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INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS

 

 

Medical Surgical Nursing  Assessment and Management Of Clinical Problems, 8th Edition  by Sharon L. Lewis – Test Bank

 

 

Sample  Questions

 

 

Lewis: Medical-Surgical Nursing, 8th Edition

 

Chapter 3: Health History and Physical Examination Test Bank

 

MULTIPLE CHOICE

 

  1. A patient who is having difficulty breathing is admitted to the hospital. The best approach for the nurse to use to obtain a complete health history is to
    1. obtain subjective data about the patient from family members.
    2. omit subjective data collection and obtain the physical examination.
    3. use the health care provider’s medical history to obtain subjective data.
    4. schedule several short sessions with the patient to gather subjective data.

 

ANS: D

In an emergency situation, the nurse may need to ask only the most pertinent questions for a specific problem and obtain more information later. A complete health history will include subjective information that is not available in the health care provider’s medical history. Family members may be able to provide some subjective data, but only the patient will be able to give subjective information about the shortness of breath. Since the subjective data about the patient’s respiratory status will be essential, obtaining the physical examination alone will not provide sufficient information.

 

DIF:   Cognitive Level: Application             REF:   38

TOP:  Nursing Process: Assessment             MSC: NCLEX: Health Promotion and Maintenance

 

  1. Immediate surgery is planned for a patient with acute abdominal pain. The question used by the nurse that will elicit the most complete information about the patient’s coping-stress tolerance pattern is

 

  1. “Can you tell me how intense your pain is now?”
  2. “What do you think caused this abdominal pain?”
  3. “How do you feel about yourself and your hospitalization?”
  4. “Are there other major problems that are a concern right now?”

 

ANS: D

The coping-stress tolerance pattern includes information about other major stressors confronting the patient. The health perception–health management pattern includes information about the patient’s ideas about risk factors. Feelings about self and the hospitalization are assessed in the self-perception–self-concept pattern. Intensity of pain is part of the cognitive-perceptual pattern.

 

DIF:   Cognitive Level: Comprehension    REF:    41-42

TOP:  Nursing Process: Assessment             MSC: NCLEX: Psychosocial Integrity

 

  1. During the health history interview, a patient tells the nurse about periodic fainting spells. Which question by the nurse will be most helpful in determining the setting in which the fainting spells occur?

 

 

 

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Test Bank 3-2

 

 

  1. “How frequently do you have the fainting spells?”

 

  1. “Where are you when you have the fainting spells?”
  2. “Do the spells tend to occur at any special time of day?”
  3. “Do you have any other symptoms along with the spells?”

 

ANS: B

Information about the setting is obtained by asking where the patient was and what the patient was doing when the symptom occurred. The other questions from the nurse are appropriate for obtaining information about chronology, frequency, and associated clinical manifestations.

 

DIF:   Cognitive Level: Comprehension    REF:   39

TOP:  Nursing Process: Assessment             MSC: NCLEX: Health Promotion and Maintenance

 

  1. The nurse records the following general survey of a patient: “The patient is a 68-year-old male Asian attended by his wife and two daughters. Alert and oriented. Does not make eye contact with the nurse and responds slowly, but appropriately, to questions. No apparent disabilities or distinguishing features.” Additional information that should be added to this general survey includes

 

  1. nutritional status.
  2. intake and output.
  3. reasons for contact with the health care system.
  4. comments of family members about his condition.

 

ANS: A

The general survey also describes the patient’s general nutritional status. The other information will be obtained when doing the complete nursing history and examination but is not obtained through the initial scanning of a patient.

 

DIF:   Cognitive Level: Application             REF:   44

TOP:  Nursing Process: Assessment             MSC: NCLEX: Health Promotion and Maintenance

 

  1. A nurse is performing a health history and physical examination for a patient with right-sided rib fractures. The pertinent negative finding is that the patient
    1. states that there have been no other health problems recently.
    2. denies having pain when the area over the fractures is palpated.
    3. has several bruised and swollen areas on the right anterior chest.
    4. refuses to take a deep breath because of the associated chest pain.

 

ANS: B

The nurse expects that a patient with rib fractures will have pain over the fractured area. The first statement is neither a positive nor a negative finding with regard to the rib fractures. The bruising and swelling and pain with breathing are positive findings.

 

DIF:   Cognitive Level: Application             REF:   42

TOP:  Nursing Process: Assessment             MSC: NCLEX: Health Promotion and Maintenance

 

  1. As the nurse assesses the patient’s neck, the patient says, “My neck is so stiff I can hardly move it.” This finding indicates the nurse should perform a(n)

 

 

 

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Test Bank 3-3

 

 

  1. focused assessment.

 

  1. screening assessment.
  2. emergency assessment.
  3. comprehensive assessment.

 

ANS: A

The focused assessment is needed when a patient has clinical manifestations that indicate a problem. An emergency assessment is done when the nurse needs to obtain information about life-threatening problems quickly while simultaneously taking action to maintain vital function. The screening examination or assessment is used to assess for possible problems such as colorectal cancer in patients who are age 50 or older. A comprehensive assessment is a detailed health history and physical examination.

 

DIF:   Cognitive Level: Application             REF:    45-46

TOP:  Nursing Process: Assessment             MSC: NCLEX: Health Promotion and Maintenance

 

  1. The nurse is preparing to perform a focused abdominal assessment for a patient who has high-pitched bowel sounds. Which equipment will be needed?
    1. Flashlight
    2. Stethoscope
    3. Tongue blades
    4. Percussion hammer

 

ANS: B

A stethoscope is used to auscultate bowel sounds. The other equipment may be used for a comprehensive assessment, but will not be needed for a focused abdominal assessment.

 

DIF:   Cognitive Level: Comprehension    REF:    43 | 45

TOP:  Nursing Process: Assessment             MSC: NCLEX: Health Promotion and Maintenance

 

  1. When the nurse is planning for the physical examination of an alert 86-year-old patient, adaptations to the examination technique should include
    1. speaking slowly when directing the patient.
    2. avoiding the use of touch as much as possible.
    3. using slightly more pressure for palpation of the liver.
    4. organizing the sequence to minimize position changes.

 

ANS: D

Older patients may have age -related changes in mobility that make it more difficult to change position. There is no need to avoid the use of touch when examining older patients. Less pressure should be used over the liver. Since the patient is alert, there is no indication that there is any age-related difficulty in understanding directions from the nurse.

 

DIF:   Cognitive Level: Application             REF:   45

TOP:  Nursing Process: Assessment             MSC: NCLEX: Health Promotion and Maintenance

 

 

 

 

 

 

 

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Test Bank 3-4

 

 

  1. While the nurse is taking the health history, a patient states, “My father and grandfather both had heart attacks and were unable to be very active afterwards.” This statement is related to the functional health pattern of

 

  1. activity-exercise.
  2. cognitive-perceptual.
  3. coping-stress tolerance.
  4. health perception–health management.

 

ANS: D

The information in the patient statement relates to risk factors that may cause cardiovascular problems in the future. Identification of risk factors falls into the health perception–health maintenance pattern.

 

DIF:    Cognitive Level: Comprehension    REF:    40-41

TOP:  Nursing Process: Assessment             MSC: NCLEX: Health Promotion and Maintenance

 

  1. A patient is seen in the emergency department with chest pain and hypotension. Which type of assessment should the nurse do at this time?
    1. Focused assessment
    2. Subjective assessment
    3. Emergency assessment
    4. Comprehensive assessment

 

ANS: C

Since the patient is hemodynamically unstable, an emergency assessment is needed. Comprehensive and focused assessments may be needed after the patient is stabilized. Subjective information is needed, but objective data such as vital signs also are essential for the unstable patient.

 

DIF:    Cognitive Level: Comprehension    REF:   46

TOP:  Nursing Process: Assessment             MSC: NCLEX: Health Promotion and Maintenance

 

  1. When caring for a patient who was admitted a few hours previously with nausea and vomiting, which nursing action can the RN delegate to an LPN/LVN?
    1. Ask the patient about any current nausea.
    2. Finish documenting the admission assessment.
    3. Determine the patient’s priority nursing diagnoses.
    4. Obtain the health history from the patient’s caregiver.

 

ANS: A

The RN may delegate parts of the focused assessment to an LPN/LVN. Obtaining the health history, documentation of the admission assessment, and determining nursing diagnoses require RN education and scope of practice.

 

DIF: Cognitive Level: Application REF: 46
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment

 

 

 

 

 

 

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Test Bank 3-5

 

 

  1. When assessing the circulation to the lower leg of a patient who has had knee surgery, which action should the nurse take first?
    1. Feel for the temperature of the foot.
    2. Visually inspect the color of the foot.
    3. Check the patient’s pedal pulses using the fingertips.
    4. Compress the nail beds to determine capillary refill time.

 

ANS: B

Inspection is the first of the major techniques used in the physical examination. Palpation and auscultation are used later in the examination.

 

DIF: Cognitive Level: Application REF: 43
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance

 

  1. When assessing a patient’s abdomen during the admission assessment, which of these actions should the nurse take first?
    1. Feel for any masses.
    2. Palpate the abdomen.
    3. Percuss the liver borders.
    4. Listen to the bowel sounds.

 

ANS: D

When assessing the abdomen, auscultation is done before palpation or percussion because palpation and percussion can cause changes in bowel sounds and alter the findings. All of the techniques are appropriate, but auscultation should be done first.

 

DIF: Cognitive Level: Comprehension REF: 43
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance

 

  1. When admitting a patient who has just arrived on the medical unit with severe abdominal pain, what should the nurse do first?
    1. Complete only basic demographic data before addressing the patient’s abdominal pain.
    2. Medicate the patient for the abdominal pain before attending to the health history and examination.
    3. Inform the patient that the abdominal pain will be treated as soon as the health history is completed.
    4. Take the initial vital signs and then deal with the abdominal pain before completing the health history.

 

ANS: D

The patient priority in this situation will be to decrease the pain level because the patient will be unlikely to cooperate in providing demographic data or the health history until the nurse addresses the pain. However, obtaining information about vital signs is essential before using either pharmacologic or nonpharmacologic therapies for pain control. The vital signs may indicate hemodynamic instability that would need to be addressed immediately.

 

 

 

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Test Bank 3-6
DIF: Cognitive Level: Application REF: 39
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

 

 

 

Lewis: Medical-Surgical Nursing, 8th Edition

 

Chapter 5: Chronic Illness and Older Adults

 

Test Bank

 

MULTIPLE CHOICE

 

  1. When caring for a patient with type 2 diabetes who has been hospitalized with severe hyperglycemia, which topic will be most important to include in discharge teaching?

 

  1. Effect of endogenous insulin on transportation of glucose into cells
  2. Function of the liver in formation of glycogen and gluconeogenesis
  3. Impact of the patient’s family history on likelihood of developing diabetes
  4. Symptoms indicating that the patient should contact the health care provider

 

ANS: D

One of the tasks for patients with chronic illnesses is to prevent and manage a crisis. The patient needs instruction on recognition of symptoms of hyperglycemia and appropriate actions to take if these symptoms occur. The other information also may be included in patient teaching, but is not as essential in the patient’s self-management of the illness.

 

DIF:   Cognitive Level: Application             REF:   63

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. Which question will provide the most useful information when the nurse is performing a comprehensive geriatric assessment of an older adult who is being assessed for admission to an assisted-living facility?

 

  1. “Have you had any recent infections?”
  2. “How frequently do you see a doctor?”
  3. “Do you have a history of heart disease?”
  4. “Are you able to prepare your own meals?”

 

ANS: D

The patient’s functional abilities, rather than the presence of acute or chronic illness, are more useful in determining how well the patient might adapt to an assisted -living situation. The other questions also will provide helpful information but are not as useful in providing a basis for determining patient needs or for developing interventions for the older patient.

 

DIF:   Cognitive Level: Application             REF:   73

TOP:  Nursing Process: Assessment             MSC: NCLEX: Health Promotion and Maintenance

 

  1. The nurse is planning care for an alert and active 85-year-old patient who takes multiple medications for chronic cardiac and respiratory disease and lives with a daughter who works during the day. Which nursing diagnosis is most appropriate?

 

  1. Risk for injury related to drug-drug interactions
  2. Social isolation related to weakness and fatigue
  3. Compromised family coping related to the patient’s many care needs

 

 

 

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Test Bank 5-2

 

 

  1. Caregiver role strain related to need to adjust family employment schedule

 

ANS: A

The patient’s age and multiple medications indicate a risk for injury caused by interactions between the multiple drugs being taken and a decreased drug metabolism rate. The patient data do not indicate problems with social isolation, caregiver role strain, or compromised family coping.

 

DIF:   Cognitive Level: Application             REF:   76                        TOP:  Nursing Process:

Diagnosis

 

MSC: NCLEX: Health Promotion and Maintenance

 

  1. To obtain the most complete information when doing an assessment for an 81-year-old patient, the nurse will
    1. interview both the patient and the primary patient caregiver.
    2. use a geriatric assessment instrument to evaluate the patient.
    3. review the patient’s chart for the history of medical problems.
    4. ask the patient to write down medical problems and medications.

 

ANS: B

The most complete information about the patient will be obtained through the use of an assessment instrument specific to the geriatric population, which includes information about both medical diagnoses and treatments and about functional health patterns and abilities. A review of the chart, interviews of the patient and caregiver, and written information by the patient will all be included in a comprehensive geriatric assessment.

 

DIF:   Cognitive Level: Application             REF:   73

 

TOP:  Nursing Process: Assessment             MSC: NCLEX: Health Promotion and Maintenance

 

  1. When developing the plan of care for an older adult who is hospitalized for an acute illness, the nurse should
    1. use a standardized geriatric nursing care plan.
    2. minimize activity level during hospitalization.
    3. plan for transfer to a long-term care facility after the hospitalization.
    4. consider the preadmission functional abilities when setting patient goals.

 

ANS: D

The plan of care for older adults should be individualized and based on the patient’s current functional abilities. A standardized geriatric nursing care plan will not address individual patient needs and strengths. A patient’s need for discharge to a long-term care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process.

 

DIF:   Cognitive Level: Application             REF:   74                        TOP:  Nursing Process:

Planning

MSC: NCLEX: Physiological Integrity

 

  1. When caring for an older adult who lives in a rural area, the nurse will plan to

 

 

 

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Test Bank 5-3

 

 

  1. assess the patient for chronic diseases that are unique to rural areas.

 

  1. ensure transportation to appointments with the health care provider.
  2. suggest that the patient move to an urban area for better health care.
  3. obtain adequate medications for the patient to last for 4 to 6 months.

 

ANS: B

Transportation can be a barrier to accessing health services in rural areas. There are no chronic diseases unique to rural areas. Because medications may change, the nurse should help the patient plan for obtaining medications through alternate means such as the mail or delivery services, not by purchasing large quantities of the medications. The patient living in a rural area may lose the benefits of a familiar situation and social support by moving to an urban area.

 

DIF:   Cognitive Level: Application             REF:   67                        TOP:  Nursing Process:

Planning

 

MSC: NCLEX: Health Promotion and Maintenance

 

  1. When the nurse is working in the outpatient clinic, which nursing action will be most helpful in decreasing the risk for drug-drug interactions in an older adult patient?

 

  1. Teach the patient to have all prescriptions filled at the same pharmacy
  2. Instruct the patient to avoid taking over-the-counter (OTC) medications.
  3. Make a medication schedule for the patient as a reminder about when to take each medication.
  4. Have the patient bring all the medications, supplements, and herbs to every health care appointment.

 

ANS: D

The most information about drug use and possible interactions is obtained when the patient brings all prescribed medications, OTC medications, and supplements to every health care appointment. The patient should discuss the use of any OTC medications with the health care provider and obtain all prescribed medications from the same pharmacy, but use of supplements and herbal medications also need to be considered in order to prevent drug-drug interactions. Use of a medication schedule will help the patient take medications as scheduled but will not prevent drug-drug interactions.

 

DIF:   Cognitive Level: Application             REF:   76

 

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. Which action will the nurse take when planning for discharge of a 68-year-old patient who will need daily assistance with activities such as shopping and transportation?
    1. Write to the state Medicaid office.
    2. Contact the Area Agency on Aging.
    3. Provide documentation to Medicare.
    4. Communicate with the patient’s insurer.

 

ANS: B

 

 

 

 

 

 

 

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Test Bank 5-4

 

 

Funding from the federal Administration on Aging is funneled through local Area Agencies on Aging to provide community services to older adults. Medicare, Medicaid, and insurers provide funding for specific medical services, but not for need such as shopping or transportation.

 

DIF:    Cognitive Level: Application             REF:   70-71                 TOP:  Nursing Process:

Planning

MSC: NCLEX: Safe and Effective Care Environment

 

  1. A 78-year-old patient with multiple health problems complains of having “no energy” and feeling increasingly weak. The patient has had an 11-pound weight loss over the last year. The nurse should initially

 

  1. ask the patient about daily dietary intake.
  2. schedule regular range-of-motion exercise.
  3. discuss long-term care placement with the patient.
  4. describe normal changes with aging to the patient.

 

ANS: A

In the frail elderly patient, nutrition is frequently compromised, and the nurse’s initial action should be to assess the patient’s nutritional status. Active range-of-motion may be helpful in improving the patient’s strength and endurance, but nutritional assessment is the priority because the patient has had a significant weight loss. The patient may be a candidate for long-term care placement, but more assessment is needed before this can be determined. The patient’s assessment data are not consistent with normal changes associated with aging.

 

DIF:    Cognitive Level: Application             REF:   68

TOP:  Nursing Process: Assessment             MSC: NCLEX: Health Promotion and Maintenance

 

  1. When admitting an 88-year-old patient to the hospital, the nurse should plan to

 

  1. speak slowly and loudly while facing the patient.
  2. obtain a detailed medical history from the patient.
  3. interview the patient before the physical assessment.
  4. determine whether the patient uses glasses or hearing aids.

 

ANS: D

Assistive devices should be in place before assessing the patient to minimize anxiety and confusion. When a patient is acutely ill, the physical assessment should be accomplished first to detect any physiologic changes that require immediate action. Not all older patients have hearing deficits, and it is insensitive of the nurse to speak loudly and slowly to all older patients. To avoid tiring the patient, much of the medical history can be obtained from medical records.

 

DIF:    Cognitive Level: Application             REF:   73                        TOP:  Nursing Process:

Planning

 

MSC: NCLEX: Health Promotion and Maintenance

 

  1. The nurse is planning discharge for an alert, homeless 70-year-old with a chronic foot infection. The most appropriate intervention by the nurse is to

 

 

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Test Bank 5-5

 

 

  1. teach the patient how to assess and care for the foot infection.

 

  1. refer to social services for further assessment of patient needs.
  2. schedule the patient to return to outpatient services for foot care.
  3. give the patient written information about shelters and meal sites.

 

ANS: B

A multidisciplinary approach, including social services, is needed when caring for homeless adults. Even with appropriate education, a homeless individual may not be able to maintain adequate foot care because of a lack of supplies or a suitable place to accomplish care. Older homeless individuals are less likely to use shelters or meal sites. A homeless person may fail to keep appointments for outpatient services because of factors such as fear of institutionalization or lack of transportation.

 

DIF:    Cognitive Level: Application             REF:    67-68

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

 

  1. The home health nurse is caring for a 71-year-old patient who lives alone and is taking seven different prescribed medications for chronic health problems. To ensure medication compliance, which nursing intervention is best?

 

  1. Use a marked pillbox to set up the patient’s medications.
  2. Discuss the option of moving to an assisted-living facility.
  3. Remind the patient about the importance of taking medications.
  4. Visit the patient daily to administer the prescribed medications.

 

ANS: A

Since forgetting to take medications is a common cause of medication errors in older adults, the use of medication reminder devices is helpful when older adults have multiple medications to take. There is no indication that the patient needs to move to assisted living or that the patient does not understand the importance of medication compliance. Home health care is not designed for the patient who needs ongoing assistance with activities of daily living (ADLs) or instrumental ADLs (IADLs).

 

DIF:    Cognitive Level: Application             REF:   77

 

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. Which information obtained by the home health nurse when making a visit to an 88-year-old with mild forgetfulness is of concern?
    1. The patient tells the nurse that a close friend recently died.
    2. The patient has lost 10 pounds (4.5 kg) during the last month.
    3. The patient is cared for by a daughter during the day and stays with a son at night.
    4. The patient’s son uses a marked pillbox to set up the patient’s medications weekly.

 

ANS: B

A 10-pound weight loss may be an indication of elder neglect or depression and requires further assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an 88-year-old would have friends who have died.

 

 

 

 

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Test Bank 5-6
DIF: Cognitive Level: Application REF: 69-70
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

 

  1. Which information about a 77-year-old patient who is being assessed by the home health nurse is of most concern?
    1. The patient organizes medications in a marked pillbox “so I don’t forget them.”
    2. The patient uses three different medications for chronic heart and joint problems.
    3. The patient says, “I don’t go on my daily walks since I had pneumonia 3 months ago.”
    4. The patient tells the nurse, “I prefer to manage my life without much help from others.”

 

ANS: C

Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should develop a plan to prevent further deconditioning and restore function for the patient. Self-management is appropriate for independently living older adults. On average, a 70-year-old takes seven different medications; the use of three medications is not unusual for a 78-year-old. The use of memory devices to assist with safe medication administration is recommended for older adults.

 

DIF:    Cognitive Level: Application             REF:   75

TOP:  Nursing Process: Assessment             MSC: NCLEX: Health Promotion and Maintenance

 

  1. When admitting a 79-year-old patient who has urinary urgency and a possible urinary tract infection (UTI), the nurse should first
    1. assess the patient’s orientation.
    2. inspect for abdominal distention.
    3. question the patient about hematuria.
    4. invite the patient to use the bathroom.

 

ANS: D

Before beginning the assessment of an older patient with a UTI and urgency, the nurse should have the patient empty the bladder because bladder fullness or discomfort will distract from the patient’s ability to provide accurate information. The patient may seem disoriented if distracted by pain or urgency. The physical assessment data are obtained after the patient is as comfortable as possible.

 

DIF: Cognitive Level: Application REF: 73
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

 

  1. Which of these patients assigned to the nurse is most likely to need planning for long-term nursing management?
    1. 22-year-old with appendicitis who has had an emergency appendectomy
    2. 56-year-old with bilateral knee osteoarthritis who weighs 350 lbs (159 kg)
    3. 34-year-old with cholecystitis who has had a laparoscopic cholecystectomy
    4. 62-year-old with acute sinusitis who will require antibiotic therapy for 5 days

 

ANS: B

 

 

 

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Test Bank 5-7

 

 

The patient’s osteoarthritis is a chronic problem that will require planning for long -term interventions such as physical therapy and nutrition counseling. The other patients have acute problems that are not likely to require long-term management.

 

DIF:    Cognitive Level: Application             REF:   63

OBJ:   Special Questions: Multiple Patients                                          TOP:  Nursing Process:

Planning

 

MSC: NCLEX: Physiological Integrity

 

  1. When a hospitalized older patient is at risk of falling because of acute confusion and weakness, which action should the nurse take first?
    1. Utilize a bed alarm system on the patient’s bed.
    2. Administer the prescribed PRN sedative medication.
    3. Ask the health care provider to order a vest restraint.
    4. Place the patient in a “geri-chair” near the nurse’s station.

 

ANS: A

The use of the least restrictive restraint alternative is required. Physical or chemical restraints may be necessary, but the nurse’s first action should be an alternative such as a bed alarm.

 

DIF: Cognitive Level: Application REF: 77-78
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment

 

  1. The nurse suspects that elder abuse may be occurring when a confused and agitated 76-year-old patient with a broken arm is brought to the emergency department by a family member. Which of these actions should the nurse take first?

 

  1. Notify an elder protective services agency about the possible abuse.
  2. Make a referral for a home assessment visit by the home health nurse.
  3. Have the family member stay in the waiting area while the patient is assessed.
  4. Ask the patient how the injury occurred and observe the family member’s reaction.

 

ANS: C

The initial action should be assessment and interviewing of the patient. The patient should be interviewed alone because the patient will be unlikely to give accurate information if the abuser is present. If abuse is occurring, the patient should not be discharged home for a later assessment by a home health nurse. The nurse needs to collect and document physiologic data before notifying the elder protective services agency.

 

DIF: Cognitive Level: Application REF: 69-70
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

 

MULTIPLE RESPONSE

 

 

 

 

 

 

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Test Bank 5-8

 

 

  1. Which nursing actions will the nurse take to assess for possible malnutrition in a 69-year-old patient (select all that apply)?
    1. Observe for depression.
    2. Review laboratory results.
    3. Assess teeth and oral mucosa.
    4. Ask about transportation needs.
    5. Determine food likes and dislikes.

 

ANS: A, B, C, D

The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor protein intake or high-fat/cholesterol intake. Transportation impacts patients’ ability to shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor condition may decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated with malnutrition.

 

DIF: Cognitive Level: Application REF:  68
OBJ: Special Questions: Alternate Item Format
TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

 

 

Lewis: Medical-Surgical Nursing, 8th Edition

 

Chapter 11: Palliative Care at End of Life

 

Test Bank

 

MULTIPLE CHOICE

 

  1. The nurse is caring for a terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. The nurse documents this finding as

 

  1. agonal breathing.
  2. apneustic breathing.
  3. death-rattle respirations.
  4. Cheyne-Stokes respirations.

 

ANS: D

Cheyne-Stokes respirations are characterized by periods of apnea alternating with deep and rapid breaths. The “death rattle” is caused by accumulation of mucus in the airways, causing wet-sounding respirations. Agonal breathing has a very slow and irregular rate and rhythm. Apneustic respirations are irregular and gasping.

 

DIF:   Cognitive Level: Comprehension    REF:    156

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. A 21-year-old is dying after an automobile accident. The family members want to donate the patient’s organs and ask the nurse how the decision about brain death is made. The nurse explains that the patient will be considered brain dead when

 

  1. the patient is flaccid and unresponsive.
  2. CPR is ineffective in restoring heartbeat.
  3. the patient is apneic and without brainstem reflexes.
  4. respiratory efforts cease and no apical pulse is audible.

 

ANS: C

The diagnosis of brain death is based on irreversible loss of all brain functions, including brainstem functions that control respirations and brainstem reflexes. The other descriptions describe other clinical manifestations associated with death but are insufficient to declare a patient brain dead.

 

DIF:   Cognitive Level: Comprehension    REF:    155

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. A hospice patient is manifesting a decrease in all body system functions except for a heart rate of 124 and a respiratory rate of 28. The nurse explains to the family that these symptoms

 

  1. will continue to increase until death finally occurs.
  2. are a normal response before these functions decrease.
  3. indicate a reflex response to the slowing of other body systems.
  4. may be associated with an improvement in the patient’s condition.

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank 11-2

 

 

ANS: B

An increase in heart and respiratory rate may occur before the slowing of these functions in the dying patient. Heart and respiratory rate typically slow as the patient progresses further toward death. In a dying patient, high respiratory and pulse rates do not indicate improvement, and it would be inappropriate for the nurse to indicate this to the family. The changes in pulse and respirations are not reflex responses.

 

DIF:   Cognitive Level: Comprehension    REF:    156

 

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. A patient who has been diagnosed with metastatic cancer and has a poor prognosis plans
    • trip across the country “to settle some issues with my sisters and brothers.” The nurse recognizes that the patient is manifesting the psychosocial response of
  1. yearning and protest.
  2. anxiety about unfinished business.
  3. fear of the meaninglessness of one’s life.

 

ANS: C

The patient’s statement indicates that there is some unfinished family business that the patient would like to address before dying. Restlessness is frequently a behavior associated with an inability to express emotional or physical distress, but this patient does not express distress and is able to communicate clearly. There is no indication that the patient is protesting the prognosis, or that there is any fear that the patient’s life has been meaningless.

 

DIF:   Cognitive Level: Application             REF:    157

 

TOP:  Nursing Process: Assessment             MSC: NCLEX: Psychosocial Integrity

 

  1. The spouse of a patient with terminal lung cancer visits daily and cheerfully talks with the patient about vacation plans for the next year. When the nurse asks about any concerns, the spouse says, “I’m busy at work, but otherwise things are fine.” An appropriate nursing diagnosis is

 

  1. ineffective coping related to lack of grieving.
  2. anxiety related to complicated grieving process.
  3. caregiver role strain related to feeling overwhelmed.
  4. hopelessness related to knowledge deficit about cancer.

 

ANS: A

The wife’s behavior and statements indicate the absence of anticipatory grieving, which may lead to impaired adjustment as the patient progresses toward death. The wife does not appear to feel overwhelmed, hopeless, or anxious.

 

DIF:   Cognitive Level: Application             REF:    156-157 | 161

 

TOP:  Nursing Process: Diagnosis                 MSC: NCLEX: Psychosocial Integrity

 

 

 

 

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank 11-3

 

 

  1. As the nurse admits a patient with severe heart failure to the hospital, the patient tells the nurse, “If my heart or breathing stop, I do not want to be resuscitated.” Which action is best for the nurse to take?

 

  1. Ask if these wishes have been discussed with the health care provider.
  2. Place a “Do Not Resuscitate” (DNR) notation in the patient’s care plan.
  3. Inform the patient that a notarized advance directive must be included in the record or resuscitation must be performed.
  4. Advise the patient to designate a person to make health care decisions when the patient is not able to make them independently.

 

ANS: A

A health care provider’s order should be written describing the actions that the nurses should take if the patient requires CPR, but the primary right to decide belongs to the patient or family. The nurse should document the patient’s request but does not have the authority to place the DNR order in the care plan. A notarized advance directive is not needed to establish the patient’s wishes. The patient may need a durable power of attorney for health care (or the equivalent), but this does not address the patient’s current concern with possible resuscitation.

 

DIF:   Cognitive Level: Application             REF:    159-160

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

 

  1. A patient who is very close to death is very restless and keeps repeating, “I am not ready to die.” Which action is best for the nurse to take?
    1. Remind the patient that no one feels ready for death.
    2. Sit at the bedside and ask if there is anything the patient needs.
    3. Insist that family members remain at the bedside with the patient.
    4. Tell the patient that everything possible is being done to delay death.

 

ANS: B

Staying at the bedside and listening allows the patient to discuss any unresolved issues or physical discomforts that should be addressed. Stating that no one feels ready for death fails to address the individual patient’s concerns. Telling the patient that everything is being done does not address the patient’s fears about dying, especially since the patient is likely to die soon. Family members may not feel comfortable staying at the bedside of a dying patient; the nurse should not insist they remain there.

 

DIF:   Cognitive Level: Application             REF:    161-164

 

TOP:  Nursing Process: Implementation     MSC: NCLEX: Psychosocial Integrity

 

  1. A patient in a hospice program is experiencing continuous, increasing amounts of pain. The nurse caring for the patient plans the scheduling of opioid pain medications to provide

 

  1. around-the-clock routine administration of analgesics.
  2. PRN doses of medication whenever the patient requests.
  3. enough pain medication to keep the patient sedated and unaware of stimuli.
  4. analgesic doses that provide pain control without decreasing respiratory rate.

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank 11-4

 

 

ANS: A

The principles of beneficence and nonmaleficence indicate that the goal of pain management in a terminally ill patient is adequate pain relief even if the effect of pain medications could hasten death. Administration of analgesics on a PRN basis will not provide the consistent level of analgesia the patient needs. Patients usually do not require so much pain medication that they are oversedated and unaware of stimuli. Adequate pain relief may require a dosage that will result in a decrease in respiratory rate.

 

DIF:    Cognitive Level: Application             REF:   162                     TOP:  Nursing Process:

Planning

 

MSC: NCLEX: Safe and Effective Care Environment

 

  1. When caring for a patient with lung cancer in a home hospice program, it is important for the nurse to
    1. discuss cancer risk factors and appropriate lifestyle modifications.
    2. encourage the patient to discuss past life events and their meaning.
    3. accomplish a thorough head-to-toe assessment several times a week.
    4. educate the patient about the purpose of chemotherapy and radiation.

 

ANS: B

The role of the hospice nurse includes assisting the patient with the important end-of-life task of finding meaning in the patient’s life. Frequent head-to-toe assessments are not needed for hospice patients and may tire the patient unnecessarily. Patients admitted to hospice forego curative treatments such as chemotherapy and radiation for lung cancer; discussion of cancer risk factors and therapies is not appropriate.

 

DIF:    Cognitive Level: Application             REF:    154-155 | 162

 

TOP:  Nursing Process: Implementation     MSC: NCLEX: Psychosocial Integrity

 

  1. A hospice nurse who has become very close to a terminally ill patient and family is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time?

 

  1. Contact a grief counselor as soon as possible.
  2. Cry along with the patient’s family members.
  3. Leave the home as quickly as possible to allow the family to grieve privately.
  4. Consider whether working in hospice is desirable since patient losses are common.

 

ANS: B

It is appropriate for the nurse to cry and express sadness in other ways when a patient dies, and the family is likely to feel that this is therapeutic. Contacting a grief counselor, leaving the family to grieve privately, and considering whether hospice continues to be a satisfying place to work are all appropriate actions as well, but the nurse’s initial action at this time should be to share the grieving process with the family.

 

DIF:    Cognitive Level: Application             REF:    165

 

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

 

 

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank 11-5

 

 

  1. A patient who is in the clinic for an immunization tells the nurse, “My mother died 4 months ago, and I just can’t seem to get over it. I’m not sure it is normal to still think about her every day.” Which nursing diagnosis is most appropriate?

 

  1. Hopelessness related to inability to resolve grief
  2. Complicated grieving related to unresolved issues
  3. Anxiety related to lack of knowledge about normal grieving
  4. Chronic sorrow related to ongoing distress about loss of mother

 

ANS: C

The patient should be reassured that grieving activities such as frequent thoughts about the deceased are considered normal for months or years after a death. The other nursing diagnoses imply that the patient’s grief is unusual or pathologic, which is not the case.

 

DIF:    Cognitive Level: Application             REF:   156-157            TOP:  Nursing Process:

Diagnosis

 

MSC: NCLEX: Psychosocial Integrity

 

  1. The family member of a dying patient tells the nurse, “Mother doesn’t really respond any more when I visit. I don’t think she knows that I am here.” Which response by the nurse is appropriate?

 

  1. “You may need to cut back your visits for now to avoid overtiring your mother.”
  2. “Withdrawal may sometimes be a normal response when preparing to leave life.”
  3. “It will be important for you to stimulate your mother as she gets closer to dying.”
  4. “Many patients don’t really know what is going on around them at the end of life.”

 

ANS: B

Withdrawal is a normal psychosocial response to approaching death. Dying patients may maintain the ability to hear while not being able to respond. Stimulation will tire the patient and is not an appropriate response to withdrawal in this circumstance. Visitors are encouraged to be “present” with the patient, talking softly and making physical contact in a way that does not demand a response from the patient.

 

DIF:    Cognitive Level: Application             REF:    157 | 161

 

TOP:  Nursing Process: Implementation     MSC: NCLEX: Psychosocial Integrity

 

  1. Which of these patients is most appropriate for the nurse to refer to hospice care?

 

  1. A 60-year-old with lymphoma whose children are unable to discuss issues related to dying
  2. A 72-year-old with chronic severe pain as a result of spinal arthritis and vertebral collapse
  3. A 28-year-old with AIDS-related dementia who needs palliative care and pain management
  4. A 56-year-old with advanced liver failure whose family members can no longer care for him or her at home

 

ANS: C

 

 

 

 

 

 

 

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Test Bank 11-6

 

 

Hospice is designed to provide palliative care such as symptom management and pain control for patients at the end of life. Patients who require more care than the family can provide, whose families are unable to discuss important issues related to dying, or who have severe pain are candidates for other nursing services but are not appropriate hospice patients.

 

DIF:    Cognitive Level: Application             REF:    154-155

OBJ:   Special Questions: Multiple Patients                                          TOP:  Nursing Process:

Planning

 

MSC: NCLEX: Safe and Effective Care Environment

 

  1. A terminally ill patient is admitted to the hospital. Which action should the nurse include in the initial plan of care?
    1. Determine the patient’s wishes regarding end-of-life care.
    2. Emphasize the importance of addressing any family issues.
    3. Discuss the normal grief process with the patient and family.
    4. Encourage the patient to talk about any fears or unresolved issues.

 

ANS: A

The nurse’s initial action should be to assess the patient’s wishes at this time. The other actions may be implemented if the patient or the family express a desire to discuss fears, understand the grief process, or address family issues, but they should not be implemented until the assessment indicates that they are appropriate.

 

DIF: Cognitive Level: Application REF: 156-157
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Psychosocial Integrity

 

 

Lewis: Medical-Surgical Nursing, 8th Edition

 

Chapter 25: Nursing Management: Burns

 

Test Bank

 

MULTIPLE CHOICE

 

  1. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is red, swollen, and covered with large blisters. The patient states that they are very painful. The nurse will document the injury as

 

  1. full-thickness skin destruction.
  2. deep full-thickness skin destruction.
  3. deep partial-thickness skin destruction.
  4. superficial partial-thickness skin destruction.

 

ANS: C

The erythema, swelling, and blisters point to a deep partial-thickness burn. With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. With superficial partial-thickness burns, the area is red, but no blisters are present.

 

DIF:   Cognitive Level: Comprehension    REF:    475

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 56%, Hb 17.2 mg/dL (172 g/L), serum K+8 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking?

 

  1. Continue to monitor the laboratory results.
  2. Increase the rate of the ordered IV solution.
  3. Type and crossmatch for a blood transfusion.
  4. Document the findings in the patient’s record.

 

ANS: B

The patient’s lab data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Documentation and continuing to monitor are inadequate responses to the data. Since the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase.

 

DIF:   Cognitive Level: Application             REF:   479-483            TOP:  Nursing Process:

Planning

 

MSC: NCLEX: Physiological Integrity

 

  1. A patient is admitted to the burn unit with burns to the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank 25-2

 

 

  1. Encourage the patient to cough and auscultate the lungs again.

 

  1. Notify the health care provider and prepare for endotracheal intubation.
  2. Document the results and continue to monitor the patient’s respiratory rate.
  3. Reposition the patient in high-Fowler’s position and reassess breath sounds.

 

ANS: B

The patient’s history and clinical manifestations suggest airway edema and the health care provider should immediately be notified so that intubation can rapidly be done. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.

 

DIF:   Cognitive Level: Application             REF:    481-482

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, the nurse will decrease the fluid infusion rate to

 

  1. 350 mL/hour.
  2. 523 mL/hour.
  3. 938 mL/hour.
  4. 1250 mL/hour.

 

ANS: C

Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr.

 

DIF:   Cognitive Level: Application             REF:    483

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. During the emergent phase of burn care, which nursing action will be most useful in determining whether the patient is receiving adequate fluid infusion?
    1. Check skin turgor.
    2. Monitor daily weight.
    3. Assess mucous membranes.
    4. Measure hourly urine output.

 

ANS: D

When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patient’s weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.

 

DIF:   Cognitive Level: Application             REF:   483                     TOP:  Nursing Process:

Evaluation

 

MSC: NCLEX: Physiological Integrity

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank 25-3

 

 

 

  1. To maintain adequate nutrition for a patient who has just been admitted with a 40% total body surface area (TBSA) burn injury, the nurse will plan to
    1. insert a feeding tube and initiate enteral feedings.
    2. infuse total parenteral nutrition via a central catheter.
    3. encourage an oral intake of at least 5000 kcal per day.
    4. administer multiple vitamins and minerals in the IV solution.

 

ANS: A

Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient’s caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients.

 

DIF:   Cognitive Level: Application             REF:   486                     TOP:  Nursing Process:

Planning

MSC: NCLEX: Physiological Integrity

 

  1. A patient with deep partial-thickness and full-thickness burns of the face and chest is having the wounds treated with the open method. Which nursing action will be included in the plan of care?

 

  1. Restrict all visitors to prevent cross-contamination of wounds.
  2. Wear gowns, caps, masks, and gloves during all care of the patient.
  3. Turn the room temperature up to at least 68° F (20° C) during dressing changes.
  4. Administer prophylactic antibiotics to prevent bacterial colonization of wounds.

 

ANS: B

Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. Restricting all visitors is not necessary and will have adverse psychosocial consequences for the patient. The room temperature should be kept at approximately 85° F for patients with open burn wounds. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.

 

DIF:   Cognitive Level: Application             REF:   483-485            TOP:  Nursing Process:

Planning

MSC: NCLEX: Physiological Integrity

 

  1. Which action will be included in the plan of care for a patient who has burns of the ears, head, neck, and right arm and hand?
    1. Place the right arm and hand flexed in a position of comfort.
    2. Elevate the right arm and hand on pillows and extend the fingers.
    3. Assist the patient to a supine position with a small pillow under the head.
    4. Position the patient in a side-lying position with rolled towel under the neck.

 

ANS: B

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank 25-4

 

 

The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow since this will put pressure on the ears and may stick to the ears. Patients with neck burns should not use a pillow, since the head should be maintained in an extended position in order to avoid contractures.

 

DIF:    Cognitive Level: Application             REF:    485

 

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. A patient with circumferential burns of both arms develops a decrease in radial pulse strength and numbness in the fingers. Which action should the nurse take?
    1. Notify the health care provider.
    2. Monitor the pulses every 2 hours.
    3. Elevate both arms above heart level with pillows.
    4. Encourage the patient to flex and extend the fingers.

 

ANS: A

The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the arms and the need for escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the hands or increasing hand movement will not improve the patient’s circulation.

 

DIF:    Cognitive Level: Application             REF:    480

 

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. Ranitidine (Zantac) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which information will the nurse collect to evaluate the effectiveness of the medication?

 

  1. Bowel sounds
  2. Stool frequency
  3. Abdominal distention
  4. Stools for occult blood

 

ANS: D

H2 blockers are given to prevent Curling’s ulcer in the patient who has suffered burn injuries. H2 blockers do not impact on bowel sounds, stool frequency, or appetite.

 

DIF:    Cognitive Level: Application             REF:   487-488            TOP:  Nursing Process:

Evaluation

MSC: NCLEX: Physiological Integrity

 

  1. Which of these medications that are prescribed as needed for a patient who has partial thickness burns will be best for the nurse to use before wound debridement?
    1. ketorolac (Toradol)
    2. lorazepam (Ativan)
    3. gabapentin (Neurontin)
    4. hydromorphone (Dilaudid)

 

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank 25-5

 

 

ANS: D

Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effect of opioids.

 

DIF:    Cognitive Level: Application             REF:    485

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. A 21-year-old patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which action by the patient indicates that the problem is resolving?

 

  1. Stating that the scarring will only be temporary.
  2. Avoiding using a pillow to prevent neck contractures.
  3. Asking about how to use make-up to cover up the scars.
  4. Expressing sadness and anger about the scar appearance.

 

ANS: C

The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance, but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image.

 

DIF:    Cognitive Level: Application             REF:   492                     TOP:  Nursing Process:

Evaluation

 

MSC: NCLEX: Psychosocial Integrity

 

  1. The nurse caring for a patient admitted with burns over 30% of the body surface will recognize that the patient has moved from the emergent to the acute phase of the burn injury when

 

  1. white blood cell levels decrease.
  2. blisters and edema have subsided.
  3. the patient has large quantities of pale urine.
  4. the patient has been hospitalized for 48 hours.

 

ANS: C

At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patient’s immune status and any infectious processes.

 

DIF:    Cognitive Level: Comprehension    REF:    479-480

 

TOP:  Nursing Process: Application             MSC: NCLEX: Physiological Integrity

 

  1. Which of these snacks will be best for the nurse to offer to a patient with burns covering 40% total body surface area (TBSA) who is in the acute phase of burn treatment?

 

  1. Strawberry gelatin
  2. Whole wheat bagel

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank 25-6

 

 

  1. Chunky applesauce

 

  1. Chocolate milkshake

 

ANS: D

A patient with a burn injury needs high protein and calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake.

 

DIF:    Cognitive Level: Application             REF:   486                     TOP:  Nursing Process:

Planning

 

MSC: NCLEX: Physiological Integrity

 

  1. What is the priority nursing assessment when caring for a patient who has just arrived in the emergency department after suffering an electrical burn from exposure to a high-voltage current?

 

  1. Oral temperature
  2. Peripheral pulses
  3. Extremity movement
  4. Pupil reaction to light

 

ANS: C

All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data also are necessary but not as essential as determining cervical spine status.

 

DIF: Cognitive Level: Application REF: 474
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

 

  1. After an employee spills industrial acids on the arms and legs at work, what is the priority action that the occupational health nurse at the facility should take?
    1. Apply an alkaline solution to the affected area.
    2. Place cool compresses on the area of exposure.
    3. Cover the affected area with dry, sterile dressings.
    4. Flush the burned area with large amounts of water.

 

ANS: D

With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended.

 

DIF: Cognitive Level: Application REF: 477
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity

 

  1. A patient who has burns on the back and chest from a house fire has become agitated and restless 9 hours after being admitted to the hospital. Which action should the nurse take first?

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank 25-7

 

 

  1. Stay at the bedside and reassure the patient.

 

  1. Administer the ordered morphine sulfate IV.
  2. Assess orientation and level of consciousness.
  3. Use pulse oximetry to check the oxygen saturation.

 

ANS: D

Agitation in a patient who may have suffered inhalation injury might indicate hypoxemia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation also is appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient.

 

DIF: Cognitive Level: Application REF: 481
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity

 

  1. Which of these actions should the nurse take first when a patient arrives in the emergency department with facial and chest burns caused by a house fire?
    1. Infuse the ordered IV solution.
    2. Auscultate the patient’s lung sounds.
    3. Determine the extent and depth of the burns.
    4. Administer the ordered opioid pain medications.

 

ANS: B

A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.

 

DIF: Cognitive Level: Application REF: 487
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity

 

  1. A patient with extensive electrical burn injuries is admitted to the emergency department. Which of these prescribed interventions should the nurse implement first?
    1. Start two large bore IVs.
    2. Place on cardiac monitor.
    3. Apply dressings to burned areas.
    4. Assess for pain at contact points.

 

ANS: B

After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. The other actions should be accomplished in the following order: Start two IVs, assess for pain, and apply dressings.

 

DIF: Cognitive Level: Application REF: 474 | 478
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity

 

 

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank 25-8

 

 

  1. Six hours after a thermal burn covering 50% of a patient’s total body surface area (TBSA), the nurse obtains these data when assessing a patient. What is the priority information to communicate to the health care provider?

 

  1. Blood pressure is 94/46 per arterial line.
  2. Serous exudate is leaking from the burns.
  3. Cardiac monitor shows a pulse rate of 104.
  4. Urine output is 20 mL per hour for the past 2 hours.

 

ANS: D

The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase.

 

DIF: Cognitive Level: Application REF: 478-483
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

 

  1. After receiving change-of-shift report, which of these patients should the nurse assess first?
    1. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour
    2. A patient with smoke inhalation who has wheezes and altered mental status
    3. A patient with full-thickness leg burns who has a dressing change scheduled
    4. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain

 

ANS: B

This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to determine need for oxygen or intubation. The other patients also should be assessed as rapidly as possible, but they do not have evidence of life-threatening complications.

 

DIF:    Cognitive Level: Application             REF:    481

OBJ:    Special Questions: Multiple Patients

TOP:  Nursing Process: Assessment             MSC: NCLEX: Safe and Effective Care

Environment

 

  1. Which of these patients is most appropriate for the burn unit charge nurse to assign to an RN staff nurse who has floated from the hospital medical unit?
    1. A 63-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration
    2. A 45-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest
    3. A 60-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns
    4. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings and parenteral nutrition (PN)

 

 

 

 

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Test Bank 25-9

 

 

ANS: D

An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings and PN. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients.

 

DIF: Cognitive Level: Analysis REF: 488-490
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment

 

  1. The nurse notes a bright red skin color for a patient who was found unconscious from smoke inhalation in a burning house. Which action should the nurse take first?
    1. Insert two large-bore IV lines.
    2. Check the patient’s orientation.
    3. Place the patient on 100% oxygen using a non-rebreather mask.
    4. Assess for singed nasal hair and dark oral mucous membranes.

 

ANS: C

The patient’s history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the actions to correct gas exchange.

 

DIF: Cognitive Level: Application REF: 474 | 481
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity

 

  1. Which of these laboratory results requires the most rapid action by the nurse who is caring for a patient who suffered a large burn 48 hours ago?
    1. Hct 52%
    2. BUN 36 mg/dL
    3. Serum sodium 146 mEq/L
    4. Serum potassium 6.2 mEq/L

 

ANS: D

Hyperkalemia can lead to fatal bradycardia and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values also are abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level.

 

DIF: Cognitive Level: Application REF: 487
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

 

  1. The RN observes all of the following actions being taken by a staff nurse who has floated to the unit. Which action requires that the RN intervene?
    1. The float nurse uses clean latex gloves when applying antibacterial cream to a burn wound.
    2. The float nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C).

 

 

 

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Test Bank 25-10

 

 

  1. The float nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change.

 

  1. The float nurse calls the health care provider for an insulin order when a nondiabetic patient has an elevated serum glucose.

 

ANS: A

Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration and should be used just before and during dressing changes for pain management.

 

DIF: Cognitive Level: Application REF: 484
OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment

 

  1. Which of these nursing actions should be done first for a patient who has suffered a burn injury while working on an electrical power line?
    1. Obtain the blood pressure.
    2. Stabilize the cervical spine.
    3. Assess for the contact points.
    4. Check alertness and orientation.

 

ANS: B

Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management. The other actions also are included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury.

 

DIF: Cognitive Level: Application REF: 474 | 478
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity

 

COMPLETION

 

  1. A 70 kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula, calculate the volume of lactated Ringer’s solution that the nursing staff will administer during the first 24 hours.

__________________

 

ANS:

8400 mL

The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours.

 

DIF: Cognitive Level: Application REF:  483
OBJ: Special Questions: Alternate Item Format
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

 

 

 

 

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Test Bank 25-11

 

 

 

  1. The nurse is estimating the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the posterior trunk and right arm. What percentage of the patient’s total body surface area (TBSA) has been injured?

 

__________________

 

ANS:

27%

When using the rule of nines, the posterior trunk is considered to cover 18% of the patient’s body and each arm is 9%.

 

DIF: Cognitive Level: Comprehension REF:  476
OBJ: Special Questions: Alternate Item Format
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

 

  1. In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient’s back? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________
    1. Apply sterile gauze dressing.
    2. Document wound appearance.
    3. Apply silver sulfadiazine cream.
    4. Administer IV fentanyl (Sublimaze).
    5. Clean wound with saline-soaked gauze.

 

ANS:

D, E, C, A, B

Since partial-thickness burns are very painful, the nurse’s first action should be to administer pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound.

 

DIF: Cognitive Level: Application REF: 488 | 490
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity

 

 

 

Lewis: Medical-Surgical Nursing, 8th Edition

 

Chapter 34: Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome

 

Test Bank

 

MULTIPLE CHOICE

 

  1. When developing a health teaching plan for a 60-year-old man with the following risk factors for coronary artery disease (CAD), the nurse should focus on the
    1. family history of coronary artery disease.
    2. increased risk associated with the patient’s gender.
    3. high incidence of cardiovascular disease in older people.
    4. elevation of the patient’s serum low density lipoprotein (LDL) level.

 

ANS: D

Because family history, gender, and age are nonmodifiable risk factors, the nurse should focus on the patient’s LDL level. Decreases in LDL will help reduce the patient’s risk for developing CAD.

 

DIF:   Cognitive Level: Application             REF:   767                     TOP:  Nursing Process:

Planning

 

MSC: NCLEX: Health Promotion and Maintenance

 

  1. To assist the patient with coronary artery disease (CAD) in making appropriate dietary changes, which of these nursing interventions will be most effective?
    1. Instruct the patient that a diet containing no saturated fat and minimal sodium will be necessary.
    2. Emphasize the increased risk for cardiac problems unless the patient makes the dietary changes.
    3. Assist the patient to modify favorite high-fat recipes by using monosaturated oils when possible.
    4. Provide the patient with a list of low-sodium, low-cholesterol foods that should be included in the diet.

 

ANS: C

Lifestyle changes are more likely to be successful when consideration is given to the patient’s values and preferences. The highest percentage of calories from fat should come from monosaturated fats. Although low-sodium and low -cholesterol foods are appropriate, providing the patient with a list alone is not likely to be successful in making dietary changes. Removing saturated fat from the diet completely is not a realistic expectation; up to 7% of calories in the therapeutic lifestyle changes (TLC) diet can come from saturated fat. Telling the patient about the increased risk without assisting further with strategies for dietary change is unlikely to be successful.

 

DIF:   Cognitive Level: Application             REF:    767-768

 

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank 34-2

 

 

 

  1. Which information collected by the nurse who is admitting a patient with chest pain suggests that the pain is caused by an acute myocardial infarction (AMI)?
    1. The pain increases with deep breathing.
    2. The pain has persisted longer than 30 minutes.
    3. The pain worsens when the patient raises the arms.
    4. The pain is relieved after the patient takes nitroglycerin.

 

ANS: B

Chest pain that lasts for 20 minutes or more is characteristic of AMI. Changes in pain that occur with raising the arms or with deep breathing are more typical of pericarditis or musculoskeletal pain. Stable angina is usually relieved when the patient takes nitroglycerin.

 

DIF:   Cognitive Level: Application             REF:    779

 

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis?
    1. The patient rates the pain at a level 3 to 5 (0 to 10 scale).
    2. The patient states that the pain “wakes me up at night.”
    3. The patient says that the frequency of the pain has increased over the last few weeks.
    4. The patient states that the pain is resolved after taking one sublingual nitroglycerin tablet.

 

ANS: D

Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.

 

DIF:   Cognitive Level: Comprehension    REF:    771-776

 

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. After the nurse has finished teaching a patient about use of sublingual nitroglycerin (Nitrostat), which patient statement indicates that the teaching has been effective?

 

  1. “I can expect indigestion as a side effect of nitroglycerin.”
  2. “I can only take the nitroglycerin if I start to have chest pain.”
  3. “I will call an ambulance if I still have pain 5 minutes after taking the nitroglycerin.”
  4. “I will help slow down the progress of the plaque formation by taking nitroglycerin.”

 

ANS: C

 

 

 

 

 

 

 

 

 

 

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Test Bank 34-3

 

 

The emergency medical services (EMS) system should be activated when chest pain or other symptoms are not completely relieved 5 minutes after taking one nitroglycerin. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis.

 

DIF:   Cognitive Level: Application             REF:   775-776            TOP:  Nursing Process:

Evaluation

MSC: NCLEX: Physiological Integrity

 

  1. Which of these statements made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes (TLC) diet indicates that further teaching is needed?

 

  1. “I will switch from whole milk to 1% or nonfat milk.”
  2. “I like fresh salmon and I will plan to eat it more often.”
  3. “I will miss being able to eat peanut butter sandwiches.”
  4. “I can have a cup of coffee with breakfast if I want one.”

 

ANS: C

Although only 30% of the daily calories should come from fats, most of the fat in the TLC diet should come from monosaturated fats such as are found in nuts, olive oil, and canola oil. The patient can include peanut butter sandwiches as part of the TLC diet. The other patient comments indicate a good understanding of the TLC diet.

 

DIF:   Cognitive Level: Application             REF:   768                     TOP:  Nursing Process:

Evaluation

 

MSC: NCLEX: Physiological Integrity

 

  1. After the nurse teaches the patient about the use of atenolol (Tenormin) in preventing anginal episodes, which statement by a patient indicates that the teaching has been effective?

 

  1. “It is important not to suddenly stop taking the atenolol.”
  2. “Atenolol will increase the strength of my heart muscle.”
  3. “I can expect to feel short of breath when taking atenolol.”
  4. “Atenolol will improve the blood flow to my coronary arteries.”

 

ANS: A

 

Patients who have been taking b-blockers can develop intense and frequent angina if the medication is suddenly discontinued. Atenolol (Tenormin) decreases myocardial

 

contractility. Shortness of breath that occurs when taking b-blockers for angina may be due to bronchospasm and should be reported to the health care provider. Atenolol works by decreasing myocardial oxygen demand, not by increasing blood flow to the coronary arteries.

 

DIF:   Cognitive Level: Application             REF:   775 | 776          TOP:  Nursing Process:

Evaluation

MSC: NCLEX: Physiological Integrity

 

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank 34-4

 

 

  1. A patient who has had severe chest pain for several hours is admitted with a diagnosis of possible acute myocardial infarction (AMI). Which of these ordered laboratory tests should the nurse monitor to help determine whether the patient has had an AMI?

 

  1. Homocysteine
  2. C-reactive protein
  3. Cardiac-specific troponin I and troponin T
  4. High-density lipoprotein (HDL) cholesterol

 

ANS: C

Troponin levels increase about 4 to 6 hours after the onset of myocardial infarction (MI). The other laboratory data are useful in determining the patient’s risk for developing coronary artery disease (CAD) but are not helpful in determining whether an acute MI is in progress.

 

DIF:    Cognitive Level: Comprehension    REF:    780-781

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. Amlodipine (Norvasc) is ordered for a patient with newly diagnosed Prinzmetal’s (variant) angina. When teaching the patient, the nurse will include the information that amlodipine will

 

  1. reduce the “fight or flight” response.
  2. decrease spasm of the coronary arteries.
  3. increase the force of myocardial contraction.
  4. help prevent clotting in the coronary arteries.

 

ANS: B

Prinzmetal’s angina is caused by coronary artery spasm. Calcium channel blockers (e.g., amlodipine, nifedipine [Procardia]) are a first-line therapy for this type of angina. Platelet

inhibitors, such as aspirin, help prevent coronary artery thrombosis, and b-blockers decrease sympathetic stimulation of the heart. Medications or activities that increase myocardial contractility will increase the incidence of angina by increasing oxygen demand.

 

DIF:    Cognitive Level: Application             REF:    776

 

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. The nurse will suspect that the patient with stable angina is experiencing a side effect of the prescribed metoprolol (Lopressor) if
    1. the patient is restless and agitated.
    2. the blood pressure is 190/110 mm Hg.
    3. the patient complains about feeling anxious.
    4. the cardiac monitor shows a heart rate of 45.

 

ANS: D

 

Patients taking b-blockers should be monitored for bradycardia. Because this category of medication inhibits the sympathetic nervous system, restlessness, agitation, hypertension, and anxiety will not be side effects.

 

DIF:    Cognitive Level: Application             REF:   776                     TOP:  Nursing Process:

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank 34-5

 

 

Evaluation

MSC: NCLEX: Physiological Integrity

 

  1. Nadolol (Corgard) is prescribed for a patient with angina. To determine whether the drug is effective, the nurse will monitor for
    1. decreased blood pressure and apical pulse rate.
    2. fewer complaints of having cold hands and feet.
    3. improvement in the quality of the peripheral pulses.
    4. the ability to do daily activities without chest discomfort.

 

ANS: D

Because the medication is ordered to improve the patient’s angina, effectiveness is indicated if the patient is able to accomplish daily activities without chest pain. Blood pressure (BP) and apical pulse rate may decrease, but these data do not indicate that the

 

goal of decreased angina has been met. The noncardioselective b-blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in peripheral pulse quality or skin temperature.

 

DIF:    Cognitive Level: Application             REF:   776                     TOP:  Nursing Process:

Evaluation

MSC: NCLEX: Physiological Integrity

 

  1. A patient with a non–ST-segment-elevation myocardial infarction (NSTEMI) is receiving heparin. What is the purpose of the heparin?
    1. Platelet aggregation is enhanced by IV heparin infusion.
    2. Heparin will dissolve the clot that is blocking blood flow to the heart.
    3. Coronary artery plaque size and adherence are decreased with heparin.
    4. Heparin will prevent the development of new clots in the coronary arteries.

 

ANS: D

Heparin helps prevent the conversion of fibrinogen to fibrin and decreases coronary artery thrombosis. It does not change coronary artery plaque, dissolve already formed clots, or enhance platelet aggregation.

 

DIF:    Cognitive Level: Comprehension    REF:    775

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. When administering IV nitroglycerin (Tridil) to a patient with a myocardial infarction (MI), which action will the nurse take to evaluate the effectiveness of the medication?

 

  1. Check blood pressure.
  2. Monitor apical pulse rate.
  3. Monitor for dysrhythmias.
  4. Ask about chest discomfort.

 

ANS: D

The goal of IV nitroglycerin administration in MI is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and BP and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank                                                                                                                                                                34-6

 

 

 

DIF:    Cognitive Level: Application             REF:   784-785            TOP:  Nursing Process:

Evaluation

MSC: NCLEX: Physiological Integrity

 

  1. A patient with ST segment elevation in several electrocardiographic (ECG) leads is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the patient is a candidate for fibrinolytic therapy?

 

  1. “Do you take aspirin on a daily basis?”
  2. “What time did your chest pain begin?”
  3. “Is there any family history of heart disease?”
  4. “Can you describe the quality of your chest pain?”

 

ANS: B

Fibrinolytic therapy should be started within 6 hours of the onset of the myocardial infarction (MI), so the time at which the chest pain started is a major determinant of the appropriateness of this treatment. The other information also will be needed, but it will not be a factor in the decision about fibrinolytic therapy.

 

DIF:    Cognitive Level: Application             REF:    782-783

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. Following an acute myocardial infarction (AMI), a patient ambulates in the hospital hallway. When the nurse is evaluating the patient’s response, which of these assessment data would indicate that the exercise level should be decreased?

 

  1. BP changes from 118/60 to 126/68 mm Hg.
  2. Oxygen saturation drops from 100% to 98%.
  3. Heart rate increases from 66 to 90 beats/minute.
  4. Respiratory rate goes from 14 to 22 breaths/minute.

 

ANS: C

A change in heart rate of more than 20 beats or more indicates that the patient should stop and rest. The increases in BP and respiratory rate, and the slight decrease in oxygen saturation, are normal responses to exercise.

 

DIF:    Cognitive Level: Application             REF:   792                     TOP:  Nursing Process:

Evaluation

 

MSC: NCLEX: Physiological Integrity

 

  1. During the administration of the fibrinolytic agent to a patient with an acute myocardial infarction (AMI), the nurse should stop the drug infusion if the patient experiences

 

  1. bleeding from the gums.
  2. surface bleeding from the IV site.
  3. a decrease in level of consciousness.
  4. a nonsustained episode of ventricular tachycardia.

 

ANS: C

 

 

 

 

 

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Test Bank 34-7

 

 

The change in level of consciousness indicates that the patient may be experiencing intracranial bleeding, a possible complication of fibrinolytic therapy. Bleeding of the gums and prolonged bleeding from IV sites are expected side effects of the therapy. The nurse should address these by avoiding any further injuries, but they are not an indication to stop infusion of the fibrinolytic medication. A nonsustained episode of ventricular tachycardia is a common reperfusion dysrhythmia and may indicate that the therapy is effective.

 

DIF:    Cognitive Level: Application             REF:   783-784            TOP:  Nursing Process:

Evaluation

MSC: NCLEX: Physiological Integrity

 

  1. Three days after a myocardial infarction (MI), the patient develops chest pain that increases when taking a deep breath and is relieved by leaning forward. Which action should the nurse take next?

 

  1. Palpate the radial pulses bilaterally.
  2. Assess the feet for peripheral edema.
  3. Auscultate for a pericardial friction rub.
  4. Check the cardiac monitor for dysrhythmias.

 

ANS: C

The patient’s symptoms are consistent with the development of pericarditis, a possible complication of MI. The other assessments listed are not consistent with the description of the patient’s symptoms.

 

DIF:    Cognitive Level: Application             REF:    780

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. After the nurse teaches a patient with chronic stable angina about how to use the prescribed short-acting and long-acting nitrates, which statement by the patient indicates that the teaching has been effective?

 

  1. “I will put on the nitroglycerin patch as soon as I develop any chest pain.”
  2. “I will check the pulse rate in my wrist just before I take any nitroglycerin.”
  3. “I will be sure to remove the nitroglycerin patch before using any sublingual nitroglycerin.”
  4. “I will stop what I am doing and sit down before I put the nitroglycerin under my tongue.”

 

ANS: D

The patient should sit down before taking the nitroglycerin to decrease cardiac workload and prevent orthostatic hypotension. Transdermal nitrates are used prophylactically rather than to treat acute pain and can be used concurrently with sublingual nitroglycerin.

Although the nurse should check blood pressure before giving nitroglycerin, patients do not need to check the pulse rate before taking nitrates.

 

DIF:    Cognitive Level: Application             REF:   775-776            TOP:  Nursing Process:

Evaluation

 

MSC: NCLEX: Physiological Integrity

 

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank 34-8

 

 

  1. Four days after having a myocardial infarction (MI), a patient who is scheduled for discharge asks for assistance with all the daily activities, saying, “I am too nervous to take care of myself.” Based on this information, which nursing diagnosis is appropriate?

 

  1. Ineffective coping related to anxiety
  2. Activity intolerance related to weakness
  3. Denial related to lack of acceptance of the MI
  4. Social isolation related to lack of support system

 

ANS: A

The patient data indicates that ineffective coping after the MI caused by anxiety about the impact of the MI is a concern. The other nursing diagnoses may be appropriate for some patients after an MI, but the data for this patient do not support denial, activity intolerance, or social isolation.

 

DIF:    Cognitive Level: Application             REF:   788-789            TOP:  Nursing Process:

Diagnosis

 

MSC: NCLEX: Psychosocial Integrity

 

  1. When caring for a patient who has survived a sudden cardiac death (SCD) event and has no evidence of an acute myocardial infarction (AMI), the nurse will anticipate teaching the patient

 

  1. that sudden cardiac death events rarely reoccur.
  2. about the purpose of outpatient Holter monitoring.
  3. how to self-administer low-molecular-weight heparin.
  4. to limit activities after discharge to prevent future events.

 

ANS: B

Holter monitoring is used to determine whether the patient is experiencing dysrhythmias such as ventricular tachycardia during normal daily activities. SCD is likely to recur. Heparin will not have any effect on the incidence of SCD, and SCD can occur even when the patient is resting.

 

DIF:    Cognitive Level: Application             REF:   793-794            TOP:  Nursing Process:

Planning

MSC: NCLEX: Physiological Integrity

 

  1. A few days after experiencing a myocardial infarction (MI), the patient states, “I just had
    • little chest pain. As soon as I get out of here, I’m going for my vacation as planned.” Which response should the nurse make?
  1. “Where are you planning to go for your vacation?”
  2. “What do you think caused your chest pain episode?”
  3. “Sometimes plans need to change after a heart attack.”
  4. “Recovery from a heart attack takes at least a few weeks.”

 

ANS: B

 

 

 

 

 

 

 

 

 

Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 

 

Test Bank 34-9

 

 

When the patient is experiencing denial, the nurse should assist the patient in testing reality until the patient has progressed beyond this step of the emotional adjustment to MI. Asking the patient about vacation plans reinforces the patient’s plan, which is not appropriate in the immediate post-MI period. Reminding the patient in denial about the MI is likely to make the patient angry and lead to distrust of the nursing staff.

 

DIF:    Cognitive Level: Application             REF:    788-789

 

TOP:  Nursing Process: Implementation     MSC: NCLEX: Psychosocial Integrity

 

  1. When evaluating the outcomes of preoperative teaching with a patient scheduled for a coronary artery bypass graft (CABG) using the internal mammary artery, the nurse determines that additional teaching is needed when the patient says,

 

  1. “I will have incisions in my leg where they will remove the vein.”
  2. “They will circulate my blood with a machine during the surgery.”
  3. “I will need to take an aspirin a day after the surgery to keep the graft open.”
  4. “They will use an artery near my heart to bypass the area that is obstructed.”

 

ANS: A

When the internal mammary artery is used there is no need to have a saphenous vein removed from the leg. The other statements by the patient are accurate and indicate that the teaching has been effective.

 

DIF:    Cognitive Level: Application             REF:   783-784            TOP:  Nursing Process:

Evaluation

MSC: NCLEX: Physiological Integrity

 

  1. A patient who has had an acute myocardial infarction (AMI) asks the nurse about when sexual intercourse can be resumed. Which response by the nurse is best?
    1. “Most patients are able to enjoy intercourse without any complications.”
    2. “Sexual activity uses about as much energy as climbing two flights of stairs.”
    3. “The doctor will discuss sexual intercourse when your heart is strong enough.”
    4. “Holding and cuddling are good ways to maintain intimacy after a heart attack.”

 

ANS: B

Sexual activity places about as much physical stress on the cardiovascular system as climbing two flights of stairs. The other responses do not directly address the patient’s question, or may not be accurate for this patient.

 

DIF:    Cognitive Level: Application             REF:    792

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. A patient with hyperlipidemia has a new order for colesevelam (Welchol). Which nursing action is appropriate when giving the medication?
    1. Administer the medication at the patient’s bedtime.
    2. Have the patient take this medication with an aspirin.
    3. Encourage the patient to take the colesevelam with a sip of water.
    4. Give the patient’s other medications 2 hours after the colesevelam.

 

ANS: D

 

 

 

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Test Bank 34-10

 

 

The bile acid sequestrants interfere with the absorption of other drugs, and giving other medications at the same time should be avoided. Taking an aspirin concurrently with the colesevelam may increase the incidence of gastrointestinal side effects such as heartburn. An increased fluid intake is encouraged for patients taking the bile acid sequestrants to reduce the risk for constipation. For maximum effect, colesevelam should be administered with meals.

 

DIF:    Cognitive Level: Application             REF:    770-771

 

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. For a patient who has been admitted the previous day to the coronary care unit with an acute myocardial infarction (AMI), the nurse will anticipate teaching about
    1. typical emotional responses to AMI.
    2. when patient cardiac rehabilitation will begin.
    3. discharge drugs such as aspirin and b-blockers.
    4. the pathophysiology of coronary artery disease.

 

ANS: B

Early after an AMI, the patient will want to know when resumption of usual activities can be expected. At this time, the patient’s anxiety level or denial will prevent good understanding of complex information such as coronary artery disease (CAD) pathophysiology. Teaching about discharge medications should be done when the time for discharge is closer. The nurse should support the patient by decreasing anxiety rather than discussing the typical emotional response to myocardial infarction (MI).

 

DIF:    Cognitive Level: Application             REF:   788-789            TOP:  Nursing Process:

Planning

 

MSC: NCLEX: Psychosocial Integrity

 

  1. A patient who has recently started taking rosuvastatin (Crestor) and niacin (Nicobid) reports all the following symptoms to the nurse. Which is most important to communicate to the health care provider?

 

  1. Generalized muscle aches and pains
  2. Skin flushing after taking the medications
  3. Dizziness when changing positions quickly
  4. Nausea when taking the drugs before eating

 

ANS: A

Muscle aches and pains may indicate myopathy and rhabdomyolysis, which have caused acute renal failure and death in some patients who have taken the statin medications. These symptoms indicate that the rosuvastatin may need to be discontinued. The other symptoms are common side effects when taking niacin, and although the nurse should follow up with the patient, they do not indicate that a change in medication is needed.

 

DIF: Cognitive Level: Application REF: 768-770
OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity

 

 

 

 

 

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Test Bank 34-11

 

 

  1. A patient who is being admitted to the emergency department with severe chest pain gives the following list of medications taken at home to the nurse. Which of the medications has the most immediate implications for the patient’s care?

 

  1. sildenafil (Viagra)
  2. furosemide (Lasix)
  3. diazepam (Valium)
  4. captopril (Capoten)

 

ANS: A

The nurse will need to avoid giving nitrates to the patient because nitrate administration is contraindicated in patients who are using sildenafil because of the risk of sudden death caused by vasodilation. The other home medications also should be documented and reported to the health care provider but do not have as immediate an impact on decisions about the patient’s treatment.

 

DIF: Cognitive Level: Application REF: 773 | 775-776
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

 

  1. Which assessment finding by the nurse who is caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the physician?

 

  1. Complaints of incisional chest pain
  2. Crackles audible at both lung bases
  3. Pallor and weakness of the right hand
  4. Redness on either side of the chest incision

 

ANS: C

The changes in the right hand indicate compromised blood flow, which requires immediate evaluation and actions such as prescribed calcium channel blockers or surgery. The other changes are expected and/or require nursing interventions.

 

DIF: Cognitive Level: Application REF: 788
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

 

  1. When caring for a patient who has just arrived on the medical-surgical unit after having cardiac catheterization, which nursing action should the nurse delegate to an LPN/LVN?

 

  1. Perform the initial assessment of the catheter insertion site.
  2. Teach the patient about the usual postprocedure plan of care.
  3. Check the rate on the infusion pump used to administer heparin.
  4. Administer the scheduled aspirin and lipid-lowering medication.

 

ANS: D

Administration of oral medications is within the scope of practice for LPNs/LVNs. The initial assessment of the patient, patient teaching, and administration of intravenous anticoagulant medications should be done by the RN.

 

DIF:    Cognitive Level: Application             REF:    793

 

 

 

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Test Bank                                                                                                                                                              34-12

 

 

OBJ:   Special Questions: Delegation           TOP:  Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

 

  1. Which electrocardiographic (ECG) change is most important for the nurse to communicate to the health care provider when caring for a patient with chest pain?

 

  1. Frequent premature atrial contractions (PACs)
  2. Inverted P wave
  3. Sinus tachycardia
  4. ST segment elevation

 

ANS: D

The patient is likely to be experiencing an ST-segment-elevation myocardial infarction (STEMI) and immediate therapy with percutaneous coronary intervention (PCI) or fibrinolytic medications is indicated to minimize the amount of myocardial damage. The other ECG changes also may suggest a need for therapy, but not as rapidly.

 

DIF: Cognitive Level: Application REF: 780-781
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

 

  1. When caring for a patient with acute coronary syndrome who has returned to the coronary care unit after having balloon angioplasty, the nurse obtains the following assessment data. Which data indicate the need for immediate intervention by the nurse?
    1. Pedal pulses 1+
    2. Heart rate 100 beats/min
    3. Blood pressure 104/56 mm Hg
    4. Chest pain level 8 on a 10-point scale

 

ANS: D

The patient’s chest pain indicates that restenosis of the coronary artery may be occurring and requires immediate actions, such as administration of oxygen and nitroglycerin, by the nurse. The other information indicates a need for ongoing assessments by the nurse.

 

DIF: Cognitive Level: Application REF: 781-782
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

 

  1. A patient admitted to the coronary care unit (CCU) with an ST-segment-elevation myocardial infarction (STEMI) is restless and anxious. The blood pressure is 86/40 and heart rate is 110. Based on this information, which nursing diagnosis is a priority for the patient?

 

  1. Acute pain related to myocardial ischemia
  2. Anxiety related to perceived threat of death
  3. Decreased cardiac output related to cardiogenic shock
  4. Activity intolerance related to decreased cardiac output

 

ANS: C

 

 

 

 

 

 

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Test Bank 34-13

 

 

All the nursing diagnoses may be appropriate for this patient, but the hypotension indicates that the priority diagnosis is decreased cardiac output, which will decrease perfusion to all vital organs (e.g., brain, kidney, heart).

 

DIF: Cognitive Level: Application REF: 786
OBJ: Special Questions: Prioritization TOP: Nursing Process: Diagnosis
MSC: NCLEX: Physiological Integrity

 

  1. When admitting a patient with a myocardial infarction (MI) to the intensive care unit, which action should the nurse carry out first?
    1. Obtain the blood pressure.
    2. Attach the cardiac monitor.
    3. Assess the peripheral pulses.
    4. Auscultate the breath sounds.

 

ANS: B

Because dysrhythmias are the most common complication of MI, the first action should be to place the patient on a cardiac monitor. The other actions also are important and should be accomplished as quickly as possible.

 

DIF: Cognitive Level: Application REF: 779-780 | 787-788
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity

 

  1. Which information about a patient who has been receiving fibrinolytic therapy for an acute myocardial infarction (AMI) is most important for the nurse to communicate to the health care provider?

 

  1. No change in the patient’s chest pain
  2. A large bruise at the patient’s IV insertion site
  3. A decrease in ST segment elevation on the electrocardiogram (ECG)
  4. An increase in cardiac enzyme levels since admission

 

ANS: A

Continued chest pain suggests that the fibrinolytic therapy is not effective and that other interventions such as percutaneous coronary intervention (PCI) may be needed. Bruising is a possible side effect of fibrinolytic therapy, but it is not an indication that therapy should be discontinued. The decrease of the ST segment elevation indicates that fibrinolysis is occurring and perfusion is returning to the injured myocardium. An increase in cardiac enzyme levels is expected with reperfusion and is related to the washout of enzymes into the circulation as the blocked vessel is opened.

 

DIF: Cognitive Level: Application REF: 782-783
OBJ: Special Questions: Prioritization TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity

 

  1. The nurse obtains the following data when caring for a patient who experienced an acute myocardial infarction (AMI) 2 days previously. Which information is most important to report to the health care provider?

 

  1. The patient denies ever having a heart attack.

 

 

 

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Test Bank 34-14

 

 

  1. The cardiac-specific troponin level is elevated.

 

  1. The patient has occasional premature atrial contractions (PACs).
  2. Crackles are auscultated bilaterally in the mid-lower lobes.

 

ANS: D

The crackles indicate that the patient may be developing heart failure, a possible complication of myocardial infarction (MI). The health care provider may need to order medications such as diuretics or angiotensin-converting enzyme (ACE) inhibitors for the patient. Elevation in cardiac troponin level at this time is expected. PACs are not life-threatening dysrhythmias. Denial is a common response in the immediate period after the MI.

 

DIF: Cognitive Level: Application REF: 779-780
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

 

  1. Which of these nursing interventions included in the plan of care for a patient who had an acute myocardial infarction (AMI) 3 days ago is most appropriate for the RN to delegate to an experienced LPN/LVN?

 

  1. Evaluating the patient’s response to ambulation in the hallway
  2. Completing the documentation for a home health nurse referral
  3. Educating the patient about the pathophysiology of heart disease
  4. Reinforcing teaching about the purpose of prescribed medications

 

ANS: D

LPN/LVN education and scope of practice include reinforcing education that has previously been done by the RN. Evaluating the patient response to exercise after an AMI requires more education and should be done by the RN. Teaching and discharge planning/documentation are higher level skills that require RN education and scope of practice.

 

DIF: Cognitive Level: Application REF: 789-793
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment

 

  1. A patient who has chest pain is admitted to the emergency department (ED), and all the following diagnostic tests are ordered. Which one will the nurse arrange to be completed first?

 

  1. Electrocardiogram (ECG)
  2. Computed tomography (CT) scan
  3. Chest x-ray
  4. Troponin level

 

ANS: A

 

 

 

 

 

 

 

 

 

 

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Test Bank 34-15

 

 

The priority for the patient is to determine whether an acute myocardial infarction (AMI) is occurring so that reperfusion therapy can begin as quickly as possible. ECG changes occur very rapidly after coronary artery occlusion. Troponin levels will increase after about 3 hours. Data from the CT scan and chest x -ray may impact the patient’s care but are not helpful in determining whether the patient is experiencing a myocardial infarction (MI).

 

DIF: Cognitive Level: Application REF: 782
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity

 

  1. The nurse has just received change-of-shift report about the following four patients. Which patient should the nurse assess first?
    1. 38-year-old who has pericarditis and is complaining of sharp, stabbing chest pain
    2. 45-year-old who had a myocardial infarction (MI) 4 days ago and is anxious about the planned discharge
    3. 51-year-old with unstable angina who has just returned to the unit after having a percutaneous coronary intervention (PCI)
    4. 60-year-old with variant angina who is to receive a scheduled dose of nifedipine (Procardia)

 

ANS: C

This patient is at risk for bleeding from the arterial access site for the PCI, so the nurse should assess the patient’s blood pressure, pulse, and the access site immediately. The other patients also should be assessed as quickly as possible, but assessment of this patient has the highest priority.

 

DIF: Cognitive Level: Analysis REF:  781-782
OBJ: Special Questions: Multiple Patients
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

 

 

 

Lewis: Medical-Surgical Nursing, 8th Edition

 

Chapter 44: Nursing Management: Liver, Pancreas, and Biliary Tract Problems Test Bank

 

MULTIPLE CHOICE

 

  1. A patient contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient’s illness, the nurse would expect serologic testing to reveal
    1. antibody to hepatitis D (anti-HDV).
    2. hepatitis B surface antigen (HBsAg).
    3. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG).
    4. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).

 

ANS: D

Hepatitis A is transmitted through the oral -fecal route, and antibody to HAV IgM appears during the acute phase of hepatitis A. The patient would not have antigen for hepatitis B or antibody for hepatitis D. Anti-HAV IgG would indicate past infection and lifelong immunity.

 

DIF:   Cognitive Level: Application             REF:    1060-1061 | 1064

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. The nurse determines that administration of hepatitis B vaccine to a patient has been effective when a specimen of the patient’s blood reveals
    1. anti-HBs.
    2. anti-HBc IgG.
    3. anti-HBc IgM.

 

ANS: B

The presence of surface antibody to HBV (anti-HBs) is a marker of a positive response to the vaccine. The other laboratory values indicate current infection with HBV.

 

DIF:   Cognitive Level: Analysis                   REF:    1061-1062 | 1064

TOP:  Nursing Process: Evaluation               MSC: NCLEX: Health Promotion and Maintenance

 

  1. A patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate?
    1. Schedule the patient for HCV genotype testing.
    2. Administer immune globulin and the HCV vaccine.
    3. Instruct the patient on ribavirin (Rebetol) treatment.
    4. Teach that the infection will resolve in a few months.

 

ANS: A

 

 

 

 

 

 

 

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Test Bank 44-2

 

 

Genotyping of HCV has an important role in managing treatment and is done before drug therapy is initiated. Since most patients with acute HCV infection convert to the chronic state, the nurse should not teach the patient that the HCV will resolve in a few months. Immune globulin or vaccine is not available for HCV. Ribavirin is used for chronic HCV infection.

 

DIF:   Cognitive Level: Application             REF:    1063-1064

 

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. When a patient is diagnosed with acute hepatitis B, the nurse will plan to teach the patient about
    1. ways to increase exercise and activity level.
    2. self-administration of α-interferon (Intron A).
    3. side effects of nucleoside and nucleotide analogs.
    4. measures that will be helpful in improving appetite.

 

ANS: D

Maintaining adequate nutritional intake is important for regeneration of hepatocytes. Interferon and antivirals may be used for chronic hepatitis B, but they are not prescribed for acute hepatitis B infection. Rest is recommended.

 

DIF:   Cognitive Level: Application             REF:    1064-1065 | 1069-1070

 

TOP:  Nursing Process: Planning                   MSC: NCLEX: Physiological Integrity

 

  1. When combination therapy of a-interferon and ribavirin (Rebetol) is being used to treat chronic hepatitis C, the nurse will plan to monitor for

 

ANS: A

 

Therapy with ribavirin and a-interferon may cause leukopenia. The other problems are not associated with this drug therapy.

 

DIF:   Cognitive Level: Application             REF:   1066                   TOP:  Nursing Process:

Planning

MSC: NCLEX: Physiological Integrity

 

  1. Which information given by a patient when the nurse is taking a health history indicates that screening for hepatitis C should be done?
    1. The patient eats frequent meals in fast-food restaurants.
    2. The patient recently traveled to an undeveloped country.
    3. The patient had a blood transfusion after surgery in 1998.
    4. The patient reports a one-time use of IV drugs 20 years ago.

 

ANS: D

 

 

 

 

 

 

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Test Bank 44-3

 

 

Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries.

 

DIF:   Cognitive Level: Application             REF:   1062

 

TOP:  Nursing Process: Assessment             MSC: NCLEX: Health Promotion and Maintenance

 

  1. A patient is admitted with an abrupt onset of jaundice, nausea, and abnormal liver function studies. Serologic testing is negative for viral causes of hepatitis. Which question by the nurse is most appropriate?

 

  1. “Is there any history of IV drug use?”
  2. “Are you taking corticosteroids for any reason?”
  3. “Do you use any over-the-counter (OTC) drugs?”
  4. “Have you recently traveled to a foreign country?”

 

ANS: C

The patient’s symptoms, lack of antibodies for hepatitis, and the abrupt onset of symptoms suggest toxic hepatitis, which can be caused by commonly used OTC drugs such as acetaminophen (Tylenol). Travel to a foreign country and a history of IV drug use are risk factors for viral hepatitis. Corticosteroid use does not cause the symptoms listed.

 

DIF:   Cognitive Level: Application             REF:    1070-1071

 

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. A patient with cirrhosis has 4+ pitting edema of the feet and legs. The data indicate that it is most important for the nurse to monitor the patient’s
    1. activity level.
    2. albumin level.

 

ANS: D

The low oncotic pressure caused by hypoalbuminemia is a major pathophysiologic factor in the development of edema. The other parameters also should be monitored, but they are not directly associated with the patient’s current symptoms.

 

DIF:   Cognitive Level: Application             REF:    1075 | 1077

 

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. A 32-year-old patient is diagnosed with early alcoholic cirrhosis. Which topic is most important to include in patient teaching?
    1. Need to abstain from alcohol
    2. Use of vitamin B supplements
    3. Maintenance of a nutritious diet
    4. Treatment with lactulose (Cephulac)

 

ANS: A

 

 

 

 

 

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Test Bank 44-4

 

 

The disease progression can be stopped or reversed by alcohol abstinence. The other interventions may be used when cirrhosis becomes more severe to decrease symptoms or complications, but the priority for this patient is to stop the progression of the disease.

 

DIF:    Cognitive Level: Application             REF:   1081 | 1085   TOP:  Nursing Process:

Planning

MSC: NCLEX: Physiological Integrity

 

  1. A patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) has a serum potassium level of 3.2 mEq/L (3.2 mmol/L). Which action should the nurse take?

 

  1. Give both drugs as scheduled.
  2. Administer the spironolactone.
  3. Administer the furosemide and withhold the spironolactone.
  4. Withhold both drugs until talking with the health care provider.

 

ANS: B

Spironolactone is a potassium-sparing diuretic and will help to increase the patient’s potassium level. The nurse does not need to talk with the doctor before giving the spironolactone, although the health care provider should be notified about the low potassium value. The furosemide will further decrease the patient’s potassium level and should be held until the nurse talks with the health care provider.

 

DIF:    Cognitive Level: Application             REF:    1077-1078 | 1080

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. To evaluate the effectiveness of treatment for a patient who has hepatic encephalopathy, which action should the nurse take?
    1. Request that the patient stand on one foot.
    2. Ask the patient to extend both arms to the front.
    3. Instruct the patient to perform the Valsalva maneuver.
    4. Have the patient walk a few steps with the eyes closed.

 

ANS: B

Extending the arms allows the nurse to check for asterixis, a classic sign of hepatic encephalopathy. The other tests also might be done as part of the neurologic assessment but would not be diagnostic for hepatic encephalopathy.

 

DIF:    Cognitive Level: Application             REF:    1076-1077

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. A patient who has advanced cirrhosis is receiving lactulose (Cephulac). Which finding by the nurse indicates that the medication is effective?
    1. The patient is alert and oriented.
    2. The patient denies nausea or anorexia.
    3. The patient’s bilirubin level decreases.
    4. The patient has at least one stool daily.

 

ANS: A

 

 

 

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Test Bank 44-5

 

 

The purpose for lactulose in the patient with cirrhosis is to lower ammonia levels and prevent encephalopathy. Although lactulose may be used to treat constipation, that is not the purpose for this patient. Lactulose will not decrease nausea and vomiting or lower bilirubin levels.

 

DIF:    Cognitive Level: Application             REF:   1078-1079      TOP:  Nursing Process:

Evaluation

MSC: NCLEX: Physiological Integrity

 

  1. Which nursing action will be included in the plan of care for a patient who is being treated for bleeding esophageal varices with balloon tamponade?
    1. Monitor the patient for shortness of breath.
    2. Encourage the patient to cough every 4 hours.
    3. Deflate the gastric balloon every 8 to 12 hours.
    4. Verify the position of the balloon every 6 hours.

 

ANS: A

The most common complication of balloon tamponade is aspiration pneumonia. In addition, if the gastric balloon ruptures, the esophageal balloon may slip upward and occlude the airway. Coughing increases the pressure on the varices and increases the risk for bleeding. Balloon position is verified after insertion and does not require further verification. The esophageal balloon is deflated every 8 to 12 hours to avoid necrosis, but if the gastric balloon is deflated, the esophageal balloon may occlude the airway.

 

DIF:    Cognitive Level: Application             REF:    1082-1083 | 1084

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. A patient with severe cirrhosis has an episode of bleeding esophageal varices. To detect possible complications of the bleeding episode, it is most important for the nurse to monitor

 

  1. bilirubin levels.
  2. ammonia levels.
  3. potassium levels.
  4. prothrombin time.

 

ANS: B

The blood in the gastrointestinal (GI) tract will be absorbed as protein and may result in an increase in ammonia level because the liver cannot metabolize protein well. The prothrombin time, bilirubin, and potassium levels also should be monitored, but these will not be affected by the bleeding episode.

 

DIF:    Cognitive Level: Application             REF:    1076-1077

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. Which nursing action will be included in the plan of care for a patient with cirrhosis who has ascites and 4+ edema of the feet and legs?
    1. Restrict dietary protein intake.
    2. Reposition the patient every 4 hours.
    3. Use a pressure-relieving mattress.

 

 

 

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Test Bank 44-6

 

 

  1. Perform passive range of motion qid.

 

ANS: C

The pressure-relieving mattress will decrease the risk for skin breakdown for this patient. Adequate dietary protein intake is necessary in patients with ascites to improve oncotic pressure. Repositioning the patient every 4 hours will not be adequate to maintain skin integrity. Passive range of motion will not take pressure off areas like the sacrum that are vulnerable to breakdown.

 

DIF:    Cognitive Level: Application             REF:    1082-1083

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. After a patient has had a transjugular intrahepatic portosystemic shunt (TIPS) placement, which finding indicates that the procedure has been effective?
    1. Lower indirect bilirubin level
    2. Increase in serum albumin level
    3. Decrease in episodes of variceal bleeding
    4. Improvement in alertness and orientation

 

ANS: C

TIPS is used to lower pressure in the portal venous system and decrease the risk of bleeding from esophageal varices. Indirect bilirubin level and serum albumin levels are not affected by shunting procedures. TIPS will increase the risk for hepatic encephalopathy.

 

DIF:    Cognitive Level: Application             REF:   1078-1080      TOP:  Nursing Process:

Evaluation

 

MSC: NCLEX: Physiological Integrity

 

  1. The health care provider plans a paracentesis for a patient with ascites caused by liver cancer. To prepare the patient for the procedure, the nurse
    1. places the patient on NPO status.
    2. assists the patient to lie flat in bed.
    3. asks the patient to empty the bladder.
    4. positions the patient on the right side.

 

ANS: C

The patient should empty the bladder to decrease the risk of bladder perforation during the procedure. The patient would be positioned in Fowler’s position and would not be able to lie flat without compromising breathing. Since no sedation is required for paracentesis, the patient does not need to be NPO.

 

DIF:    Cognitive Level: Application             REF:    1081 | 1083-1084

 

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. When assessing a patient who had a liver transplant a week previously, the nurse obtains the following data. Which finding is most important to communicate to the health care provider?

 

  1. Dry lips and oral mucosa

 

 

 

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Test Bank 44-7

 

 

  1. Crackles at both lung bases

 

  1. Temperature 100.8° F (38.2° C)
  2. No bowel movement for 4 days

 

ANS: C

Infection risk is high in the first few months after liver transplant and fever is frequently the only sign of infection. The other patient data indicate the need for further assessment or nursing actions, but do not indicate a need for urgent action.

 

DIF:    Cognitive Level: Application             REF:   1088

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. Which of these laboratory test results will be most important for the nurse to monitor when evaluating the effects of therapy for a patient who has acute pancreatitis?

 

  1. Calcium
  2. Bilirubin
  3. Amylase
  4. Potassium

 

ANS: C

Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be as useful in evaluating whether the prescribed therapies have been effective.

 

DIF:    Cognitive Level: Application             REF:   1090                   TOP:  Nursing Process:

Evaluation

 

MSC: NCLEX: Physiological Integrity

 

  1. Which assessment finding in a patient with acute pancreatitis would the nurse need to report most quickly to the health care provider?
    1. Nausea and vomiting
    2. Hypotonic bowel sounds
    3. Abdominal tenderness and guarding
    4. Muscle twitching and finger numbness

 

ANS: D

Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Although the other findings also should be reported to the health care provider, they do not indicate complications that require rapid action.

 

DIF:    Cognitive Level: Application             REF:    1091-1092

 

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. When obtaining a health history from a patient with acute pancreatitis, the nurse asks the patient specifically about a history of
    1. alcohol use.
    2. diabetes mellitus.
    3. high-protein diet.

 

 

 

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Test Bank 44-8

 

 

  1. cigarette smoking.

 

ANS: A

Alcohol use is one of the most common risk factors for pancreatitis in the United States.

Cigarette smoking, diabetes, and high-protein diets are not risk factors.

 

DIF:    Cognitive Level: Comprehension    REF:    1088-1089

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. When educating a patient with chronic pancreatitis about the prescribed pancrelipase (Viokase), the nurse will teach the patient to take the medication
    1. at bedtime.
    2. with every meal.
    3. upon arising in the morning.
    4. as soon as abdominal pain occurs.

 

ANS: B

Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.

 

DIF:    Cognitive Level: Application             REF:    1093-1094

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. After providing discharge instructions to a patient following a laparoscopic cholecystectomy, the nurse recognizes that teaching has been effective when the patient states,

 

  1. “I can remove the bandages on my incisions tomorrow and take a shower.”
  2. “I can expect some yellow-green drainage from the incision for a few days.”
  3. “I should plan to limit my activities and not return to work for 4 to 6 weeks.”
  4. “I will always need to maintain a low-fat diet since I no longer have a gallbladder.”

 

ANS: A

After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a life-long requirement.

 

DIF:    Cognitive Level: Application             REF:   1100                   TOP:  Nursing Process:

Evaluation

 

MSC: NCLEX: Physiological Integrity

 

  1. Which data obtained by the nurse during the assessment of a patient with cirrhosis will be of most concern?
    1. The patient’s hands flap back and forth when the arms are extended.
    2. The patient has ascites and a 2-kg weight gain from the previous day.

 

  1. The patient’s skin has multiple spider-shaped blood vessels on the abdomen.
  2. The patient complains of right upper-quadrant pain with abdominal palpation.

 

ANS: A

 

 

 

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Test Bank 44-9

 

 

The asterixis indicates that the patient has hepatic encephalopathy, and hepatic coma may occur. The spider angiomas and right upper quadrant abdominal pain are not unusual for the patient with cirrhosis and do not require a change in treatment. The ascites and weight gain do indicate the need for treatment but not as urgently as the changes in neurologic status.

 

DIF:    Cognitive Level: Application             REF:    1072-1074 | 1075-1077

 

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. A patient with cirrhosis and esophageal varices has a new prescription for propranolol (Inderal). Which assessment finding is the best indicator that the medication has been effective?

 

  1. The apical pulse rate is 68 beats/minute.
  2. Stools test negative for occult blood.
  3. The patient denies complaints of chest pain.
  4. Blood pressure is less than 140/90 mm Hg.

 

ANS: B

 

Since the purpose of b-blocker therapy for patients with esophageal varices is to decrease the risk for bleeding from esophageal varices, the best indicator of the effectiveness for propranolol is the lack of blood in the stools. Although propranolol is used to treat hypertension, angina, and tachycardia, the purpose for use in this patient is to decrease the risk for bleeding from esophageal varices.

 

DIF:    Cognitive Level: Application             REF:   1077-1078      TOP:  Nursing Process:

Evaluation

 

MSC: NCLEX: Physiological Integrity

 

  1. A patient who was admitted with acute bleeding from esophageal varices asks the nurse the purpose for the ordered ranitidine (Zantac). Which response by the nurse is most appropriate?

 

  1. The medication will reduce the risk for aspiration.
  2. The medication will decrease nausea and anorexia.
  3. The medication will inhibit the development of gastric ulcers.
  4. The medication will prevent irritation to the esophageal varices.

 

ANS: D

The therapeutic action of H2 receptor blockers in patients with esophageal varices is to prevent irritation and bleeding from the varices caused by reflux of acid gastric contents. Although ranitidine does decrease the risk for peptic ulcers, reduce nausea, and help prevent aspiration pneumonia, these are not the primary purpose for H2 receptor blockade in this patient.

 

DIF:    Cognitive Level: Application             REF:   1080

 

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. When taking the BP of a patient with severe acute pancreatitis, the nurse notices carpal spasm of the patient’s hand. Which action should the nurse take next?

 

 

 

 

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Test Bank 44-10

 

 

  1. Ask the patient about any arm pain.

 

  1. Retake the patient’s blood pressure.
  2. Check the calcium level on the chart.
  3. Notify the health care provider immediately.

 

ANS: C

The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau’s sign. The health care provider should be notified after the nurse checks the patient’s calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain.

 

DIF:    Cognitive Level: Application             REF:    1091-1092

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. A patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective?

 

  1. Bowel sounds are present.
  2. Grey Turner sign resolves.
  3. Electrolyte levels are normal.
  4. Abdominal pain is decreased.

 

ANS: D

NG suction and NPO status will decrease the release of pancreatic enzymes into the pancreas and decrease pain. Although bowel sounds may be hypotonic with acute pancreatitis, the presence of bowel sounds does not indicate that treatment with NG suction and NPO status have been effective. Electrolyte levels will be abnormal with NG suction and must be replaced by appropriate IV infusion. Although Grey Turner sign will eventually resolve, it would not be appropriate to wait for this occur to determine whether treatment was effective.

 

DIF:    Cognitive Level: Application             REF:   1091                   TOP:  Nursing Process:

Evaluation

 

MSC: NCLEX: Physiological Integrity

 

  1. When the nurse is caring for a patient with acute pancreatitis, which assessment finding is of most concern?
    1. Absent bowel sounds
    2. Abdominal tenderness
    3. Left upper quadrant pain
    4. Palpable abdominal mass

 

ANS: D

A palpable abdominal mass may indicate the presence of a pancreatic abscess, which will require rapid surgical drainage to prevent sepsis. Absent bowel sounds, abdominal tenderness, and left upper quadrant pain are common in acute pancreatitis and do not require rapid action to prevent further complications.

 

DIF:    Cognitive Level: Application             REF:    1089-1090

 

 

 

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Test Bank                                                                                                                                                              44-11

 

 

TOP:  Nursing Process: Assessment             MSC: NCLEX: Physiological Integrity

 

  1. Which nursing action will be included in the plan of care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?

 

  1. Teach symptoms of variceal bleeding.
  2. Discuss the need to increase caloric intake.
  3. Review the patient’s current medication list.
  4. Draw blood for hepatitis serology testing.

 

ANS: C

Some medications can increase the risk for NAFLD and these should be eliminated. NAFLD is not associated with hepatitis, weight loss is usually indicated, and variceal bleeding would not be a concern in a patient with asymptomatic NAFLD.

 

DIF:    Cognitive Level: Application             REF:   1071-1072      TOP:  Nursing Process:

Planning

MSC: NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient with chronic hepatitis C infection who has these medications prescribed. Which medication requires further discussion with the health care provider prior to administration?

 

  1. ribavirin (Rebetol, Copegus) 600 mg PO bid
  2. pegylated α-interferon (PEG-Intron, Pegasys) SQ daily
  3. diphenhydramine (Benadryl) 25 mg PO every 4 hours PRN itching
  4. dimenhydrinate (Dramamine) 50 mg PO every 6 hours PRN nausea

 

ANS: B

Pegylated α-interferon is administered weekly. The other medications are appropriate for a patient with chronic hepatitis C infection.

 

DIF:    Cognitive Level: Application             REF:    1064-1066

TOP:  Nursing Process: Implementation     MSC: NCLEX: Physiological Integrity

 

  1. During change-of-shift report, the nurse learns about the following four patients. Which patient requires the most rapid assessment?
    1. 50-year-old with chronic pancreatitis who has gnawing abdominal pain
    2. 48-year-old who has compensated cirrhosis and is complaining of anorexia
    3. 45-year-old with cirrhosis and severe ascites who has an oral temperature of 102° F (38.8° C)
    4. 56-year-old who is recovering from a laparoscopic cholecystectomy and has severe shoulder pain

 

ANS: C

This patient’s history and fever suggest spontaneous bacterial peritonitis, which would require rapid assessment and interventions such as antibiotic therapy. The clinical manifestations for the other patients are consistent with their diagnoses and do not indicate complications are occurring.

 

DIF:    Cognitive Level: Analysis                   REF:    1075-1076

 

 

 

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Test Bank                                                                                                                                                              44-12

 

 

OBJ:    Special Questions: Multiple Patients

TOP:  Nursing Process: Assessment             MSC: NCLEX: Safe and Effective Care

 

Environment

 

  1. A homeless patient with severe anorexia and fatigue is admitted to the hospital with viral hepatitis. Which patient goal has the highest priority when the nurse is developing the plan of care?

 

  1. Increase activity level.
  2. Maintain adequate nutrition.
  3. Establish a stable home environment.
  4. Identify the source of exposure to hepatitis.

 

ANS: B

The highest priority outcome is to maintain nutrition because adequate nutrition is needed for hepatocyte regeneration. Finding a home for the patient and identifying the source of the infection would be appropriate activities, but they do not have as high a priority as ensuring adequate nutrition. Although the patient’s activity level will be gradually increased, rest is indicated during the acute phase of hepatitis.

 

DIF: Cognitive Level: Application REF: 1066
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity

 

  1. A patient with cirrhosis who has been vomiting blood is admitted to the emergency department. Which action should the nurse take first?
    1. Insert a large-gauge IV catheter.
    2. Draw blood for coagulation studies.
    3. Check BP, heart rate, and respirations.
    4. Place the patient in the supine position.

 

ANS: C

The nurse’s first action should be to determine the patient’s hemodynamic status by assessing vital signs. Drawing blood for coagulation studies and inserting an IV catheter also are appropriate. However, the vital signs may indicate the need for more urgent actions. Since aspiration is a concern for this patient, the nurse will need to assess the patient’s vital signs and neurologic status before placing the patient in the supine position.

 

DIF: Cognitive Level: Application REF: 1084
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity

 

  1. In planning care for a patient with acute severe pancreatitis, the nurse assigns the highest priority to the patient outcome of
    1. expressing satisfaction with pain control.
    2. developing no ongoing pancreatic problems.
    3. maintenance of normal respiratory function.
    4. having adequate fluid and electrolyte balance.

 

 

 

 

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Test Bank 44-13

 

 

ANS: C

Respiratory failure can occur as a complication of acute pancreatitis, and maintenance of adequate respiratory function is the priority goal. The other outcomes also would be appropriate for the patient.

 

DIF: Cognitive Level: Application REF: 1091-1092
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity

 

  1. Which nursing action is a priority when the nurse is caring for a patient with pancreatic cancer?
    1. Offer high-calorie, high-protein dietary choices.
    2. Offer psychologic support for anxiety or depression.
    3. Educate about the need to avoid scratching pruritic areas.
    4. Administer prescribed opioids to relieve pain as needed.

 

ANS: D

Effective pain management will be necessary in order for the patient to improve nutrition, be receptive to education, or manage anxiety or depression.

 

DIF: Cognitive Level: Application REF: 1094-1096
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity

 

  1. A patient is admitted to the hospital with acute cholecystitis. Which assessment information will be most important for the nurse to report to the health care provider?

 

  1. The patient’s urine is bright yellow.
  2. The patient’s stools are clay colored.
  3. The patient complains of chronic heartburn.
  4. The patient has an increase in pain after eating.

 

ANS: B

The clay-colored stools indicate biliary obstruction, which requires rapid intervention to resolve. The other data are not unusual for a patient with this diagnosis, although the nurse also would report the other assessment information to the health care provider.

 

DIF: Cognitive Level: Application REF: 1096 | 1099
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity

 

  1. When caring for a patient following an incisional cholecystectomy for cholelithiasis, the nurse places the highest priority on assisting the patient to
    1. choose low-fat foods from the menu.
    2. perform leg exercises hourly while awake.
    3. ambulate the evening of the operative day.
    4. turn, cough, and deep breathe every 2 hours.

 

ANS: D

 

 

 

 

 

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Test Bank 44-14

 

 

Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions also are important to implement but are not as high a priority as ensuring adequate ventilation.

 

DIF: Cognitive Level: Application REF: 1099-1100
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity

 

  1. Which of the following nursing actions included in the plan of care for a patient with cirrhosis can the RN delegate to nursing assistive personnel?
    1. Assessing the patient for jaundice
    2. Providing oral hygiene before meals
    3. Palpating the abdomen for distention
    4. Assisting the patient in choosing the diet

 

ANS: B

Providing oral hygiene is included in the education and scope of practice of nursing assistants. Assessments and assisting patients to choose therapeutic diets are nursing actions that require higher-level nursing education and scope of practice and would be delegated to LPNs/LVNs or RNs.

 

DIF: Cognitive Level: Application REF: 1080-1085
OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment

 

MULTIPLE RESPONSE

 

  1. After an unimmunized individual is exposed to hepatitis B through a needle-stick injury, which actions will the nurse plan to take (select all that apply)?
    1. Administer hepatitis B vaccine.
    2. Test for antibodies to hepatitis B.
    3. Teach about α-interferon therapy.
    4. Give hepatitis B immune globulin.
    5. Educate about oral antiviral therapy.

 

ANS: A, B, D

The recommendations for hepatitis B exposure include both vaccination and immune globulin administration. In addition, baseline testing for hepatitis B antibodies will be needed. Interferon and oral antivirals are not used for hepatitis B prophylaxis.

 

DIF:    Cognitive Level: Application             REF:   1069

OBJ:   Special Questions: Alternate Item Format                               TOP:  Nursing Process:

Planning

MSC: NCLEX: Safe and Effective Care Environment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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