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Clinical Nursing Skills and Techniques 8th Edition by Anne Griffin Perry – Test Bank

 

Chapter 3: Communication

 

MULTIPLE CHOICE

 

  1. The patient is a 54-year-old man who has made a living as a construction worker. He dropped out of high school at age 16 and has been a laborer ever since. He never saw any need for “book learning,” and has lived his life “my way” since he was a teenager. He has smoked a pack of cigarettes a day for 40 years and follows no special diet, eating a lot of “fast food” while on the job. He now is admitted to the coronary care unit for complaints of chest pain and is scheduled for a cardiac catheterization in the morning. Which of the following would be the best way for the nurse to explain why he needs the procedure?
a. “The doctor believes that you have atherosclerotic plaques occluding the major arteries in your heart, causing ischemia and possible necrosis of heart tissue.”
b. “There may be a blockage of one of the arteries in your heart, causing the chest discomfort. He needs to know where it is to see how he can treat it.”
c. “We have pamphlets here that can explain everything. Let me get you one.”
d. “It’s just like a clogged pipe. All the doctor has to do is ‘Roto-Rooter’ it to get it cleaned out.”

 

 

ANS:  B

To send an accurate message, the sender of verbal communication must be aware of different developmental perspectives as well as cultural differences between sender and receiver, such as the use of dialect or slang.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 28

OBJ:   Explain the communication process.                                         TOP:    Verbal Communication

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse is assessing a patient who says that she is feeling fine. The patient, however, is wringing her hands and is teary eyed. The nurse should respond to the patient in which of the following ways?
a. “You seem anxious today. Is there anything on your mind?”
b. “I’m glad you’re feeling better. I’ll be back later to help you with your bath.”
c. “I can see you’re upset. Let me get you some tissue.”
d. “It looks to me like you’re in pain. I’ll get you some medication.”

 

 

ANS:  A

When assessing a patient’s needs, assess both the verbal and the nonverbal messages and validate them. In this case, if you see a patient wringing her hands and sighing, it is appropriate to ask, “You seem anxious today. Is there anything on your mind?” It is not enough to accept only the verbal message if nonverbal signals conflict, and it is inappropriate to jump to conclusions about what the nonverbal signals mean.

 

DIF:    Cognitive Level: Application          REF:   Text reference: pp. 36-37

OBJ:   Explain the communication process.                                         TOP:    Nonverbal Communication

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. Nonverbal communication incorporates messages conveyed by:
a. touch.
b. cadence.
c. tone quality.
d. use of jargon.

 

 

ANS:  A

Nonverbal communication describes all behaviors that convey messages without the use of words. This type of communication includes body movement, physical appearance, personal space, and touch. Cadence, tone quality, and the use of jargon are all part of verbal communication.

 

DIF:    Cognitive Level: Knowledge          REF:   Text reference: p. 28

OBJ:   Explain the communication process.                                         TOP:    Nonverbal Communication

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The patient is an elderly male who had hip surgery 3 days ago. He states that his hip hurts, but he does not like how the medicine makes him feel. He believes that he can tolerate the pain better than he can tolerate the medication. What would be the best response from the nurse?
a. Explain the need for the pain medication using a slower rate of speech.
b. Explain the need for the pain medication using a simpler vocabulary.
c. Explain the need for the pain medication, but ask the patient if he would like the doctor called and the medication changed.
d. Explain in a loud manner the need for the pain medication.

 

 

ANS:  C

Suggesting, which is presenting alternative ideas for patient consideration relative to problem solving, can be effective in helping the patient maintain control by increasing the patient’s perceived options or choices. Nurses often use elder-speak, which includes a slower rate of speech, greater repetition, and simpler grammar than normal adult speech, when caring for older adults. However, many older patients perceive this type of communication as patronizing.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 31

OBJ:   Identify the purpose of therapeutic communication, communication in various phases of the nurse-patient relationship, and special issues related to communication.

TOP:   Communication with the Elderly    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. When comparing therapeutic communication versus social communication, the professional nurse realizes that therapeutic communication:
a. allows equal opportunity for personal disclosure.
b. allows both participants to have personal needs met.
c. is goal directed and patient centered.
d. provides an opportunity to compare intimate details.

 

 

ANS:  C

Therapeutic communication empowers patients to make decisions but differs from social communication in that it is patient centered and goal directed with limited disclosure from the professional. Social communication involves equal opportunity for personal disclosure, and both participants seek to have personal needs met. Nurses do not share with patients intimate details of their personal lives.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 30

OBJ:   Develop skills for therapeutic communication in various phases of the nurse-patient relationship.      TOP:           Establishing the Nurse-Patient Relationship

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse is explaining a procedure to a 2-year-old child. Which is the best approach to use?
a. Showing the needles and bandages in advance
b. Telling the patient exactly what discomfort to expect
c. Using dolls and stories to demonstrate what will be done
d. Asking the child to draw pictures of what he or she thinks will happen

 

 

ANS:  C

Some age-appropriate communication techniques for a 2-year-old child include storytelling and drawing. Showing the child needles or telling the child about discomfort would increase anxiety. Having a child draw what he expects does not explain what is going to happen.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 36

OBJ:   Develop skills for therapeutic communication in various phases of the nurse-patient relationship.      TOP:           Establishing the Nurse-Patient Relationship—Pediatric Considerations

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse is about to go over the patient’s preoperative teaching per hospital protocol. She finds the patient sitting in bed wringing her hands, which are sweaty, and acting slightly agitated. The patient states, “I’m scared that something will go wrong tomorrow.” How should the nurse respond?
a. Redirect her focus to dealing with the patient’s anxiety.
b. Tell the patient that everything will be all right and continue teaching.
c. Tell the patient that she will return later to do the teaching.
d. Give the patient antianxiety medication.

 

 

ANS:  A

Anxiety interferes with comprehension, attention, and problem-solving abilities and thus interferes with the patient’s care and treatment. To ensure the effectiveness of treatment, the nurse should try to help the patient understand the source of the anxiety. Ignoring the anxiety, medicating for it, and postponing the discussion are all inappropriate.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 36

OBJ:   Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients.           TOP:              Establishing the Nurse-Patient Relationship

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse is attempting to teach the patient and his family about his care after discharge. The patient and the family demonstrate signs of anxiety during the teaching session. The nurse should consider doing what?
a. Using more gestures or pictures
b. Focusing on the physical complaints
c. Getting another staff member to speak to the patient
d. Repeating information to the patient and the family at a later time

 

 

ANS:  D

Remember that patients and their family members who are under stress often require repeated explanations. Increasing gestures and pictures is additional stimulation that may increase anxiety. Physical complaints should be acknowledged, but dwelling on them can also increase the patient’s anxiety. Involving another staff member would cause a break in the continuity of care.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 38

OBJ:   Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients.           TOP:              Establishing the Nurse-Patient Relationship

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The patient is an elderly man who was brought to the hospital from an assisted-living community with complaints of anorexia and general malaise. The nurse at the assisted-living community reported that the patient was very ritualistic in his behavior and fastidious in his dress and always took a shower in the evening before bed. The patient became very angry and upset when the patient care technician asked him to take his bath in the morning. What does this behavior tell the nurse?
a. The patient is exhibiting anxiety because of a change in his rituals.
b. The patient is suffering from sensory overstimulation.
c. The patient is basically an angry person.
d. The patient has to follow hospital protocol.

 

 

ANS:  A

Patients often become ritualistic and intent on performing activities a certain way. Anxiety develops as a result of a specific event or a general pattern of change.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 38

OBJ:   Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients.           TOP:              Gerontological Considerations—Anxiety

KEY:  Nursing Process Step: Diagnosis     MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse is preparing to give an intramuscular injection to the patient in room 320. The patient care technician comes to the medication room and tells the nurse that the patient in room 316 is very angry with his roommate and is threatening to hit him. How should the nurse respond?
a. Tell the patient care technician to calm the patient down until she can get there.
b. Have the angry patient’s roommate moved to another location.
c. Tell the angry patient to calm down until she can get there.
d. Tell the angry patient that he has to act civilized in the hospital, and that’s that.

 

 

ANS:  B

A potentially violent patient needs to be in an environment with decreased stimuli and to have protection from injury to self and against others. Encourage other people, particularly those who provoke anger, to leave the room or area. De-escalation is a skill that cannot be delegated to nursing assistive personnel (NAP).

 

DIF:    Cognitive Level: Application          REF:   Text reference: pp. 39-40

OBJ:   Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients.           TOP:              Communicating With the Angry Patient

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. Which behavior should the nurse who is communicating with a potentially violent patient employ?
a. Sit closer to the patient.
b. Speak loudly and firmly.
c. Use slow, deliberate gestures.
d. Always block the door to prevent escape.

 

 

ANS:  C

Make sure that gestures are slow and deliberate rather than sudden and abrupt. There is less chance for misinterpretation of the message, and slow, deliberate gestures are less threatening. Keep an adequate distance between yourself and the patient to reduce your risk of injury and to avoid making the patient feel pressured. Try to talk in a comfortable, reassuring voice. Position yourself closest to the door to facilitate escape from a potentially violent situation. Do not block the exit; if the patient feels unable to escape, this may cause a violent outburst.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 40

OBJ:   Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients.           TOP:              Communicating With the Angry Patient

KEY:  Nursing Process Step: Intervention MSC:  NCLEX: Psychosocial Integrity

 

  1. The patient is sitting at the bedside. He has not been eating and is just staring out of the window. The nurse approaches the patient and asks, “What are you thinking about?” What type of communication technique is this?
a. Restating
b. Clarification
c. Broad openings
d. Reflection

 

 

ANS:  C

Broad openings encourage patients to select topics for discussion. They affirm the value of the patient’s initiative. Restating is repeating a main thought that the patient has expressed. Clarification is attempting to put into words vague ideas or asking the patient to explain what he or she means. Reflection is directing back to the patient ideas, feelings, questions, or content.

 

DIF:    Cognitive Level: Knowledge          REF:   Text reference: p. 31

OBJ:   Explain the communication process.

TOP:   Therapeutic Communication Techniques

KEY:  Nursing Process Step: Diagnosis     MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient tells the nurse, “I want to die.” Which response is the most appropriate for the nurse to make?
a. “Why would you say that?”
b. “Tell me more about how you are feeling.”
c. “The doctor should be told how you feel.”
d. “You have too much to live for to think that way.”

 

 

ANS:  B

Broad openings encourage the patient to select topics for discussion and indicate acceptance by the nurse and the value of the patient’s initiative. “Why” questions can cause defensiveness and can hinder communication. Saying you will inform the doctor leads the conversation away from the patient’s feelings. Saying the patient has too much to live for is false reassurance and negates the patient’s feelings.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 31 |Text reference: p. 42

OBJ:   Explain the communication process.

TOP:   Therapeutic Communication Techniques

KEY:  Nursing Process Step: Intervention MSC:  NCLEX: Psychosocial Integrity

 

  1. The patient states, “I don’t know what my family will think about this.” The nurse wishes to use the communication technique of clarification. Which of the following statements would fit that need best?
a. “You don’t know what your family will think?”
b. “I’m not sure that I understand what you mean.”
c. “I think it would be helpful if we talk more about your family.”
d. “I sense that you may be anxious about something.”

 

 

ANS:  B

The definition of clarification is attempting to put into words vague ideas or unclear thoughts of the patient to enhance the nurse’s understanding, or asking the patient to explain what he or she means. Repeating main thoughts expressed by patients is known as “restating.” Using questions or statements that help patients expand on a topic of importance is known as “focusing.” Asking a patient to verify the nurse’s understanding of what the patient is thinking or feeling is known as “sharing perceptions.”

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 31

OBJ:   Explain the communication process.

TOP:   Therapeutic Communication Techniques

KEY:  Nursing Process Step: Intervention MSC:  NCLEX: Psychosocial Integrity

 

  1. A patient tells the nurse, “I think that I must be really sick. All of these tests are being done.” Which response by the nurse uses the specific communication technique of reflection?
a. “I sense that you are worried.”
b. “I think that we should talk about this more.”
c. “You think that you must be very sick because of all the tests.”
d. “I’ve noticed that this is an underlying issue whenever we talk.”

 

 

ANS:  C

Reflecting is directing back to the patient ideas, feelings, questions, or content, validating the nurse’s understanding of what the patient is saying, and signifying empathy, interest, and respect for the patient. Asking the patient to confirm your sense of his or her anxiety is “sharing perceptions.” Stating that “we should talk about this more,” that is, putting forth questions or statements to expand on a topic, is “focusing.” Pointing out underlying issues or problems that occur repeatedly is known as “theme identification.”

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 31

OBJ:   Explain the communication process.

TOP:   Therapeutic Communication Techniques

KEY:  Nursing Process Step: Intervention MSC:  NCLEX: Psychosocial Integrity

 

  1. The patient is admitted to the hospital with complaints of headache, nausea, and dizziness. She states that she has a final exam in the morning and needs to do well on it to pass the course, but she can’t seem to get into it. She appears nervous and distracted, and is unable to recall details. She most likely is showing manifestations of _____ anxiety.
a. mild
b. moderate
c. severe
d. panic state of

 

 

ANS:  C

Severe anxiety manifests as a focus on fragmented details, as well as headache, nausea, dizziness, inability to see connections between details, and poor recall. Mild anxiety manifests as increased auditory and visual perception, increased awareness of relationships, and increased alertness and ability to problem-solve. Moderate anxiety manifests as selective inattention, decreased perceptual field, focus only on relevant information, muscle tension, and diaphoresis. Panic state of anxiety manifests as an inability to notice surroundings, feelings of terror, and inability to cope with any problem.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 36

OBJ:   Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients.           TOP:              Manifestations of Anxiety

KEY:  Nursing Process Step: Diagnosis     MSC:  NCLEX: Physiological Integrity

 

  1. The patient is admitted to the emergency department for trauma received in a fist fight. He states that he could not control himself. He says that his wife left him for another man. He thinks it was because he was always too tired after working to do things. He says he has to work, and there is nothing he could do to change things. He says that he feels trapped in his job, but he knows nothing else. What was the altercation with the other man probably a manifestation of?
a. Mild anxiety
b. Depression
c. Severe anxiety
d. Moderate anxiety

 

 

ANS:  B

Symptoms of depression include apathy, sadness, sleep disturbances, hopelessness, helplessness, worthlessness, guilt, anger, fatigue, thoughts of death, decreased libido, ruminations of inadequacy, psychomotor agitation, verbal berating of self, spontaneous crying, dependency, and passiveness. Mild anxiety manifests as increased auditory and visual perception, increased awareness of relationships, increased alertness, and an increased ability to problem-solve. Moderate anxiety manifests as selective inattention, decreased perceptual field, focus only on relevant information, muscle tension, and diaphoresis. Severe anxiety manifests as a focus on fragmented details, headache, nausea, dizziness, an inability to see connections between details, and poor recall.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 42

OBJ:   Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients.           TOP:              Manifestations of Depression

KEY:  Nursing Process Step: Diagnosis     MSC:  NCLEX: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. Verbal communication includes which of the following? (Select all that apply.)
a. Speech
b. Personal space
c. Body movement
d. Writing

 

 

ANS:  A, D

Verbal communication includes both spoken word and written word. Nonverbal communication describes all behaviors that convey messages without the use of words. This type of communication includes body movement, physical appearance, personal space, and touch.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 28

OBJ:   Explain the communication process.                                         TOP:    Verbal Communication

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Psychosocial Integrity

 

  1. In caring for patients of different cultures, it is important for the nurse to: (Select all that apply.)
a. use appropriate linguistic services.
b. display empathy and respect.
c. use accurate health history-taking techniques.
d. use patient-centered communication.

 

 

ANS:  A, B, C, D

The following factors are essential in providing effective care for culturally and linguistically diverse patients: (1) use of appropriate linguistic services (e.g., interpreter or bilingual health care workers) and/or other communication strategies, (2) display of empathy and respect for culturally and linguistically diverse patients, (3) use of accurate health history-taking techniques for diagnostic and treatment purposes and health teaching, and (4) use of patient-centered communication behaviors, including participatory decision making. It also is helpful to speak plainly and to avoid mimicking a patient’s accent or dialect.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 30

OBJ:   Identify the purpose of therapeutic communication, communication in various phases of the nurse-patient relationship, and special issues related to communication.

TOP:   Cultural Communication                KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. In establishing the nurse-patient relationship, personal self-disclosure by the nurse is useful for which of the following goals? (Select all that apply.)
a. To educate the patient
b. To build the therapeutic alliance
c. To encourage the patient’s independence
d. To offer opinions that may influence the patient’s decisions

 

 

ANS:  A, B, C

Personal self-disclosure is used with caution and only in selected situations. Personal self-disclosure by the nurse is useful for the following goals: (1) to educate the patient, (2) to build a therapeutic alliance with the patient, and (3) to encourage the patient’s independence. Barriers to therapeutic communication include giving an opinion, offering false reassurance, being defensive, showing approval or disapproval, stereotyping, and asking “Why?” The use of “why” questions causes increased defensiveness in the patient and hinders communication.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 30

OBJ:   Develop skills for therapeutic communication in various phases of the nurse-patient relationship.      TOP:           Establishing the Nurse-Patient Relationship

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. In dealing with angry patients, the nurse realizes that anger: (Select all that apply.)
a. may be important to recovery.
b. may be a means to cope with grief.
c. often hides a specific problem.
d. should not be allowed to compromise care.

 

 

ANS:  A, B, C, D

It is important for you to understand that in many cases the patient’s ability to express anger is important for recovery. For example, when a patient has experienced a significant loss, anger becomes a means to help cope with grief. Some patients express anger toward the nurse, but the anger often hides a specific problem or concern. Allow patients to express anger openly, and do not feel threatened by their words. However, do not allow a patient’s anger to threaten or compromise care.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 38

OBJ:   Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients.           TOP:              Establishing the Nurse-Patient Relationship

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The nurse observes that the patient is pacing in his room with clenched fists. When asked “What’s wrong?” the patient states, “There’s nothing wrong. I just want out of here.” He then bangs his fist on the table and yells, “I’ve had it!” How should the nurse respond? (Select all that apply.)
a. Tell the patient that he needs to calm down.
b. Pause to collect her own thoughts.
c. Block the doorway.
d. Notify the proper authorities.

 

 

ANS:  B, D

Awareness and control of your own reaction and responses will facilitate more constructive interaction. Maintain an open exit. Position yourself closest to the door to facilitate escape from a potentially violent situation. Do not block the exit so the patient feels escape is unattainable; this may cause a violent outburst. An angry patient loses the ability to process information rationally and therefore may impulsively express anger through intimidation. If a strong likelihood of imminent harm to another is present upon discharge, notify the proper authorities (e.g., nurse manager).

 

DIF:    Cognitive Level: Synthesis             REF:   Text reference: pp. 39-41

OBJ:   Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients.           TOP:              Communicating With the Angry Patient

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

COMPLETION

 

  1. The nurse is starting her first set of morning rounds. As she interacts with the patient, her questions revolve around his reactions to his disease process. She also asks if there is anything that she can do to make him more comfortable. This type of interaction is known as _______________.

 

ANS:

therapeutic communication

Therapeutic communication is an application of the process of communication to promote the well-being of the patient.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 29

OBJ:   Identify guidelines to use in therapeutic communication.          TOP:    Therapeutic Communication

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. An active process of receiving information that nonverbally communicates to the patient the nurse’s interest and acceptance is classified as _____________.

 

ANS:

listening

Definition: An active process of receiving information and examining one’s reaction to messages received. Therapeutic value: Nonverbally communicates to the patient the nurse’s interest and acceptance.

 

DIF:    Cognitive Level: Knowledge          REF:   Text reference: p. 31

OBJ:   Explain the communication process.

TOP:   Therapeutic Communication Techniques

KEY:  Nursing Process Step: Diagnosis     MSC:  NCLEX: Psychosocial Integrity

 

  1. The patient is talking about his fear of having surgery but is being vague and is using a lot of jargon. The nurse states, “I’m not sure what you mean. Could you tell me again?” This is an example of __________________.

 

ANS:

clarification

Clarification is attempting to put into words vague ideas or unclear thoughts of the patient to enhance the nurse’s understanding, or asking the patient to explain what he or she means. This may help to clarify the patient’s feelings, ideas, and perceptions, and may provide an explicit correlation between them and the patient’s actions.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 31

OBJ:   Explain the communication process.

TOP:   Therapeutic Communication Techniques

KEY:  Nursing Process Step: Diagnosis     MSC:  NCLEX: Psychosocial Integrity

 

  1. Directing the conversation back to patient ideas, feelings, questions, or content is known as ___________________.

 

ANS:

reflection

Reflection or directing back to the patient ideas, feelings, questions, or content validates the nurse’s understanding of what the patient is saying and signifies empathy, interest, and respect for the patient.

 

DIF:    Cognitive Level: Knowledge          REF:   Text reference: p. 31

OBJ:   Explain the communication process.

TOP:   Therapeutic Communication Techniques

KEY:  Nursing Process Step: Diagnosis     MSC:  NCLEX: Psychosocial Integrity

 

  1. The patient tells the nurse that his mother left him when he was 5 years old. The nurse responds by saying, “You say that your mother left you when you were 5 years old?” This is an example of _______________.

 

ANS:

restating

Restating is a technique whereby the nurse repeats the main thought that the patient has expressed. It indicates that the nurse is listening, and validates, reinforces, or calls attention to something important that has been said.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 31

OBJ:   Explain the communication process.

TOP:   Therapeutic Communication Techniques

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. The patient has been agitated for the entire morning but refuses to say why he is angry. Instead, whenever the nurse speaks to him, he smiles at her while clenching his fist at the same time. The nurse states, “I can see that you’re smiling, but I sense that you are really very angry.” This is an example of ___________________.

 

ANS:

sharing perceptions

Sharing perceptions is asking the patient to verify the nurse’s understanding of what the patient is thinking or feeling. It conveys to the patient the nurse’s understanding and has the potential for clearing up confusing communication.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 31

OBJ:   Explain the communication process.

TOP:   Therapeutic Communication Techniques

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Psychosocial Integrity

 

  1. Lack of verbal communication for a therapeutic reason is known as ___________________.

 

ANS:

therapeutic silence

Lack of verbal communication for a therapeutic reason is known as therapeutic silence. It allows the patient time to think and gain insights, slows the pace of the interaction, and encourages the patient to initiate conversation, while conveying the nurse’s support, understanding, and acceptance.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 31

OBJ:   Explain the communication process.                                         TOP:    Therapeutic Silence

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Psychosocial Integrity

 

  1. Anxiety that is the source of inattention, decreased perceptual field, and diaphoresis is classified as ____________________.

 

ANS:

moderate anxiety

Moderate anxiety is characterized by selective inattention, decreased perceptual field, the ability to focus only on relevant information, muscle tension, and/or diaphoresis.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 36

OBJ:   Develop therapeutic communication skills for communicating with anxious, angry, and depressed patients.           TOP:              Anxiety                    KEY:  Nursing Process Step: Diagnosis

MSC:  NCLEX: Psychosocial Integrity

 

Chapter 11: Orthopedic Measures

 

MULTIPLE CHOICE

 

  1. According to the National Association of Orthopaedic Nurses (NAON), which of the following is possibly the most effective cleansing solution for pin-site care?
a. Normal saline
b. Hydrogen peroxide
c. Chlorhexidine
d. None of the above

 

 

ANS:  C

The second group to develop clinical practice guidelines is the United States–based NAON, which indicated that chlorhexidine 2 mg/mL solution is possibly the most effective cleansing solution for pin-site care. A British consensus group of orthopedic nurse experts recommends that pin sites be cleaned only with sterile normal saline or water to remove crusts around the pins (Walker, 2007). Walker found no definitive evidence to support a pin-site dressing containing an antimicrobial agent. Several studies have found that although hydrogen peroxide is a common cleansing agent, it may cause damage to the healthy tissue surrounding the pin.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 264

OBJ:   Explain nursing measures for complications from traction.

TOP:   Pin-Site Care                                   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The patient has a broken leg and needs to have a cast applied. When plaster of Paris is compared and contrasted versus the newer synthetic casts, which of the following statements is true?
a. Plaster of Paris can tolerate earlier weight bearing than synthetic casts.
b. Plaster of Paris is more expensive than synthetic casts.
c. Synthetic casts can withstand contact with water better than plaster of Paris.
d. Synthetic casts are lighter but take longer to set than plaster of Paris.

 

 

ANS:  C

Although the newer synthetic casts are more expensive than plaster of Paris, they can withstand contact with water without crumbling. A plaster of Paris cast has multiple rolls of open-weave cotton saturated with calcium sulfate crystals. These casts are heavier than synthetic casts and take 24 to 72 hours with no weight bearing or application of pressure while drying. Synthetic casts are lightweight, set in 15 minutes, and can sustain weight bearing or pressure in 15 to 30 minutes.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 251

OBJ:   Explain nursing measures for complications from traction.

TOP:   Comparison of Cast Material          KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. An expected outcome of cast application that the nurse evaluates is:
a. skin irritation at the cast edges.
b. decreased capillary refill and pallor.
c. tingling and numbness distal to the cast.
d. slight edema, soreness, and limited range of motion.

 

 

ANS:  D

Expected outcomes after completion of the procedure: Patient initially experiences only slight edema, soreness, mild pain, and some limitation of active range of joint motion (ROJM) from being in the cast. Expected outcomes after completion of the procedure: Skin around proximal and distal cast edges remains intact without irritation, is free of pressure and friction from the cast edges, and is warm and of normal color with capillary refill of 3 seconds or less; and the patient verbalizes no abnormal or unusual sensations and is able to move the fingers or toes below the casted part. Neurovascular function to the body part is maintained.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 252

OBJ:   Describe neurovascular assessments of a patient with an orthopedic injury.

TOP:   Expected Outcomes                        KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. The patient is admitted for a fractured tibia. The nurse is preparing for cast application and expects to administer a(n) _____ to the patient minutes before the procedure.
a. oral analgesic 10
b. intramuscular (IM) analgesic 10
c. intravenous (IV) analgesic 2 to 5
d. muscle relaxant 10

 

 

ANS:  C

Administer analgesic per order before cast application: IV, 2 to 5 minutes before the procedure. This is the most effective way to reduce pain during cast application.

Alternately, you could administer analgesic by mouth (PO), 30 to 40 minutes before cast application to obtain optimal analgesic effect.  If administering analgesic via  IM injection, give does 20 to 30 minutes before cast application for optimal analgesic effect. Administer muscle relaxant 30 minutes before cast application if spasms are present. Often, muscle spasms are treated more effectively with skeletal muscle relaxants than with opioids.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 252

OBJ:   Describe how to assist in application of casts.                 TOP:   Preprocedure Medication

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. An appropriate technique for the nurse to implement for the patient who is being casted is to:
a. apply ice to the top of the cast.
b. maintain the extremity below heart level.
c. handle the wet cast with the fingertips.
d. fold the stockinette or padding over the outer cast edges.

 

 

ANS:  D

Assist with “finishing” by folding the stockinette or other padding down over the outer edge of the cast to provide a smooth edge. Smooth edges lessen possible skin irritation. When the cast is finished with a stockinette, later “petaling” with tape is not required when the cast is dry. Elevation and ice can be ordered, but ice would not be applied to the top of the wet cast because the weight could change the shape of the cast, causing indentations that can lead to pressure areas. Maintain elevation at or above heart level; elevation enhances venous return and decreases edema. Handle the casted extremity with palms only until the cast is dry. Fingers can cause indentations that can lead to pressure areas.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 254

OBJ:   Describe how to assist in application of casts.                 TOP:   Finishing the Cast

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. When teaching cast care, the nurse instructs the patient to:
a. blow dry the wet cast on the “hot” setting.
b. report changes in sensation or mobility to the area.
c. use only soft objects to slide down the cast for scratching.
d. cut away the edges of the cast if the skin becomes irritated.

 

 

ANS:  B

The patient must monitor neurovascular status, paying particular attention to blueness or paleness of the nails, pain, a feeling of tightness, numbness, or a tingling sensation. Caution the patient against drying a wet cast with a hair dryer; this can cause plaster to crack or the skin underneath to be damaged. The patient should avoid sticking objects down or into the cast to scratch because these objects can cause breaks in underlying skin and subsequent infection. Inform the patient to inspect the cast and petal rough edges to reduce the risk of trauma to underlying skin and the need for cast changes. Small pieces (petals) of adhesive tape 2.5 to 5.0 cm (1 to 2 inches) are cut and taped smoothly over the edge of the cast.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: pp. 254-256

OBJ:   Describe elements of education for the patient with a cast and after removal of a cast.

TOP:   Cast Care       KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. For cast removal, which of the following instructions should the nurse provide to the patient?
a. Discomfort will be felt from the cast saw.
b. An enzyme wash may be applied to intact skin.
c. The skin will be scrubbed very well after the removal.
d. Aggressive range-of-motion exercises will be performed after removal.

 

 

ANS:  B

If the skin is intact, gently apply a cold water enzyme wash to the skin; let it stay on the skin 15 to 20 minutes. This helps dissolve or emulsify dead cells and fatty deposits on tissues and prevents injury to delicate tissue. A cast saw vibrates the cast loose; the patient will feel heat and vibration. Do not scrub the skin because this may traumatize delicate tissue and lead to skin breakdown. It may take several days before all residue is removed from the skin. Obtain a physician’s order to gently put joints through active and passive ROJM. Clarify the level of activity allowed. Joints and muscles will be stiff and weak. Activity is resumed slowly to avoid reinjury.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: pp. 257-258

OBJ:   Describe elements of education for the patient with a cast and after removal of a cast.

TOP:   Cast Removal                                 KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The patient is brought into the emergency department after falling on the ice in her driveway. She is suspected of having a fractured hip. After comparing different available types of traction, she anticipates that which of the following will be used?
a. Bryant’s traction
b. Dunlop’s traction
c. Buck’s extension
d. Gallows traction

 

 

ANS:  C

Buck’s extension provides temporary immobilization of a hip fracture until open reduction and internal fixation (ORIF) can be performed. It also reduces muscle spasms, contractures, and dislocations and occasionally is used as an interim treatment for lumbosacral muscle spasms that cause low back pain. Bryant’s traction (called Gallows in England) is no longer used because of the risk for gravitational vascular draining of the extremities and the possible tourniquet effect of bandages, triggering vasospasms and avascular necrosis. Dunlop’s traction is a simultaneous horizontal form of Buck’s extension to the humerus with an accompanying vertical Buck’s extension to the forearm.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 258

OBJ:   Explain the purposes of placing a patient in skin or skeletal traction.

TOP:   Buck’s Traction                              KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which type of traction does the nurse anticipate will be used for an adult patient with a fractured humerus?
a. Bryant’s traction
b. Dunlop’s traction
c. Gallows traction
d. Buck’s extension

 

 

ANS:  B

Dunlop’s traction is a simultaneous horizontal form of Buck’s extension to the humerus with an accompanying vertical Buck’s extension to the forearm. Bryant’s traction (called Gallows in England) is no longer used because of the risk for gravitational vascular draining of the extremities and the possible tourniquet effect of bandages, triggering vasospasms and avascular necrosis. Buck’s extension provides temporary immobilization of a hip fracture until ORIF can be performed. It also reduces muscle spasms, contractures, and dislocations and occasionally is used as an interim treatment for lumbosacral muscle spasms that cause low back pain.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 258

OBJ:   Explain the purposes of placing a patient in skin or skeletal traction.

TOP:   Dunlop’s Traction                          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. For a patient who is to be placed in Russell’s traction, the nurse prepares the:
a. occipital area.
b. arm and forearm.
c. back and abdomen.
d. lower extremities.

 

 

ANS:  D

Russell’s traction is a modification of Buck’s extension in which Newton’s third law of motion (for each force in one direction, there is an equal force in the opposite direction) is used to double the amount of pull through the arrangement of ropes, pulleys, and weights.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 258

OBJ:   Explain the purposes of placing a patient in skin or skeletal traction.

TOP:   Russell’s Traction                           KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse places the patient in traction. Expected outcomes would include which of the following?
a. Alignment of fracture fragments with formation of callus within 24 hours
b. Verbalization of pain level as a “4” on a scale of 0 to 10
c. Verbalization of immediate relief of symptoms
d. Distal skin tissue becoming cooler, with capillary refill greater than 3 seconds

 

 

ANS:  B

Expected outcomes would include verbalization of increased comfort after traction application and rating of pain as 4 or lower on a scale of 0 to 10 since injured tissues and bone are stabilized. Evidence of callus may not become apparent for 7 to 10 days or longer. Sufficient time in traction (varying from 1 to 10 or more days) elicits symptom relief. It takes time for inflammation to decrease and tissues to regain more normal function. Neurovascular status should remain stable. Distal skin tissue remains warm and of a normal color with capillary refill of 3 seconds or less.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: pp. 261-262

OBJ:   Explain the purposes of placing a patient in skin or skeletal traction.

TOP:   Expected Outcomes of Traction     KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. While in Buck’s extension traction, the patient may be positioned on the back:
a. with the head of the bed elevated 45 degrees.
b. turning to the unaffected side for 10- to 15-minute periods.
c. with the buttocks slightly elevated off of the bed.
d. with the bed tilted toward the side that is opposite the traction.

 

 

ANS:  B

Position varies with the part of the body to be placed in traction, plus effects of weight and gravity. Body parts are kept aligned anatomically. With Buck’s extension, the patient is primarily on his back but may be allowed to turn to the unaffected side for brief periods (10 to 15 minutes). With Buck’s extension, the patient is on his back with the head of the bed flat or elevated no more than 30 degrees. With Dunlop’s traction, the patient may be tilted on low-shock blocks toward the side opposite the traction.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 261

OBJ:   Explain the purposes of placing a patient in skin or skeletal traction.

TOP:   Positioning     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. An appropriate technique for the nurse to implement for a patient who is being placed in traction is to:
a. apply a traction boot tightly.
b. drop the weights after the traction is attached.
c. assess neurovascular status every 1 to 2 hours for the first day.
d. shave the hair off the area where traction is to be placed.

 

 

ANS:  C

Assess neurovascular status 15 minutes after application of skin traction and every 1 to 2 hours for 24 hours, and then extend to every 4 hours if the patient is stabilizing. Ensure that boot size is correct. A traction boot should fit snugly (not too tight or too loose). Too tight leads to pressure on skin, peroneal nerve, and vascular structures. When all traction materials and spreader bars are in place, weights are placed on weight holders and are attached to a loop in the rope. The weights then are lowered slowly and gently until the rope is taut. Traction is established slowly to avoid involuntary muscle spasms or pain for the patient. Shaving may create micro nicks that could become inflamed under traction strips.

 

DIF:    Cognitive Level: Application          REF:   Text reference: pp. 261-262

OBJ:   Explain the purposes of placing a patient in skin or skeletal traction.

TOP:   Evaluation of Traction                    KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. For a patient in traction who has skeletal pins, the nurse should:
a. use povidone-iodine to cleanse the pin site.
b. apply antiseptic ointment and cover with a split dressing.
c. use hydrogen peroxide as a rinse before a dressing is applied.
d. do both pin sites at the same time, with the same swab and solution.

 

 

ANS:  B

Using a sterile applicator, apply a small amount of topical antibiotic ointment to the pin site and cover with a sterile 2 ´ 2 split gauze dressing. (Note: Some physicians leave the site uncovered.) Dip a sterile cotton-tipped applicator into a sterile container of chlorhexidine 2 mg/mL solution. Place a sterile applicator by the pin, and roll it along the skin, away from the insertion site. Clean outward in a circular fashion from the pin. Dispose of the applicator. Remove crusts from the pin site when signs of infection are present. Chlorhexidine 2 mg/mL is the most effective cleansing solution for pin-site care. Never touch one pin site with material used on another. This prevents cross-contamination.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 266

OBJ:   Describe steps for applying each form of skin or skeletal traction.

TOP:   Pin Care         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. For a patient with a fractured femur, a nurse is alert to the possibility of a fat embolus. What should the nurse specifically watch for?
a. Bradypnea
b. Restlessness
c. Bradycardia
d. Calf pain

 

 

ANS:  B

Assess for indicators of hypoxemia, such as restlessness or agitation. Recognize early signs of fat embolism syndrome. Signs of hypoxemia include tachypnea, not bradypnea. Signs of hypoxemia include tachycardia, not bradycardia. Calf pain would indicate a DVT, not a fat embolism.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 267

OBJ:   Explain nursing measures for complications from traction.

TOP:   Fat Embolism Syndrome                KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. In planning nursing care, the nurse knows that she will need to provide an abduction pillow for which patient?
a. A patient who will be immobilized for a long time
b. A patient who has undergone repair of a fractured right arm
c. A patient who is post hip replacement surgery
d. A patient who has a severely sprained ankle

 

 

ANS:  C

The abduction splint or pillow, used after hip replacement surgery, maintains the patient’s legs in an abducted position. This permits the patient to be turned without changing the position of the healing limb, and prevents dislocation of the hip prosthesis.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 268

OBJ:   Explain nursing measures for complications from immobilization.

TOP:   Abduction Pillows                          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. The nurse is caring for a patient who has had a new cast applied. The nurse is performing a neurovascular assessment so as to detect signs of possible compartment syndrome. Which of the following are signs of compartment syndrome? (Select all that apply.)
a. Inability to move body parts distal to the cast
b. Pain on passive motion of distal body parts
c. Hyperventilation
d. Tachycardia

 

 

ANS:  A, B, C, D

Signs of development of compartment syndrome, cast syndrome, or severe claustrophobia may result from snugness of the cast, which is common for patients in a spica or body cast. Observe the patient for signs of pain or anxiety; ask the patient to rate pain on a scale from 0 to 10; observe for inability to move body parts distal to the cast, pain on passive motion of distal body parts, hyperventilation, swallowing of air (aerophagia), nausea and/or vomiting, tachycardia, and blood pressure elevation.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 255

OBJ:   Describe neurovascular assessments of a patient with an orthopedic injury.

TOP:   Compartment Syndrome                 KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. The patient is in traction and is at risk for fat embolism syndrome. Signs and symptoms of fat embolism include which of the following? (Select all that apply.)
a. Chest pain
b. Tachypnea
c. Tachycardia
d. Apprehension
e. Altered LOC

 

 

ANS:  A, B, C, D

Symptoms of possible fat embolism include clinical manifestations of dyspnea, tachycardia, cyanosis, and circulatory collapse.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 267

OBJ:   Explain nursing measures for complications from traction.

TOP:   Fat Embolism Syndrome                KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. The patient has been in skeletal traction for external fixation of his femur for 2 days. Suddenly, he calls the nurse complaining of chest pain and shortness of breath. The nurse notes that the patient appears anxious, and that his pulse and respirations are elevated. She should do which of the following? (Select all that apply.)
a. Massage the lower extremity
b. Elevate the head of the bed
c. Administer oxygen
d. Notify the physician

 

 

ANS:  B, C, D

If symptoms of pulmonary embolus are evident, elevate the head of the bed (if conscious), administer oxygen, and notify the physician immediately. Do not massage the lower extremity.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 267

OBJ:   Explain nursing measures for complications from traction.

TOP:   Pulmonary Embolism                                KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Skeletal traction is implemented primarily for: (Select all that apply.)
a. simple fracture.
b. multiple trauma.
c. fractured ankle.
d. acetabular fracture.
e. cervical fracture.

 

 

ANS:  B, C, D, E

Skeletal traction immobilizes fractures of the cervical spine, fractures of the femur below the trochanter, and some fractures of the bones of the arm or ankle. It is also used to immobilize the femoral head in an acetabular fracture.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 263

OBJ:   Describe steps for applying each form of skin or skeletal traction.

TOP:   Evaluation of Traction                    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

COMPLETION

 

  1. __________________ involves monitoring for the five Ps (pain, pallor, pulselessness, paresthesia, and paralysis).

 

ANS:

Neurovascular assessment

It is essential to monitor for the five Ps (pain, pallor, pulselessness, paresthesia, and paralysis) of neurovascular status because permanent damage may result if circulation is not restored or pressure is not removed.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 256

OBJ:   Explain nursing measures for complications from traction.

TOP:   Neurovascular Assessment             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The patient has fallen and broken her leg. To keep the leg bones aligned and to reduce muscle spasms, the physician orders the patient to be placed in ____________.

 

ANS:

Buck’s traction

Buck’s traction is the most common type of adult skin traction. It is applied to the legs to provide temporary immobilization of the hip while reducing muscle spasms, contractures, and dislocations.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: pp. 258-259

OBJ:   Explain nursing measures for complications from traction.

TOP:   Traction         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. A _______________ is an externally applied structure that holds musculoskeletal tissues in a specific position to permit healing of injuries or fractures or to align malpositioned tissues.

 

ANS:

cast

A cast is an externally applied structure that holds musculoskeletal tissues in a specific position to permit healing of injuries or fractures or to align malpositioned tissues, as in clubfoot or congenital hip dislocation.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 250

OBJ:   Explain nursing measures for complications from traction.

TOP:   Cast                KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. After application of the cast, the nurse ensures that plaster crumbs are removed and rough edges are _________ to prevent skin breakdown.

 

ANS:

petaled

After application of the cast, ensure that plaster crumbs are removed and rough edges are “petaled” to prevent skin breakdown.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 254

OBJ:   Explain nursing measures for complications from traction.

TOP:   Petaling          KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. When applying a plaster of Paris cast, it is important to keep the cast exposed for at least _____________ minutes.

 

ANS:

15

fifteen

Explain that the patient may experience warmth during the cast application process. Plaster gives off heat from a chemical reaction when drying. Keep the cast exposed to permit maximum dissipation of the heat. Most casts cool in about 15 minutes.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 253

OBJ:   Describe how to assist in application of casts.                 TOP:   Heat Dissipation

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. After applying a cast, the nurse should be able to insert _______ fingers between the cast and the limb.

 

ANS:

2

two

Plaster must be of sufficient thickness to give strength to the cast. More than two fingers’ space in the cast indicates that the cast is too loose and will not support the limb; less than two fingers’ space indicates that the cast may be too tight and may inhibit circulation.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 255

OBJ:   Describe how to assist in application of casts.

TOP:   Spacing Between Cast and Limb    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. _________________ may occur when pressure within a casted extremity increases.

 

ANS:

Compartment syndrome

When pressure within a casted extremity increases, this may lead to compartment syndrome, which occurs when pressure within the muscle compartment increases as a result of edema, bleeding, or decreased venous return. The fascia covering the muscle group acts as a tourniquet on structures within the compartment such as nerves, blood vessels, and muscle tissue.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 255

OBJ:   Describe neurovascular assessments of a patient with an orthopedic injury.

TOP:   Compartment Syndrome                 KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. _____________________ applies a pull indirectly to the bone via straps attached to the skin around the structure.

 

ANS:

Skin traction

Skin traction applies a pull indirectly to the bone via straps and a sling or boot applied to the skin around the structure. Skin traction typically applies between 5 and 7 lb and is commonly used for minor trauma or immediate immobilization before surgery.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 258

OBJ:   Explain the purposes of placing a patient in skin or skeletal traction.

TOP:   Skin Traction                                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. ____________________ consists of a metal frame that secures pins inserted through the bone above and below the fracture site. It stabilizes a fracture with hardware visible outside the body.

 

ANS:

External fixation

External fixation consists of a metal frame that secures pins inserted through the bone above and below a fracture site. External fixation stabilizes a fracture with hardware visible outside the body. It fosters the healing of complex fractured bones, usually in the lower extremities.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 263

OBJ:   Describe steps for applying each form of skin or skeletal traction.

TOP:   Evaluation of Traction                    KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. An immobilization device used to immobilize and protect a body part is known as a ________.

 

ANS:

splint

Immobilization devices increase stability, support weak extremities, or reduce the load on weight-bearing structures such as hips, knees, or ankles. A splint immobilizes and protects a body part.

 

DIF:    Cognitive Level: Knowledge          REF:   Text reference: p. 268

OBJ:   Explain nursing measures for complications from traction.

TOP:   Splints            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

Chapter 26: Closed Chest Drainage Systems

 

MULTIPLE CHOICE

 

  1. The nurse is caring for a patient who is comatose and on a ventilator. When she enters the room, she notices that the patient’s trachea has shifted toward the left side of the patient’s neck, and he has become tachycardic. She assesses the patient’s blood pressure and notes that it is 84/38. The nurse calls for help, having recognized that the patient has developed which of the following conditions?
a. Hemothorax
b. Pneumothorax on the left side
c. Pneumothorax on the right side
d. Myocardial infarction

 

 

ANS:  C

A tension pneumothorax occurs from rupture in the pleura when air accumulates in the pleural space more rapidly than it is removed. If left untreated, the lung on the affected side collapses, and the mediastinum and the trachea shift to the opposite (unaffected) side. The patient has sudden chest pain, a fall in blood pressure, and tachycardia, and cardiopulmonary arrest can occur. Patients with chest trauma, fractured ribs, and invasive thoracic bedside procedures (such as insertion of central lines) and those on high-pressure mechanical ventilation are at risk for tension pneumothorax. A hemothorax is a collapse of the lung caused by an accumulation of blood and fluid in the pleural cavity between the chest wall and the lung, usually as a result of trauma. Nothing in this scenario would suggest myocardial infarction.

 

DIF:    Cognitive Level: Synthesis             REF:   Text reference: p. 656

OBJ:   List three conditions requiring chest tube insertion.         TOP:   Pneumothorax

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. For a patient with a pneumothorax, where does the nurse anticipate that the chest tube will be located?
a. Second to third intercostal space (apical), anterior
b. Fifth to sixth intercostal space, posterior
c. Fifth to sixth intercostal space, lateral
d. Mediastinal area

 

 

ANS:  A

Apical (second or third intercostal space) and anterior chest tube placement promotes removal of air, which is necessary in the case of a pneumothorax. Chest tubes are placed low (usually in the fifth or sixth intercostal space) and posterior or lateral to drain fluid. A mediastinal chest tube is placed in the mediastinum, just below the sternum. This tube drains blood or fluid, preventing its accumulation around the heart. A mediastinal tube commonly is used after open heart surgery.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 656

OBJ:   List three common sites for chest tube placement.          TOP:   Chest Tube Position

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. The patient’s chest tube is attached to a one-way flutter valve that allows air to escape the chest cavity and prevents air from reentering. How does the nurse document this finding?
a. Heimlich chest drain valve
b. Pneumovax
c. Water seal
d. Pleurovac

 

 

ANS:  A

The device described is a Heimlich chest drain valve. Pneumovax is a pneumococcal vaccine that is effective against 23 common strains of Pneumococcus. A Pleurovac is the brand name of a water-seal set.

 

DIF:    Cognitive Level: Knowledge          REF:   Text reference: p. 657

OBJ:   Define the key terms used in the care of patients with chest tubes.

TOP:   Type of Chest Tube                        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient who has a chest tube connected to a water seal. The patient is not on a ventilator. Which of the following would the nurse consider normal?
a. The fluid level in the water seal rises with inspiration.
b. The fluid level in the water seal falls with inspiration.
c. Constant bubbling occurs in the water seal.
d. The fluid level in the water seal falls with expiration 3 days after insertion.

 

 

ANS:  A

Observe the water seal for intermittent bubbling from its U tube or for a rise and fall of fluid that is synchronous with respirations. (For example, in a nonmechanically ventilated patient, the fluid rises during inspiration, and the fluid level falls during expiration. When a patient is on a mechanical ventilator, the opposite occurs.) In a nonmechanically ventilated patient, the fluid rises during inspiration, and the fluid level falls during expiration. Constant bubbling in the water seal or a sudden, unexpected stoppage of water-seal activity is considered abnormal and requires immediate attention. After 2 to 3 days, tidaling or bubbling on expiration is expected to stop, indicating that the lung has reexpanded.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 658

OBJ:   Discuss the nursing principles involved in caring for patients with chest tubes.

TOP:   Water-Seal Tidaling                        KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient with a chest tube that was inserted 4 days earlier. She notices that the drainage contains a large amount of pus. What does the presence of the pus indicate?
a. Malignancy
b. Pulmonary infarction
c. Empyema
d. Hemothorax

 

 

ANS:  C

Pus indicates an empyema, which is a collection of pus in the pleural cavity, and the drainage is pus colored. Blood-tinged fluid usually indicates malignancy, pulmonary infarction, or severe inflammation. Frank blood indicates a hemothorax.

 

DIF:    Cognitive Level: Knowledge          REF:   Text reference: p. 658

OBJ:   Discuss the nursing principles involved in caring for patients with chest tubes.

TOP:   Pleural Drainage                             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is indicated by continuous bubbling in the water-seal chamber with no bubbles noted in the suction control chamber of the drainage system?
a. A leak in the system
b. Normal functioning
c. A drainage obstruction
d. Insufficient suction pressure

 

 

ANS:  A

Continuous bubbling in the water-seal chamber with an absence of bubbles in the suction control chamber indicates that there is a leak in the system. Normal functioning is indicated by gentle, continuous bubbling in the suction chamber and occasional bubbling in the water seal, with fluctuations on inspiration and expiration. Constant bubbling in the water seal or a sudden, unexpected stoppage of water-seal activity is considered abnormal and requires immediate attention. Insufficient suction pressure has little to no bubbling in the suction chamber.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 659

OBJ:   Describe methods of troubleshooting chest tube systems.

TOP:   Bubbling in Suction Control Chamber

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. What condition is indicated when a patient with a chest tube experiences sharp, stabbing chest pain without a change in pulse or blood pressure?
a. Pneumonitis
b. Tube displacement
c. A myocardial infarction
d. A tension pneumothorax

 

 

ANS:  D

Sharp, stabbing chest pain with or without decreased blood pressure and increased heart rate may indicate a tension pneumothorax. A chest tube is not an expected treatment for pneumonitis. Tube displacement is an unexpected outcome and can lead to increased pneumothorax. Immediately apply pressure over the chest tube insertion site. Myocardial infarction pain is expressed as “crushing” or “pressure” over the sternal area.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 662

OBJ:   Describe methods of troubleshooting chest tube systems.         TOP:    Tension Pneumothorax

KEY:  Nursing Process Step: Evaluation   MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following is an expected outcome of chest tube insertion?
a. Mild chest pain is maintained.
b. Breath sounds are auscultated in all lobes.
c. Drainage from the pleural cavity increases over time.
d. Lung expansion is increased beyond the unaffected side.

 

 

ANS:  B

When breath sounds are auscultated in all lobes, lung expansion is symmetrical, oxygen saturation (SaO2) is stable or improved, and respirations are nonlabored. Chest pain is not an expected outcome. Treatment is effective when the patient reports no chest pain. Drainage from the pleural cavity decreases over time with reexpansion of the lung. Lung expansion would be equal to preinjury status.

 

DIF:    Cognitive Level: Knowledge          REF:   Text reference: p. 663

OBJ:   Describe methods of troubleshooting chest tube systems.

TOP:   Expected Outcomes of Chest Tube Insertion

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. What should the nurse do to establish a two-chamber waterless chest tube system?
a. Add sterile water to the suction chamber
b. Add sterile solution to the water seal
c. Set the float ball to the correct drainage pressure
d. Connect directly to the chest tube and add nothing

 

 

ANS:  D

The waterless two-chamber system is ready for connecting to the patient’s chest tube after the wrappers have been opened. The waterless system’s principles are similar to those of the water-seal system, except that fluid is not required for setup. Because water is not used, accidentally tipping over the system does not compromise the patient’s condition. The suction chamber does not depend on water. Instead, it contains a float ball, which is set by a suction control dial after the suction source is turned on.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 660

OBJ:   Describe closed chest drainage systems: water-seal and waterless systems.

TOP:   Two-Chamber Waterless Chest Tube System

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following represents appropriate technique when providing care for a patient with chest tubes?
a. Applying an occlusive dressing over the site
b. “Stripping” the tube on a regular basis
c. Assessing the patient hourly after insertion
d. Keeping excess loops of tubing from hanging over the side of the bed

 

 

ANS:  D

Lay excess tubing horizontally on the mattress next to the patient. Secure with a rubber band and safety pin or with the system’s clamp. This prevents excess tubing from hanging over the edge of the mattress in a dependent loop. Drainage could collect in the loop and occlude the drainage system. Physician responsibility in chest tube placement includes covering the insertion site with sterile petroleum gauze, 4 ´ 4-inch gauze, and a large dressing to form an occlusive dressing supported with an elastic bandage. Strip or milk the chest tube only if indicated (this means compressing the tube to encourage clots to press through the tube). Stripping may cause complications because it creates excessive negative intrapleural pressure. Check agency policy. Monitor vital signs, SaO2, and the insertion site every 15 minutes for the first 2 hours.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 658

OBJ:   Discuss the nursing principles involved in caring for patients with chest tubes.

TOP:   Providing Care to the Patient Who Has a Chest Tube

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following is the correct positioning for a patient after a chest tube has been inserted for a hemothorax?
a. Supine
b. Side-lying
c. Semi-Fowler’s
d. High-Fowler’s

 

 

ANS:  D

After the tube is placed, assist the patient to a comfortable position. Supine does not facilitate drainage or removal of air or fluid, and side-lying does not facilitate lung expansion. The high-Fowler’s position is used to evacuate air (pneumothorax).

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 665

OBJ:   Discuss the nursing principles involved in caring for patients with chest tubes.

TOP:   Positioning the Patient Who Has a Chest Tube

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What is the expected amount of drainage for an adult patient with a mediastinal chest tube?
a. Less than 100 mL/hr during the immediate postoperative period
b. Less than 10 mL/hr during the immediate postoperative period
c. 1000 mL/hr during the first 24-hour period
d. 200 mL/hr during the first 24-hour period

 

 

ANS:  A

In the adult, less than 50 to 200 mL/hr is drained immediately after surgery in a mediastinal chest tube. No standard is known for 10 mL/hr in the immediate postoperative period. Expected drainage in the adult with a mediastinal chest tube is approximately 500 mL in the first 24 hours.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 666

OBJ:   Discuss the nursing principles involved in caring for patients with chest tubes.

TOP:   Postoperative Drainage From a Mediastinal Chest Tube

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. What is the expected amount of drainage for an adult patient with a posterior chest tube?
a. 100 to 300 mL during the first 3 hours
b. 10 to 50 mL during the first 2 hours
c. 200 mL during the first 24 hours
d. 400 to 500 mL during the first 24 hours

 

 

ANS:  A

In the adult, between 100 and 300 mL of fluid may drain from a posterior tube during the first 3 hours after insertion. The 24-hour rate is 500 to 1000 mL.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 666

OBJ:   Discuss the nursing principles involved in caring for patients with chest tubes.

TOP:   Drainage from a Pleural Chest Tube

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. A nurse determines that there may be a leak in the chest tube system. Clamps are applied near the patient’s chest, and the nurse finds that the bubbling stops. What should the nurse do next?
a. Change the tubing.
b. Change the drainage container.
c. Move the clamps farther down the chest tube.
d. Reinforce the dressing and notify the physician.

 

 

ANS:  D

Assess for the location of the air leak by clamping the chest tube close to the chest wall with two shodded hemostats. If the bubbling stops, the leak is inside the thorax or insertion site. Unclamp the tube, reinforce the dressing, and notify the physician immediately. If bubbling continues with the clamps near the chest wall, gradually move one clamp at a time down the tubing toward the patient. If bubbling stops, replace the tubing or secure the connections. If bubbling continues, replace the drainage system.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 667

OBJ:   Discuss the nursing principles involved in caring for patients with chest tubes.

TOP:   Detecting Air Leak in a Chest Tube System

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. During assessment of a patient, the chest tube becomes dislodged. What should the nurse do first?
a. Have an assistant apply an occlusive gauze dressing and tape on all four sides.
b. Clamp the chest tube.
c. Attempt to gently reinsert the tube.
d. Apply pressure over the insertion site.

 

 

ANS:  D

If the chest tube becomes dislodged, immediately apply pressure over the chest tube insertion site. The nurse should first stabilize the patient to the best of his or her ability before calling the physician. Applying gauze to all four sides of an occlusive dressing would not allow for the escape of any air from the pleural space and could lead to a tension pneumothorax. Because the chest tube has become dislodged, it is outside of the body. Clamping the tube at this point would be useless. Nurses are not allowed to reinsert chest tubes. Immediately apply pressure over chest tube insertion site. Have an assistant apply gauze dressing and tape three sides. Notify the health care provider.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 667

OBJ:   Discuss the nursing principles involved in caring for patients with chest tubes.

TOP:   Dislodged Chest Tube                    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What does the expected role of the nurse include during chest tube removal?
a. Prepares an occlusive dressing
b. Performs clipping of the sutures
c. Provides support and assessment of the patient
d. Removes the chest tube firmly and quickly

 

 

ANS:  C

The nurse supports the patient physically and emotionally while the physician or an advanced practice nurse (APN) removes the dressing and clips the sutures. A physician or an APN prepares an occlusive dressing of petroleum gauze on a pressure dressing, sets it aside on a sterile field, and applies sterile gloves; removes the dressing and clips the sutures; and pulls out the chest tube.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 668

OBJ:   Discuss the nursing principles involved in caring for patients with chest tubes.

TOP:   Chest Tube Removal                                 KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Appropriate intervention for the patient who is having a reinfusion of chest tube drainage is noted when the nurse:
a. Hangs the reinfusion lower than the usual intravenous (IV) bag
b. Uses a microaggregate filter on the reinfusion bag
c. Maintains 500 mm Hg pressure in the gravity blood cuff
d. Keeps the clamps open on the drainage tubing during bag transfer

 

 

ANS:  B

Use a new microaggregate filter to reinfuse each autotransfusion bag. Hang the bag on an IV pole and continue to prime the tubing until all air is gone. Clamp the tubing, attach it to the patient’s IV access, and adjust the clamp to deliver the reinfusion at the appropriate rate. Reinfusion is delivered by gravity or by application of a blood cuff (not to exceed 150 mm Hg pressure) or a blood-compatible IV pump. Connect the red and blue connectors on top of the initial collection bag, and remove it by lifting it from the side hook and then from the foot hook. This maintains a closed system within the bag and removes it for use in autotransfusion.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 672

OBJ:   Describe autotransfusion.               TOP:   Autotransfusion

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Of the following nursing assessments, which should be reported to the primary care provider immediately by the nurse?
a. Bloody drainage from a patient with a hemothorax
b. Subcutaneous emphysema is noted on assessment
c. Bubbling in the water seal stops on a patient with a pneumothorax
d. Over 300 mL of drainage has been collected in the system in the past hour

 

 

ANS:  D

Drainage exceeding 100 mL/hr should be reported immediately because this would be considered abnormal. Drainage would be expected to be bloody if the patient has a hemothorax. Cessation of bubbling in the water seal indicates that the air has been evacuated in the patient with a pneumothorax. Although the finding of subcutaneous emphysema should be reported, documented, and monitored, it is not an emergency.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 658

OBJ:   Demonstrate appropriate documentation and reporting of chest tube care.

TOP:   Chest Tube Assessment                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Safe and Effective Care Environment

 

  1. The nurse is providing care for a patient with a pneumothorax. She anticipated removal of the chest tube because of the absence of an air leak for the past _____ hours.
a. 6 to 8
b. 12 to 16
c. 18 to 24
d. 48 to 72

 

 

ANS:  C

One of the signs that indicate that the chest tube may be removed is lack of an air leak for 24 to 48 hours. Lack of an air leak for less than 24 hours is usually not long enough, and there is no need to wait 4 days. Other findings that indicate that the chest tube may be removed include a chest x-ray showing lung reexpansion, minimal tube drainage, and lack of water-seal tidaling.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 658

OBJ:   Verbalize the steps used in assisting with chest tube removal.

TOP:   Chest Tube Removal                                 KEY:              Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient with blood collecting in the pleural space. The nurse documents this as:
a. pleural effusion.
b. hemothorax.
c. pulmonary hemorrhage.
d. pneumothorax.

 

 

ANS:  B

A hemothorax is a collection of blood in the pleural space. A pneumothorax is the collection of air in the pleural space. A pulmonary hemorrhage is bleeding inside the lung. A pleural effusion is the collection of fluid within the pleura.

 

DIF:    Cognitive Level: Knowledge          REF:   Text reference: p. 656

OBJ:   Define the key terms used in the care of patients with chest tubes.

TOP:   Chest Tubes Drainage                     KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse knows that _______________ is the proper term to describe that the patient’s water seal is fluctuating up and down with each breath.
a. bubbling
b. tidaling
c. fluttering
d. alternating

 

 

ANS:  B

The term for the fluctuation of the water-seal chamber when the patient breathes is tidaling. Bubbling is different from tidaling, because bubbling is the presence of gas moving through the chamber, whereas tidaling is an up and down movement that correlates with the patient’s breathing. Fluttering and alternating reflect incorrect terminology.

 

DIF:    Cognitive Level: Knowledge          REF:   Text reference: p. 661

OBJ:   Define the key terms used in the care of patients with chest tubes.

TOP:   Chest Tube Functioning                  KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient with a chest tube connected to water-seal drainage. The nurse may delegate which of the following tasks to nursing assistive personnel (NAP)?
a. Changing the chest tube drainage system
b. Milking the chest tube
c. Measuring chest tube output
d. Turning and positioning the patient

 

 

ANS:  D

The NAP may turn and position the patient as long as the nurse ensures that the NAP understands how to manipulate the tubing safely and what signs and symptoms should be reported immediately. Care of the chest tube, including milking the tube if ordered, measuring chest tube output, and changing the chest tube drainage system, should never be delegated to unlicensed assistive personnel.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 661

OBJ:   Recognize when it is appropriate to delegate aspects of the care of patients with chest tubes to unlicensed assistive personnel.   TOP:   Chest Tube Assessment

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Safe and Effective Care Environment

 

  1. The patient has a chest tube for a pneumothorax. Assessment revealed no continuous bubbling in the water-seal chamber. The nurse finds no loose connections. After the chest tube near the patient is clamped, the bubbling stops. The nurse’s first action should be to:
a. apply pressure to the dressing around the chest tube insertion site.
b. move the clamp farther down the tube and note whether bubbling resumes.
c. replace the entire collection tubing and system.
d. increase suction control until bubbling does not resume when the clamp is removed.

 

 

ANS:  A

If bubbling stops when the chest tube is clamped between the collecting system and the body, the leak is at the insertion site or inside the patient. Applying pressure to the dressing will determine which of the sites is leaking. If bubbling continues after the chest tube is clamped, the leak is below the clamp, and the next step would be to move the clamp farther away from the patient and reassess. Only if the bubbling never stops after the clamp is moved all the way down the tubing should the collection system be replaced. Turning the suction device higher will increase bubbling in the suction chamber and will not affect bubbling in the water-seal chamber.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 667

OBJ:   Verbalize the steps used in maintaining chest tube drainage.

TOP:   Chest Tube Assessment                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. A pneumothorax can be caused by which of the following? (Select all that apply.)
a. Trauma
b. Rupture of a blister
c. Emphysema
d. Dyspnea

 

 

ANS:  A, B, C

A variety of mechanisms can cause a pneumothorax. A traumatic pneumothorax develops as a result of penetrating chest trauma, such as a stabbing or a case of the chest striking the steering wheel in an automobile accident. A spontaneous or primary pneumothorax sometimes occurs from the rupture of a small bleb (blister) on the surface of the lung or from an invasive procedure, such as insertion of a subclavian IV line. Secondary pneumothorax occurs because of underlying disease, such as emphysema. A patient with a pneumothorax usually feels pain as atmospheric air irritates the parietal pleura. Dyspnea is a symptom of pneumothorax, not a cause.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 657

OBJ:   Describe causes of pneumothorax. TOP:   Pneumothorax

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient with a chest tube connected to wall suction. To keep the tube patent, the nurse should implement which of the following? (Select all that apply.)
a. Routinely “milk” the drainage tubing.
b. Avoid dependent loops of the drainage tubing.
c. Lift and clear the tube every 15 minutes.
d. Coil the drainage tubing to prevent dependent loops.

 

 

ANS:  B, C

Chest tube milking or stripping usually is contraindicated because it does not improve catheter patency. Careful management of chest tube drainage prevents the need to milk the chest tube. Institute nursing interventions to maintain tube patency. These interventions include avoiding dependent loops of the drainage tube, or, when these loops cannot be avoided, such as when the patient is sitting, lifting and clearing the tube every 15 minutes. If the tubing is coiled, looped, or clotted, drainage is impeded, and this can result in a tension pneumothorax.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 658

OBJ:   Discuss the nursing principles involved in caring for patients with chest tubes.

TOP:   Chest Tube Patency                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient with a chest tube that was inserted 4 days earlier. She notices that the drainage is blood-tinged. What might this indicate to the nurse? (Select all that apply.)
a. Malignancy
b. Pulmonary infarction
c. Empyema
d. Hemothorax

 

 

ANS:  A, B

Blood-tinged fluid usually indicates malignancy, pulmonary infarction, or severe inflammation. Pus indicates an empyema, which is a collection of pus in the pleural cavity, and the drainage is pus-colored. Frank blood indicates a hemothorax.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 658

OBJ:   Discuss the nursing principles involved in caring for patients with chest tubes.

TOP:   Pleural Drainage                             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is preparing to assist the physician in removal of a chest tube. What should the nurse do to prepare the patient? (Select all that apply.)
a. Assess the patient’s need for pain medication.
b. Instruct the patient about the process.
c. Teach the patient to take a deep breath and hold it.
d. Clamp the chest tubes.

 

 

ANS:  A, B, C

The nurse should prepare the patient for chest tube removal by (1) assessing the need for pre-removal analgesia and obtaining the required medication orders, and (2) instructing the patient about the process and what will be requested of the patient. During removal of the chest tube, it is important to instruct the patient to take a deep breath and hold it until the tube is removed. This maneuver prevents air from being sucked into the chest as the tube is pulled out and an occlusive dressing is applied. Although clamping of the chest tubes is done to determine whether the chest tube can be eliminated, this is not part of the immediate chest tube removal procedure.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 668

OBJ:   Discuss the nursing principles involved in caring for patients with chest tubes.

TOP:   Chest Tube Removal                                 KEY:              Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient who has a chest tube. Attached to the top of the patient’s bed are two shodded hemostats. In which situations would these be used? (Select all that apply.)
a. To assess an air leak
b. To quickly empty or change disposable systems
c. To quickly seal off the lungs if the system becomes disconnected
d. To assess whether the patient is ready to have the chest tube removed

 

 

ANS:  A, B, D

Chest tubes are clamped only under the following specific circumstances, per health care provider order or nursing policy and procedure: to assess air leak, to quickly empty or change disposable systems, or to assess whether the patient is ready to have the chest tube removed (which is done by a health care provider’s order). Clamping an open system could lead to a tension pneumothorax.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 665 |Text reference: p. 667

OBJ:   Describe methods of troubleshooting chest tube systems.

TOP:   Two-Chamber Waterless Chest Tube System

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is performing an initial assessment of a patient with a chest tube placed in the eighth intercostal space. Which of the following findings would the nurse need to assess further? (Select all that apply.)
a. Respiratory rate of 18 breaths per minute
b. Continuous bubbling in the water-seal chamber
c. The presence of subcutaneous emphysema
d. Complaints of pain at the insertion site
e. Serous drainage on the chest tube dressing the size of a bean

 

 

ANS:  B, C, D

Continuous bubbling in the water-seal chamber could indicate a leak in the system and should be assessed further. The presence of subcutaneous emphysema must be assessed further because it can be caused by a poor seal at the chest tube insertion site. Complaints of pain at the insertion site can be expected but should be fully assessed before analgesics are administered. A respiratory rate of 18 breaths per minute falls within the normal range and does not, by itself, indicate a need for further assessment. A small amount of drainage on the chest tube dressing can be expected and serous drainage would be normal; however, it should be monitored for any change in appearance.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: pp. 666-667

OBJ:   Demonstrate appropriate documentation and reporting of chest tube care.

TOP:   Chest Tube Assessment                  KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient who has had a chest tube in place for 2 days. As the nurse begins her shift assessment, she should ensure that what equipment is at the bedside? (Select all that apply.)
a. Two rubber-tipped clamps
b. Plain gauze 4 ´ 4
c. Sterile petroleum gauze
d. Extra drainage system
e. A sterile chest tube of the same size as the one inserted in the patient

 

 

ANS:  A, B, C, D

The nurse should ensure that two rubber-tipped clamps are at the bedside to clamp the tubing in case of emergency, as well as a plain gauze 4 ´ 4 and sterile petroleum gauze to make an occlusive dressing should the chest tube become dislodged, and an extra drainage system, should the current system become full. There is no need to keep a spare chest tube in most instances because it could be obtained while waiting for the primary care provider to arrive and reinsert.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 667

OBJ:   Demonstrate appropriate documentation and reporting of chest tube care.

TOP:   Chest Tube Assessment                  KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

Chapter 37: Intraoperative Care

 

MULTIPLE CHOICE

 

  1. The charge nurse is assigning duties in the surgical arena. Which member of the surgical team should be assigned to the role of circulating nurse?
a. Registered nurse (RN)
b. Licensed practical nurse (LPN)
c. Certified surgical technologist (CST)
d. Licensed nursing assistant

 

 

ANS:  A

The circulating nurse is always an RN who is the charge nurse in the operating room.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 908

OBJ:   Describe the roles of a registered nurse in the operating room.

TOP:   The Circulating Nurse                     KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following is true about the circulating nurse’s primary responsibility?
a. She is a “sterile” member of the surgical team.
b. She provides the surgeon with instruments.
c. She is a “nonsterile” member of the surgical team.
d. She performs delegated medical functions or skills.

 

 

ANS:  C

The circulating nurse is a “nonsterile” member of the surgical team who assumes responsibility and accountability for maintaining patient safety and continuity of quality care. This includes supervising the conduct of the scrub technician and delegating tasks to licensed and unlicensed nursing assistive personnel (NAP) as appropriate. The circulating nurse is also an assistant to the first assistant, the scrub nurse/technician, and the surgeon. The scrub nurse/technician provides the surgeon with instruments and supplies. The registered nurse first assistant (RNFA) performs a combination of nursing and delegated medical functions and/or skills.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 908

OBJ:   Describe the roles of a registered nurse in the operating room.

TOP:   The Circulating Nurse                     KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. The scrub nurse’s hands are being washed in preparation for a surgical procedure. As the nurse finishes, the scrub nurse accidentally touches the faucet with one hand. Which action should the nurse take next?
a. Apply sterile gloves.
b. Apply a sterile gown.
c. Apply a sterile mask.
d. Wash her hands.

 

 

ANS:  D

The scrub nurse/technician who accidentally touches the faucet with one hand while rinsing will rescrub. This is an example of following a sterile conscience and being committed to safe, quality patient care.

 

DIF:    Cognitive Level: Application          REF:   Text reference: pp. 908-909

OBJ:   Describe the meaning of a sterile conscience.                 TOP:   Sterile Conscience

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse recognizes that evidence-based care is appropriate when the nurse witnesses the surgeon take which step?
a. Washing hands for a minimum of 15 minutes with soap and water
b. Using alcohol hand scrub for 15 minutes
c. Using alcohol combined with chlorhexidine gluconate hand scrubs
d. Using a combination of soap and alcohol as a scrub

 

 

ANS:  C

Recent research demonstrates that hand scrub preparations containing 50% to 90% alcohol combined with chlorhexidine gluconate are just as effective as the traditional scrubbing method in preventing SSI.

 

DIF:    Cognitive Level: Analysis               REF:   Text reference: p. 910

OBJ:   Identify guidelines for the use of sterile technique in the operating room.

TOP:   Hand Scrub    KEY:  Nursing Process Step: Evaluation

MSC:  NCLEX: Physiological Integrity

 

  1. When planning care for a surgical patient, the nurse implements which technique to maintain sterility in the operating room?
a. Keeps the hands below the waist
b. Tucks the hands under the axilla
c. Uses sterile gloved hands to move a sterile drape under a table
d. Has anyone who is unscrubbed stay at least 1 foot away from the sterile field

 

 

ANS:  D

Unscrubbed persons should always stay at least 1 foot away from the sterile field while keeping it in constant view and should contact only unsterile areas. Sterile persons must keep their hands in view, above waist level and below the neckline, to avoid contamination. When wearing a sterile gown, do not fold the arms with hands tucked in the axillary region. This area is not considered sterile once operating room personnel have donned gowns. Sterile-draped tables are sterile only at table level. The sides of the drape extending below table level are unsterile.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 911

OBJ:   Identify guidelines for the use of sterile technique in the operating room.

TOP:   Principles of Sterile Technique       KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. When one prepares to enter the operating room, which technique demonstrates the safest outcome?
a. Keeping the hands below the elbows
b. Applying surgical gloves before the scrub
c. Scrubbing for at least 3 to 5 minutes with an antimicrobial
d. Drying the hands and arms, starting at the elbow and moving toward the fingers

 

 

ANS:  C

The Association of periOperative Registered Nurses (AORN) recommends a 3- to 5-minute hand and arm scrub with an approved antimicrobial agent for all surgical procedures. Rinse hands and arms thoroughly under running water. Grasp one end of the sterile towel to dry one hand thoroughly, moving from fingers to elbow in a rotating motion. Use the opposite end of the towel to dry the other hand.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 911

OBJ:   Correctly perform surgical hand antisepsis.                               TOP:    The Surgical Hand Scrub

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. When evaluating a health care team member’s ability to put on a sterile gown and perform closed gloving, it is most important for the nurse to assess for which outcome?
a. Opening the sterile gown pack on a sterile surface
b. Holding the gown close to the body before applying
c. Having the circulating nurse tie the gown at the hip
d. Keeping the hands inside the sleeves of the gown until the gloves are applied

 

 

ANS:  D

Apply gloves using the closed-glove method, with hands covered by gown cuffs and sleeves. Open the sterile gown and glove package on a clean, dry, flat surface. This can be done by the scrub nurse (before scrubbing hands) or the circulating nurse. While keeping it at arm’s length away from the body, allow the gown to unfold with the inside of the gown toward the body. Do not touch the outside of the gown, and do not allow it to touch the floor. Have the circulating nurse tie the gown at the neck and waist. If the gown is wraparound style, the sterile front flap is not touched until the scrub nurse has gloved.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 916

OBJ:   Correctly apply sterile gloves using the closed technique.

TOP:   Applying Gloves Via Closed Technique

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The charge nurse is assigning members of the surgical team; the nurse recognizes that which member is responsible for ensuring preoperative and postoperative patient management in collaboration with other health care providers?
a. RN
b. LPN
c. Circulating RN
d. RNFA

 

 

ANS:  D

The role of the RNFA is an expansion of the traditional perioperative nursing role, and areas of responsibility will overlap. Responsibilities specific to the practice of first assisting include participating in “time out” procedures with other surgical team members (safety measures taken to ensure correct patient, correct procedure, correct site and side, correct patient position, and correct implants/equipment present), providing surgical exposure (assisting in retraction of tissues and suctioning of surgical field), providing hemostasis (control of bleeding), handling and/or cutting tissue, using surgical instruments/medical devices and suturing, performing wound closure, applying human anatomical and physiological considerations in practice, recognizing structure, function, and location of tissues and organs, manipulating tissues accordingly to avoid injury, and ensuring preoperative and postoperative patient management in collaboration with other health care providers. The scrub nurse gowns and gloves surgeons and assistants as they enter the operating room, provides the surgeon with instruments and supplies, disposes of soiled sponges, and accounts for sponges, needles, and instruments in the surgical field.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 909

OBJ:   Describe the roles of a registered nurse in the operating room.

TOP:   Role of the Registered Nurse First Assistant

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. When planning care for a surgical patient, which nursing diagnosis has the highest priority?
a. Risk for infection
b. Risk for constipation
c. Risk for falls
d. Risk for knowledge deficit

 

 

ANS:  A

Surgical patients are at risk for surgical site infection from the stress of surgery and their procedure. Studies have found that surgical staff may transmit pathogens via contact with patients and contaminated items.

 

DIF:    Cognitive Level: Application          REF:   Text reference: p. 910

OBJ:   Describe the meaning of a sterile conscience.

TOP:   Evidence-Based Practice Trends     KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. While supervising the surgical team, the charge nurse notices that a team member’s nails are long and chipped. Which action should the nurse take next?
a. Allow the team member to complete the task.
b. Remove the team member to have the nails cut.
c. Turn the team member in to the RNFA.
d. Ask the team member why the nails are long and chipped.

 

 

ANS:  B

The team member must be removed immediately to allow cutting of the nails. Long nails and chipped or old polish harbor greater numbers of bacteria. Long fingernails can puncture gloves, causing contamination.

 

DIF:    Cognitive Level: Application          REF:   Text reference: pp. 910-911

OBJ:   Describe the meaning of a sterile conscience.                 TOP:   Surgical Hand Antisepsis

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. Who of the following can assume the role of the scrub nurse/assistant? (Select all that apply.)
a. RN
b. LPN
c. CST
d. Licensed nursing assistant
e. Medical transcriptionist

 

 

ANS:  A, B, C

RNs, LPNs, and CSTs may assume the scrub nurse role.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 908

OBJ:   Describe the roles of a registered nurse in the operating room.

TOP:   The Scrub Nurse                             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The consequences of double gloving during surgery include which of the following? (Select all that apply.)
a. Decreased need for handwashing
b. Decreased risk for exposure to bloodborne pathogens
c. Increased perforations to the innermost glove
d. Decreased risk for surgical wound infection
e. Increased patient cost

 

 

ANS:  B, D

Benefits of double gloving during surgery include decreasing the risk for exposure to bloodborne pathogens for surgical team members and decreasing the risk for surgical wound infection for the patient. Double gloving significantly reduces perforations to the innermost glove. Handwashing remains the cornerstone of surgical asepsis.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 915

OBJ:   Identify guidelines for the use of sterile technique in the operating room.

TOP:   Double Gloving                              KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following are principles of sterile procedure? (Select all that apply.)
a. Gowns are sterile from the chest and shoulder to table level.
b. Sterile persons must keep hands in view and above the waist and below the neck.
c. Sterile persons must fold arms across chest with hands tucked into the axillary region.
d. Unscrubbed persons must stay at least 6 inches away from the sterile field.
e. Sterile persons may position themselves with their back to the sterile field.

 

 

ANS:  A, B

Once in place, gowns are sterile from the front chest and shoulders to table level and on the sleeves to 2 inches (5 cm) above the elbow. Sterile persons must keep their hands in view, above waist level and below the neckline, and must not turn their back to the sterile field to avoid contamination. When wearing a sterile gown, do not fold arms with hands tucked into the axillary region. This area is not considered sterile once operating room personnel have donned gowns. Perspiration can lead to strike through, or contamination that occurs when moisture permeates a sterile barrier. Unscrubbed persons always stay at least 1 foot away from the sterile field while keeping it in constant view; they touch only unsterile areas.

 

DIF:    Cognitive Level: Application          REF:   Text reference: pp. 910-911

OBJ:   Identify guidelines for the use of sterile technique in the operating room.

TOP:   Principles of Sterile Technique       KEY:  Nursing Process Step: Planning

MSC:  NCLEX: Physiological Integrity

 

  1. Through the use of an antimicrobial agent and sterile brushes or sponges, which of the following occurs? (Select all that apply.)
a. Debris and transient microorganisms are removed from the nails, hands, and forearms.
b. The resident microbial count is reduced to a minimum.
c. The skin is sterilized.
d. Rapid/rebound growth of microorganisms is inhibited.
e. The need to wash between patients is reduced.

 

 

ANS:  A, B, D

Although the skin cannot be sterilized, operating room personnel can greatly reduce the number of microorganisms by chemical, physical, and mechanical means. Through the use of an antimicrobial agent and sterile brushes or sponges, the surgical hand scrub removes debris and transient microorganisms from the nails, hands, and forearms, and inhibits rapid/rebound growth of microorganisms.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: pp. 911-912

OBJ:   Correctly perform surgical hand antisepsis.                               TOP:    The Surgical Hand Scrub

KEY:  Nursing Process Step: Planning       MSC:  NCLEX: Physiological Integrity

 

  1. Which of the following are sources of contamination in the operating room? (Select all that apply.)
a. A wristwatch
b. Chipped nail polish
c. Artificial fingernails
d. Abrasions on the hands
e. Tattoos to the arms

 

 

ANS:  A, B, C, D

Jewelry harbors and protects microorganisms from removal. Allergic skin reactions may occur as a result of scrub agent or glove powder accumulating under jewelry. Long nails and chipped or old polish harbor great numbers of bacteria. Long fingernails can puncture gloves, causing contamination. Artificial nails harbor gram-negative microorganisms and fungus. Cuts, abrasions, exudative lesions, and hangnails tend to ooze serum, which may contain pathogens. Broken skin permits microorganisms to enter various layers of the skin, providing deeper microbial breeding.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: pp. 911-912

OBJ:   Identify guidelines for the use of sterile technique in the operating room.

TOP:   Sources of Contamination              KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The surgeon is about to finish surgery and requests a sponge count. Who would normally perform this task? (Select all that apply.)
a. Scrub nurse
b. Registered nurse first assistant
c. Circulating nurse
d. Certified registered nurse anesthetist
e. Surgical technician

 

 

ANS:  A, C

Part of the role of the scrub nurse is to perform sponge, sharps, and instrument counts with the circulating nurse before an incision is made, at the beginning of wound closure, and at the end of the surgical procedure.

 

DIF:    Cognitive Level: Comprehension   REF:   Text reference: p. 909

OBJ:   Describe the roles of a registered nurse in the operating room.

TOP:   Role of the Scrub Nurse and Circulating Nurse

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. While the patient is in the OR and the OR team is gowned and gloved, the nurse recommends completion of a safety checklist. The nurse understands that the checklist verifies which of the following? (Select all that apply.)
a. Patient identity
b. Patient allergies
c. Accurate marking of surgical site
d. Patient cultural preferences
e. Questions posed by the patient

 

 

ANS:  A, B, C

While the patient is in the OR and the OR team is gowned and gloved, it is recommended that a surgical safety checklist or the World Health Organization (WHO) checklist be conducted. The WHO checklist verifies the patient’s identity, ascertains whether the patient has any allergies, checks if the surgical site is marked and reverifies the site marking, and asks the patient if he or she has any questions.

 

DIF:    Cognitive Level: Application          REF:   Text reference: pp. 909-910

OBJ:   Describe the roles of a registered nurse in the operating room.

TOP:   Role of the Checklist Coordinator  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

COMPLETION

 

  1. The _______________ phase begins when the patient enters the operating room suite and ends with admission to the postanesthesia care unit (PACU).

 

ANS:

intraoperative

The intraoperative phase begins when the patient enters the operating room suite and ends with admission to the PACU.

 

DIF:    Cognitive Level: Knowledge          REF:   Text reference: p. 908

OBJ:   Describe the roles of a registered nurse in the operating room.

TOP:   The Intraoperative Phase                KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The _________________ is a nurse with advanced education who assists the surgeon with the surgical procedure, performing a combination of nursing and delegated medical functions and/or skills.

 

ANS:

registered nurse first assistant (RNFA)

The RNFA is a nurse with advanced education who assists the surgeon with the surgical procedure, performing a combination of nursing and delegated medical functions and/or skills.

 

DIF:    Cognitive Level: Knowledge          REF:   Text reference: p. 908

OBJ:   Describe the roles of a registered nurse in the operating room.

TOP:   The Registered Nurse First Assistant

KEY:  Nursing Process Step: Assessment  MSC:  NCLEX: Physiological Integrity

 

  1. The ________________ is a “sterile” team member who provides the surgeon with instruments and supplies, disposes of soiled sponges, and accounts for sponges, sharps, and instruments in the surgical field.

 

ANS:

scrub nurse/technician

The scrub nurse/technician is a “sterile” team member who provides the surgeon with instruments and supplies, disposes of soiled sponges, and accounts for sponges, sharps, and instruments in the surgical field.

 

DIF:    Cognitive Level: Knowledge          REF:   Text reference: pp. 908-909

OBJ:   Describe the roles of a registered nurse in the operating room.

TOP:   The Scrub Nurse                             KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity