Sample Chapter

Brunner And Suddarth’s Textbook Of Medical Surgical Nursing,11th Edition By Suzanne C. Smeltzer -Test Bank
Sample  Question   
1. The school nurse teaching a health promotion class to high-school students informs the group that health may be defined as:
A) Being disease free
B) Having fulfilling relationships
C) Having a clean drinking source and nutritious food
D) Being connected in body, mind, and spirit


2. Which of the following desirable characteristics would an effective nurse possess?
A) Sensitivity to cultural differences C) Strict adherence to routine
B) Team-focused nursing approach D) One set cultural practice


3. What type of health problem is the nurse most likely to see in the health care system?
A) Poor prenatal care C) Immobility
B) Lack of information D) Chronic disease


4. The nurse is assisting a patient in planning to return to work after an extensive illness. The patient’s need for self-fulfillment fits in which level of Maslow’s Hierarchy of basic needs?
A) Physiologic C) Love and belonging
B) Safety and security D) Self-actualization


5. Viewing health and illness on a continuum assists the nurse in understanding that:
A) Care should focus on the treatment of disease.
B) A person’s state of health is ever-changing.
C) A person does not have varying degrees of illness.
D) Care should focus on the patient’s response to medications.


6. The nurse working in a community health clinic teaches that disease prevention is best achieved through:
A) Attending self-help groups C) Community social events
B) Yearly physicals D) Behaviors that promote health


7. A nurse on a medical-surgical unit has been asked to become a member of the hospital’s Continuous Quality Improvement (CQI) committee. In preparing to serve on this committee, the nurse learns that CQI programs:
A) Establish accountability on the part of health care professionals
B) Focus on the process used to provide care
C) Identify incidents rather than processes
D) Justify health care costs


8. Managed health care has led to significant changes in the health care delivery system. What effect has managed health care had on the hospital’s patient population?
A) Patients are in the hospital for a longer period of time.
B) Pre-negotiated payment rates have remained unchanged.
C) Patients with high home care needs are being discharged into the community.
D) Use of ambulatory care has decreased.


9. The Patient’s Bill of Rights includes the patient’s right to privacy. When might the nurse break this right?
A) When the patient has threatened to harm himself or herself
B) When the patient has been diagnosed with a terminal disease
C) If a family member has called to inquire about the patient’s condition
D) There are no circumstances when this rule may be broken.


10. In order for the nurse to implement the interventions in a clinical pathway, what first must be done?
A) Interventions must have a signed physician’s order.
B) The nurse manager must review the plan.
C) The unit must approve the document.
D) The nurse must sign the document prior to initiating.


11. A nurse researcher is conducting a study about the effects of noise on hospitalized patients’ pain levels. The primary purpose of nursing research is to:
A) Involve patients in their care while hospitalized
B) Contribute to the scientific base of nursing practice
C) Draw conclusions about the quality of patient care
D) Explain ongoing medical studies to patients


12. Home health care is becoming one of the largest practice areas for nurses. What has contributed to this change?
A) Chronic nursing shortage
B) Focus on treatment of disease
C) Nurses prefer working during the day instead of evening or night shifts
D) More critically ill patients being discharged to home from the hospital


13. A nurse is practicing in an oncology clinic and her role includes clinical practice, education, management, consultation, and research. Which of the following would most accurately describe this nurse’s title?
A)  Midwife    B)  Clinical nurse specialist    C)  Nurse manager    D)  Staff nurse


14. Nursing continues to recognize the importance of collaboration with other health care disciplines to meet the complex needs of the patient. Which of the following would be an example of a collaborative practice model?
A) The nurse and the physician discussing and jointly making clinical decisions
B) The nurse accompanying the physician on rounds
C) The nurse making a referral on behalf of the patient
D) The nurse attending an appointment with the patient


15. According to Maslow’s Hierarchy of needs, which dimension of care is considered primary in importance when caring for a dying patient?
A)  Spiritual    B)  Social    C)  Physiologic    D)  Emotional


16. When prioritizing a patient’s care plan based on Maslow’s Hierarchy of needs, the nurse’s first priority would be:
A) Allowing the family to see a newly admitted patient
B) Ambulating the patient in the hallway
C) Administering pain medication
D) Teaching the patient to self-administer insulin


1. A nurse is applying for work at a clinic that offers therapeutic abortions, which contradicts the nurse’s personal beliefs. The nurse feels unable to care for these patients objectively. What is the nurse’s ethical obligation to these patients?
A) The nurse is required by law to continue service to these patients.
B) The nurse should make the choice to decline this position.
C) The nurse may discriminate between patients and refuse to care for the patient.
D) The nurse may express his or her opinion and provide another option to terminating the pregnancy.


2. The physician has ordered a large dose of narcotic via intravenous infusion for a terminally ill patient whose respiratory rate has decreased from 16 breaths/min to 10 breaths/min. What action should the nurse take?
A) Decrease the IV infusion
B) Stimulate the patient
C) Report the decreased respiratory rate to the physician
D) Allow the patient to rest comfortably


3. A terminally ill patient has requested a “do not resuscitate” (DNR) order. The family of the patient is strongly opposed to the patient’s request. What is the responsibility of the nurse?
A) Perform a “slow code” until a decision is made.
B) Honor the request of the patient.
C) Contact a lawyer to intervene.
D) Terminate nursing care until the physician talks to the family.


4. Upon admission the nurse asks the patient, “Do you have a living will?” Which of the following would correctly define a living will?
A) A legal document that is always honored.
B) A legal document that specifies the patient’s wishes before hospitalization.
C) A legal document that is binding for the duration of the patient’s life.
D) A legal document drawn by the patient’s family to determine DNR status.


5. Which of the following would be considered a nursing implementation?
A) The patient will ambulate twice a day.
B) The patient appears diaphoretic.
C) The patient is at risk for aspiration.
D) The patient is monitored for peripheral edema twice a day.


6. Which of the following would be considered a contradiction to the nurse’s duty of nonmaleficence?
A) Provide comfort measures for a terminally ill patient.
B) Assist the patient with ADLs.
C) Refuse to administer pain medication as ordered.
D) Provide all information related to procedures.


7. The physician has arranged an amniocentesis for an 18-year-old woman who is 34 weeks’ gestation and does not want this procedure. The physician insisting that the patient have the procedure would be an example of which of the following?
A)  Veracity    B)  Beneficence    C)  Paternalism    D)  Autonomy


8. Which of the following would be an example of the nurse practicing fidelity?
A) Regulating visitors
B) Staying with the patient during his or her death as promised
C) Withholding information as requested
D) Providing continuity of care


9. The patient has been given the wrong medication and asks the nurse if an error has been made. Which of the following principles would apply if the nurse gives an accurate response?
A)  Veracity    B)  Confidentiality    C)  Respect    D)  Justice


10. When using restraints in a long-term-care setting, what ethical dilemma does this pose?
A) Limits personal safety C) Threatens autonomy
B) Increases confusion D) Prevents self-directed care


11. The nurse is receiving report on her patients and learns that a patient with terminal cancer has granted power of attorney to her brother. Which of the following applies to the power of attorney?
A) Another individual has been identified to make decisions on behalf of the patient.
B) It is binding even if the patient changes his or her mind.
C) The named individual is in charge of the patient’s finances.
D) It is a legal document delegating custody of children.


12. After a discussion with the patient’s husband, the nurse discovers that the patient has a living will. Which of the following applies to a living will?
A) The patient is legally unable to refuse basic life support.
B) The physician may disagree with the patient’s desires for treatment.
C) The patient may nullify the living will during the illness.
D) Power of attorney may change while the patient is hospitalized.


13. Which of the following organizations is responsible for developing the taxonomy of a nursing diagnosis?
A) American Nurses Association (ANA)
B) North American Nursing Diagnosis Association (NANDA)
C) National League for Nursing (NLN)
D) Joint Commission on Accreditation of Healthcare Organizations (JCAHO)


14. Which of the following must be done prior to making a nursing diagnosis?
A) Establish a plan.
B) Assign a positive value to each consequence.
C) Collect and analyze data.
D) Evaluate the plan of care.


15. The phase of the nursing process accomplished by a nurse who administers an antiemetic medication to a patient who is suffering from postoperative vomiting is the:
A) Assessment phase C) Implementation phase
B) Planning phase D) Evaluation phase


16. One hour after the administration of Zofran to a patient with nausea and vomiting, the nurse determines that the medication has been effective and documents this in the patient’s record. This phase of the nursing process is termed:
A)  Analysis    B)  Evaluation    C)  Assessment    D)  Data collection


17. Which of the following nursing diagnoses would be applicable to a patient who has rheumatoid arthritis?
A) Self-care deficit related to fatigue and joint stiffness
B) Ineffective airway clearance related to body image disturbance
C) Risk for violence related to anxiety
D) Urinary retention related to chronic pain


18. The rationale for documenting and planning the patient’s care upon admission is to:
A) Provide continuity of care
B) Create a teaching log for family
C) Verify staffing
D) Provide the patient with information about treatments


19. Nursing diagnoses can be best defined as:
A) Health problems that are amenable to resolution by nursing actions
B) Medical treatments prescribed by the physician
C) Problems that the nurse experiences while caring for the patient
D) The equipment used to implement medical therapy


20. How might the nurse establish a good rapport with the patient during the initial assessment interview?
A) Ask open-ended questions.
B) Physically distance himself or herself from the patient during the interview.
C) Keep questions short and focused.
D) Perform invasive procedures at the beginning of the assessment.


21. A 65-year-old patient admitted to the hospital with pneumonia has decreased air entry to bilateral lung bases. An appropriate nursing diagnosis for the patient is:
A) Ineffective airway clearance related to copious tracheobronchial secretions
B) Pneumonia related to disease process
C) Poor ventilation related to infection
D) Immobility related to fatigue


22. Which of the following would be classified as the planning phase of the nursing process for a patient diagnosed with pneumonia?
A) Improved airway patency C) Administer fluids
B) Promote fluid intake D) Avoid overexertion


23. A nurse is caring for a patient with an allergy to peanuts. Which of the following would be an immediate goal with a nursing diagnosis of knowledge deficit related to the patient’s administration of an EpiPen?
A) The patient will demonstrate correct injection technique with today’s teaching session.
B) The patient will 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 in 2 weeks to demonstrate the injection.


24. A nurse is performing an interdependent nursing intervention when he or she:
A) Provides a back rub to a restless patient to help her sleep
B) Provides mouth care
C) Administers IV fluid
D) Elevates the head of the bed


25. During the evaluation phase of the nursing process, the nurse should:
A) Have the patient provide input on quality of care
B) Discontinue surgical sutures
C) Provide a follow-up appointment for the postoperative patient
D) Document improved gas exchange with incentive spirometry use


26. The nurse is caring for a patient with a fractured hip who is combative and confused, and he’s trying to get out of bed. The nurse should:
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.


27. A patient is to be discharged from an acute-care facility following treatment for right leg thrombophlebitis. The nurse notes that the patient’s leg is pain-free, without redness or edema. The nurse’s actions reflect which step of the nursing process?
A)  Assessment    B)  Analysis    C)  Implementation    D)  Evaluation


28. To maintain a therapeutic environment with a patient and his family, the nurse can use such communication techniques as the clarification technique. An example of the clarification technique is:
A) “How is it going?”
B) “You say you aren’t concerned, but you’ve asked me many questions on this same subject.”
C) “What do you mean when you say…?”
D) “For now, I would like to concentrate on…”


29. After completing rounds, the physician prescribes restraints for four patients on the floor. Upon reviewing the orders, the nurse knows that it’s inappropriate to apply restraints to which of the following patients?
A) A postlaryngectomy patient attempting to pull out his tracheostomy tube
B) A patient in hypovolemic shock trying to pull out his IV catheter
C) A patient with urosepsis who rings the call bell often to use the bedside commode
D) A paranoid patient who has just tried to commit suicide and is refusing restraints


30. What phase of the nursing process is the nurse performing after admitting a new patient and focusing on risk factors that could affect the health of this patient?
A)  Evaluation    B)  Diagnosis    C)  Analysis    D)  Implementation


31. A 76-year-old patient who has been diagnosed with cancer is weighing his options to undergo chemotherapy or radiation as his treatment. This patient is utilizing which ethical principle in making his decision?
A)  Beneficence    B)  Confidentiality    C)  Autonomy    D)  Justice


32. A staff nurse discussing the treatment plan of a patient with others members of the health care team is exhibiting which ethical principle?
A)  Confidentiality    B)  Autonomy    C)  Justice    D)  Beneficence


33. Restraints are utilized in certain circumstances to prevent the patient from harming himself or others. When a nurse uses a restraint on a patient, the nurse is infringing on which ethical principle?
A)  Veracity    B)  Autonomy    C)  Double effect    D)  Fidelity


34. A 45-year-old patient who is in a research study dealing with management of migraine headaches does not know that she is receiving a placebo for pain management. Which ethical principle is involved in this situation?
A)  Sanctity of life    B)  Confidentiality    C)  Veracity    D)  Fidelity


35. A nurse who has been assigned to care for a patient with AIDS refuses to assist in his care. 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


36. A terminally ill patient with liver cancer is moaning and very agitated. He is going in and out of consciousness. The nurse has an order to given morphine sulfate IV for pain control. His respiratory rate is 10. Which ethical principle would the nurse use to decide whether or not to administer the medication?
A)  Veracity    B)  Double effect    C)  Confidentiality    D)  Autonomy


37. A patient who sustained a T3 spinal cord injury one month ago is now entering the rehabilitation phase of his treatment. The nurse developing goals and measurable outcomes for his treatment is working in which step of the nursing process?
A)  Assessment    B)  Planning    C)  Diagnosis    D)  Evaluation


38. A 7-year-old child suspected of having meningitis is to undergo a lumbar puncture. The nurse discussing postprocedure teaching with the child and the mother is demonstrating which therapeutic communication technique?
A)  Informing    B)  Suggesting    C)  Humor    D)  Broad openings


39. The nurse who is preparing to discharge a patient who has undergone a left knee replacement examines whether or not patient goals have been met. What stage of the nursing process is being explored?
A)  Assessment    B)  Planning    C)  Intervention    D)  Evaluation


40. Which of the following would be an important component of the assessment phase of the nursing process?
A) Comparing the patient’s actual outcomes and expected outcomes
B) Interviewing the patient’s family and significant others
C) Putting the plan of nursing care into action
D) Identifying the etiology of the nursing problems


41. A patient diagnosed with terminal brain cancer is discussing the different types of advance directives with the nurse. The nurse knows that the most important aspect of a living will consists of which of the following?
A) The patient retains the option to nullify the document.
B) The patient’s health overrules his desired wishes.
C) The patient cannot terminate the living will.
D) The patient must be in a terminal state for a living will to be upheld.


42. A patient in the ICU has been slowly deteriorating over the last few days. No decision has been made related to do not resuscitate (DNR) status. The nurse has been given a verbal order to perform a “slow code” in the event that the patient needs cardiopulmonary resuscitation (CPR). The most important reason that this order cannot be executed is due to which of the following?
A) The patient did not verbalize that she wanted to be resuscitated.
B) The order is unethical.
C) A living will was not executed.
D) The patient is not competent to make a decision.


43. When assigning priorities related to the care of the patient, it is important for the nurse and the patient’s family to look at the urgency of specific problems. Which of the following provides the best framework for prioritizing patient problems?
A) Availability of hospital resources C) Maslow’s Hierarchy of needs
B) Family member statements D) Nursing skill


44. The nurse is developing a plan of care for an obese patient with hypertension. The nursing diagnosis is noncompliance with dietary regimen related to knowledge deficit and lifestyle. Which of the following would be an appropriate expected outcome for this diagnosis?
A) No evidence of peripheral edema C) Absence of infection
B) Limits visitors to family in the evenings D) Identifies harmful effects of obesity


45. Nurses have a duty to inflict no harm as well as prevent and remove harm when caring for their patients. This is an example of which ethical principle?
A)  Fidelity    B)  Nonmaleficence    C)  Justice    D)  Confidentiality


1. A nurse is caring for a patient following a stroke who is unwilling to attempt any self-care. The nurse should include which of the following as an initial goal?
A) The patient will demonstrate independent self-care.
B) The patient’s family will manage the patient’s care.
C) The nurse will delegate the patient’s care to a nursing assistant.
D) The patient will participate in a social program.


2. A nurse practitioner working in an outpatient rehabilitation facility realizes that an elderly disabled patient may be at an increased risk for which of the following social problems?
A)  Discrimination and abuse    B)  Incontinence    C)  Contractures    D)  Poor mobility


3. A patient is undergoing rehabilitation following a total left knee replacement. The key member of the rehabilitation team is the:
A)  Occupational health worker    B)  Nurse    C)  Physical therapist    D)  Patient


4. A nurse is caring for a patient during rehabilitation following a stroke. When the nurse coordinates the patient’s total rehabilitative plan of care, the nurse is functioning as a:
A)  Patient educator    B)  Caregiver    C)  Case manager    D)  Patient advocate


5. An adult patient has just been diagnosed with paralysis due to a skiing accident that injured the spinal cord. The nurse can anticipate that, emotionally, the patient will:
A) Go through all stages of grief before adaptation takes place
B) Progress sequentially through five stages of the grief process
C) Need humor therapy
D) Respond to grief in an individual manner


6. An elderly female with osteoarthritis has difficulty ambulating because of pain. What intervention may the nurse take to help with the patient’s mobility?
A) Motivate the patient to walk in the afternoon.
B) Determine if self-care devices are needed.
C) Administer an analgesic as ordered to increase mobility.
D) Have another person with osteoarthritis visit the patient.


7. A nurse is assessing a patient with limited mobility following a stroke. To examine the patient for contractures, the nurse should assess the patient’s:
A)  Orientation    B)  Muscle flexibility    C)  Muscle strength    D)  Range of motion


8. A patient is hospitalized following a total hip replacement. To prevent inward rotation of the patient’s hip when the patient is in a partial lateral position, the nurse should:
A) Use a triangular pillow.
B) Align the head with the spine and support it with a pillow.
C) Support the back with a small pillow.
D) Place trochanter rolls under the greater trochanter.


9. While assisting a patient with limited mobility to perform range-of-motion exercises, the nurse plans to assess the patient’s adduction of the arm, which is the patient’s ability to:
A) Move the limb toward the midline of the body.
B) Bend the joint so that the angle of the joint diminishes.
C) Turn the limb towards the center of the body.
D) Rotate the forearm so that the palm of the hand is down.


10. A nurse preparing to assist an adult patient to stand for the first time following abdominal surgery should:
A) Have the patient place his arms around the nurse’s neck.
B) Allow the patient to initially sit at the side of the bed.
C) Have the patient pull up with the nurse to assist.
D) Instruct the patient to push off the bed with the wrists.


11. Which instruction should the nurse give an adult patient in crutch walking?
A) Wear shoes.
B) Partially bear weight on the injured foot.
C) Support weight on the axilla pieces of the crutches.
D) Have the crutches at level with the axilla.


12. The nurse should teach which of the following to a patient receiving an orthosis?
A) Oil the joints of the device every other day.
B) Use a hanger to relieve pruritus under the device.
C) Wear tight-fitting stockings under the device.
D) Clean and inspect the skin daily under the device.


13. A nurse has just admitted an elderly patient who appears malnourished following a fractured tibia. She is concerned about the patient’s healing process related to insufficient protein levels. To assess the patient for protein deficiency, the nurse should review which of the following laboratory findings?
A)  Hemoglobin    B)  White blood cells    C)  Albumin    D)  TSH


14. A nurse assessing an immobilized patient for impaired skin integrity due to shear and friction should examine the patient’s:
A)  Elbows    B)  Soles of the feet    C)  Heels    D)  Knees


15. A nurse assesses a patient’s heels for skin breakdown and notes that both heels have a reddened area that does not blanch. The nurse should document the presence of a pressure ulcer in stage:
A)  I    B)  II    C)  III    D)  IV


16. Which of the following would be the best meal choice for a patient with a stage III pressure ulcer?
A) Cheeseburger and fries
B) Skim milk, oatmeal, and whole wheat toast
C) Steak, baked potato, spinach, and strawberry salad
D) Eggs, bacon, hash browns, and an apple


17. A nurse caring for a paralyzed patient who has been diagnosed with reflex incontinence should include which of the following preventative measures in the teaching plan with this patient?
A) Regular perineal care to prevent skin breakdown
B) Kegel exercises to strengthen the pelvic floor
C) Small frequent meals
D) Limited fluid intake to prevent incontinence


18. The nurse should instruct a 47-year-old female patient who visits the clinic because she has been experiencing stress incontinence when she sneezes to:
A) Keep a record of when the incontinence occurs.
B) Perform clean intermittent catheterization.
C) Perform Kegel exercises 4 to 6 times per day.
D) Wear a protective undergarment as incontinence is part of aging.


19. A nurse working as a volunteer with a group of severely disabled individuals should explain to the group that there is a growing trend for severely disabled individuals toward:
A) Extended rehabilitation care
B) Independent living
C) Acute care center treatment
D) State institutions that provide care for life


20. To prevent pressure ulcers a bedridden, elderly adult, which intervention should the nurse include in the care plan?
A) Turn and reposition the patient a minimum of every 8 hours.
B) Vigorously massage lotion into bony prominences.
C) Post a turning schedule at the patient’s bedside.
D) When turning, slide the patient rather than lift.


21. When performing an assessment, the nurse identifies the following: impaired coordination, decreased muscle strength, limited range of motion, and the patient’s reluctance to move. These signs and symptoms indicate which nursing diagnosis?
A) Health-seeking behavior C) Disturbed sensory perception
B) Impaired physical mobility D) Deficient knowledge


22. A patient who recently had a stroke requires a cane to ambulate. When the nurse is teaching about cane use, the rationale for holding a cane on the uninvolved side is to:
A) Prevent leaning
B) Distribute weight away from the involved side
C) Maintain stride length
D) Prevent edema


23. The nurse is instructing a patient with a left fractured tibia how to walk with crutches. Which instruction would be appropriate?
A) Use the axillae to help carry the weight.
B) All weight should be on the hands.
C) Keep feet 11″ (28 cm) apart to provide stability and a wide base of support.
D) Take long strides to maintain maximum mobility.


24. For the nurse providing care to an immobilized patient, the most appropriate and most effective nursing intervention would be:
A) Getting the patient out of bed and into a chair for 30 minutes, twice daily.
B) Avoiding repositioning the patient if he’s comfortable.
C) Repositioning the patient on alternate sides at least every 2 hours.
D) Positioning the patient with the pressure on the bony prominence.


25. A 52-year-old married man with two adolescent children is beginning rehabilitation following a stroke. When planning the patient’s care, the nurse should recognize that the patient’s condition will affect:
A) Only himself C) Himself and his entire family
B) Only his wife and children D) No one, if he has a complete recovery


26. A patient who has suffered a stroke is too weak to move on his own. To help the patient avoid pressure ulcers, the nurse should:
A) Turn the patient frequently.
B) Perform passive range-of-motion (ROM) exercises.
C) Reduce the patient’s fluid intake.
D) Encourage the patient to use a footboard.


27. Which of the following nursing actions is most important for a patient with a neurogenic bladder beginning bladder training?
A) Set up specific times to empty the bladder.
B) Force fluids.
C) Provide adequate roughage.
D) Encourage the use of an indwelling urinary catheter.


28. Which of the following measures should the nurse include when establishing a bladder retraining plan of care for a patient with bladder incontinence?
A) Establishing a predetermined fluid intake pattern for the patient
B) Encouraging the patient to increase the time between voidings
C) Restricting fluid intake to reduce the need to void
D) Assessing present elimination patterns


29. The nurse is caring for a patient with an acute head injury. The patient is stabilized and ready to begin rehabilitation. When transferring the patient from his bed to a chair, what should the nurse do to ensure patient safety?
A) Raise the side rails on both sides of the bed
B) Position the chair approximately 2′ (0.6 m) from the bed
C) Lock the brakes on the bed
D) Place socks on the patient’s feet


30. The nurse teaching a patient with a long leg cast how to use crutches properly while descending a staircase should tell the patient to:
A) Advance both legs first. C) Advance the affected leg first.
B) Advance the unaffected leg first. D) Advance both crutches first.


31. A nurse is assessing an elderly patient’s skin for intactness. When checking the patient’s sacrum, she notices an ulcerated area that extends into the subcutaneous tissue and is draining. This skin alteration would be documented as which pressure ulcer stage?
A)  I    B)  II    C)  III    D)  IV


32. The nurse knows that for a patient receiving rehabilitation after a stroke the following is a major goal of the rehabilitative process?
A) Providing 24-hour care for the patient
B) Restoring the patient’s ability to function independently
C) Allowing for a longer hospital stay
D) Adjusting treatment based on available staff


33. Which of the following would be considered an instrumental activity of daily living (IADL)?
A)  Dressing    B)  Bathing    C)  Feeding    D)  Meal preparation


34. The Americans with Disabilities Act (ADA) states which of the following with regard to persons with disabilities seeking employment?
A) Employers must make reasonable accommodations to facilitate employment of a person with a disability.
B) Employers must hire all disabled persons who apply for a job.
C) Employers may discriminate on an individual basis.
D) Employers must pay a person with disabilities more than those with no disability.


35. Rehabilitation is a team of professionals working together with the patient and the family. Which member of the rehabilitation team determines the final outcome of the process?
A)  Nurse    B)  Patient    C)  Family    D)  Doctor


36. Which of the following tools would a rehabilitation nurse be expected to use in assessing the level of independence of a recent spinal cord injured adult patient?
A) Wee-FIM instrument
B) Functional independence measure (FIM)
C) Braden scale
D) Rule of the nines


37. To prevent footdrop in a patient with a nursing diagnosis of impaired physical mobility, the nurse would implement which of the following?
A) Apply protective boots or padded splints
B) Allow bedding to cover the feet
C) Allow prolonged bed rest so patient may gain energy
D) Enable the patient to turn himself as he feels necessary


38. Orthostatic hypotension may occur in patients with impaired physical mobility when they assume a standing position from a lying position. Which clinical manifestation should the nurse be alert to?
A) Increased heart rate C) Low blood pressure
B) Decreased heart rate D) High blood pressure


39. The rehabilitation nurse assisting a stroke patient to exercise is coaching him to contract and relax his muscles while keeping the extremity in a fixed position. Which type of exercise is the patient performing?
A)  Passive    B)  Isometric    C)  Resistive    D)  Abduction


40. The nurse assessing a patient with a sacral decubitus finds that the ulcer extends into the muscle and bone. In which stage is this ulcer?
A)  I    B)  II    C)  III    D)  IV


41. The nurse discussing nutritional requirements with a rehabilitation patient emphasizes the need for additional protein in the diet. Which of the following is the rationale for additional protein in the diet?
A) Promotes collagen formation C) Restores normal weight
B) Promotes tissue repair D) Maintains homeostasis


42. The nurse is caring for a patient with a pressure ulcer. An expected outcome of a patient with impaired skin integrity is healing of the pressure ulcer. The nurse assesses that the outcome has been achieved by observing which of the following?
A) Patient performs range-of-motion exercises
B) Patient avoids pressure on the healing site
C) Patient elevates body parts susceptible to edema
D) Patient demonstrates improved level of consciousness


43. An 83-year-old stroke patient is exhibiting urinary incontinence. The nurse knows that various factors alter elimination patterns in older patients. Which of the following is an example of these factors?
A) Decreased residual volume C) Increased bladder capacity
B) Increased muscle tone D) Decreased muscle tone


44. An elderly patient who has been on a bowel training program due to weakness caused by a stroke is now exhibiting normal bowel patterns. It is important to avoid which of the following once a bowel routine has been well established?
A) Bedpan C) Massage of the abdomen
B) Padded commode D) Bedside toilet


45. The nurse caring for a male patient with urinary incontinence would avoid which of the following interventions?
A) Intermittent self-catheterization C) External condom catheter
B) Indwelling catheter D) Incontinence pads


1. A patient who is having his tonsils removed asks the nurse what function the tonsils serve. Which of the following would be the most accurate response?
A) “The tonsils aid in digestion.”
B) “The tonsils help to guard the body from invasion of organisms.”
C) “The tonsils contain nerves that provoke sneezing.”
D) “The tonsils regulate the airflow to the bronchi.”


2. The nurse is analyzing a patient’s laboratory data. Which of the following values of PaO2 in an adult would be considered normal?
A)  75 mm Hg    B)  50 mm Hg    C)  35 mm Hg    D)  80 mm Hg


3. A nurse is assessing a newly admitted patient and observes that he has an irritated, high-pitched cough. The nurse suspects that the patient has:
A)  Stridor    B)  Laryngotracheitis    C)  Bronchitis    D)  Pneumonia


4. A nurse caring for a hospitalized patient who has copious green sputum notifies the patient’s physician because these symptoms are indicative of:
A)  Lung cancer    B)  Lung tumors    C)  Infection    D)  Pulmonary edema


5. The patient is complaining of dyspnea. The nurse assesses the patient’s chest and hears wheezing throughout the lung fields. What might this indicate?
A) The patient is in bronchospasm. C) The patient needs physiotherapy.
B) The patient has pneumonia. D) The patient has a hemothorax.


6. During assessment of the patient admitted to the hospital for dehydration, the nurse notes that he has a barrel chest. Understanding this assessment finding, the nurse asks the patient if he has a history of:
A)  Emphysema    B)  Asthma    C)  Chronic bronchitis    D)  Pneumonia


7. A patient has a bacterial pneumonia and is finding it very difficult to cough up secretions because they are too thick. What instructions should the nurse provide to the patient to assist in secretion removal?
A) Increase fluid intake. C) Increase activity.
B) Take analgesics to assist coughing. D) Increase meal size.


8. A nurse assessing the chest of a patient with Marfan syndrome observes that there is an increase in the anteroposterior diameter, and the sternum is displaced. The nurse should document the presence of:
A)  Pigeon chest    B)  Barrel chest    C)  Scoliosis    D)  Clubbing


9. The nurse observes that the patient has an abnormal respiratory pattern and has documented that the patient is demonstrating Cheyne-Stokes respirations. What respiratory pattern description is characteristic of a patient who has Cheyne-Stokes respirations?
A) Rapid shallow breaths
B) Low respiratory rate with hiccups
C) Alternating periods of deep breathing and periods of apnea
D) Increased rate and depth in breaths


10. During assessment of a patient, a nurse percussing the anterior chest notes dullness over the right lower lung. What might this assessment indicate?
A) Accumulation of fluid in the pleural space
B) Overinflation of the lung tissue
C) Bronchospasm
D) Emphysema


11. A patient who is diagnosed with heart failure should be assessed by the nurse for which of the following breath sounds?
A)  Expiratory wheezes    B)  Inspiratory wheezes    C)  Rhonchi    D)  Crackles


12. While percussing the thorax of an adult patient, the nurse detects dullness over the right lung. The patient may be exhibiting symptoms of:
A)  Lung tumor    B)  Pneumothorax    C)  Emphysema    D)  COPD


13. A nurse is preparing to auscultate an adult patient’s lungs. To hear bronchial breath sounds, the nurse should place the stethoscope on the patient’s:
A)  Lungs    B)  Manubrium    C)  First intercostal space    D)  Scapulae


14. A nurse assessing the respiratory system of an adult patient notes a significant decrease in respiratory breath sounds on the left side of the patient’s chest. Percussion reveals resonant sounds. The nurse suspects that the patient is most likely exhibiting symptoms of:
A)  Pulmonary edema    B)  Bronchitis    C)  Pneumothorax    D)  Pneumonia


15. A patient admitted with chronic obstructive pulmonary disease is experiencing a change in his respiratory and mental status. The nurse is aware that the most accurate measurement of the concentration of oxygen in the patient’s blood is:
A) A capillary blood sample C) An arterial blood gas studies
B) Pulse oximetry D) Assessment of the patient’s nail beds


16. The patient has returned to the unit following a bronchoscopy. Which of the following criteria will determine when the nurse can allow the patient to drink fluids?
A) Presence of a cough and gag reflex C) Ability to demonstrate deep inspiration
B) Absence of nausea D) Ability to speak


17. Which phrase is used to describe the volume of air inspired and expired with a normal breath?
A) Total lung capacity C) Tidal volume
B) Forced vital capacity D) Residual volume


18. What is the best procedure for the nurse to assess arterial oxygen saturation (SaO2)?
A) Incentive spirometry C) Peak flow measurement
B) Arterial blood gas (ABG) measurement D) Pulse oximetry


19. A patient is concerned about his inability to speak clearly due to an infection in the upper respiratory system. Which of the following structures serve as the patient’s resonating chamber in speech?
A)  Trachea    B)  Pharynx    C)  Paranasal sinuses    D)  Larynx


20. While caring for patients on the respiratory intensive care unit, the nurse is aware that several respiratory conditions can affect the compliance of the lung tissue. Which condition leads to an increase in lung compliance?
A) Emphysema C) Pleural effusion
B) Pulmonary fibrosis D) Acute respiratory distress syndrome


21. The nurse enters a patient’s room and assesses that the patient is exhibiting signs of dyspnea. The nurse will place the patient in which of the following positions?
A)  Supine    B)  High-Fowler’s    C)  Trendelenburg    D)  Lithotomy


22. The cause of a patient’s cough may be determined after careful assessment of the characteristics of the cough. A “brassy cough” may be caused by which of the following conditions?
A) Bronchogenic carcinoma C) Sinusitis
B) Tracheal lesions D) A side effect of ACE inhibitor therapy


23. Upon collection of a patient’s sputum sample, the nurse documents that the sputum is pink and frothy. Sputum with these characteristics often indicates a diagnosis of:
A)  Pulmonary edema    B)  Bronchiectasis    C)  Viral bronchitis    D)  A lung abscess


24. A patient diagnosed with multiple sclerosis has decreased vital lung capacity. The nurse is aware that vital capacity measures:
A) The volume of air inhaled and exhaled with each breath
B) The volume of air in the lungs after a maximum inspiration
C) The maximum volume of air inhaled after normal expiration
D) The maximum volume of air exhaled from the point of maximum inspiration


25. While assessing the patient’s respiratory rate, the nurse assesses 4 normal breaths followed by an episode of apnea lasting 20 seconds. The nurse will describe this breathing pattern in her documentation as:
A)  Eupnea    B)  Apnea    C)  Biot’s respiration    D)  Cheyne-Stokes


26. What approach should the nurse take to assess the lung fields of a patient who is in a recumbent position?
A) Inform that physician that the patient is in a recumbent position and anticipate an order for a portable chest x-ray.
B) Turn the patient to assess all lung fields so that dependent areas can be assessed for breath sounds.
C) Avoid turning the patient, and assess the accessible breath sounds from the anterior chest wall.
D) Obtain a pulse oximetry reading and if the reading is low, reposition the patient and auscultate breath sounds.


27. Which of the following respiratory findings will the nurse expect to find upon assessment of a patient with a pleural effusion?
A) Increased tactile fremitus, egophony, and a dull sound upon percussion of the chest wall
B) Decreased tactile fremitus, wheezes, and a hyperresonant sound upon percussion of the chest wall
C) Absent tactile fremitus, bronchial breath sounds, and a flat sound upon percussion of the chest wall
D) Normal tactile fremitus, decreased breath sounds, and a resonant sound upon percussion of the chest wall


28. The nurse notices a sputum specimen sitting on the bedside table in a patient’s room. After asking the patient when he produced the sputum specimen, he learns the specimen is about 4 hours old. Knowing this information, the nurse:
A) Immediately takes the sputum specimen to the laboratory
B) Discards the specimen and assists the patient in obtaining another specimen
C) Refrigerates the sputum specimen
D) Waits an additional 2 hours before sending the specimen to the laboratory


29. The nurse caring for an elderly patient in the PACU after a bronchoscopy is monitoring for complications related to the administration of lidocaine. The nurse recognizes the complications related to the administration of large doses of lidocaine in the elderly as:
A) Decreased urine output and hypertension
B) Headache and vision changes
C) Confusion and lethargy
D) Jaundice and elevated liver enzymes


30. A patient admitted with a heart murmur is noted to have a depression in the lower portion of the sternum. This type of chest deformity is called:
A)  A barrel chest    B)  A funnel chest    C)  A pigeon chest    D)  Kyphoscoliosis


31. The nurse instructs the patient to repeat the letter E, while assessing voice sounds. Upon auscultation, the nurse notes that the voice sounds are distorted and she hears the letter A instead of the letter E. The nurse will document this voice sound as:
A) Bronchophony C) Whispered pectoriloquy
B) Egophony D) Sonorous wheezes


32. Auscultation of the lung fields provides the nurse with information on the type of breath sound the patient is exhibiting. While listening over the manubrium, the nurse auscultates loud expiratory sounds that last longer than inspiratory sounds. The nurse will document her findings as:
A) Vesicular breath sounds C) Bronchial breath sounds
B) Bronchovesicular breath sounds D) Tracheal breath sounds


33. A patient with a pleural friction rub has presented to the emergency room. Upon initial assessment, the nurse is aware that a pleural friction rub is best heard:
A) Over the lower lateral anterior surface of the thorax
B) Over the upper medial posterior surface of the thorax
C) Over the trachea
D) Over the mediastinum