deceive others is termed veracity. The other answers are incorrect because they are not obligations to tell the truth.

 

 

7. A nurse has begun creating a patient’s plan of care shortly after the patient’s admission. It is important that the wording of the chosen nursing diagnoses falls within the taxonomy of nursing. Which organization is responsible for developing the taxonomy of a nursing diagnosis?
A) American Nurses Association (ANA)
B) NANDA
C) National League for Nursing (NLN)
D) Joint Commission
Ans: B
Feedback:
NANDA International is the official organization responsible for developing the taxonomy of nursing diagnoses and formulating nursing diagnoses acceptable for study. The ANA, NLN, and Joint Commission are not charged with the task of developing the taxonomy of nursing diagnoses.

 

 

8. In response to a patient’s complaint of pain, the nurse administered a PRN dose of hydromorphone (Dilaudid). In what phase of the nursing process will the nurse determine whether this medication has had the desired effect?
A) Analysis
B) Evaluation
C) Assessment
D) Data collection
Ans: B
Feedback:
Evaluation, the final step of the nursing process, allows the nurse to determine the patient’s response to nursing interventions and the extent to which the objectives have been achieved.

 

 

9. A medical nurse has obtained a new patient’s health history and completed the admission assessment. The nurse has followed this by documenting the results and creating a care plan for the patient. Which of the following is the most important rationale for documenting the patient’s care?
A) It provides continuity of care.
B) It creates a teaching log for the family.
C) It verifies appropriate staffing levels.
D) It keeps the patient fully informed.
Ans: A
Feedback:
This record provides a means of communication among members of the health care team and facilitates coordinated planning and continuity of care. It serves as the legal and business record for a health care agency and for the professional staff members who are responsible for the patient’s care. Documentation is not primarily a teaching log; it does not verify staffing; and it is not intended to provide the patient with information about treatments.

 

 

10. The nurse is caring for a patient who is withdrawing from heavy alcohol use and who is consequently combative and confused, despite the administration of benzodiazepines. The patient has a fractured hip that he suffered in a traumatic accident and is trying to get out of bed. What is the most appropriate action for the nurse to take?
A) Leave the patient and get help.
B) Obtain a physician’s order to restrain the patient.
C) Read the facility’s policy on restraints.
D) Order soft restraints from the storeroom.
Ans: B
Feedback:
It is mandatory in most settings to have a physician’s order before restraining a patient. Before restraints are used, other strategies, such as asking family members to sit with the patient, or utilizing a specially trained sitter, should be tried. A patient should never be left alone while the nurse summons assistance.

 

 

11. A patient admitted with right leg thrombophlebitis is to be discharged from an acute-care facility. Following treatment with a heparin infusion, the nurse notes that the patient’s leg is pain-free, without redness or edema. Which step of the nursing process does this reflect?
A) Diagnosis
B) Analysis
C) Implementation
D) Evaluation
Ans: D
Feedback:
The nursing actions described constitute evaluation of the expected outcomes. The findings show that the expected outcomes have been achieved. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the nurse puts the care plan into action. This nurse’s actions do not constitute diagnosis.

 

 

12. During report, a nurse finds that she has been assigned to care for a patient admitted with an opportunistic infection secondary to AIDS. The nurse informs the clinical nurse leader that she is refusing to care for him because he has AIDS. The nurse has an obligation to this patient under which legal premise?
A) Good Samaritan Act
B) Nursing Interventions Classification (NIC)
C) Patient Self-Determination Act
D) ANA Code of Ethics
Ans: D
Feedback:
The ethical obligation to care for all patients is clearly identified in the first statement of the ANA Code of Ethics for Nurses. The Good Samaritan Act relates to lay people helping others in need. The NIC is a standardized classification of nursing treatment that includes independent and collaborative interventions. The Patient Self-Determination Act encourages people to prepare advance directives in which they indicate their wishes concerning the degree of supportive care to be provided if they become incapacitated.

 

 

13. An emergency department nurse is caring for a 7-year-old child suspected of having meningitis. The patient is to have a lumbar puncture performed, and the nurse is doing preprocedure teaching with the child and the mother. The nurse’s action is an example of which therapeutic communication technique?
A) Informing
B) Suggesting
C) Expectation-setting
D) Enlightening
Ans: A
Feedback:
Informing involves providing information to the patient regarding his or her care. Suggesting is the presentation of an alternative idea for the patient’s consideration relative to problem solving. This action is not characterized as expectation-setting or enlightening.

 

 

14. The nurse, in collaboration with the patient’s family, is determining priorities related to the care of the patient. The nurse explains that it is important to consider the urgency of specific problems when setting priorities. What provides the best framework for prioritizing patient problems?
A) Availability of hospital resources
B) Family member statements
C) Maslow’s hierarchy of needs
D) The nurse’s skill set
Ans: C
Feedback:
Maslow’s hierarchy of needs provides a useful framework for prioritizing problems, with the first level given to meeting physical needs of the patient. Availability of hospital resources, family member statements, and nursing skill do not provide a framework for prioritization of patient problems, though each may be considered.

 

 

15. A medical nurse is caring for a patient who is palliative following metastasis. The nurse is aware of the need to uphold the ethical principle of beneficence. How can the nurse best exemplify this principle in the care of this patient?
A) The nurse tactfully regulates the number and timing of visitors as per the patient’s wishes.
B) The nurse stays with the patient during his or her death.
C) The nurse ensures that all members of the care team are aware of the patient’s DNR order.
D) The nurse liaises with members of the care team to ensure continuity of care.
Ans: B
Feedback:
Beneficence is the duty to do good and the active promotion of benevolent acts. Enacting the patient’s wishes around visitors is an example of this. Each of the other nursing actions is consistent with ethical practice, but none directly exemplifies the principle of beneficence.

 

 

16. The care team has deemed the occasional use of restraints necessary in the care of a patient with Alzheimer’s disease. What ethical violation is most often posed when using restraints in a long-term care setting?
A) It limits the patient’s personal safety.
B) It exacerbates the patient’s disease process.
C) It threatens the patient’s autonomy.
D) It is not normally legal.
Ans: C
Feedback:
Because safety risks are involved when using restraints on elderly confused patients, this is a common ethical problem, especially in long-term care settings. By definition, restraints limit the individual’s autonomy. Restraints are not without risks, but they should not normally limit a patient’s safety. Restraints will not affect the course of the patient’s underlying disease process, though they may exacerbate confusion. The use of restraints is closely legislated, but they are not illegal.

 

 

17. While receiving report on a group of patients, the nurse learns that a patient with terminal cancer has granted power of attorney for health care to her brother. How does this affect the course of the patient’s care?
A) Another individual has been identified to make decisions on behalf of the patient.
B) There are binding parameters for care even if the patient changes her mind.
C) The named individual is in charge of the patient’s finances.
D) There is a document delegating custody of children to other than her spouse.
Ans: A
Feedback:
A power of attorney is said to be in effect when a patient has identified another individual to make decisions on her behalf. The patient has the right to change her mind. A power-of-attorney for health care does not give anyone the right to make financial decisions for the patient nor does it delegate custody of minor children.

 

 

18. In the process of planning a patient’s care, the nurse has identified a nursing diagnosis of Ineffective Health Maintenance related to alcohol use. What must precede the determination of this nursing diagnosis?
A) Establishment of a plan to address the underlying problem
B) Assigning a positive value to each consequence of the diagnosis
C) Collecting and analyzing data that corroborates the diagnosis
D) Evaluating the patient’s chances of recovery
Ans: C
Feedback:
In the diagnostic phase of the nursing process, the patient’s nursing problems are defined through analysis of patient data. Establishing a plan comes after collecting and analyzing data; evaluating a plan is the last step of the nursing process and assigning a positive value to each consequence is not done.

 

 

19. You are following the care plan that was created for a patient newly admitted to your unit. Which of the following aspects of the care plan would be considered a nursing implementation?
A) The patient will express an understanding of her diagnosis.
B) The patient appears diaphoretic.
C) The patient is at risk for aspiration.
D) Ambulate the patient twice per day with partial assistance.
Ans: D
Feedback:
Implementation refers to carrying out the plan of nursing care. The other listed options exemplify goals, assessment findings, and diagnoses.

 

 

20. The physician has recommended an amniocentesis for an 18-year-old primiparous woman. The patient is 34 weeks’ gestation and does not want this procedure. The physician is insistent the patient have the procedure. The physician arranges for the amniocentesis to be performed. The nurse should recognize that the physician is in violation of what ethical principle?
A) Veracity
B) Beneficence
C) Nonmaleficence
D) Autonomy
Ans: D
Feedback:
The principle of autonomy specifies that individuals have the ability to make a choice free from external constraints. The physician’s actions in this case violate this principle. This action may or may not violate the principle of beneficence. Veracity centers on truth-telling and nonmaleficence is avoiding the infliction of harm.

 

 

21. During discussion with the patient and the patient’s husband, you discover that the patient has a living will. How does the presence of a living will influence the patient’s care?
A) The patient is legally unable to refuse basic life support.
B) The physician can override the patient’s desires for treatment if desires are not evidence-based.
C) The patient may nullify the living will during her hospitalization if she chooses to do so.
D) Power-of-attorney may change while the patient is hospitalized.
Ans: C
Feedback:
Because living wills are often written when the person is in good health, it is not unusual for the patient to nullify the living will during illness. A living will does not make a patient legally unable to refuse basic life support. The physician may disagree with the patient’s wishes, but he or she is ethically bound to carry out those wishes. A power-of-attorney is not synonymous with a living will.

 

 

22. Your older adult patient has a diagnosis of rheumatoid arthritis (RA) and has been achieving only modest relief of her symptoms with the use of nonsteroidal anti-inflammatory drugs (NSAIDs). When creating this patient’s plan of care, which nursing diagnosis would most likely be appropriate?
A) Self-care deficit related to fatigue and joint stiffness
B) Ineffective airway clearance related to chronic pain
C) Risk for hopelessness related to body image disturbance
D) Anxiety related to chronic joint pain
Ans: A
Feedback:
Nursing diagnoses are actual or potential problems that can be managed by independent nursing actions. Self-care deficit would be the most likely consequence of rheumatoid arthritis. Anxiety and hopelessness are plausible consequences of a chronic illness such as RA, but challenges with self-care are more likely. Ineffective airway clearance is unlikely.

 

 

23. You are writing a care plan for an 85-year-old patient who has community-acquired pneumonia and you note decreased breath sounds to bilateral lung bases on auscultation. What is the most appropriate nursing diagnosis for this patient?
A) Ineffective airway clearance related to tracheobronchial secretions
B) Pneumonia related to progression of disease process
C) Poor ventilation related to acute lung infection
D) Immobility related to fatigue
Ans: A
Feedback:
Nursing diagnoses are not medical diagnoses or treatments. The most appropriate nursing diagnosis for this patient is “ineffective airway clearance related to copious tracheobronchial secretions.” “Pneumonia” and “poor ventilation” are not nursing diagnoses. Immobility is likely, but is less directly related to the patient’s admitting medical diagnosis and the nurse’s assessment finding.

 

 

24. You are providing care for a patient who has a diagnosis of pneumonia attributed to Streptococcus pneumonia infection. Which of the following aspects of nursing care would constitute part of the planning phase of the nursing process?
A) Achieve SaO2 ³ 92% at all times.
B) Auscultate chest q4h.
C) Administer oral fluids q1h and PRN.
D) Avoid overexertion at all times.
Ans: A
Feedback:
The planning phase entails specifying the immediate, intermediate, and long-term goals of nursing action, such as maintaining a certain level of oxygen saturation in a patient with pneumonia. Providing fluids and avoiding overexertion are parts of the implementation phase of the nursing process. Chest auscultation is an assessment.

 

 

25. You are the nurse who is caring for a patient with a newly diagnosed allergy to peanuts. Which of the following is an immediate goal that is most relevant to a nursing diagnosis of “deficient knowledge related to appropriate use of an EpiPen”?
A) The patient will demonstrate correct injection technique with today’s teaching session.
B) The patient will closely observe the nurse demonstrating the injection.
C) The nurse will teach the patient’s family member to administer the injection.
D) The patient will return to the clinic within 2 weeks to demonstrate the injection.
Ans: A
Feedback:
Immediate goals are those that can be reached in a short period of time. An appropriate immediate goal for this patient is that the patient will demonstrate correct administration of the medication today. The goal should specify that the patient administer the EpiPen. A 2-week time frame is inconsistent with an immediate goal.

 

 

26. A recent nursing graduate is aware of the differences between nursing actions that are independent and nursing actions that are interdependent. A nurse performs an interdependent nursing intervention when performing which of the following actions?
A) Auscultating a patient’s apical heart rate during an admission assessment
B) Providing mouth care to a patient who is unconscious following a cerebrovascular accident
C) Administering an IV bolus of normal saline to a patient with hypotension
D) Providing discharge teaching to a postsurgical patient about the rationale for a course of oral antibiotics
Ans: C
Feedback:
Although many nursing actions are independent, others are interdependent, such as carrying out prescribed treatments, administering medications and therapies, and collaborating with other health care team members to accomplish specific, expected outcomes and to monitor and manage potential complications. Irrigating a wound, administering pain medication, and administering IV fluids are interdependent nursing actions and require a physician’s order. An independent nursing action occurs when the nurse assesses a patient’s heart rate, provides discharge education, or provides mouth care.

 

 

27. A nurse has been using the nursing process as a framework for planning and providing patient care. What action would the nurse do during the evaluation phase of the nursing process?
A) Have a patient provide input on the quality of care received.
B) Remove a patient’s surgical staples on the scheduled postoperative day.
C) Provide information on a follow-up appointment for a postoperative patient.
D) Document a patient’s improved air entry with incentive spirometric use.
Ans: D
Feedback:
During the evaluation phase of the nursing process, the nurse determines the patient’s response to nursing interventions. An example of this is when the nurse documents whether the patient’s spirometry use has improved his or her condition. A patient does not do the evaluation. Removing staples and providing information on follow-up appointments are interventions, not evaluations.

 

 

28. An audit of a large, university medical center reveals that four patients in the hospital have current orders for restraints. You know that restraints are an intervention of last resort, and that it is inappropriate to apply restraints to which of the following patients?
A) A postlaryngectomy patient who is attempting to pull out his tracheostomy tube
B) A patient in hypovolemic shock trying to remove the dressing over his central venous catheter
C) A patient with urosepsis who is ringing the call bell incessantly to use the bedside commode
D) A patient with depression who has just tried to commit suicide and whose medications are not achieving adequate symptom control
Ans: C
Feedback:
Restraints should never be applied for staff convenience. The patient with urosepsis who is frequently ringing the call bell is requesting assistance to the bedside commode; this is appropriate behavior that will not result in patient harm. The other described situations could plausibly result in patient harm; therefore, it is more likely appropriate to apply restraints in these instances.

 

 

29. A patient has been diagnosed with small-cell lung cancer. He has met with the oncologist and is now weighing the relative risks and benefits of chemotherapy and radiotherapy as his treatment. This patient is demonstrating which ethical principle in making his decision?
A) Beneficence
B) Confidentiality
C) Autonomy
D) Justice
Ans: C
Feedback:
Autonomy entails the ability to make a choice free from external constraints. Beneficence is the duty to do good and the active promotion of benevolent acts. Confidentiality relates to the concept of privacy. Justice states that cases should be treated equitably.

 

 

30. A patient with migraines does not know whether she is receiving a placebo for pain management or the new drug that is undergoing clinical trials. Upon discussing the patient’s distress, it becomes evident to the nurse that the patient did not fully understand the informed consent document that she signed. Which ethical principle is most likely involved in this situation?
A) Sanctity of life
B) Confidentiality
C) Veracity
D) Fidelity
Ans: C
Feedback:
Telling the truth (veracity) is one of the basic principles of our culture. Three ethical dilemmas in clinical practice that can directly conflict with this principle are the use of placebos (nonactive substances used for treatment), not revealing a diagnosis to a patient, and revealing a diagnosis to persons other than the patient with the diagnosis. All involve the issue of trust, which is an essential element in the nurse–patient relationship. Sanctity of life is the perspective that life is the highest good. Confidentiality deals with privacy of the patient. Fidelity is promise-keeping and the duty to be faithful to one’s commitments.

 

 

31. The nursing instructor is explaining critical thinking to a class of first-semester nursing students. When promoting critical thinking skills in these students, the instructor should encourage them to do which of the following actions?
A) Disregard input from people who do not have to make the particular decision.
B) Set aside all prejudices and personal experiences when making decisions.
C) Weigh each of the potential negative outcomes in a situation.
D) Examine and analyze all available information.
Ans: D
Feedback:
Critical thinking involves reasoning and purposeful, systematic, reflective, rational, outcome-directed thinking based on a body of knowledge, as well as examination and analysis of all available information and ideas. A full disregard of one’s own experiences is not possible. Critical thinking does not denote a focus on potential negative outcomes. Input from others is a valuable resource that should not be ignored.

 

 

32. A care conference has been organized for a patient with complex medical and psychosocial needs. When applying the principles of critical thinking to this patient’s care planning, the nurse should most exemplify what characteristic?
A) Willingness to observe behaviors
B) A desire to utilize the nursing scope of practice fully
C) An ability to base decisions on what has happened in the past
D) Openness to various viewpoints
Ans: D
Feedback:
Willingness and openness to various viewpoints are inherent in critical thinking; these allow the nurse to reflect on the current situation. An emphasis on the past, willingness to observe behaviors, and a desire to utilize the nursing scope of practice fully are not central characteristics of critical thinkers.

 

 

33. Achieving adequate pain management for a postoperative patient will require sophisticated critical thinking skills by the nurse. What are the potential benefits of critical thinking in nursing? Select all that apply.
A) Enhancing the nurse’s clinical decision making
B) Identifying the patient’s individual preferences
C) Planning the best nursing actions to assist the patient
D) Increasing the accuracy of the nurse’s judgments
E) Helping identify the patient’s priority needs
Ans: A, C, D, E
Feedback:
Independent judgments and decisions evolve from a sound knowledge base and the ability to synthesize information within the context in which it is presented. Critical thinking enhances clinical decision making, helping to identify patient needs and the best nursing actions that will assist patients in meeting those needs. Critical thinking does not normally focus on identify patient desires; these would be identified by asking the patient.

 

 

34. A nurse is unsure how best to respond to a patient’s vague complaint of “feeling off.” The nurse is attempting to apply the principles of critical thinking, including metacognition. How can the nurse best foster metacognition?
A) By eliciting input from a variety of trusted colleagues
B) By examining the way that she thinks and applies reason
C) By evaluating her responses to similar situations in the past
D) By thinking about the way that an “ideal” nurse would respond in this situation
Ans: B
Feedback:
Critical thinking includes metacognition, the examination of one’s own reasoning or thought processes, to help refine thinking skills. Metacognition is not characterized by eliciting input from others or evaluating previous responses.

 

 

35. The nursing instructor cites a list of skills that support critical thinking in clinical situations. The nurse should describe skills in which of the following domains? Select all that apply.
A) Self-esteem
B) Self-regulation
C) Inference
D) Autonomy
E) Interpretation
Ans: B, C, E
Feedback:
Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Self-esteem and autonomy would not be on the list because they are not skills.

 

 

36. The nurse is providing care for a patient with chronic obstructive pulmonary disease (COPD). The nurse’s most recent assessment reveals an SaO2 of 89%. The nurse is aware that part of critical thinking is determining the significance of data that have been gathered. What characteristic of critical thinking is used in determining the best response to this assessment finding?
A) Extrapolation
B) Inference
C) Characterization
D) Interpretation
Ans: D
Feedback:
Nurses use interpretation to determine the significance of data that are gathered. This specific process is not described as extrapolation, inference, or characterization.

 

 

37. A nurse is admitting a new patient to the medical unit. During the initial nursing assessment, the nurse has asked many supplementary open-ended questions while gathering information about the new patient. What is the nurse achieving through this approach?
A) Interpreting what the patient has said
B) Evaluating what the patient has said
C) Assessing what the patient has said
D) Validating what the patient has said
Ans: D
Feedback:
Critical thinkers validate the information presented to make sure that it is accurate (not just supposition or opinion), that it makes sense, and that it is based on fact and evidence. The nurse is not interpreting, evaluating, or assessing the information the patient has given.

 

 

38. A nurse uses critical thinking every day when going through the nursing process. Which of the following is an outcome of critical thinking in nursing practice?
A) A comprehensive plan of care with a high potential for success
B) Identification of the nurse’s preferred goals for the patient
C) A collaborative basis for assigning care
D) Increased cost efficiency in health care
Ans: A
Feedback:
Critical thinking in nursing practice results in a comprehensive plan of care with maximized potential for success. Critical thinking does not identify the nurse’s goal for the patient or provide a collaborative basis for assigning care. Critical thinking may or may not lead to increased cost efficiency; the patient’s outcomes are paramount.

 

 

39. A nurse provides care on an orthopedic reconstruction unit and is admitting two new patients, both status post knee replacement. What would be the best explanation why their care plans may be different from each other?
A) Patients may have different insurers, or one may qualify for Medicare.
B) Individual patients are seen as unique and dynamic, with individual needs.
C) Nursing care may be coordinated by members of two different health disciplines.
D) Patients are viewed as dissimilar according to their attitude toward surgery.
Ans: B
Feedback:
Regardless of the setting, each patient situation is viewed as unique and dynamic. Differences in insurance coverage and attitude may be relevant, but these should not fundamentally explain the differences in their nursing care. Nursing care should be planned by nurses, not by members of other disciplines.

 

 

40. A class of nursing students is in their first semester of nursing school. The instructor explains that one of the changes they will undergo while in nursing school is learning to “think like a nurse.” What is the most current model of this thinking process?
A) Critical-thinking Model
B) Nursing Process Model
C) Clinical Judgment Model
D) Active Practice Model
Ans: C
Feedback:
To depict the process of “thinking like a nurse,” Tanner (2006) developed a model known as the clinical judgment model.

 

 

41. Critical thinking and decision-making skills are essential parts of nursing in all venues. What are examples of the use of critical thinking in the venue of genetics-related nursing? Select all that apply.
A) Notifying individuals and family members of the results of genetic testing
B) Providing a written report on genetic testing to an insurance company
C) Assessing and analyzing family history data for genetic risk factors
D) Identifying individuals and families in need of referral for genetic testing
E) Ensuring privacy and confidentiality of genetic information
Ans: C, D, E
Feedback:
Nurses use critical thinking and decision-making skills in providing genetics-related nursing care when they assess and analyze family history data for genetic risk factors, identify those individuals and families in need of referral for genetic testing or counseling, and ensure the privacy and confidentiality of genetic information. Nurses who work in the venue of genetics-related nursing do not notify family members of the results of an individual’s genetic testing, and they do not provide written reports to insurance companies concerning the results of genetic testing.

 

 

42. A student nurse has been assigned to provide basic care for a 58-year-old man with a diagnosis of AIDS-related pneumonia. The student tells the instructor that she is unwilling to care for this patient. What key component of critical thinking is most likely missing from this student’s practice?
A) Compliance with direction
B) Respect for authority
C) Analyzing information and situations
D) Withholding judgment
Ans: D
Feedback:
Key components of critical thinking behavior are withholding judgment and being open to options and explanations from one patient to another in similar circumstances. The other listed options are incorrect because they are not components of critical thinking.

 

 

43. A group of students have been challenged to prioritize ethical practice when working with a marginalized population. How should the students best understand the concept of ethics?
A) The formal, systematic study of moral beliefs
B) The informal study of patterns of ideal behavior
C) The adherence to culturally rooted, behavioral norms
D) The adherence to informal personal values
Ans: A
Feedback:
In essence, ethics is the formal, systematic study of moral beliefs, whereas morality is the adherence to informal personal values.

 

 

44. Your patient has been admitted for a liver biopsy because the physician believes the patient may have liver cancer. The family has told both you and the physician that if the patient is terminal, the family does not want the patient to know. The biopsy results are positive for an aggressive form of liver cancer and the patient asks you repeatedly what the results of the biopsy show. What strategy can you use to give ethical care to this patient?
A) Obtain the results of the biopsy and provide them to the patient.
B) Tell the patient that only the physician knows the results of the biopsy.
C) Promptly communicate the patient’s request for information to the family and the physician.
D) Tell the patient that the biopsy results are not back yet in order  temporarily to appease him.
Ans: C
Feedback:
Strategies nurses could consider include the following: not lying to the patient, providing all information related to nursing procedures and diagnoses, and communicating the patient’s requests for information to the family and physician. Ethically, you cannot tell the patient the results of the biopsy and you cannot lie to the patient.

 

 

45. The nurse admits a patient to an oncology unit that is a site for a study on the efficacy of a new chemotherapeutic drug. The patient knows that placebos are going to be used for some participants in the study but does not know that he is receiving a placebo. When is it ethically acceptable to use placebos?
A) Whenever the potential benefits of a study are applicable to the larger population
B) When the patient is unaware of it and it is deemed unlikely that it would cause harm
C) Whenever the placebo replaces an active drug
D) When the patient knows placebos are being used and is involved in the decision-making process
Ans: D
Feedback:
Placebos may be used in experimental research in which a patient is involved in the decision-making process and is aware that placebos are being used in the treatment regimen. Placebos may not ethically be used solely when there is a potential benefit, when the patient is unaware, or when a placebo replaces an active drug.

 

 

46. The nurse caring for a patient who is two days post hip replacement notifies the physician that the patient’s incision is red around the edges, warm to the touch, and seeping a white liquid with a foul odor. What type of problem is the nurse dealing with?
A) Collaborative problem
B) Nursing problem
C) Medical problem
D) Administrative problem
Ans: A
Feedback:
In addition to nursing diagnoses and their related nursing interventions, nursing practice involves certain situations and interventions that do not fall within the definition of nursing diagnoses. These activities pertain to potential problems or complications that are medical in origin and require collaborative interventions with the physician and other members of the health care team. The other answers are incorrect because the signs and symptoms of infection are a medical complication that requires interventions by the nurse.

 

 

47. While developing the plan of care for a new patient on the unit, the nurse must identify expected outcomes that are appropriate for the new patient. What resource should the nurse prioritize for identifying these appropriate outcomes?
A) Community Specific Outcomes Classification (CSO)
B) Nursing-Sensitive Outcomes Classification (NOC)
C) State Specific Nursing Outcomes Classification (SSNOC)
D) Department of Health and Human Services Outcomes Classification (DHHSOC)
Ans: B
Feedback:
Resources for identifying appropriate expected outcomes include the NOC and standard outcome criteria established by health care agencies for people with specific health problems. The other options are incorrect because they do not exist.

 

 

48. The nurse has just taken report on a newly admitted patient who is a 15-year-old girl who is a recent immigrant to the United States. When planning interventions for this patient, the nurse knows the interventions must be which of the following? Select all that apply.
A) Appropriate to the nurse’s preferences
B) Appropriate to the patient’s age
C) Ethical
D) Appropriate to the patient’s culture
E) Applicable to others with the same diagnosis
Ans: B, C, D
Feedback:
Planned interventions should be ethical and appropriate to the patient’s culture, age, and gender. Planned interventions do not have to be in alignment with the nurse’s preferences nor do they have to be shared by everyone with the same diagnosis.

 

1. You are providing care for an 82-year-old man whose signs and symptoms of Parkinson disease have become more severe over the past several months. The man tells you that he can no longer do as many things for himself as he used to be able to do. What factor should you recognize as impacting your patient’s life most significantly?
A) Neurologic deficits
B) Loss of independence
C) Age-related changes
D) Tremors and decreased mobility
Ans: B
Feedback:
This patient’s statement places a priority on his loss of independence. This is undoubtedly a result of the neurologic changes associated with his disease, but this is not the focus of his statement. This is a disease process, not an age-related physiological change.

 

 

2. A gerontologic nurse practitioner provides primary care for a large number of older adults who are living with various forms of cardiovascular disease. This nurse is well aware that heart disease is the leading cause of death in the aged. What is an age-related physiological change that contributes to this trend?
A) Heart muscle and arteries lose their elasticity.
B) Systolic blood pressure decreases.
C) Resting heart rate decreases with age.
D) Atrial-septal defects develop with age.
Ans: A
Feedback:
The leading cause of death for patients over the age of 65 years is cardiovascular disease. With age, heart muscle and arteries lose their elasticity, resulting in a reduced stroke volume. As a person ages, systolic blood pressure does not decrease, resting heart rate does not decrease, and the aged are not less likely to adopt a healthy lifestyle.

 

 

3. An occupational health nurse overhears an employee talking to his manager about a 65-year-old coworker. What phenomenon would the nurse identify when hearing the employee state, “He should just retire and make way for some new blood.”?
A) Intolerance
B) Ageism
C) Dependence
D) Nonspecific prejudice
Ans: B
Feedback:
Ageism refers to prejudice against the aged. Intolerance is implied by the employee’s statement, but the intolerance is aimed at the coworker’s age. The employee’s statement does not raise concern about dependence. The prejudice exhibited in the statement is very specific.

 

 

4. The nurse is caring for a 65-year-old patient who has previously been diagnosed with hypertension. Which of the following blood pressure readings represents the threshold between high-normal blood pressure and hypertension?
A) 140/90 mm Hg
B) 145/95 mm Hg
C) 150/100 mm Hg
D) 160/100 mm Hg
Ans: A
Feedback:
Hypertension is the diagnosis given when the blood pressure is greater than 140/90 mm Hg. This makes the other options incorrect.

 

 

5. You are the nurse caring for an 85-year-old patient who has been hospitalized for a fractured radius. The patient’s daughter has accompanied the patient to the hospital and asks you what her father can do for his very dry skin, which has become susceptible to cracking and shearing. What would be your best response?
A) “He should likely take showers rather than baths, if possible.”
B) “Make sure that he applies sunscreen each morning.”
C) “Dry skin is an age-related change that is largely inevitable.”
D) “Try to help your father increase his intake of dairy products.”
Ans: A
Feedback:
Showers are less drying than hot tub baths. Sun exposure should indeed be limited, but daily application of sunscreen is not necessary for many patients. Dry skin is an age-related change, but this does not mean that no appropriate interventions exist to address it. Dairy intake is unrelated.

 

 

6. An elderly patient has come in to the clinic for her twice-yearly physical. The patient tells the nurse that she is generally enjoying good health, but that she has been having occasional episodes of constipation over the past 6 months. What intervention should the nurse first suggest?
A) Reduce the amount of stress she currently experiences.
B) Increase carbohydrate intake and reduce protein intake.
C) Take herbal laxatives, such as senna, each night at bedtime.
D) Increase daily intake of water.
Ans: D
Feedback:
Constipation is a common problem in older adults and increasing fluid intake is an appropriate early intervention. This should likely be attempted prior to recommending senna or other laxatives. Stress reduction is unlikely to wholly resolve the problem and there is no need to increase carbohydrate intake and reduce protein intake.

 

 

7. An 84-year-old patient has returned from the post-anesthetic care unit (PACU) following hip arthroplasty. The patient is oriented to name only. The patient’s family is very upset because, before having surgery, the patient had no cognitive deficits. The patient is subsequently diagnosed with postoperative delirium. What should the nurse explain to the patient’s family?
A) This problem is self-limiting and there is nothing to worry about.
B) Delirium involves a progressive decline in memory loss and overall cognitive function.
C) Delirium of this type is treatable and her cognition will return to previous levels.
D) This problem can be resolved by administering antidotes to the anesthetic that was used in surgery.
Ans: C
Feedback:
Surgery is a common cause of delirium in older adults. Delirium differs from other types of dementia in that delirium begins with confusion and progresses to disorientation. It has symptoms that are reversible with treatment, and, with treatment, is short term in nature. It is patronizing and inaccurate to reassure the family that there is “nothing to worry about.” The problem is not treated by the administration of antidotes to anesthetic.

 

 

8. The nurse is providing patient teaching to a patient with early stage Alzheimer’s disease (AD) and her family. The patient has been prescribed donepezil hydrochloride (Aricept). What should the nurse explain to the patient and family about this drug?
A) It slows the progression of AD.
B) It cures AD in a small minority of patients.
C) It removes the patient’s insight that he or she has AD.
D) It limits the physical effects of AD and other dementias.
Ans: A
Feedback:
There is no cure for AD, but several medications have been introduced to slow the progression of the disease, including donepezil hydrochloride (Aricept). These medications do not remove the patient’s insight or address physical symptoms of AD.

 

 

9. A nurse is caring for an 86-year-old female patient who has become increasingly frail and unsteady on her feet. During the assessment, the patient indicates that she has fallen three times in the month, though she has not yet suffered an injury. The nurse should take action in the knowledge that this patient is at a high risk for what health problem?
A) A hip fracture
B) A femoral fracture
C) Pelvic dysplasia
D) Tearing of a meniscus or bursa
Ans: A
Feedback:
The most common fracture resulting from a fall is a fractured hip resulting from osteoporosis and the condition or situation that produced the fall. The other listed injuries are possible, but less likely than a hip fracture.

 

 

10. The case manager is working with an 84-year-old patient newly admitted to a rehabilitation facility. When developing a care plan for this older adult, which factors should the nurse identify as positive attributes that benefit coping in this age group? Select all that apply.
A) Decreased risk taking
B) Effective adaptation skills
C) Avoiding participation in untested roles
D) Increased life experience
E) Resiliency during change
Ans: B, D, E
Feedback:
Because changes in life patterns are inevitable over a lifetime, older people need resiliency and coping skills when confronting stresses and change. It is beneficial if older adults continue to participate in risk taking and participation in new, untested roles.

 

 

11. A nurse will conduct an influenza vaccination campaign at an extended care facility. The nurse will be administering intramuscular (IM) doses of the vaccine. Of what age-related change should the nurse be aware when planning the appropriate administration of this drug?
A) An older patient has less subcutaneous tissue and less muscle mass than a younger patient.
B) An older patient has more subcutaneous tissue and less durable skin than a younger patient.
C) An older patient has more superficial and tortuous nerve distribution than a younger patient.
D) An older patient has a higher risk of bleeding after an IM injection than a younger patient.
Ans: A
Feedback:
When administering IM injections, the nurse should remember that in an older patient, subcutaneous fat diminishes, particularly in the extremities. Muscle mass also decreases. There are no significant differences in nerve distribution or bleeding risk.

 

 

12. An elderly patient, while being seen in an urgent care facility for a possible respiratory infection, asks the nurse if Medicare is going to cover the cost of the visit. What information can the nurse give the patient to help allay her concerns?
A) Medicare has a copayment for many of the services it covers. This requires the patient to pay a part of the bill.
B) Medicare pays for 100% of the cost for acute-care services, so the cost of the visit will be covered.
C) Medicare will only pay the cost for acute-care services if the patient has a very low income.
D) Medicare will not pay for the cost of acute-care services so the patient will be billed for the services provided.
Ans: A
Feedback:
The two major programs that finance health in the United States are Medicare and Medicaid, both of which are overseen by the Centers for Medicaid and Medicare Services (CMS). Both programs cover acute-care needs such as inpatient hospitalization, physician care, outpatient care, home health services, and skilled nursing care in a nursing. Medicare is a plan specifically for the elderly population, and Medicaid is a program that provides services based on income.

 

 

13. The admissions department at a local hospital is registering an elderly man for an outpatient diagnostic test. The admissions nurse asks the man if he has an advanced directive. The man responds that he does not want to complete an advance directive because he does not want anyone controlling his finances. What would be appropriate information for the nurse to share with this patient?
A) “Advance directives are not legal documents, so you have nothing to worry about.”
B) “Advance directives are limited only to health care instructions and directives.”
C) “Your finances cannot be managed without an advance directive.”
D) “Advance directives are implemented when you become incapacitated, and then you will use a living will to allow the state to manage your money.”
Ans: B
Feedback:
An advance directive is a formal, legally endorsed document that provides instructions for care (living will) or names a proxy decision maker (durable power of attorney for health care) and covers only issues related specifically to health care, not financial issues. They do not address financial issues. Advance directives are implemented when a patient becomes incapacitated, but financial issues are addressed with a durable power of attorney for finances, or financial power of attorney.

 

 

14. A nurse is planning discharge teaching for an 80-year-old patient with mild short-term memory loss. The discharge teaching will include how to perform basic wound care for the venous ulcer on his lower leg. When planning the necessary health education for this patient, what should the nurse plan to do?
A) Set long-term goals with the patient.
B) Provide a list of useful Web sites to supplement learning.
C) Keep visual cues to a minimum to enhance the patient’s focus.
D) Keep teaching periods short.
Ans: D
Feedback:
To assist the elderly patient with short-term memory loss, the nurse should keep teaching periods short, provide glare-free lighting, link new information with familiar information, use visual and auditory cues, and set short-term goals with the patient. The patient may or may not be open to the use of online resources.

 

 

15. You are the nurse planning an educational event for the nurses on a subacute medical unit on the topic of normal, age-related physiological changes. What phenomenon would you include in your teaching plan?
A) A decrease in cognition, judgment, and memory
B) A decrease in muscle mass and bone density
C) The disappearance of sexual desire for both men and women
D) An increase in sebaceous and sweat gland function in both men and women
Ans: B
Feedback:
Normal signs of aging include a decrease in the sense of smell, a decrease in muscle mass, a decline but not disappearance of sexual desire, and decreased sebaceous and sweat glands for both men and women. Cognitive changes are usually attributable to pathologic processes, not healthy aging.

 

 

16. A home health nurse makes a home visit to a 90-year-old patient who has cardiovascular disease. During the visit the nurse observes that the patient has begun exhibiting subtle and unprecedented signs of confusion and agitation. What should the home health nurse do?
A) Increase the frequency of the patient’s home care.
B) Have a family member check in on the patient in the evening.
C) Arrange for the patient to see his primary care physician.
D) Refer the patient to an adult day program.
Ans: C
Feedback:
In more than half of the cases, sudden confusion and hallucinations are evident in multi-infarct dementia. This condition is also associated with cardiovascular disease. Having the patient’s home care increased does not address the problem, neither does having a family member check on the patient in the evening. Referring the patient to an adult day program may be beneficial to the patient, but it does not address the acute problem the patient is having, the nurse should arrange for the patient to see his primary care physician.

 

 

17. The home health nurse is making an initial home visit to a 76-year-old widower. The patient takes multiple medications for the treatment of varied chronic health problems. The patient states that he has also begun taking some herbal remedies. What should the nurse be sure to include in the patient’s teaching?
A) Herbal remedies are consistent with holistic health care.
B) Herbal remedies are often cheaper than prescribed medication.
C) It is safest to avoid the use of herbal remedies.
D) There is a need to inform his physician and pharmacist about the herbal remedies.
Ans: D
Feedback:
Herbal remedies combined with prescribed medications can lead to interactions that may be toxic. Patients should notify the physician and pharmacist of any herbal remedies they are using. Even though herbal remedies are considered holistic, this is not something that is necessary to include in the patient’s teaching. Herbal remedies may be cheaper than prescribed medicine, but this is still not something that is necessary to include in the patient’s teaching. For most people, it is not necessary to wholly avoid herbal remedies.

 

 

18. You are the nurse caring for an elderly patient who is being treated for community-acquired pneumonia. Since the time of admission, the patient has been disoriented and agitated to varying degrees. Appropriate referrals were made and the patient was subsequently diagnosed with dementia. What nursing diagnosis should the nurse prioritize when planning this patient’s care?
A) Social isolation related to dementia
B) Hopelessness related to dementia
C) Risk for infection related to dementia
D) Acute confusion related to dementia
Ans: D
Feedback:
Acute confusion is a priority problem in patients with dementia, and it is an immediate threat to their health and safety. Hopelessness and social isolation are plausible problems, but the patient’s cognition is a priority. The patient’s risk for infection is not directly influenced by dementia.

 

 

19. You are caring for a patient with late-stage Alzheimer’s disease. The patient’s wife tells you that the patient has now become completely dependent and that she feels guilty if she takes any time for herself. What outcomes would be appropriate for the nurse to develop to assist the patient’s wife?
A) The caregiver learns to explain to the patient why she needs time for herself.
B) The caregiver distinguishes essential obligations from those that can be controlled or limited.
C) The caregiver leaves the patient at home alone for short periods of time to encourage independence.
D) The caregiver prioritizes her own health over that of the patient.
Ans: B
Feedback:
For prolonged periods, it is not uncommon for caregivers to neglect their own emotional and health needs. The caregiver must learn to distinguish obligations that she must fulfill and limit those that are not completely necessary. The caregiver can tell the patient when she leaves, but she should not expect that the patient will remember or will not become angry with her for leaving. The caregiver should not leave the patient home alone for any length of time because it may compromise the patient’s safety. Being thoughtful and selective with her time and energy is not synonymous with prioritizing her own health over than of the patient; it is more indicative of balance and sustainability.

 

 

20. A 47-year-old patient who has come to the physician’s office for his annual physical is being assessed by the office nurse. The nurse who is performing routine health screening for this patient should be aware that one of the first physical signs of aging is what?
A) Having more frequent aches and pains
B) Failing eyesight, especially close vision
C) Increasing loss of muscle tone
D) Accepting limitations while developing assets
Ans: B
Feedback:
Failing eyesight, especially close vision, is one of the first signs of aging in middle life. More frequent aches and pains begin in the “early” late years (between ages 65 and 79). Increase in loss of muscle tone occurs in later years (ages 80 and older). Accepting limitations while developing assets is socialization development that occurs in adulthood.

 

 

21. A gerontologic nurse is aware of the demographic changes that are occurring in the United States, and this affects the way that the nurse plans and provides care. Which of the following phenomena is currently undergoing the most rapid and profound change?
A) More families are having to provide care for their aging members.
B) Adult children find themselves participating in chronic disease management.
C) A growing number of people live to a very old age.
D) Elderly people are having more accidents, increasing the costs of health care.
Ans: C
Feedback:
As the older population increases, the number of people who live to a very old age is dramatically increasing. The other options are all correct, but none is a factor that is most dramatically increasing in this age group.

 

 

22. As the population of the United States ages, research has shown that this aging will occur across all racial and ethnic groups. A community health nurse is planning an initiative that will focus on the group in which the aging population is expected to rise the fastest. What group should the nurse identify?
A) Asian-Americans
B) White non-Hispanics
C) Hispanics
D) African-Americans
Ans: C
Feedback:
Although the older population will increase in number for all racial and ethnic groups, the rate of growth is projected to be fastest in the Hispanic population that is expected to increase from 6 million in 2004 to an estimated 17.5 million by 2050.

 

 

23. An 83-year-old woman was diagnosed with Alzheimer’s disease 2 years ago and the disease has progressed at an increasing pace in recent months. The patient has lost 16 pounds over the past 3 months, leading to a nursing diagnosis of Imbalanced Nutrition: Less than Body Requirements. What intervention should the nurse include in this patient’s plan of care?
A) Offer the patient rewards for finishing all the food on her tray.
B) Offer the patient bland, low-salt foods to limit offensiveness.
C) Offer the patient only one food item at a time to promote focused eating.
D) Arrange for insertion of a gastrostomy tube and initiate enteral feeding.
Ans: C
Feedback:
To avoid any “playing” with food, one dish should be offered at a time. Foods should be familiar and appealing, not bland. Tube feeding is not likely necessary at this time and a reward system is unlikely to be beneficial.

 

 

24. A gerontologic nurse is making an effort to address some of the misconceptions about older adults that exist among health care providers. The nurse has made the point that most people aged 75 years remains functionally independent. The nurse should attribute this trend to what factor?
A) Early detection of disease and increased advocacy by older adults
B) Application of health-promotion and disease-prevention activities
C) Changes in the medical treatment of hypertension and hyperlipidemia
D) Genetic changes that have resulted in increased resiliency to acute infection
Ans: B
Feedback:
Even among people 75 years of age and over, most remain functionally independent, and the proportion of older Americans with limitations in activities is declining. These declines in limitations reflect recent trends in health-promotion and disease-prevention activities, such as improved nutrition, decreased smoking, increased exercise, and early detection and treatment of risk factors such as hypertension and elevated serum cholesterol levels. This phenomenon is not attributed to genetics, medical treatment, or increased advocacy.

 

 

25. After a sudden decline in cognition, a 77-year-old man who has been diagnosed with vascular dementia is receiving care in his home. To reduce this man’s risk of future infarcts, what action should the nurse most strongly encourage?
A) Activity limitation and falls reduction efforts
B) Adequate nutrition and fluid intake
C) Rigorous control of the patient’s blood pressure and serum lipid levels
D) Use of mobility aids to promote independence
Ans: C
Feedback:
Because vascular dementia is associated with hypertension and cardiovascular disease, risk factors (e.g., hypercholesterolemia, history of smoking, diabetes) are similar. Prevention and management are also similar. Therefore, measures to decrease blood pressure and lower cholesterol levels may prevent future infarcts. Activity limitation is unnecessary and infarcts are not prevented by nutrition or the use of mobility aids.

 

 

26. Nurses and members of other health disciplines at a state’s public health division are planning programs for the next 5 years. The group has made the decision to focus on diseases that are experiencing the sharpest increases in their contributions to the overall death rate in the state. This team should plan health promotion and disease prevention activities to address what health problem?
A) Stroke
B) Cancer
C) Respiratory infections
D) Alzheimer’s disease
Ans: D
Feedback:
In the past 60 years, overall deaths, and specifically, deaths from heart disease, have declined.  Recently, deaths from cancer and cerebrovascular disease have declined. However, deaths from Alzheimer’s disease have risen more than 50% between 1999 and 2007.

 

 

27. Mrs. Harris is an 83-year-old woman who has returned to the community following knee replacement surgery. The community health nurse recognizes that Mrs. Harris has prescriptions for nine different medications for the treatment of varied health problems. In addition, she has experienced occasional episodes of dizziness and lightheadedness since her discharge. The nurse should identify which of the following nursing diagnoses?
A) Risk for infection related to polypharmacy and hypotension
B) Risk for falls related to polypharmacy and impaired balance
C) Adult failure to thrive related to chronic disease and circulatory disturbance
D) Disturbed thought processes related to adverse drug effects and hypotension
Ans: B
Feedback:
Polypharmacy and loss of balance are major contributors to falls in the elderly. This patient does not exhibit failure to thrive or disturbed thought processes. There is no evidence of a heightened risk of infection.

 

 

28. A gerontologic nurse has been working hard to change the perceptions of the elderly, many of which are negative, by other segments of the population. What negative perceptions of older people have been identified in the literature?  Select all that apply.
A) As being the cause of social problems
B) As not contributing to society
C) As draining economic resources
D) As competing with children for resources
E) As dominating health care research
Ans: B, C, D
Feedback:
Retirement and perceived nonproductivity are responsible for negative feelings because a younger working person may falsely see older people as not contributing to society and as draining economic resources. Younger working people may actually feel that older people are in competition with children for resources. However, the older population is generally not seen as dominating health care research or causing social problems.

 

 

29. You are caring for an 82-year-old man who was recently admitted to the geriatric medical unit in which you work. Since admission, he has spoken frequently of becoming a burden to his children and “staying afloat” financially. When planning this patient’s care, you should recognize his heightened risk of what nursing diagnosis?
A) Disturbed thought processes
B) Impaired social interaction
C) Decisional conflict
D) Anxiety
Ans: D
Feedback:
Economic concerns and fear of becoming a burden to families often lead to high anxiety in older people. There is no clear indication that the patient has disturbed thought processes, impaired social interaction, or decisional conflict.

 

 

30. For several years, a community health nurse has been working with a 78-year-old man who requires a wheelchair for mobility. The nurse is aware that the interactions between disabilities and aging are not yet clearly understood. This interaction varies, depending on what variable?
A) Socioeconomics
B) Ethnicity
C) Education
D) Pharmacotherapy
Ans: A
Feedback:
Large gaps exist in our understanding of the interaction between disabilities and aging, including how this interaction varies, depending on the type and degree of disability, and other factors such as socioeconomics and gender. Ethnicity, education, and pharmacotherapy are not identified as salient influences on this interaction.

 

 

31. Gerontologic nursing is a specialty area of nursing that provides care for the elderly in our population. What goal of care should a gerontologic nurse prioritize when working with this population?
A) Helping older adults determine how to reduce their use of external resources
B) Helping older adults use their strengths to optimize independence
C) Helping older adults promote social integration
D) Helping older adults identify the weaknesses that most limit them
Ans: B
Feedback:
Gerontologic nursing is provided in acute care, skilled and assisted living, community, and home settings. The goals of care include promoting and maintaining functional status and helping older adults identify and use their strengths to achieve optimal independence. Goals of gerontologic nursing do not include helping older adults “promote social integration” or identify their weaknesses. Optimal independence does not necessarily involve reducing the use of available resources.

 

 

32. The presence of a gerontologic advanced practice nurse in a long-term care facility has proved beneficial to both the patients and the larger community in which they live. Nurses in this advanced practice role have been shown to cause what outcome?
A) Greater interaction between younger adults and older adults occurs.
B) The elderly recover more quickly from acute illnesses.
C) Less deterioration takes place in the overall health of patients.
D) The elderly are happier in long-term care facilities than at home.
Ans: C
Feedback:
The use of advanced practice nurses who have been educated in geriatric nursing concepts has proved to be very effective when dealing with the complex care needs of an older patient. When best practices are used and current scientific knowledge applied to clinical problems, significantly less deterioration occurs in the overall health of aging patients. This does not necessarily mean that patients are happier in long-term care than at home, that they recover more quickly from acute illnesses, or greater interaction occurs between younger and older adults.

 

 

33. A gerontologic nurse is basing the therapeutic programs at a long-term care facility on Miller’s Functional Consequences Theory. To actualize this theory of aging, the nurse should prioritize what task?
A) Attempting to control age-related physiological changes
B) Lowering expectations for recovery from acute and chronic illnesses
C) Helping older adults accept the inevitability of death
D) Differentiating between age-related changes and modifiable risk factors
Ans: D
Feedback:
The Functional Consequences Theory requires the nurse to differentiate between normal, irreversible age-related changes and modifiable risk factors. This theory does not emphasize lowering expectations, controlling age-related changes, or helping adults accept the inevitability of death.

 

 

34. Based on a patient’s vague explanations for recurring injuries, the nurse suspects that a community-dwelling older adult may be the victim of abuse. What is the nurse’s primary responsibility?
A) Report the findings to adult protective services.
B) Confront the suspected perpetrator.
C) Gather evidence to corroborate the abuse.
D) Work with the family to promote healthy conflict resolution.
Ans: A
Feedback:
If neglect or abuse of any kind—including physical, emotional, sexual, or financial abuse—is suspected, the local adult protective services agency must be notified. The responsibility of the nurse is to report the suspected abuse, not to prove it, confront the suspected perpetrator, or work with the family to promote resolution.

 

 

35. You are the nurse caring for an elderly patient with cardiovascular disease. The patient comes to the clinic with a suspected respiratory infection and is diagnosed with pneumonia. As the nurse, what do you know about the altered responses of older adults?
A) Treatments for older adults need to be more holistic than treatments used in the younger population.
B) The altered responses of older adults reinforce the need for the nurse to monitor all body systems to identify possible systemic complications.
C) The altered responses of older adults define the nursing interactions with the patient.
D) Older adults become hypersensitive to antibiotic treatments for infectious disease states.
Ans: B
Feedback:
Older people may be unable to respond effectively to an acute illness, or, if a chronic health condition is present, they may be unable to sustain appropriate responses over a long period. Furthermore, their ability to respond to definitive treatment is impaired. The altered responses of older adults reinforce the need for nurses to monitor all body system functions closely, being alert to signs of impending systemic complication. Holism should be integrated into all patients’ care. Altered responses in the older adult do not define the interactions between the nurse and the patient. Older adults do not become hypersensitive to antibiotic treatments for infectious disease states.

 

 

36. You are the nurse caring for patients in the urology clinic. A new patient, 78 years old, presents with complaints of urinary incontinence. An anticholinergic is prescribed. Why might this type of medication be an inappropriate choice in the elderly population?
A) Gastrointestinal hypermotility can be an adverse effect of this medication.
B) Detrusor instability can be an adverse effect of this medication.
C) Confusion can be an adverse effect of this medication.
D) Increased symptoms of urge incontinence can be an adverse effect of this medication.
Ans: C
Feedback:
Although medications such as anticholinergics may decrease some of the symptoms of urge incontinence (detrusor instability), the adverse effects of these medications (dry mouth, slowed gastrointestinal motility, and confusion) may make them inappropriate choices for the elderly.

 

 

37. A gerontologic nurse is overseeing the care that is provided in a large, long-term care facility. The nurse is educating staff about the significant threat posed by influenza in older, frail adults. What action should the nurse prioritize to reduce the incidence and prevalence of influenza in the facility?
A) Teach staff how to administer prophylactic antiviral medications effectively.
B) Ensure that residents receive a high-calorie, high-protein diet during the winter.
C) Make arrangements for residents to limit social interaction during winter months.
D) Ensure that residents receive influenza vaccinations in the fall of each year.
Ans: D
Feedback:
The influenza and the pneumococcal vaccinations lower the risks of hospitalization and death in elderly people. The influenza vaccine, which is prepared yearly to adjust for the specific immunologic characteristics of the influenza viruses at that time, should be administered annually in autumn. Prophylactic antiviral medications are not used. Limiting social interaction is not required in most instances. Nutrition enhances immune response, but this is not specific to influenza prevention.

 

 

38. Falls, which are a major health problem in the elderly population, occur from multifactorial causes. When implementing a comprehensive plan to reduce the incidence of falls on a geriatric unit, what risk factors should nurses identify? Select all that apply.
A) Medication effects
B) Overdependence on assistive devices
C) Poor lighting
D) Sensory impairment
E) Ineffective use of coping strategies
Ans: A, C, D
Feedback:
Causes of falls are multifactorial. Both extrinsic factors, such as changes in the environment or poor lighting, and intrinsic factors, such as physical illness, neurologic changes, or sensory impairment, play a role. Mobility difficulties, medication effects, foot problems or unsafe footwear, postural hypotension, visual problems, and tripping hazards are common, treatable causes. Overdependence on assistive devices and ineffective use of coping strategies have not been shown to be factors in the rate of falls in the elderly population.

 

 

39. Older people have many altered reactions to disease that are based on age-related physiological changes. When the nurse observes physical indicators of illness in the older population, that nurse must remember which of the following principles?
A) Potential life-threatening problems in the older adult population are not as serious as they are in a middle-aged population.
B) Indicators that are useful and reliable in younger populations cannot be relied on as indications of potential life-threatening problems in older adults.
C) The same physiological processes that indicate serious health care problems in a younger population indicate mild disease states in the elderly.
D) Middle-aged people do not react to disease states the same as a younger population does.
Ans: B
Feedback:
Physical indicators of illness that are useful and reliable in young and middle-aged people cannot be relied on for the diagnosis of potential life-threatening problems in older adults. Option A is incorrect because a potentially life-threatening problem in an older person is more serious than it would be in a middle-aged person because the older adult does not have the physical resources of the middle-aged person. Physical indicators of serious health care problems in a young or middle-aged population do not indicate disease states that are considered “mild” in the elderly population. It is true that middle-aged people do not react to disease states the same as a younger population, but this option does not answer the question.

 

 

40. You are the nurse caring for a 91-year-old patient admitted to the hospital for a fall. The patient complains of urge incontinence and tells you he most often falls when he tries to get to the bathroom in his home. You identify the nursing diagnosis of risk for falls related to impaired mobility and urinary incontinence. The older adult’s risk for falls is considered to be which of the following?
A) The result of impaired cognitive functioning
B) The accumulation of environmental hazards
C) A geriatric syndrome
D) An age-related health deficit
Ans: C
Feedback:
A number of problems commonly experienced by the elderly are becoming recognized as geriatric syndromes. These conditions do not fit into discrete disease categories. Examples include frailty, delirium, falls, urinary incontinence, and pressure ulcers. Impaired cognitive functioning, environmental hazards in the home, and an age-related health deficit may all play a part in the episodes in this patient’s life that led to falls, but they are not diagnoses and are, therefore, incorrect.

 

1. The nurse is caring for a patient who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what?
A) Lipids and fibrous tissue
B) White blood cells
C) Lipoproteins
D) High-density cholesterol
Ans: A
Feedback:
As T-lymphocytes and monocytes infiltrate to ingest lipids on the arterial wall and then die, a fibrous tissue develops. This causes plaques to form on the inner lumen of arterial walls. These plaques do not consist of white cells, lipoproteins, or high-density cholesterol.

 

 

2. A patient presents to the walk-in clinic complaining of intermittent chest pain on exertion, which is eventually attributed to angina. The nurse should inform the patient that angina is most often attributable to what cause?
A) Decreased cardiac output
B) Decreased cardiac contractility
C) Infarction of the myocardium
D) Coronary arteriosclerosis
Ans: D
Feedback:
In most cases, angina pectoris is due to arteriosclerosis. The disease is not a result of impaired cardiac output or contractility. Infarction may result from untreated angina, but it is not a cause of the disease.

 

 

3. The nurse is caring for an adult patient who had symptoms of unstable angina upon admission to the hospital. What nursing diagnosis underlies the discomfort associated with angina?
A) Ineffective breathing pattern related to decreased cardiac output
B) Anxiety related to fear of death
C) Ineffective cardiopulmonary tissue perfusion related to coronary artery disease (CAD)
D) Impaired skin integrity related to CAD
Ans: C
Feedback:
Ineffective cardiopulmonary tissue perfusion directly results in the symptoms of discomfort associated with angina. Anxiety and ineffective breathing may result from angina chest pain, but they are not the causes. Skin integrity is not impaired by the effects of angina.

 

 

4. The triage nurse in the ED assesses a 66-year-old male patient who presents to the ED with complaints of midsternal chest pain that has lasted for the last 5 hours. If the patient’s symptoms are due to an MI, what will have happened to the myocardium?
A) It may have developed an increased area of infarction during the time without treatment.
B) It will probably not have more damage than if he came in immediately.
C) It may be responsive to restoration of the area of dead cells with proper treatment.
D) It has been irreparably damaged, so immediate treatment is no longer necessary.
Ans: A
Feedback:
When the patient experiences lack of oxygen to myocardium cells during an MI, the sooner treatment is initiated, the more likely the treatment will prevent or minimize myocardial tissue necrosis. Delays in treatment equate with increased myocardial damage. Despite the length of time the symptoms have been present, treatment needs to be initiated immediately to minimize further damage. Dead cells cannot be restored by any means.

 

 

5. Family members bring a patient to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?
A) The symptoms indicate angina and should be treated as such.
B) The symptoms indicate a pulmonary etiology rather than a cardiac etiology.
C) The symptoms indicate an acute coronary episode and should be treated as such.
D) Treatment should be determined pending the results of an exercise stress test.
Ans: C
Feedback:
Angina and MI have similar symptoms and are considered the same process, but are on different points along a continuum. That the patient’s symptoms are unrelieved by rest suggests an acute coronary episode rather than angina. Pale cool skin and sudden onset are inconsistent with a pulmonary etiology. Treatment should be initiated immediately regardless of diagnosis.

 

 

6. An OR nurse is preparing to assist with a coronary artery bypass graft (CABG). The OR nurse knows that the vessel most commonly used as source for a CABG is what?
A) Brachial artery
B) Brachial vein
C) Femoral artery
D) Greater saphenous vein
Ans: D
Feedback:
The greater saphenous vein is the most commonly used graft site for CABG. The right and left internal mammary arteries, radial arteries, and gastroepiploic artery are other graft sites used, though not as frequently. The femoral artery, brachial artery, and brachial vein are never harvested.

 

 

7. A patient with an occluded coronary artery is admitted and has an emergency percutaneous transluminal coronary angioplasty (PTCA). The patient is admitted to the cardiac critical care unit after the PTCA. For what complication should the nurse most closely monitor the patient?
A) Hyperlipidemia
B) Bleeding at insertion site
C) Left ventricular hypertrophy
D) Congestive heart failure
Ans: B
Feedback:
Complications of PTCA may include bleeding at the insertion site, abrupt closure of the artery, arterial thrombosis, and perforation of the artery. Complications do not include hyperlipidemia, left ventricular hypertrophy, or congestive heart failure; each of these problems takes an extended time to develop and none is emergent.

 

 

8. The nurse is caring for a patient who is scheduled for cardiac surgery. What should the nurse include in preoperative care?
A) With the patient, clarify the surgical procedure that will be performed.
B) Withhold the patient’s scheduled medications for at least 12 hours preoperatively.
C) Inform the patient that health teaching will begin as soon as possible after surgery.
D) Avoid discussing the patient’s fears as not to exacerbate them.
Ans: A
Feedback:
Preoperatively, it is necessary to evaluate the patient’s understanding of the surgical procedure, informed consent, and adherence to treatment protocols. Teaching would begin on admission or even prior to admission. The physician would write orders to alter the patient’s medication regimen if necessary; this will vary from patient to patient. Fears should be addressed directly and empathically.

 

 

9. The OR nurse is explaining to a patient that cardiac surgery requires the absence of blood from the surgical field. At the same time, it is imperative to maintain perfusion of body organs and tissues. What technique for achieving these simultaneous goals should the nurse describe?
A) Coronary artery bypass graft (CABG)
B) Percutaneous transluminal coronary angioplasty (PTCA)
C) Atherectomy
D) Cardiopulmonary bypass
Ans: D
Feedback:
Cardiopulmonary bypass is often used to circulate and oxygenate blood mechanically while bypassing the heart and lungs. PTCA, atherectomy, and CABG are all surgical procedures, none of which achieves the two goals listed.

 

 

10. The nurse has just admitted a 66-year-old patient for cardiac surgery. The patient tearfully admits to the nurse that she is afraid of dying while undergoing the surgery. What is the nurse’s best response?
A) Explore the factors underlying the patient’s anxiety.
B) Teach the patient guided imagery techniques.
C) Obtain an order for a PRN benzodiazepine.
D) Describe the procedure in greater detail.
Ans: A
Feedback:
An assessment of anxiety levels is required in the patient to assist the patient in identifying fears and developing coping mechanisms for those fears. The nurse must further assess and explore the patient’s anxiety before providing interventions such as education or medications.

 

 

11. A patient with angina has been prescribed nitroglycerin. Before administering the drug, the nurse should inform the patient about what potential adverse effects?
A) Nervousness or paresthesia
B) Throbbing headache or dizziness
C) Drowsiness or blurred vision
D) Tinnitus or diplopia
Ans: B
Feedback:
Headache and dizziness commonly occur when nitroglycerin is taken at the beginning of therapy. Nervousness, paresthesia, drowsiness, blurred vision, tinnitus, and diplopia do not typically occur as a result of nitroglycerin therapy.

 

 

12. The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors would the nurse list that can be controlled or modified?
A) Gender, obesity, family history, and smoking
B) Inactivity, stress, gender, and smoking
C) Obesity, inactivity, diet, and smoking
D) Stress, family history, and obesity
Ans: C
Feedback:
The risk factors for CAD that can be controlled or modified include obesity, inactivity, diet, stress, and smoking. Gender and family history are risk factors that cannot be controlled.

 

 

13. A 48-year-old man presents to the ED complaining of severe substernal chest pain radiating down his left arm. He is admitted to the coronary care unit (CCU) with a diagnosis of myocardial infarction (MI). What nursing assessment activity is a priority on admission to the CCU?
A) Begin ECG monitoring.
B) Obtain information about family history of heart disease.
C) Auscultate lung fields.
D) Determine if the patient smokes.
Ans: A
Feedback:
The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the ED. By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored; life-threatening arrhythmias are the leading cause of death in the first hours after an MI. Obtaining information about family history of heart disease and whether the patient smokes are not immediate priorities in the acute phase of MI. Data may be obtained from family members later. Lung fields are auscultated after oxygenation and pain control needs are met.

 

 

14. The public health nurse is participating in a health fair and interviews a patient with a history of hypertension, who is currently smoking one pack of cigarettes per day. She denies any of the most common manifestations of CAD. Based on these data, the nurse would expect the focuses of CAD treatment most likely to be which of the following?
A) Drug therapy and smoking cessation
B) Diet and drug therapy
C) Diet therapy only
D) Diet therapy and smoking cessation
Ans: D
Feedback:
Due to the absence of symptoms, dietary therapy would likely be selected as the first-line treatment for possible CAD. Drug therapy would be determined based on a number of considerations and diagnostics findings, but would not be directly indicated. Smoking cessation is always indicated, regardless of the presence or absence of symptoms.

 

 

15. The nurse is working with a patient who had an MI and is now active in rehabilitation. The nurse should teach this patient to cease activity if which of the following occurs?
A) The patient experiences chest pain, palpitations, or dyspnea.
B) The patient experiences a noticeable increase in heart rate during activity.
C) The patient’s oxygen saturation level drops below 96%.
D) The patient’s respiratory rate exceeds 30 breaths/min.
Ans: A
Feedback:
Any activity or exercise that causes dyspnea and chest pain should be stopped in the patient with CAD. Heart rate must not exceed the target rate, but an increase above resting rate is expected and is therapeutic. In most patients, a respiratory rate that exceeds 30 breaths/min is not problematic. Similarly, oxygen saturation slightly below 96% does not necessitate cessation of activity.

 

 

16. A patient with cardiovascular disease is being treated with amlodipine (Norvasc), a calcium channel blocking agent. The therapeutic effects of calcium channel blockers include which of the following?
A) Reducing the heart’s workload by decreasing heart rate and myocardial contraction
B) Preventing platelet aggregation and subsequent thrombosis
C) Reducing myocardial oxygen consumption by blocking adrenergic stimulation to the heart
D) Increasing the efficiency of myocardial oxygen consumption, thus decreasing ischemia and relieving pain
Ans: A
Feedback:
Calcium channel blocking agents decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of the heart muscle contraction. These effects decrease the workload of the heart. Antiplatelet and anticoagulation medications are administered to prevent platelet aggregation and subsequent thrombosis, which impedes blood flow. Beta-blockers reduce myocardial consumption by blocking beta-adrenergic sympathetic stimulation to the heart. The result is reduced myocardial contractility (force of contraction) to balance the myocardium oxygen needs and supply. Nitrates reduce myocardial oxygen consumption, which decreases ischemia and relieves pain by dilating the veins and, in higher doses, the arteries.

 

 

17. The nurse is providing care for a patient with high cholesterol and triglyceride values. In teaching the patient about therapeutic lifestyle changes such as diet and exercise, the nurse realizes that the desired goal for cholesterol levels is which of the following?
A) High HDL values and high triglyceride values
B) Absence of detectable total cholesterol levels
C) Elevated blood lipids, fasting glucose less than 100
D) Low LDL values and high HDL values
Ans: D
Feedback:
The desired goal for cholesterol readings is for a patient to have low LDL and high HDL values. LDL exerts a harmful effect on the coronary vasculature because the small LDL particles can be easily transported into the vessel lining. In contrast, HDL promotes the use of total cholesterol by transporting LDL to the liver, where it is excreted. Elevated triglycerides are also a major risk factor for cardiovascular disease. A goal is also to keep triglyceride levels less than 150 mg/dL. All individuals possess detectable levels of total cholesterol.

 

 

18. When discussing angina pectoris secondary to atherosclerotic disease with a patient, the patient asks why he tends to experience chest pain when he exerts himself. The nurse should describe which of the following phenomena?
A) Exercise increases the heart’s oxygen demands.
B) Exercise causes vasoconstriction of the coronary arteries.
C) Exercise shunts blood flow from the heart to the mesenteric area.
D) Exercise increases the metabolism of cardiac medications.
Ans: A
Feedback:
Physical exertion increases the myocardial oxygen demand. If the patient has arteriosclerosis of the coronary arteries, then blood supply is diminished to the myocardium. Exercise does not cause vasoconstriction or interfere with drug metabolism. Exercise does not shunt blood flow away from the heart.

 

 

19. The nurse is caring for a patient who is believed to have just experienced an MI. The nurse notes changes in the ECG of the patient. What change on an ECG most strongly suggests to the nurse that ischemia is occurring?
A) P wave inversion
B) T wave inversion
C) Q wave changes with no change in ST or T wave
D) P wave enlargement
Ans: B
Feedback:
T-wave inversion is an indicator of ischemic damage to myocardium. Typically, few changes to P waves occur during or after an MI, whereas Q-wave changes with no change in the ST or T wave indicate an old MI.

 

 

20. An adult patient is admitted to the ED with chest pain. The patient states that he had developed unrelieved chest pain that was present for approximately 20 minutes before coming to the hospital. To minimize cardiac damage, the nurse should expect to administer which of the following interventions?
A) Thrombolytics, oxygen administration, and nonsteroidal anti-inflammatories
B) Morphine sulphate, oxygen, and bed rest
C) Oxygen and beta-adrenergic blockers
D) Bed rest, albuterol nebulizer treatments, and oxygen
Ans: B
Feedback:
The patient with suspected MI should immediately receive supplemental oxygen, aspirin, nitroglycerin, and morphine. Morphine sulphate reduces preload and decreases workload of the heart, along with increased oxygen from oxygen therapy and bed rest. With decreased cardiac demand, this provides the best chance of decreasing cardiac damage. NSAIDs and beta-blockers are not normally indicated. Albuterol, which is a medication used to manage asthma and respiratory conditions, will increase the heart rate.

 

 

21. The nurse is assessing a patient who was admitted to the critical care unit 3 hours ago following cardiac surgery. The nurse’s most recent assessment reveals that the patient’s left pedal pulses are not palpable and that the right pedal pulses are rated at +2. What is the nurse’s best response?
A) Document this expected assessment finding during the initial postoperative period.
B) Reposition the patient with his left leg in a dependent position.
C) Inform the patient’s physician of this assessment finding.
D) Administer an ordered dose of subcutaneous heparin.
Ans: C
Feedback:
If a pulse is absent in any extremity, the cause may be prior catheterization of that extremity, chronic peripheral vascular disease, or a thromboembolic obstruction. The nurse immediately reports newly identified absence of any pulse.

 

 

22. In preparation for cardiac surgery, a patient was taught about measures to prevent venous thromboembolism. What statement indicates that the patient clearly understood this education?
A) “I’ll try to stay in bed for the first few days to allow myself to heal.”
B) “I’ll make sure that I don’t cross my legs when I’m resting in bed.”
C) “I’ll keep pillows under my knees to help my blood circulate better.”
D) “I’ll put on those compression stockings if I get pain in my calves.”
Ans: B
Feedback:
To prevent venous thromboembolism, patients should avoid crossing the legs. Activity is generally begun as soon as possible and pillows should not be placed under the popliteal space. Compression stockings are often used to prevent venous thromboembolism, but they would not be applied when symptoms emerge.

 

 

23. An ED nurse is assessing an adult woman for a suspected MI. When planning the assessment, the nurse should be cognizant of what signs and symptoms of MI that are particularly common in female patients? Select all that apply.
A) Shortness of breath
B) Chest pain
C) Anxiety
D) Numbness
E) Weakness
Ans: D, E
Feedback:
Although these symptoms are not wholly absent in men, many women have been found to have atypical symptoms of MI, including indigestion, nausea, palpitations, and numbness. Shortness of breath, chest pain, and anxiety are common symptoms of MI among patients of all ages and genders.

 

 

24. When assessing a patient diagnosed with angina pectoris it is most important for the nurse to gather what information?
A) The patient’s activities limitations and level of consciousness after the attacks
B) The patient’s symptoms and the activities that precipitate attacks
C) The patient’s understanding of the pathology of angina
D) The patient’s coping strategies surrounding the attacks
Ans: B
Feedback:
The nurse must gather information about the patient’s symptoms and activities, especially those that precede and precipitate attacks of angina pectoris. The patient’s coping, understanding of the disease, and status following attacks are all important to know, but causative factors are a primary focus of the assessment interview.

 

 

25. You are writing a care plan for a patient who has been diagnosed with angina pectoris. The patient describes herself as being “distressed” and “shocked” by her new diagnosis. What nursing diagnosis is most clearly suggested by the woman’s statement?
A) Spiritual distress related to change in health status
B) Acute confusion related to prognosis for recovery
C) Anxiety related to cardiac symptoms
D) Deficient knowledge related to treatment of angina pectoris
Ans: C
Feedback:
Although further assessment is warranted, it is not unlikely that the patient is experiencing anxiety. In patients with CAD, this often relates to the threat of sudden death. There is no evidence of confusion (i.e., delirium or dementia) and there may or may not be a spiritual element to her concerns. Similarly, it is not clear that a lack of knowledge or information is the root of her anxiety.

 

 

26. The nurse is caring for patient who tells the nurse that he has an angina attack beginning. What is the nurse’s most appropriate initial action?
A) Have the patient sit down and put his head between his knees.
B) Have the patient perform pursed-lip breathing.
C) Have the patient stand still and bend over at the waist.
D) Place the patient on bed rest in a semi-Fowler’s position.
Ans: D
Feedback:
When a patient experiences angina, the patient is directed to stop all activities and sit or rest in bed in a semi-Fowler’s position to reduce the oxygen requirements of the ischemic myocardium. Pursed-lip breathing and standing will not reduce workload to the same extent. No need to have the patient put his head between his legs because cerebral perfusion is not lacking.

 

 

27. A patient presents to the ED in distress and complaining of “crushing” chest pain. What is the nurse’s priority for assessment?
A) Prompt initiation of an ECG
B) Auscultation of the patient’s point of maximal impulse (PMI)
C) Rapid assessment of the patient’s peripheral pulses
D) Palpation of the patient’s cardiac apex
Ans: A
Feedback:
The 12-lead ECG provides information that assists in ruling out or diagnosing an acute MI. It should be obtained within 10 minutes from the time a patient reports pain or arrives in the ED. Each of the other listed assessments is valid, but ECG monitoring is the most time dependent priority.

 

 

28. The ED nurse is caring for a patient with a suspected MI. What drug should the nurse anticipate administering to this patient?
A) Oxycodone
B) Warfarin
C) Morphine
D) Acetaminophen
Ans: C
Feedback:
The patient with suspected MI is given aspirin, nitroglycerin, morphine, an IV beta- blocker, and other medications, as indicated, while the diagnosis is being confirmed. Tylenol, warfarin, and oxycodone are not typically used.

 

 

29. The nurse is assessing a patient with acute coronary syndrome (ACS). The nurse includes a careful history in the assessment, especially with regard to signs and symptoms. What signs and symptoms are suggestive of ACS? Select all that apply.
A) Dyspnea
B) Unusual fatigue
C) Hypotension
D) Syncope
E) Peripheral cyanosis
Ans: A, B, D
Feedback:
Systematic assessment includes a careful history, particularly as it relates to symptoms: chest pain or discomfort, difficulty breathing (dyspnea), palpitations, unusual fatigue, faintness (syncope), or sweating (diaphoresis). Each symptom must be evaluated with regard to time, duration, and the factors that precipitate the symptom and relieve it, and in comparison with previous symptoms. Hypotension and peripheral cyanosis are not typically associated with ACS.

 

 

30. The nurse is creating a plan of care for a patient with acute coronary syndrome. What nursing action should be included in the patient’s care plan?
A) Facilitate daily arterial blood gas (ABG) sampling.
B) Administer supplementary oxygen, as needed.
C) Have patient maintain supine positioning when in bed.
D) Perform chest physiotherapy, as indicated.
Ans: B
Feedback:
Oxygen should be administered along with medication therapy to assist with symptom relief. Administration of oxygen raises the circulating level of oxygen to reduce pain associated with low levels of myocardial oxygen. Physical rest in bed with the head of the bed elevated or in a supportive chair helps decrease chest discomfort and dyspnea. ABGs are diagnostic, not therapeutic, and they are rarely needed on a daily basis. Chest physiotherapy is not used in the treatment of ACS.

 

 

31. The nurse is participating in the care conference for a patient with ACS. What goal should guide the care team’s selection of assessments, interventions, and treatments?
A) Maximizing cardiac output while minimizing heart rate
B) Decreasing energy expenditure of the myocardium
C) Balancing myocardial oxygen supply with demand
D) Increasing the size of the myocardial muscle
Ans: C
Feedback:
Balancing myocardial oxygen supply with demand (e.g., as evidenced by the relief of chest pain) is the top priority in the care of the patient with ACS. Treatment is not aimed directly at minimizing heart rate because some patients experience bradycardia. Increasing the size of the myocardium is never a goal. Reducing the myocardium’s energy expenditure is often beneficial, but this must be balanced with productivity.

 

 

32. The nurse working on the coronary care unit is caring for a patient with ACS. How can the nurse best meet the patient’s psychosocial needs?
A) Reinforce the fact that treatment will be successful.
B) Facilitate a referral to a chaplain or spiritual leader.
C) Increase the patient’s participation in rehabilitation activities.
D) Directly address the patient’s anxieties and fears.
Ans: D
Feedback:
Alleviating anxiety and decreasing fear are important nursing functions that reduce the sympathetic stress response. Referrals to spiritual care may or may not be appropriate, and this does not relieve the nurse of responsibility for addressing the patient’s psychosocial needs. Treatment is not always successful, and false hope should never be fostered. Participation in rehabilitation may alleviate anxiety for some patients, but it may exacerbate it for others.

 

 

33. The nurse is caring for a patient who has undergone percutaneous transluminal coronary angioplasty (PTCA). What is the major indicator of success for this procedure?
A) Increase in the size of the artery’s lumen
B) Decrease in arterial blood flow in relation to venous flow
C) Increase in the patient’s resting heart rate
D) Increase in the patient’s level of consciousness (LOC)
Ans: A
Feedback:
PTCA is used to open blocked coronary vessels and resolve ischemia. The procedure may result in beneficial changes to the patient’s LOC or heart rate, but these are not the overarching goals of PTCA. Increased arterial flow is the focus of the procedures.

 

 

34. A nurse has taken on the care of a patient who had a coronary artery stent placed yesterday. When reviewing the patient’s daily medication administration record, the nurse should anticipate administering what drug?
A) Ibuprofen
B) Clopidogrel
C) Dipyridamole
D) Acetaminophen
Ans: B
Feedback:
Because of the risk of thrombus formation within the stent, the patient receives antiplatelet medications, usually aspirin and clopidogrel. Ibuprofen and acetaminophen are not antiplatelet drugs. Dipyridamole is not the drug of choice following stent placement.

 

 

35. A nurse is working with a patient who has been scheduled for a percutaneous coronary intervention (PCI) later in the week. What anticipatory guidance should the nurse provide to the patient?
A) He will remain on bed rest for 48 to 72 hours after the procedure.
B) He will be given vitamin K infusions to prevent bleeding following PCI.
C) A sheath will be placed over the insertion site after the procedure is finished.
D) The procedure will likely be repeated in 6 to 8 weeks to ensure success.
Ans: C
Feedback:
A sheath is placed over the PCI access site and kept in place until adequate coagulation is achieved. Patients resume activity a few hours after PCI and repeated treatments may or may not be necessary. Anticoagulants, not vitamin K, are administered during PCI.

 

 

36. Preoperative education is an important part of the nursing care of patients having coronary artery revascularization. When explaining the pre- and postoperative regimens, the nurse would be sure to include education about which subject?
A) Symptoms of hypovolemia
B) Symptoms of low blood pressure
C) Complications requiring graft removal
D) Intubation and mechanical ventilation
Ans: D
Feedback:
Most patients remain intubated and on mechanical ventilation for several hours after surgery. It is important that patients realize that this will prevent them from talking, and the nurse should reassure them that the staff will be able to assist them with other means of communication. Teaching would generally not include symptoms of low blood pressure or hypovolemia, as these are not applicable to most patients. Teaching would also generally not include rare complications that would require graft removal.

 

 

37. A patient in the cardiac step-down unit has begun bleeding from the percutaneous coronary intervention (PCI) access site in her femoral region. What is the nurse’s most appropriate action?
A) Call for assistance and initiate cardiopulmonary resuscitation.
B) Reposition the patient’s leg in a nondependent position.
C) Promptly remove the femoral sheath.
D) Call for help and apply pressure to the access site.
Ans: D
Feedback:
The femoral sheath produces pressure on the access site. Pressure will temporarily reduce bleeding and allow for subsequent interventions. Removing the sheath would exacerbate bleeding and repositioning would not halt it. CPR is not indicated unless there is evidence of respiratory or cardiac arrest.

 

 

38. The nurse providing care for a patient post PTCA knows to monitor the patient closely. For what complications should the nurse monitor the patient? Select all that apply.
A) Abrupt closure of the coronary artery
B) Venous insufficiency
C) Bleeding at the insertion site
D) Retroperitoneal bleeding
E) Arterial occlusion
Ans: A, C, D, E
Feedback:
Complications after the procedure may include abrupt closure of the coronary artery and vascular complications, such as bleeding at the insertion site, retroperitoneal bleeding, hematoma, and arterial occlusion, as well as acute renal failure. Venous insufficiency is not a postprocedure complication of a PTCA.

 

 

39. A patient who is postoperative day 1 following a CABG has produced 20 mL of urine in the past 3 hours and the nurse has confirmed the patency of the urinary catheter. What is the nurse’s most appropriate action?
A) Document the patient’s low urine output and monitor closely for the next several hours.
B) Contact the dietitian and suggest the need for increased oral fluid intake.
C) Contact the patient’s physician and suggest assessment of fluid balance and renal function.
D) Increase the infusion rate of the patient’s IV fluid to prompt an increase in renal function.
Ans: C
Feedback:
Nursing management includes accurate measurement of urine output. An output of less than 1 mL/kg/h may indicate hypovolemia or renal insufficiency. Prompt referral is necessary. IV fluid replacement may be indicated, but is beyond the independent scope of the dietitian or nurse.

 

 

40. A patient is recovering in the hospital from cardiac surgery. The nurse has identified the diagnosis of risk for ineffective airway clearance related to pulmonary secretions. What intervention best addresses this risk?
A) Administration of bronchodilators by nebulizer
B) Administration of inhaled corticosteroids by metered dose inhaler (MDI)
C) Patient’s consistent performance of deep breathing and coughing exercises
D) Patient’s active participation in the cardiac rehabilitation program
Ans: C
Feedback:
Clearance of pulmonary secretions is accomplished by frequent repositioning of the patient, suctioning, and chest physical therapy, as well as educating and encouraging the patient to breathe deeply and cough. Medications are not normally used to achieve this goal. Rehabilitation is important, but will not necessarily aid the mobilization of respiratory secretions.

 

1. A nurse is caring for a patient who has had a plaster arm cast applied. Immediately postapplication, the nurse should provide what teaching to the patient?
A) The cast will feel cool to touch for the first 30 minutes.
B) The cast should be wrapped snuggly with a towel until the patient gets home.
C) The cast should be supported on a board while drying.
D) The cast will only have full strength when dry.
Ans: D
Feedback:
A cast requires approximately 24 to 72 hours to dry, and until dry, it does not have full strength. While drying, the cast should not be placed on a hard surface. The cast will exude heat while it dries and should not be wrapped.

 

 

2. A patient broke his arm in a sports accident and required the application of a cast. Shortly following application, the patient complained of an inability to straighten his fingers and was subsequently diagnosed with Volkmann contracture. What pathophysiologic process caused this complication?
A) Obstructed arterial blood flow to the forearm and hand
B) Simultaneous pressure on the ulnar and radial nerves
C) Irritation of Merkel cells in the patient’s skin surfaces
D) Uncontrolled muscle spasms in the patient’s forearm
Ans: A
Feedback:
Volkmann contracture occurs when arterial blood flow is restricted to the forearm and hand and results in contractures of the fingers and wrist. It does not result from nerve pressure, skin irritation, or spasms.

 

 

3. A patient is admitted to the unit in traction for a fractured proximal femur and requires traction prior to surgery. What is the most appropriate type of traction to apply to a fractured proximal femur?
A) Russell’s traction
B) Dunlop’s traction
C) Buck’s extension traction
D) Cervical head halter
Ans: C
Feedback:
Buck’s extension is used for fractures of the proximal femur. Russell’s traction is used for lower leg fractures. Dunlop’s traction is applied to the upper extremity for supracondylar fractures of the elbow and humerus. Cervical head halters are used to stabilize the neck.

 

 

4. A nurse is caring for a patient who is in skeletal traction. To prevent the complication of skin breakdown in a patient with skeletal traction, what action should be included in the plan of care?
A) Apply occlusive dressings to the pin sites.
B) Encourage the patient to push up with the elbows when repositioning.
C) Encourage the patient to perform isometric exercises once a shift.
D) Assess the pin insertion site every 8 hours.
Ans: D
Feedback:
The pin insertion site should be assessed every 8 hours for inflammation and infection. Loose cover dressings should be applied to pin sites. The patient should be encouraged to use the overhead trapeze to shift weight for repositioning. Isometric exercises should be done 10 times an hour while awake.

 

 

5. A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient?
A) Keep the patient’s hips in abduction at all times.
B) Keep hips flexed at no less than 90 degrees.
C) Elevate the head of the bed to high Fowler’s.
D) Seat the patient in a low chair as soon as possible.
Ans: A
Feedback:
The hips should be kept in abduction by an abductor pillow. Hips should not be flexed more than 90 degrees, and the head of bed should not be elevated more than 60 degrees. The patient’s hips should be higher than the knees; as such, high seat chairs should be used.

 

 

6. While assessing a patient who has had knee replacement surgery, the nurse notes that the patient has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this patient?
A) Risk for Infection
B) Risk for Peripheral Neurovascular Dysfunction
C) Unilateral Neglect
D) Disturbed Kinesthetic Sensory Perception
Ans: B
Feedback:
The hematoma may cause an interruption of tissue perfusion, so the most appropriate nursing diagnosis is Risk of Peripheral Neurovascular Dysfunction.  There is also an associated risk for infection because of the hematoma, but impaired neurovascular function is a more acute threat. Unilateral neglect and impaired sensation are lower priorities than neurovascular status.

 

 

7. A patient was brought to the emergency department after a fall. The patient is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize?
A) “Make sure you don’t bring your knees close together.”
B) “Try to lie as still as possible for the first few days.”
C) “Try to avoid bending your knees until next week.”
D) “Keep your legs higher than your chest whenever you can.”
Ans: A
Feedback:
After receiving a hip prosthesis, the affected leg should be kept abducted. Mobility should be encouraged within safe limits. There is no need to avoid knee flexion and the patient’s legs do not need to be higher than the level of the chest.

 

 

8. A patient with a fractured femur is in balanced suspension traction.  The patient needs to be repositioned toward the head of the bed. During repositioning, what should the nurse do?
A) Place slight additional tension on the traction cords.
B) Release the weights and replace them immediately after positioning.
C) Reposition the bed instead of repositioning the patient.
D) Maintain consistent traction tension while repositioning.
Ans: D
Feedback:
Traction is used to reduce the fracture and must be maintained at all times, including during repositioning. It would be inappropriate to add tension or release the weights. Moving the bed instead of the patient is not feasible.

 

 

9. A patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurse’s best action?
A) Administer pain medication as ordered.
B) Assess the surgical site and the affected extremity.
C) Reassure the patient that pain is a direct result of increased activity.
D) Assess the patient for signs and symptoms of systemic infection.
Ans: B
Feedback:
Worsening pain after a total hip replacement may indicate dislocation of the prosthesis. Assessment of pain should include evaluation of the wound and the affected extremity. Assuming he’s anxious about discharge and administering pain medication do not address the cause of the pain. Sudden severe pain is not considered normal after hip replacement. Sudden pain is rarely indicative of a systemic infection.

 

 

10. A nurse is caring for a patient who has a leg cast. The nurse observes that the patient uses a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation?
A) Allow the patient to continue to scratch inside the cast with a pencil but encourage him to be cautious.
B) Give the patient a sterile tongue depressor to use for scratching instead of the pencil.
C) Encourage the patient to avoid scratching, and obtain an order for an antihistamine if severe itching persists.
D) Obtain an order for a sedative, such as lorazepam (Ativan), to prevent the patient from scratching.
Ans: C
Feedback:
Scratching should be discouraged because of the risk for skin breakdown or damage to the cast. Most patients can be discouraged from scratching if given a mild antihistamine, such as diphenhydramine, to relieve itching. Benzodiazepines would not be given for this purpose.

 

 

11. The nurse is caring for a patient who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis?
A) Keep the affected leg in a position of adduction.
B) Have the patient reposition himself independently.
C) Protect the affected leg from internal rotation.
D) Keep the hip flexed by placing pillows under the patient’s knee.
Ans: C
Feedback:
Abduction of the hip helps to prevent dislocation of a new hip joint. Rotation and adduction should be avoided. While the hip may be flexed slightly, it shouldn’t exceed 90 degrees and maintenance of flexion isn’t necessary. The patient may not be capable of safe independent repositioning at this early stage of recovery.

 

 

12. A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication?
A) Subcutaneous emphysema
B) Skin breakdown
C) Compartment syndrome
D) Disuse syndrome
Ans: C
Feedback:
Compartment syndrome may manifest as unrelenting, uncontrollable pain. This presentation of pain is not suggestive of disuse syndrome or skin breakdown. Subcutaneous emphysema is not a complication of casting.

 

 

13. The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote?
A) Knots in the rope should not be resting against pulleys.
B) Weights should rest against the bed rails.
C) The end of the limb in traction should be braced by the footboard of the bed.
D) Skeletal traction may be removed for brief periods to facilitate the patient’s independence.
Ans: A
Feedback:
Knots in the rope should not rest against pulleys, because this interferes with traction. Weights are used to apply the vector of force necessary to achieve effective traction and should hang freely at all times. To avoid interrupting traction, the limb in traction should not rest against anything. Skeletal traction is never interrupted.

 

 

14. The orthopedic surgeon has prescribed balanced skeletal traction for a patient. What advantage is conferred by balanced traction?
A) Balanced traction can be applied at night and removed during the day.
B) Balanced traction allows for greater patient movement and independence than other forms of traction.
C) Balanced traction is portable and may accompany the patient’s movements.
D) Balanced traction facilitates bone remodeling in as little as 4 days.
Ans: B
Feedback:
Often, skeletal traction is balanced traction, which supports the affected extremity, allows for some patient movement, and facilitates patient independence and nursing care while maintaining effective traction. It is not portable, however, and it cannot be removed. Bone remodeling takes longer than 4 days.

 

 

15. The nursing care plan for a patient in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a patient’s lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?
A) Increased warmth of the calf
B) Decreased circumference of the calf
C) Loss of sensation to the calf
D) Pale-appearing calf
Ans: A
Feedback:
Signs of DVT include increased warmth, redness, swelling, and calf tenderness. These findings are promptly reported to the physician for definitive evaluation and therapy. Signs and symptoms of a DVT do not include a decreased circumference of the calf, a loss of sensation in the calf, or a pale-appearing calf.

 

 

16. A nurse is providing discharge education to a patient who is going home with a cast on his leg. What teaching point should the nurse emphasize in the teaching session?
A) Using crutches efficiently
B) Exercising joints above and below the cast, as ordered
C) Removing the cast correctly at the end of the treatment period
D) Reporting signs of impaired circulation
Ans: D
Feedback:
Reporting signs of impaired circulation is critical; signs of impaired circulation must be reported to the physician immediately to prevent permanent damage. For this reason, this education is a priority over exercise and crutch use. The patient does not independently remove the cast.

 

 

17. A patient with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the patient’s cast care?
A) “Cover the cast with a blanket until the cast dries.”
B) “Keep your right leg elevated above heart level.”
C) “Use a clean object to scratch itches inside the cast.”
D) “A foul smell from the cast is normal after the first few days.”
Ans: B
Feedback:
The leg should be elevated to promote venous return and prevent edema. The cast shouldn’t be covered while drying because this will cause heat buildup and prevent air circulation. No foreign object should be inserted inside the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.

 

 

18. An elderly patient’s hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse’s priority assessment?
A) The presence of leg shortening
B) The patient’s complaints of pain
C) Signs of neurovascular compromise
D) The presence of internal or external rotation
Ans: C
Feedback:
Because impaired circulation can cause permanent damage, neurovascular assessment of the affected leg is always a priority assessment. Leg shortening and internal or external rotation are common findings with a fractured hip. Pain, especially on movement, is also common after a hip fracture.

 

 

19. A nurse is caring for a patient who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the patient’s statements would indicate to the nurse that the patient requires further teaching?
A) “I’ll need to keep several pillows between my legs at night.”
B) “I need to remember not to cross my legs. It’s such a habit.”
C) “The occupational therapist is showing me how to use a ‘sock puller’ to help me get dressed.”
D) “I will need my husband to assist me in getting off the low toilet seat at home.”
Ans: D
Feedback:
To prevent hip dislocation after a total hip replacement, the patient must avoid bending the hips beyond 90 degrees. Assistive devices, such as a raised toilet seat, should be used to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs. Likewise, teaching the patient to avoid crossing the legs also reduces the risk of hip dislocation. A sock puller helps a patient get dressed without flexing the hips beyond 90 degrees.

 

 

20. A nurse is admitting a patient to the unit who presented with a lower extremity fracture. What signs and symptoms would suggest to the nurse that the patient may have aperoneal nerve injury?
A) Numbness and burning of the foot
B) Pallor to the dorsal surface of the foot
C) Visible cyanosis in the toes
D) Inadequate capillary refill to the toes
Ans: A
Feedback:
Peroneal nerve injury may result in numbness, tingling, and burning in the feet. Cyanosis, pallor, and decreased capillary refill are signs of inadequate circulation.

 

 

21. A patient has suffered a muscle strain and is complaining of pain that she rates at 6 on a 10-point scale. The nurse should recommend what action?
A) Taking an opioid analgesic as ordered
B) Applying a cold pack to the injured site
C) Performing passive ROM exercises
D) Applying a heating pad to the affected muscle
Ans: B
Feedback:
Most pain can be relieved by elevating the involved part, applying cold packs, and administering analgesics as prescribed. Heat may exacerbate the pain by increasing blood circulation, and ROM exercises would likely be painful. Analgesia is likely necessary, but NSAIDs would be more appropriate than opioids.

 

 

22. A patient has had a brace prescribed to facilitate recovery from a knee injury. What are the potential therapeutic benefits of a brace? Select all that apply.
A) Preventing additional injury
B) Immobilizing prior to surgery
C) Providing support
D) Controlling movement
E) Promoting bone remodeling
Ans: A, C, D
Feedback:
Braces (i.e., orthoses) are used to provide support, control movement, and prevent additional injury. They are not used to immobilize body parts or to facilitate bone remodeling.

 

 

23. A nurse is assessing the neurovascular status of a patient who has had a leg cast recently applied. The nurse is unable to palpate the patient’s dorsalis pedis or posterior tibial pulse and the patient’s foot is pale. What is the nurse’s most appropriate action?
A) Warm the patient’s foot and determine whether circulation improves.
B) Reposition the patient with the affected foot dependent.
C) Reassess the patient’s neurovascular status in 15 minutes.
D) Promptly inform the primary care provider.
Ans: D
Feedback:
Signs of neurovascular dysfunction warrant immediate medical follow-up. It would be unsafe to delay. Warming the foot or repositioning the patient may be of some benefit, but the care provider should be informed first.

 

 

24. A physician writes an order to discontinue skeletal traction on an orthopedic patient. The nurse should anticipate what subsequent intervention?
A) Application of a walking boot
B) Application of a cast
C) Education on how to use crutches
D) Passive range of motion exercises
Ans: B
Feedback:
After skeletal traction is discontinued, internal fixation, casts, or splints are then used to immobilize and support the healing bone. The use of a walking boot, crutches, or ROM exercises could easily damage delicate, remodeled bone.

 

 

25. A patient has just begun been receiving skeletal traction and the nurse is aware that muscles in the patient’s affected limb are spastic. How does this change in muscle tone affect the patient’s traction prescription?
A) Traction must temporarily be aligned in a slightly different direction.
B) Extra weight is needed initially to keep the limb in proper alignment.
C) A lighter weight should be initially used.
D) Weight will temporarily alternate between heavier and lighter weights.
Ans: B
Feedback:
The traction weights applied initially must overcome the shortening spasms of the affected muscles. As the muscles relax, the traction weight is reduced to prevent fracture dislocation and to promote healing. Weights never alternate between heavy and light.

 

 

26. A nurse is planning the care of a patient who will require a prolonged course of skeletal traction. When planning this patient’s care, the nurse should prioritize interventions related to which of the following risk nursing diagnoses?
A) Risk for Impaired Skin Integrity
B) Risk for Falls
C) Risk for Imbalanced Fluid Volume
D) Risk for Aspiration
Ans: A
Feedback:
Impaired skin integrity is a high-probability risk in patients receiving traction. Falls are not a threat, due to the patient’s immobility. There are not normally high risks of fluid imbalance or aspiration associated with traction.

 

 

27. A nurse is caring for a patient receiving skeletal traction. Due to the patient’s severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications?
A) Perform chest physiotherapy once per shift and as needed.
B) Teach the patient to perform deep breathing and coughing exercises.
C) Administer prophylactic antibiotics as ordered.
D) Administer nebulized bronchodilators and corticosteroids as ordered.
Ans: B
Feedback:
To prevent these complications, the nurse should educate the patient about performing deep-breathing and coughing exercises to aid in fully expanding the lungs and clearing pulmonary secretions. Antibiotics, bronchodilators, and steroids are not used on a preventative basis and chest physiotherapy is unnecessary and implausible for a patient in traction.

 

 

28. The nurse has identified the diagnosis of Risk for Impaired Tissue Perfusion Related to Deep Vein Thrombosis in the care of a patient receiving skeletal traction. What nursing intervention best addresses this risk?
A) Encourage independence with ADLs whenever possible.
B) Monitor the patient’s nutritional status closely.
C) Teach the patient to perform ankle and foot exercises within the limitations of traction.
D) Administer clopidogrel (Plavix) as ordered.
Ans: C
Feedback:
The nurse educates the patient how to perform ankle and foot exercises within the limits of the traction therapy every 1 to 2 hours when awake to prevent DVT. Nutrition is important, but does not directly prevent DVT. Similarly, independence with ADLs should be promoted, but this does not confer significant prevention of DVT, which often affects the lower limbs. Plavix is not normally used for DVT prophylaxis.

 

 

29. A patient is scheduled for a total hip replacement and the surgeon has explained the risks of blood loss associated with orthopedic surgery. The risk of blood loss is the indication for which of the following actions?
A) Use of a cardiopulmonary bypass machine
B) Postoperative blood salvage
C) Prophylactic blood transfusion
D) Autologous blood donation
Ans: D
Feedback:
Many patients donate their own blood during the weeks preceding their surgery. Autologous blood donations are cost effective and eliminate many of the risks of transfusion therapy. Orthopedic surgery does not necessitate cardiopulmonary bypass and blood is not salvaged postoperatively. Transfusions are not given prophylactically.

 

 

30. The nurse is helping to set up Buck’s traction on an orthopedic patient.  How often should the nurse assess circulation to the affected leg?
A) Within 30 minutes, then every 1 to 2 hours
B) Within 30 minutes, then every 4 hours
C) Within 30 minutes, then every 8 hours
D) Within 30 minutes, then every shift
Ans: A
Feedback:
After skin traction is applied, the nurse assesses circulation of the foot or hand within 15 to 30 minutes and then every 1 to 2 hours.

 

 

31. A nurse is assessing a patient who is receiving traction. The nurse’s assessment confirms that the patient is able to perform plantar flexion. What conclusion can the nurse draw from this finding?
A) The leg that was assessed is free from DVT.
B) The patient’s tibial nerve is functional.
C) Circulation to the distal extremity is adequate.
D) The patient does not have peripheral neurovascular dysfunction.
Ans: B
Feedback:
Plantar flexion demonstrates function of the tibial nerve. It does not demonstrate the absence of DVT and does not allow the nurse to ascertain adequate circulation. The nurse must perform more assessments on more sites in order to determine an absence of peripheral neurovascular dysfunction.

 

 

32. A nurse is caring for a patient in skeletal traction. In order to prevent bony fragments from moving against one another, the nurse should caution the patient against which of the following actions?
A) Shifting one’s weight in bed
B) Bearing down while having a bowel movement
C) Turning from side to side
D) Coughing without splinting
Ans: C
Feedback:
To prevent bony fragments from moving against one another, the patient should not turn from side to side; however, the patient may shift position slightly with assistance. Bearing down and coughing do not pose a threat to bone union.

 

 

33. A nurse is caring for an older adult patient who is preparing for discharge following recovery from a total hip replacement. Which of the following outcomes must be met prior to discharge?
A) Patient is able to perform ADLs independently.
B) Patient is able to perform transfers safely.
C) Patient is able to weight-bear equally on both legs.
D) Patient is able to demonstrate full ROM of the affected hip.
Ans: B
Feedback:
The patient must be able to perform transfers and to use mobility aids safely. Each of the other listed goals is unrealistic for the patient who has undergone recent hip replacement.

 

 

34. A nurse is caring for a patient who is recovering in the hospital following orthopedic surgery. The nurse is performing frequent assessments for signs and symptoms of infection in the knowledge that the patient faces a high risk of what infectious complication?
A) Cellulitis
B) Septic arthritis
C) Sepsis
D) Osteomyelitis
Ans: D
Feedback:
Infection is a risk after any surgery, but it is of particular concern for the postoperative orthopedic patient because of the risk of osteomyelitis. Orthopedic patients do not have an exaggerated risk of cellulitis, sepsis, or septic arthritis when compared to other surgical patients.

 

 

35. A patient is being prepared for a total hip arthroplasty, and the nurse is providing relevant education. The patient is concerned about being on bed rest for several days after the surgery. The nurse should explain what expectation for activity following hip replacement?
A) “Actually, patients are only on bed rest for 2 to 3 days before they begin walking with assistance.”
B) “The physical therapist will likely help you get up using a walker the day after your surgery.”
C) “Our goal will actually be to have you walking normally within 5 days of your surgery.”
D) “For the first two weeks after the surgery, you can use a wheelchair to meet your mobility needs.”
Ans: B
Feedback:
Patients post-THA begin ambulation with the assistance of a walker or crutches within a day after surgery. Wheelchairs are not normally utilized. Baseline levels of mobility are not normally achieved until several weeks after surgery, however.

 

 

36. A patient has recently been admitted to the orthopedic unit following total hip arthroplasty. The patient has a closed suction device in place and the nurse has determined that there were 320 mL of output in the first 24 hours. How should the nurse best respond to this assessment finding?
A) Inform the primary care provider promptly.
B) Document this as an expected assessment finding.
C) Limit the patient’s fluid intake to 2 liters for the next 24 hours.
D) Administer a loop diuretic as ordered.
Ans: B
Feedback:
Drainage of 200 to 500 mL in the first 24 hours is expected. Consequently, the nurse does not need to inform the physician. Fluid restriction and medication administration are not indicated.

 

 

37. A nurse is reviewing a patient’s activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation?
A) Straining during a bowel movement
B) Bending down to put on socks
C) Lifting items above shoulder level
D) Transferring from a sitting to standing position
Ans: B
Feedback:
Bending to put on socks or shoes can cause hip dislocation. None of the other listed actions poses a serious threat to the integrity of the new hip.

 

 

38. A 91-year-old patient is slated for orthopedic surgery and the nurse is integrated gerontologic considerations into the patient’s plan of care. What intervention is most justified in the care of this patient?
A) Administration of prophylactic antibiotics
B) Total parenteral nutrition (TPN)
C) Use of a pressure-relieving mattress
D) Use of a Foley catheter until discharge
Ans: C
Feedback:
Older adults have a heightened risk of skin breakdown; use of a pressure-reducing mattress addresses this risk. Older adults do not necessarily need TPN and the Foley catheter should be discontinued as soon as possible to prevent urinary tract infections. Prophylactic antibiotics are not a standard infection prevention measure.

 

 

39. A nurse is emptying an orthopedic surgery patient’s closed suction drainage at the end of a shift. The nurse notes that the volume is within expected parameters but that the drainage has a foul odor. What is the nurse’s best action?
A) Aspirate a small amount of drainage for culturing.
B) Advance the drain 1 to 1.5 cm.
C) Irrigate the drain with normal saline.
D) Inform the surgeon of this finding.
Ans: D
Feedback:
The nurse should promptly notify the surgeon of excessive or foul-smelling drainage.  It would be inappropriate to advance the drain, irrigate the drain, or aspirate more drainage.

 

 

40. A nurse is planning the care of a patient who has undergone orthopedic surgery. What main goal should guide the nurse’s choice of interventions?
A) Improving the patient’s level of function
B) Helping the patient come to terms with limitations
C) Administering medications safely
D) Improving the patient’s adherence to treatment
Ans: A
Feedback:
Improving function is the overarching goal after orthopedic surgery. Some patients may need to come to terms with limitations, but this is not true of every patient. Safe medication administration is imperative, but this is not a goal that guides other aspects of care. Similarly, adherence to treatment is important, but this is motivated by the need to improve functional status.

 

1. A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient?
A) Bathe daily and keep the perineal region clean.
B) Avoid voiding immediately after sexual intercourse.
C) Drink liberal amounts of fluids.
D) Void at least every 6 to 8 hours.
Ans: C
Feedback:
The patient is encouraged to drink liberal amounts of fluids (water is the best choice) to increase urine production and flow, which flushes the bacteria from the urinary tract. Frequent voiding (every 2 to 3 hours) is encouraged to empty the bladder completely because this can significantly lower urine bacterial counts, reduce urinary stasis, and prevent reinfection. The patient should be encouraged to shower rather than bathe.

 

 

2. A 42-year-old woman comes to the clinic complaining of occasional urinary incontinence when she sneezes. The clinic nurse should recognize what type of incontinence?
A) Stress incontinence
B) Reflex incontinence
C) Overflow incontinence
D) Functional incontinence
Ans: A
Feedback:
Stress incontinence is the involuntary loss of urine through an intact urethra as a result of sudden increase in intra-abdominal pressure. Reflex incontinence is loss of urine due to hyperreflexia or involuntary urethral relaxation in the absence of normal sensations usually associated with voiding. Overflow incontinence is an involuntary urine loss associated with overdistension of the bladder. Functional incontinence refers to those instances in which the function of the lower urinary tract is intact, but other factors (outside the urinary system) make it difficult or impossible for the patient to reach the toilet in time for voiding.

 

 

3. A nurse is caring for a female patient whose urinary retention has not responded to conservative treatment. When educating this patient about self-catheterization, the nurse should encourage what practice?
A) Assuming a supine position for self-catheterization
B) Using clean technique at home to catheterize
C) Inserting the catheter 1 to 2 inches into the urethra
D) Self-catheterizing every 2 hours at home
Ans: B
Feedback:
The patient may use a “clean” (nonsterile) technique at home, where the risk of cross-contamination is reduced. The average daytime clean intermittent catheterization schedule is every 4 to 6 hours and just before bedtime. The female patient assumes a Fowler’s position and uses a mirror to help locate the urinary meatus. The nurse teaches her to catheterize herself by inserting a catheter 7.5 cm (3 inches) into the urethra, in a downward and backward direction.

 

 

4. A 52-year-old patient is scheduled to undergo ileal conduit surgery. When planning this patient’s discharge education, what is the most plausible nursing diagnosis that the nurse should address?
A) Impaired mobility related to limitations posed by the ileal conduit
B) Deficient knowledge related to care of the ileal conduit
C) Risk for deficient fluid volume related to urinary diversion
D) Risk for autonomic dysreflexia related to disruption of the sacral plexus
Ans: B
Feedback:
The patient will most likely require extensive teaching about the care and maintenance of a new urinary diversion. A diversion does not create a serious risk of fluid volume deficit. Mobility is unlikely to be impaired after the immediate postsurgical recovery. The sacral plexus is not threatened by the creation of a urinary diversion.

 

 

5. The nurse on a urology unit is working with a patient who has been diagnosed with oxalate renal calculi. When planning this patient’s health education, what nutritional guidelines should the nurse provide?
A) Restrict protein intake as ordered.
B) Increase intake of potassium-rich foods.
C) Follow a low-calcium diet.
D) Encourage intake of food containing oxalates.
Ans: A
Feedback:
Protein is restricted to 60 g/d, while sodium is restricted to 3 to 4 g/d. Low-calcium diets are generally not recommended except for true absorptive hypercalciuria. The patient should avoid intake of oxalate-containing foods and there is no need to increase potassium intake.

 

 

6. The nurse is caring for a patient who underwent percutaneous lithotripsy earlier in the day.  What instruction should the nurse give the patient?
A) Limit oral fluid intake for 1 to 2 days.
B) Report the presence of fine, sand like particles through the nephrostomy tube.
C) Notify the physician about cloudy or foul-smelling urine.
D) Report any pink-tinged urine within 24 hours after the procedure.
Ans: C
Feedback:
The patient should report the presence of foul-smelling or cloudy urine since this is suggestive of a UTI. Unless contraindicated, the patient should be instructed to drink large quantities of fluid each day to flush the kidneys. Sand like debris is normal due to residual stone products. Hematuria is common after lithotripsy.

 

 

7. A female patient’s most recent urinalysis results are suggestive of bacteriuria. When assessing this patient, the nurse’s data analysis should be informed by what principle?
A) Most UTIs in female patients are caused by viruses and do not cause obvious symptoms.
B) A diagnosis of bacteriuria requires three consecutive positive results.
C) Urine contains varying levels of healthy bacterial flora.
D) Urine samples are frequently contaminated by bacteria normally present in the urethral area.
Ans: D
Feedback:
Because urine samples (especially in women) are commonly contaminated by the bacteria normally present in the urethral area, a bacterial count exceeding 105 colonies/mL of clean-catch, midstream urine is the measure that distinguishes true bacteriuria from contamination. A diagnosis does not require three consecutive positive results and urine does not contain a normal flora in the absence of a UTI. Most UTIs have a bacterial etiology.

 

 

8. The clinic nurse is preparing a plan of care for a patient with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach?
A) Provide medication teaching related to pseudoephedrine sulfate.
B) Teach the patient to perform pelvic floor muscle exercises.
C) Prepare the patient for an anterior vaginal repair procedure.
D) Provide information on periurethral bulking.
Ans: B
Feedback:
Pelvic floor muscle exercises (sometimes called Kegel exercises) represent the cornerstone of behavioral intervention for addressing symptoms of stress, urge, and mixed incontinence. None of the other listed interventions has a behavioral approach.

 

 

9. The nurse and urologist have both been unsuccessful in catheterizing a patient with a prostatic obstruction and a full bladder. What approach does the nurse anticipate the physician using to drain the patient’s bladder?
A) Insertion of a suprapubic catheter
B) Scheduling the patient immediately for a prostatectomy
C) Application of warm compresses to the perineum to assist with relaxation
D) Medication administration to relax the bladder muscles and reattempting catheterization in 6 hours
Ans: A
Feedback:
When the patient cannot void, catheterization is used to prevent overdistention of the bladder. In the case of prostatic obstruction, attempts at catheterization by the urologist may not be successful, requiring insertion of a suprapubic catheter. A prostatectomy may be necessary, but would not be undertaken for the sole purpose of relieving a urethral obstruction. Delaying by applying compresses or administering medications could result in harm.

 

 

10. The nurse has implemented a bladder retraining program for an older adult patient. The nurse places the patient on a timed voiding schedule and performs an ultrasonic bladder scan after each void. The nurse notes that the patient typically has approximately 50 mL of urine remaining in her bladder after voiding. What would be the nurse’s best response to this finding?
A) Perform a straight catheterization on this patient.
B) Avoid further interventions at this time, as this is an acceptable finding.
C) Place an indwelling urinary catheter.
D) Press on the patient’s bladder in an attempt to encourage complete emptying.
Ans: B
Feedback:
In adults older than 60 years of age, 50 to 100 mL of residual urine may remain after each voiding because of the decreased contractility of the detrusor muscle. Consequently, further interventions are not likely warranted.

 

 

11. The nurse is caring for a patient recently diagnosed with renal calculi. The nurse should instruct the patient to increase fluid intake to a level where the patient produces at least how much urine each day?
A) 1,250 mL
B) 2,000 mL
C) 2,750 mL
D) 3,500 mL
Ans: B
Feedback:
Unless contraindicated by renal failure or hydronephrosis, patients with renal stones should drink at least eight 8-ounce glasses of water daily or have IV fluids prescribed to keep the urine dilute. A urine output exceeding 2 L a day is advisable.

 

 

12. A patient with cancer of the bladder has just returned to the unit from the PACU after surgery to create an ileal conduit. The nurse is monitoring the patient’s urine output hourly and notifies the physician when the hourly output is less than what?
A) 30 mL
B) 50 mL
C) 100 mL
D) 125 mL
Ans: A
Feedback:
A urine output below 30 mL/hr may indicate dehydration or an obstruction in the ileal conduit, with possible backflow or leakage from the ureteroileal anastomosis.

 

 

13. The nurse is caring for a patient with an indwelling urinary catheter. The nurse is aware that what nursing action helps prevent infection in a patient with an indwelling catheter?
A) Vigorously clean the meatus area daily.
B) Apply powder to the perineal area twice daily.
C) Empty the drainage bag at least every 8 hours.
D) Irrigate the catheter every 8 hours with normal saline.
Ans: C
Feedback:
To reduce the risk of bacterial proliferation, the nurse should empty the collection bag at least every 8 hours through the drainage spout, and more frequently if there is a large volume of urine. Vigorous cleaning of the meatus while the catheter is in place is discouraged, because the cleaning action can move the catheter, increasing the risk of infection. The spout (or drainage port) of any urinary drainage bag can become contaminated when opened to drain the bag. Irrigation of the catheter opens the closed system, increasing the likelihood of infection.

 

 

14. The nurse is teaching a health class about UTIs to a group of older adults. What characteristic of UTIs should the nurse cite?
A) Men over age 65 are equally prone to UTIs as women, but are more often asymptomatic.
B) The prevalence of UTIs in men older than 50 years of age approaches that of women in the same age group.
C) Men of all ages are less prone to UTIs, but typically experience more severe symptoms.
D) The prevalence of UTIs in men cannot be reliably measured, as men generally do not report UTIs.
Ans: B
Feedback:
The antibacterial activity of the prostatic secretions that protect men from bacterial colonization of the urethra and bladder decreases with aging. The prevalence of infection in men older than 50 years of age approaches that of women in the same age group. Men are not more likely to be asymptomatic and are not known to be reluctant to report UTIs.

 

 

15. A patient has been admitted to the postsurgical unit following the creation of an ileal conduit. What should the nurse measure to determine the size of the appliance needed?
A) The circumference of the stoma
B) The narrowest part of the stoma
C) The widest part of the stoma
D) Half the width of the stoma
Ans: C
Feedback:
The correct appliance size is determined by measuring the widest part of the stoma with a ruler. The permanent appliance should be no more than 1.6 mm (1/8 inch) larger than the diameter of the stoma and the same shape as the stoma to prevent contact of the skin with drainage.

 

 

16. A patient being treated in the hospital has been experiencing occasional urinary retention. What nursing action should the nurse take to encourage a patient who is having difficulty voiding?
A) Use a slipper bedpan.
B) Apply a cold compress to the perineum.
C) Have the patient lie in a supine position.
D) Provide privacy for the patient.
Ans: D
Feedback:
Nursing measures to encourage normal voiding patterns include providing privacy, ensuring an environment and body position conducive to voiding, and assisting the patient with the use of the bathroom or bedside commode, rather than a bedpan, to provide a more natural setting for voiding. Most people find supine positioning not conducive to voiding.

 

 

17. A nurse’s colleague has applied an incontinence pad to an older adult patient who has experienced occasional episodes of functional incontinence. What principle should guide the nurse’s management of urinary incontinence in older adults?
A) Diuretics should be promptly discontinued when an older adult experiences incontinence.
B) Restricting fluid intake is recommended for older adults experiencing incontinence.
C) Urinary catheterization is a first-line treatment for incontinence in older adults with incontinence.
D) Urinary incontinence is not considered a normal consequence of aging.
Ans: D
Feedback:
Nursing management is based on the premise that incontinence is not inevitable with illness or aging and that it is often reversible and treatable. Diuretics cannot always be safely discontinued. Fluid restriction and catheterization are not considered to be safe, first-line interventions for the treatment of incontinence.

 

 

18. The nurse is working with a patient who has been experiencing episodes of urinary retention. What assessment finding would suggest that the patient is experiencing retention?
A) The patient’s suprapubic region is dull on percussion.
B) The patient is uncharacteristically drowsy.
C) The patient claims to void large amounts of urine 2 to 3 times daily.
D) The patient takes a beta adrenergic blocker for the treatment of hypertension.
Ans: A
Feedback:
Dullness on percussion of the suprapubic region is suggestive of urinary retention. Patients retaining urine are typically restless, not drowsy. A patient experiencing retention usually voids frequent, small amounts of urine and the use of beta-blockers is unrelated to urinary retention.

 

 

19. A patient with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the patient’s post-procedure care?
A) Strain the patient’s urine following the procedure.
B) Administer a bolus of 500 mL normal saline following the procedure.
C) Monitor the patient for fluid overload following the procedure.
D) Insert a urinary catheter for 24 to 48 hours after the procedure.
Ans: A
Feedback:
Following ESWL, the nurse should strain the patient’s urine for gravel or sand. There is no need to administer an IV bolus after the procedure and there is not a heightened risk of fluid overload. Catheter insertion is not normally indicated following ESWL.

 

 

20. The nurse is caring for a patient who has undergone creation of a urinary diversion. Forty-eight hours postoperatively, the nurse’s assessment reveals that the stoma is a dark purplish color. What is the nurse’s most appropriate response?
A) Document the presence of a healthy stoma.
B) Assess the patient for further signs and symptoms of infection.
C) Inform the primary care provider that the vascular supply may be compromised.
D) Liaise with the wound-ostomy-continence (WOC) nurse because the ostomy appliance around the stoma may be too loose.
Ans: C
Feedback:
A healthy stoma is pink or red. A change from this normal color to a dark purplish color suggests that the vascular supply may be compromised. A loose ostomy appliance and infections do not cause a dark purplish stoma.

 

 

21. A patient is undergoing diagnostic testing for a suspected urinary obstruction. The nurse should know that incomplete emptying of the bladder due to bladder outlet obstruction can cause what?
A) Hydronephrosis
B) Nephritic syndrome
C) Pylonephritis
D) Nephrotoxicity
Ans: A
Feedback:
If voiding dysfunction goes undetected and untreated, the upper urinary system may become compromised. Chronic incomplete bladder emptying from poor detrusor pressure results in recurrent bladder infection. Incomplete bladder emptying due to bladder outlet obstruction, causing high-pressure detrusor contractions, can result in hydronephrosis from the high detrusor pressure that radiates up the ureters to the renal pelvis. This problem does not normally cause nephritic syndrome or pyelonephritis. Nephrotoxicity results from chemical causes.

 

 

22. The nurse is assessing a patient admitted with renal stones. During the admission assessment, what parameters would be priorities for the nurse to address? Select all that apply.
A) Dietary history
B) Family history of renal stones
C) Medication history
D) Surgical history
E) Vaccination history
Ans: A, B, C
Feedback:
Dietary and medication histories and family history of renal stones are obtained to identify factors predisposing the patient to stone formation. When caring for a patient with renal stones it would not normally be a priority to assess the vaccination history or surgical history, since these factors are not usually related to the etiology of kidney stones.

 

 

23. A nurse who provides care in a long-term care facility is aware of the high incidence and prevalence of urinary tract infections among older adults. What action has the greatest potential to prevent UTIs in this population?
A) Administer prophylactic antibiotics as ordered.
B) Limit the use of indwelling urinary catheters.
C) Encourage frequent mobility and repositioning.
D) Toilet residents who are immobile on a scheduled basis.
Ans: B
Feedback:
When indwelling catheters are used, the risk of UTI increases dramatically. Limiting their use significantly reduces an older adult’s risk of developing a UTI. Regular toileting promotes continence, but has only an indirect effect on the risk of UTIs. Prophylactic antibiotics are not normally administered. Mobility does not have a direct effect on UTI risk.

 

 

24. A gerontologic nurse is assessing a patient who has numerous comorbid health problems. What assessment findings should prompt the nurse to suspect a UTI? Select all that apply.
A) Food cravings
B) Upper abdominal pain
C) Insatiable thirst
D) Uncharacteristic fatigue
E) New onset of confusion
Ans: D
Feedback:
The most common subjective presenting symptom of UTI in older adults is generalized fatigue. The most common objective finding is a change in cognitive functioning. Food cravings, increased thirst, and upper abdominal pain necessitate further assessment and intervention, but none is directly suggestive of a UTI.

 

 

25. A female patient has been prescribed a course of antibiotics for the treatment of a UTI. When providing health education for the patient, the nurse should address what topic?
A) The risk of developing a vaginal yeast infection as a consequent of antibiotic therapy
B) The need to expect a heavy menstrual period following the course of antibiotics
C) The risk of developing antibiotic resistance after the course of antibiotics
D) The need to undergo a series of three urine cultures after the antibiotics have been completed
Ans: A
Feedback:
Yeast vaginitis occurs in as many as 25% of patients treated with antimicrobial agents that affect vaginal flora. Yeast vaginitis can cause more symptoms and be more difficult and costly to treat than the original UTI. Antibiotics do not affect menstrual periods and serial urine cultures are not normally necessary. Resistance is normally a result of failing to complete a prescribed course of antibiotics.

 

 

26. An adult patient has been hospitalized with pyelonephritis. The nurse’s review of the patient’s intake and output records reveals that the patient has been consuming between 3 L and 3.5 L of oral fluid each day since admission. How should the nurse best respond to this finding?
A) Supplement the patient’s fluid intake with a high-calorie diet.
B) Emphasize the need to limit intake to 2 L of fluid daily.
C) Obtain an order for a high-sodium diet to prevent dilutional hyponatremia.
D) Encourage the patient to continue this pattern of fluid intake.
Ans: D
Feedback:
Unless contraindicated, 3 to 4 L of fluids per day is encouraged to dilute the urine, decrease burning on urination, and prevent dehydration. No need to supplement this fluid intake with additional calories or sodium.

 

 

27. An older adult has experienced a new onset of urinary incontinence and family members identify this problem as being unprecedented. When assessing the patient for factors that may have contributed to incontinence, the nurse should prioritize what assessment?
A) Reviewing the patient’s 24-hour food recall for changes in diet
B) Assessing for recent contact with individuals who have UTIs
C) Assessing for changes in the patient’s level of psychosocial stress
D) Reviewing the patient’s medication administration record for recent changes
Ans: D
Feedback:
Many medications affect urinary continence in addition to causing other unwanted or unexpected effects. Stress and dietary changes could potentially affect the patient’s continence, but medications are more frequently causative of incontinence. UTIs can cause incontinence, but these infections do not result from contact with infected individuals.

 

 

28. A nurse is working with a female patient who has developed stress urinary incontinence. Pelvic floor muscle exercises have been prescribed by the primary care provider. How can the nurse best promote successful treatment?
A) Clearly explain the potential benefits of pelvic floor muscle exercises.
B) Ensure the patient knows that surgery will be required if the exercises are unsuccessful.
C) Arrange for biofeedback when the patient is learning to perform the exercises.
D) Contact the patient weekly to ensure that she is performing the exercises consistently.
Ans: C
Feedback:
Research shows that written or verbal instruction alone is usually inadequate to teach an individual how to identify and strengthen the pelvic floor for sufficient bladder and bowel control. Biofeedback-assisted pelvic muscle exercise (PME) uses either electromyography or manometry to help the individual identify the pelvic muscles as he or she attempts to learn which muscle group is involved when performing PME. This objective assessment is likely superior to weekly contact with the patient. Surgery is not necessarily indicated if behavioral techniques are unsuccessful.

 

 

29. A patient has a flaccid bladder secondary to a spinal cord injury. The nurse recognizes this patient’s high risk for urinary retention and should implement what intervention in the patient’s plan of care?
A) Relaxation techniques
B) Sodium restriction
C) Lower abdominal massage
D) Double voiding
Ans: D
Feedback:
To enhance emptying of a flaccid bladder, the patient may be taught to “double void.” After each voiding, the patient is instructed to remain on the toilet, relax for 1 to 2 minutes, and then attempt to void again in an effort to further empty the bladder. Relaxation does not affect the neurologic etiology of a flaccid bladder. Sodium restriction and massage are similarly ineffective.

 

 

30. A patient with a sacral pressure ulcer has had a urinary catheter inserted. As a result of this new intervention, the nurse should prioritize what nursing diagnosis in the patient’s plan of care?
A) Impaired physical mobility related to presence of an indwelling urinary catheter
B) Risk for infection related to presence of an indwelling urinary catheter
C) Toileting self-care deficit related to urinary catheterization
D) Disturbed body image related to urinary catheterization
Ans: B
Feedback:
Catheters create a high risk for UTIs. Because of this acute physiologic threat, the patient’s risk for infection is usually prioritized over functional and psychosocial diagnoses.

 

 

31. A patient has had her indwelling urinary catheter removed after having it in place for 10 days during recovery from an acute illness. Two hours after removal of the catheter, the patient informs the nurse that she is experiencing urinary urgency resulting in several small-volume voids. What is the nurse’s best response?
A) Inform the patient that urgency and occasional incontinence are expected for the first few weeks post-removal.
B) Obtain an order for a loop diuretic in order to enhance urine output and bladder function.
C) Inform the patient that this is not unexpected in the short term and scan the patient’s bladder following each void.
D) Obtain an order to reinsert the patient’s urinary catheter and attempt removal in 24 to 48 hours.
Ans: C
Feedback:
Immediately after the indwelling catheter is removed, the patient is placed on a timed voiding schedule, usually every 2 to 3 hours. At the given time interval, the patient is instructed to void. The bladder is then scanned using a portable ultrasonic bladder scanner; if the bladder has not emptied completely, straight catheterization may be performed. An indwelling catheter would not be reinserted to resolve the problem and diuretics would not be beneficial. Ongoing incontinence is not an expected finding after catheter removal.

 

 

32. A nurse on a busy medical unit provides care for many patients who require indwelling urinary catheters at some point during their hospital care. The nurse should recognize a heightened risk of injury associated with indwelling catheter use in which patient?
A) A patient whose diagnosis of chronic kidney disease requires a fluid restriction
B) A patient who has Alzheimer’s disease and who is acutely agitated
C) A patient who is on bed rest following a recent episode of venous thromboembolism
D) A patient who has decreased mobility following a transmetatarsal amputation
Ans: B
Feedback:
Patients who are confused and agitated risk trauma through the removal of an indwelling catheter which has the balloon still inflated. Recent VTE, amputation, and fluid restriction do not directly create a risk for injury or trauma associated with indwelling catheter use.

 

 

33. A patient has been admitted to the medical unit with a diagnosis of ureteral colic secondary to urolithiasis. When planning the patient’s admission assessment, the nurse should be aware of the signs and symptoms that are characteristic of this diagnosis? Select all that apply.
A) Diarrhea
B) High fever
C) Hematuria
D) Urinary frequency
E) Acute pain
Ans: C, D, E
Feedback:
Stones lodged in the ureter (ureteral obstruction) cause acute, excruciating, colicky, wavelike pain, radiating down the thigh and to the genitalia. Often, the patient has a desire to void, but little urine is passed, and it usually contains blood because of the abrasive action of the stone. This group of symptoms is called ureteral colic. Diarrhea is not associated with this presentation and a fever is usually absent due to the noninfectious nature of the health problem.

 

 

34. A patient with a recent history of nephrolithiasis has presented to the ED. After determining that the patient’s cardiopulmonary status is stable, what aspect of care should the nurse prioritize?
A) IV fluid administration
B) Insertion of an indwelling urinary catheter
C) Pain management
D) Assisting with aspiration of the stone
Ans: C
Feedback:
The patient with kidney stones is often in excruciating pain, and this is a high priority for nursing interventions. In the short term, this would supersede the patient’s need for IV fluids or for catheterization. Kidney stones cannot be aspirated.

 

 

35. A patient has been successfully treated for kidney stones and is preparing for discharge. The nurse recognizes the risk of recurrence and has planned the patient’s discharge education accordingly. What preventative measure should the nurse encourage the patient to adopt?
A) Increasing intake of protein from plant sources
B) Increasing fluid intake
C) Adopting a high-calcium diet
D) Eating several small meals each day
Ans: B
Feedback:
Increased fluid intake is encouraged to prevent the recurrence of kidney stones. Protein intake from all sources should be limited. Most patients do not require a low-calcium diet, but increased calcium intake would be contraindicated for all patients. Eating small, frequent meals does not influence the risk for recurrence.

 

 

36. A patient who has recently undergone ESWL for the treatment of renal calculi has phoned the urology unit where he was treated, telling the nurse that he has a temperature of 101.1ºF (38.4ºC). How should the nurse best respond to the patient?
A) Remind the patient that renal calculi have a noninfectious etiology and that a fever is unrelated to their recurrence.
B) Remind the patient that occasional febrile episodes are expected following ESWL.
C) Tell the patient to report to the ED for further assessment.
D) Tell the patient to monitor his temperature for the next 24 hours and then contact his urologist’s office.
Ans: C
Feedback:
Following ESWL, the development of a fever is abnormal and is suggestive of a UTI; prompt medical assessment and treatment are warranted. It would be inappropriate to delay further treatment.

 

 

37. The nurse who is leading a wellness workshop has been asked about actions to reduce the risk of bladder cancer. What health promotion action most directly addresses a major risk factor for bladder cancer?
A) Smoking cessation
B) Reduction of alcohol intake
C) Maintenance of a diet high in vitamins and nutrients
D) Vitamin D supplementation
Ans: A
Feedback:
People who smoke develop bladder cancer twice as often as those who do not smoke. High alcohol intake and low vitamin intake are not noted to contribute to bladder cancer.

 

 

38. Resection of a patient’s bladder tumor has been incomplete and the patient is preparing for the administration of the first ordered instillation of topical chemotherapy. When preparing the patient, the nurse should emphasize the need to do which of the following?
A) Remain NPO for 12 hours prior to the treatment.
B) Hold the solution in the bladder for 2 hours before voiding.
C) Drink the intravesical solution quickly and on an empty stomach.
D) Avoid acidic foods and beverages until the full cycle of treatment is complete.
Ans: B
Feedback:
The patient is allowed to eat and drink before the instillation procedure. Once the bladder is full, the patient must retain the intravesical solution for 2 hours before voiding. The solution is instilled through the meatus; it is not consumed orally. There is no need to avoid acidic foods and beverages during treatment.

 

 

39. The nurse has tested the pH of urine from a patient’s newly created ileal conduit and obtained a result of 6.8. What is the nurse’s best response to this assessment finding?
A) Obtain an order to increase the patient’s dose of ascorbic acid.
B) Administer IV sodium bicarbonate as ordered.
C) Encourage the patient to drink at least 500 mL of water and retest in 3 hours.
D) Irrigate the ileal conduit with a dilute citric acid solution as ordered.
Ans: A
Feedback:
Because severe alkaline encrustation can accumulate rapidly around the stoma, the urine pH is kept below 6.5 by administration of ascorbic acid by mouth. An increased pH may suggest a need to increase ascorbic acid dosing. This is not treated by administering bicarbonate or citric acid, nor by increasing fluid intake.

 

 

40. A patient is postoperative day 3 following the creation of an ileal conduit for the treatment of invasive bladder cancer. The patient is quickly learning to self-manage the urinary diversion, but expresses concern about the presence of mucus in the urine. What is the nurse’s most appropriate response?
A) Report this finding promptly to the primary care provider.
B) Obtain a sterile urine sample and send it for culture.
C) Obtain a urine sample and check it for pH.
D) Reassure the patient that this is an expected phenomenon.
Ans: D
Feedback:
Because mucous membrane is used in forming the conduit, the patient may excrete a large amount of mucus mixed with urine. This causes anxiety in many patients. To help relieve this anxiety, the nurse reassures the patient that this is a normal occurrence after an ileal conduit procedure. Urine testing for culture or pH is not required.

 

 

41. The nurse is collaborating with the wound-ostomy-continence (WOC) nurse to teach a patient how to manage her new ileal conduit in the home setting. To prevent leakage or skin breakdown, the nurse should encourage which of the following practices?
A) Empty the collection bag when it is between one-half and two-thirds full.
B) Limit fluid intake to prevent production of large volumes of dilute urine.
C) Reinforce the appliance with tape if small leaks are detected.
D) Avoid using moisturizing soaps and body washes when cleaning the peristomal area.
Ans: D
Feedback:
The patient is instructed to avoid moisturizing soaps and body washes when cleaning the area because they interfere with the adhesion of the pouch. To maintain skin integrity, a skin barrier or leaking pouch is never patched with tape to prevent accumulation of urine under the skin barrier or faceplate. Fluids should be encouraged, not limited, and the collection bag should not be allowed to become more than one-third full.

 

 

42. A patient has undergone the creation of an Indiana pouch for the treatment of bladder cancer. The nurse identified the nursing diagnosis of “disturbed body image.” How can the nurse best address the effects of this urinary diversion on the patient’s body image?
A) Emphasize that the diversion is an integral part of successful cancer treatment.
B) Encourage the patient to speak openly and frankly about the diversion.
C) Allow the patient to initiate the process of providing care for the diversion.
D) Provide the patient with detailed written materials about the diversion at the time of discharge.
Ans: B
Feedback:
Allowing the patient to express concerns and anxious feelings can help with body image, especially in adjusting to the changes in toileting habits. The nurse may have to initiate dialogue about the management of the diversion, especially if the patient is hesitant. Provision of educational materials is rarely sufficient to address a sudden change and profound change in body image. Emphasizing the role of the diversion in cancer treatment does not directly address the patient’s body image.

 

1. A male patient comes to the clinic and is diagnosed with gonorrhea. Which symptom most likely prompted him to seek medical attention?
A) Rashes on the palms of the hands and soles of the feet
B) Cauliflower-like warts on the penis
C) Painful, red papules on the shaft of the penis
D) Foul-smelling discharge from the penis
Ans: D
Feedback:
Signs and symptoms of gonorrhea in men include purulent, foul-smelling drainage from the penis and painful urination. Rashes on the palms of the hands and soles of the feet are a sign of the secondary stage of syphilis. Cauliflower-like warts on the penis are a sign of human papillomavirus. Painful red papules on the shaft of the penis may be a sign of the first stage of genital herpes.

 

 

2. A nurse is caring for a child who was admitted to the pediatric unit with infectious diarrhea.  The nurse should be alert to what assessment finding as an indicator of dehydration?
A) Labile BP
B) Weak pulse
C) Fever
D) Diaphoresis
Ans: B
Feedback:
Assessment of dehydration includes evaluation of thirst, oral mucous membrane dryness, sunken eyes, a weakened pulse, and loss of skin turgor.  Diaphoresis, labile BP, and fever are not characteristic signs and symptoms of dehydration.

 

 

3. A nursing home patient has been diagnosed with Clostridium difficile. What type of precautions should the nurse implement to prevent the spread of this infectious disease to other residents?
A) Contact
B) Droplet
C) Airborne
D) Positive pressure isolation
Ans: A
Feedback:
Contact precautions are used for organisms that are spread by skin-to-skin contact, such as antibiotic-resistant organisms or Clostridium difficile. Droplet precautions are used for organisms that can be transmitted by close, face-to-face contact, such as influenza or meningococcal meningitis. Airborne precautions are required for patients with presumed or proven pulmonary TB or chickenpox. Positive pressure isolation is unnecessary and ineffective.

 

 

4. A nurse who provides care in a busy ED is in contact with hundreds of patients each year. The nurse has a responsibility to receive what vaccine?
A) Hepatitis B vaccine
B) Human papillomavirus (HPV) vaccine
C) Clostridium difficile vaccine
D) Staphylococcus aureus vaccine
Ans: A
Feedback:
Nurses should recognize their personal responsibility to receive the hepatitis B vaccine and an annual influenza vaccine to reduce potential transmission to themselves and vulnerable patient groups. HPV is not a threat because it is sexually transmitted. No vaccines are available against C. difficile and S. aureus.

 

 

5. When a disease infects a host a portal of entry is needed for an organism to gain access. What has been identified as the portal of entry for tuberculosis?
A) Integumentary system
B) Urinary system
C) Respiratory system
D) Gastrointestinal system
Ans: C
Feedback:
The portal of entry for M. tuberculosis is through the respiratory tract.

 

 

6. A patient has a concentration of S. aureus located on his skin. The patient is not showing signs of increased temperature, redness, or pain at the site. The nurse is aware that this is a sign of a microorganism at which of the following stages?
A) Infection
B) Colonization
C) Disease
D) Bacteremia
Ans: B
Feedback:
Colonization refers to the presence of microorganisms without host interference or interaction. Infection is a condition in which the host interacts physiologically and immunologically with a microorganism. Disease is the decline in wellness of a host due to infection. Bacteremia is a condition of bacteria in the blood.

 

 

7. An infectious outbreak of unknown origin has occurred in a long-term care facility. The nurse who oversees care at the facility should report the outbreak to what organization?
A) Centers for Disease Control and Prevention (CDC)
B) American Medical Association (AMA)
C) Environmental Protection Agency (EPA)
D) American Nurses Association (ANA)
Ans: A
Feedback:
The goals of the CDC are to provide scientific recommendations regarding disease prevention and control to reduce disease, which it includes in publications. As such, outbreaks of unknown origin should normally be reported to the CDC. The AMA is the professional organization for medical doctors; the EPA oversees our environment; the ANA is the professional organization for American nurses.

 

 

8. The infectious control nurse is presenting a program on West Nile virus for a local community group. To reduce the incidence of this disease, the nurse should recommend what action?
A) Covering open wounds at all times
B) Vigilant handwashing in home and work settings
C) Consistent use of mosquito repellants
D) Annual vaccination
Ans: C
Feedback:
West Nile virus is transmitted by mosquitoes, which become infected by biting birds that are infected with the virus. Prevention of mosquito bites can reduce the risk of contracting the disease. Handwashing and bandaging open wounds are appropriate general infection control measures, but these actions do not specifically prevent West Nile virus for which no vaccine currently exists.

 

 

9. An immunosuppressed patient is receiving chemotherapy treatment at home. What infection-control measure should the nurse recommend to the family?
A) Family members should avoid receiving vaccinations until the patient has recovered from his or her illness.
B) Wipe down hard surfaces with a dilute bleach solution once per day.
C) Maintain cleanliness in the home, but recognize that the home does not need to be sterile.
D) Avoid physical contact with the patient unless absolutely necessary.
Ans: C
Feedback:
When assessing the risk of the immunosuppressed patient in the home environment for infection, it is important to realize that intrinsic colonizing bacteria and latent viral infections present a greater risk than do extrinsic environmental contaminants. The nurse should reassure the patient and family that their home needs to be clean but not sterile. Common-sense approaches to cleanliness and risk reduction are helpful. The family need not avoid vaccinations and it is unnecessary to avoid all contact or to wipe down surfaces daily.

 

 

10. A medical nurse is careful to adhere to infection control protocols, including handwashing. Which statement about handwashing supports the nurse’s practice?
A) Frequent handwashing reduces transmission of pathogens from one patient to another.
B) Wearing gloves is known to be an adequate substitute for handwashing.
C) Bar soap is preferable to liquid soap.
D) Waterless products should be avoided in situations where running water is unavailable.
Ans: A
Feedback:
Whether gloves are worn or not, handwashing is required before and after patient contact because thorough handwashing reduces the risk of cross-contamination. Bar soap should not be used because it is a potential carrier of bacteria. Soap dispensers are preferable, but they must also be checked for bacteria. When water is unavailable, the nurse should wash using a liquid hand sanitizer.

 

 

11. A male patient with gonorrhea asks the nurse how he can reduce his risk of contracting another sexually transmitted infection. The patient is not in a monogamous relationship. The nurse should instruct the patient to do which of the following?
A) Ask all potential sexual partners if they have a sexually transmitted disease.
B) Wear a condom every time he has intercourse.
C) Consider intercourse to be risk-free if his partner has no visible discharge, lesions, or rashes.
D) Aim to limit the number of sexual partners to fewer than five over his lifetime.
Ans: B
Feedback:
Wearing a condom during intercourse considerably reduces the risk of contracting STIs. The other options may help reduce the risk for contracting an STI, but not to the extent that wearing a condom will. A monogamous relationship reduces the risk of contracting STIs.

 

 

12. The nurse places a patient in isolation. Isolation techniques have the potential to break the chain of infection by interfering with what component of the chain of infection?
A) Mode of transmission
B) Agent
C) Susceptible host
D) Portal of entry
Ans: A
Feedback:
Isolation techniques attempt to break the chain of infection by interfering with the transmission mode. These techniques do not directly affect the agent, host, or portal of entry.

 

 

13. The nurse is caring for a patient who is colonized with methicillin-resistant Staphylococcus aureus (MRSA). What infection control measure has the greatest potential to reduce transmission of MRSA and other nosocomial pathogens in a health care setting?
A) Using antibacterial soap when bathing patients with MRSA
B) Conducting culture surveys on a regularly scheduled basis
C) Performing hand hygiene before and after contact with every patient
D) Using aseptic housekeeping practices for environmental cleaning
Ans: C
Feedback:
Handwashing is the major infection control measure to reduce the risk of transmission of MRSA and other nosocomial pathogens. No convincing evidence exists to support that bathing patients with antibacterial soap is effective. Culture surveys can help establish the true prevalence of MRSA in a facility, but are used only to help implement where and when infection-control measures are needed. Hand hygiene is known to be more clinically important than housekeeping.

 

 

14. A patient on Airborne Precautions asks the nurse to leave his door open. What is the nurse’s best reply?
A) “I have to keep your door shut at all times. I’ll open the curtains so that you don’t feel so closed in.”
B) “I’ll keep the door open for you, but please try to avoid moving around the room too much.”
C) “I can open your door if you wear this mask.”
D) “I can open your door, but I’ll have to come back and close it in a few minutes.”
Ans: A
Feedback:
The nurse is placing the patient on airborne precautions, which require that doors and windows be closed at all times. Opening the curtains is acceptable. Antibiotics, wearing a mask, and standard precautions are not sufficient to allow the patient’s door to be open.

 

 

15. Family members are caring for a patient with HIV in the patient’s home. What should the nurse encourage family members to do to reduce the risk of infection transmission?
A) Use caution when shaving the patient.
B) Use separate dishes for the patient and family members.
C) Use separate bed linens for the patient.
D) Disinfect the patient’s bedclothes regularly.
Ans: A
Feedback:
When caring for a patient with HIV at home, family members should use caution when providing care that may expose them to the patient’s blood, such as shaving. Dishes, bed linens, and bedclothes, unless contaminated with blood, only require the usual cleaning.

 

 

16. A nurse is preparing to administer a patient’s scheduled dose of subcutaneous heparin. To reduce the risk of needlestick injury, the nurse should perform what action?
A) Recap the needle before leaving the bedside.
B) Recap the needle immediately before leaving the room.
C) Avoid recapping the needle before disposing of it.
D) Wear gloves when administering the injection.
Ans: C
Feedback:
Used needles should not be recapped. Instead, they are placed directly into puncture-resistant containers near the place where they are used. Gloves do not prevent needlestick injuries.

 

 

17. A 16-year-old male patient comes to the free clinic and is subsequently diagnosed with primary syphilis. What health problem most likely prompted the patient to seek care?
A) The emergence of a chancre on his penis
B) Painful urination
C) Signs of a systemic infection
D) Unilateral testicular swelling
Ans: A
Feedback:
Primary syphilis occurs 2 to 3 weeks after initial inoculation with the organism. A painless chancre develops at the site of infection. Initial infection with syphilis is not associated with testicular swelling, painful voiding, or signs of systemic infection.

 

 

18. A patient on the medical unit is found to have pulmonary tuberculosis (TB). What is the most appropriate precaution for the staff to take to prevent transmission of this disease?
A) Standard precautions only
B) Droplet precautions
C) Standard and contact precautions
D) Standard and airborne precautions
Ans: D
Feedback:
Airborne precautions are required for proven or suspected pulmonary TB. Standard precaution techniques are used in conjunction with the transmission-based precautions, regardless of the patient’s diagnosis. Droplet and contact precautions are insufficient.

 

 

19. An adult patient in the ICU has a central venous catheter in place. Over the past 24 hours, the patient has developed signs and symptoms that are suggestive of a central line associated bloodstream infection (CLABSI). What aspect of the patient’s care may have increased susceptibility to CLABSI?
A) The patient’s central line was placed in the femoral vein.
B) The patient had blood cultures drawn from the central line.
C) The patient was treated for vancomycin-resistant enterococcus (VRE) during a previous admission.
D) The patient has received antibiotics and IV fluids through the same line.
Ans: A
Feedback:
In adult patients, the femoral site should be avoided in order to reduce the risk of CLABSI. Drawing blood cultures, receiving treatment for VRE, and receiving fluids and drugs through the same line are not known to increase the risk for CLABSI.

 

 

20. What is the best rationale for health care providers receiving the influenza vaccination on a yearly basis?
A) To decreased nurses’ susceptibility to health care-associated infections
B) To decrease risk of transmission to vulnerable patients
C) To eventually eradicate the influenza virus in the United States
D) To prevent the emergence of drug-resistant strains of the influenza virus
Ans: B
Feedback:
To reduce the chance of transmission to vulnerable patients, health care workers are advised to obtain influenza vaccinations. The vaccine will not decrease nurses’ risks of developing health care-associated infections, eradicate the influenza virus, or decrease the risk of developing new strains of the influenza virus.

 

 

21. A patient has presented at the ED with copious diarrhea and accompanying signs of dehydration. During the patient’s health history, the nurse learns that the patient recently ate oysters from the Gulf of Mexico. The nurse should recognize the need to have the patient’s stool cultured for microorganisms associated with what disease?
A) Ebola
B) West Nile virus
C) Legionnaire’s disease
D) Cholera
Ans: D
Feedback:
In the U.S., cholera should be suspected in patients who have watery diarrhea after eating shellfish harvested from the Gulf of Mexico.

 

 

22. A patient is alarmed that she has tested positive for MRSA following culture testing during her admission to the hospital. What should the nurse teach the patient about this diagnostic finding?
A) “There are promising treatments for MRSA, so this is no cause for serious concern.”
B) “This doesn’t mean that you have an infection; it shows that the bacteria live on one of your skin surfaces.”
C) “The vast majority of patients in the hospital test positive for MRSA, but the infection doesn’t normally cause serious symptoms.”
D) “This finding is only preliminary, and your doctor will likely order further testing.”
Ans: B
Feedback:
This patient’s testing results are indicative of colonization, which is not synonymous with infection. The test results are considered reliable, and would not be characterized as “preliminary.” Treatment is not normally prescribed for colonizations.

 

 

23. A patient’s diagnostic testing revealed that he is colonized with vancomycin-resistant enterococcus (VRE). What change in the patient’s health status could precipitate an infection?
A) Use of a narrow-spectrum antibiotic
B) Treatment of a concurrent infection using vancomycin
C) Development of a skin break
D) Persistent contact of the bacteria with skin surfaces
Ans: C
Feedback:
Colonization can progress to infection if there is a portal of entry by which bacteria can invade body tissues. The use of vancomycin, or any other antibiotic, would not necessarily precipitate a VRE infection.  Prolonged skin contact is similarly unlikely to cause infection, provided the skin remains intact.

 

 

24. A clinic nurse is caring for a male patient diagnosed with gonorrhea who has been prescribed ceftriaxone and doxycycline. The patient asks why he is receiving two antibiotics. What is the nurse’s best response?
A) “There are many drug-resistant strains of gonorrhea, so more than one antibiotic may be required for successful treatment.”
B) “The combination of these two antibiotics reduces the later risk of reinfection.”
C) “Many people infected with gonorrhea are infected with chlamydia as well.”
D) “This combination of medications will eradicate the infection twice as fast than a single antibiotic.”
Ans: C
Feedback:
Because patients are often coinfected with both gonorrhea and chlamydia, the CDC recommends dual therapy even if only gonorrhea has been laboratory proven. Although the number of resistant strains of gonorrhea has increased, that is not the reason for use of combination antibiotic therapy. Dual therapy is prescribed to treat both gonorrhea and chlamydia, because many patients with gonorrhea have a coexisting chlamydial infection. This combination of antibiotics does not reduce the risk of reinfection or provide a faster cure.

 

 

25. A student nurse completing a preceptorship is reviewing the use of standard precautions. Which of the following practices is most consistent with standard precautions?
A) Wearing a mask and gown when starting an IV line
B) Washing hands immediately after removing gloves
C) Recapping all needles promptly after use to prevent needlestick injuries
D) Double-gloving when working with a patient who has a blood-borne illness
Ans: B
Feedback:
Standard precautions are used to prevent contamination from blood and body fluids. Gloves are worn whenever exposure is possible, and hands should be washed after removing gloves. Needles are never recapped after use because this increases the risk of accidental needlesticks. Under ordinary circumstances, masks and gowns are not necessary for starting an IV line. Double-gloving is not a recognized component of standard precautions.

 

 

26. A patient is admitted from the ED diagnosed with Neisseria meningitides. What type of isolation precautions should the nurse institute?
A) Contact precautions
B) Droplet precautions
C) Airborne precautions
D) Observation precautions
Ans: B
Feedback:
This patient requires droplet precautions because the organism can be transmitted through large airborne droplets when the patient coughs, sneezes, or fails to cover the mouth. Smaller droplets can be addressed by airborne precautions, but this is insufficient for this microorganism.

 

 

27. During a health education session, a participant asks the nurse how a vaccine can protect from future exposures to diseases against which she is vaccinated. What would be the nurse’s best response?
A) The vaccine causes an antibody response in the body.
B) The vaccine responds to an infection in the body after it occurs.
C) The vaccine is similar to an antibiotic that is used to treat an infection.
D) The vaccine actively attacks the microorganism.
Ans: A
Feedback:
Vaccines are an antigen preparation that produces an antibody response in a human to protect him or her from future exposure to the vaccinated organism. A vaccine does not respond to an infection after it occurs; it does not act like an antibiotic and does not actively attack the microorganism.

 

 

28. A 2-year-old is brought to the clinic by her mother who tells the nurse her daughter has diarrhea and the child is complaining of pain in her stomach. The mother says that the little girl had not eaten anything unusual, consuming homemade chicken strips and carrot sticks the evening prior. Which bacterial infection would the nurse suspect this little girl of contracting?
A) Escherichia coli
B) Salmonella
C) Shigella
D) Giardia lamblia
Ans: B
Feedback:
Annually in the United States, Salmonella species contaminate approximately 2.2 million eggs (1 in 20,000 eggs) and one in eight chickens raised as meat. Diarrhea with gastroenteritis is a common manifestation associated with Salmonella.  Recent outbreaks of E. coli have been associated with ingestion of undercooked beef. Shigella spreads through the fecal–oral route, with easy transmission from one person to another. People infected with Giardia lamblia contract the disease by drinking contaminated water.

 

 

29. A public health nurse is teaching a mother about vaccinations prior to obtaining informed consent for her child’s vaccination. What should the nurse cite as the most common adverse effect of vaccinations?
A) Temporary sensitivity to the sun
B) Allergic reactions to the antigen or carrier solution
C) Nausea and vomiting
D) Joint pain near the injection site
Ans: B
Feedback:
The most common adverse effects are an allergic reaction to the antigen or carrier solution and the occurrence of the actual disease (often in modified form) when live vaccine is used. Reactions to vaccines do not typically include sensitivity to the sun, nausea and vomiting, or joint pain.

 

 

30. A mother brings her 12 month-old son into the clinic for his measles-mumps-rubella (MMR) vaccination. What would the clinic nurse advise the mother about the MMR vaccine?
A) Photophobia and hives might occur.
B) There are no documented reactions to an MMR.
C) Fever and hypersensitivity reaction might occur.
D) Hypothermia might occur.
Ans: C
Feedback:
Patients should be advised that fever, transient lymphadenopathy, or a hypersensitivity reaction might occur following an MMR vaccination. Reactions to an MMR do not include photophobia or hypothermia.

 

 

31. An older adult patient tells the nurse that she had chicken pox as a child and is eager to be vaccinated against shingles. What should the nurse teach the patient about this vaccine?
A) Vaccination against shingles is contraindicated in patients over the age of 80.
B) Vaccination can reduce her risk of shingles by approximately 50%.
C) Vaccination against shingles involves a series of three injections over the course of 6 months.
D) Vaccination against shingles is only effective if preceded by a childhood varicella vaccination.
Ans: B
Feedback:
Zostavax, a vaccine to reduce the risk of shingles, is recommended for people older than 60 years of age because it reduces the risk of shingles by approximately 50%. It does not need to be preceded by childhood varicella vaccine. The vaccine consists of a single injection.

 

 

32. The nurse educator is discussing emerging diseases with a group of nurses. The educator should cite what causes of emerging diseases? Select all that apply.
A) Progressive weakening of human immune systems
B) Use of extended-spectrum antibiotics
C) Population movements
D) Increased global travel
E) Globalization of food supplies
Ans: B, C, D, E
Feedback:
Many factors contribute to newly emerging or re-emerging infectious diseases. These include travel, globalization of food supply and central processing of food, population growth, increased urban crowding, population movements (e.g., those that result from war, famine, or man-made or natural disasters), ecologic changes, human behavior (e.g., risky sexual behavior, IV/injection drug use), antimicrobial resistance, and breakdown in public health measures. Not noted is an overall decline in human immunity.

 

 

33. An older adult patient has been diagnosed with Legionella infection. When planning this patient’s care, the nurse should prioritize which of the following nursing actions?
A) Monitoring for evidence of skin breakdown
B) Emotional support and promotion of coping
C) Assessment for signs of internal hemorrhage
D) Vigilant monitoring of respiratory status
Ans: D
Feedback:
The lungs are the principal organs of Legionella infection. The patient develops increasing pulmonary symptoms, including productive cough, dyspnea, and chest pain. Consequently, respiratory support is vital. Hemorrhage and skin breakdown are not central manifestations of the disease. Preservation of the patient’s airway is a priority over emotional support, even though this aspect of care is important.

 

 

34. The nurse is caring for a patient with secondary syphilis. What intervention should the nurse institute when caring for this patient?
A) Ensure that the patient is housed in a private room.
B) Administer hydrocortisone ointment to the lesions as ordered.
C) Administer combination therapy with antiretrovirals as ordered.
D) Wear gloves if contact with lesions is possible.
Ans: D
Feedback:
Lesions of primary and secondary syphilis may be highly infective. Gloves are worn when direct contact with lesions is likely, and hand hygiene is performed after gloves are removed. Isolation in a private room is not required. Corticosteroids antiviral medications are not indicated.

 

 

35. A long-term care facility is the site of an outbreak of infectious diarrhea. The nurse educator has emphasized the importance of hand hygiene to staff members. The use of alcohol-based cleansers may be ineffective if the causative microorganism is identified as what?
A) Shigella
B) Escherichia coli
C) Clostridium difficile
D) Norovirus
Ans: C
Feedback:
The spore form of the bacterium C. difficile is resistant to alcohol and other hand disinfectants; therefore, the use of gloves and handwashing (soap and water for physical removal) are required when C. difficile has been identified. Each of the other listed microorganisms is susceptible to alcohol-based cleansers.

 

 

36. The nurse is providing care for an older adult patient who has developed signs and symptoms of Calicivirus (Norovirus). What assessment should the nurse prioritize when planning this patient’s care?
A) Respiratory status
B) Pain
C) Fluid intake and output
D) Deep tendon reflexes and neurological status
Ans: C
Feedback:
The vomiting and diarrhea that accompany Norovirus create a severe risk of fluid volume deficit. For this reason, assessments relating to fluid balance should be prioritized, even though each of the listed assessments should be included in the plan of care.

 

 

37. The nurse who provides care at a wilderness camp is teaching staff members about measures that reduce campers’ and workers’ risks of developing Giardia infections. The nurse should emphasize which of the following practices?
A) Making sure not to drink water that has not been purified
B) Avoiding the consumption of wild berries
C) Removing ticks safely and promptly
D) Using mosquito repellant consistently
Ans: D
Feedback:
Transmission of the protozoan Giardia lamblia occurs when food or drink is contaminated with viable cysts of the organism. People often become infected while traveling to endemic areas or by drinking contaminated water from mountain streams within the United States. Berries, mosquitoes, and ticks are not sources of this microorganism.

 

 

38. A nurse is participating in a vaccination clinic at the local public health clinic. The nurse is describing the public health benefits of vaccinations to participants. Vaccine programs addressing which of the following diseases have been deemed successful? Select all that apply.
A) Polio
B) Diphtheria
C) Hepatitis
D) Tuberculosis
E) Pertussis
Ans: A, B, E
Feedback:
The most successful vaccine programs have been ones for the prevention of smallpox, measles, mumps, rubella, polio, diphtheria, pertussis, and tetanus. There is no vaccine for tuberculosis. Hepatitis is not counted as one of the most successful vaccination programs, because vaccination rates for hepatitis leave room for improvement.

 

 

39. A public health nurse promoting the annual influenza vaccination is focusing health promotion efforts on the populations most vulnerable to death from influenza. The nurse should focus on which of the following groups?
A) Preschool-aged children
B) Adults with diabetes and/or renal failure
C) Older adults with compromised health status
D) Infants under the age of 12 months
Ans: C
Feedback:
Influenza vaccination is particularly beneficial in preventing death among older adults, especially those with compromised health status or those who live in institutional settings.  It is recommended for children and adults, but carries the greatest reduction in morbidity and mortality in older adults.

 

 

40. The nurse receives a phone call from a clinic patient who experienced fever and slight dyspnea several hours after receiving the pneumococcus vaccine. What is the nurse’s most appropriate action?
A) Instruct the patient to call 911.
B) Inform the patient that this is an expected response to vaccination.
C) Encourage the patient to take NSAIDs until symptoms are relieved.
D) Ensure that the adverse reaction is reported.
Ans: D
Feedback:
Nurses should ask adult vaccine recipients to provide information about any problems encountered after vaccination. As mandated by law, a Vaccine Adverse Event Reporting System (VAERS) form must be completed with the following information: type of vaccine received, timing of vaccination, onset of the adverse event, current illnesses or medication, history of adverse events after vaccination, and demographic information about the recipient. NSAIDs are not necessarily required and no evidence of distress warrants a call to 911. This is not an expected response to vaccination.