Medical Surgical Nursing Concepts & Practice, 2nd Edition by Susan C. – Test Bank
To Purchase
this Complete Test Bank with Answers Click the link Below
If face any problem or
Further information contact us At tbzuiqe@gmail.com
Sample Test
Chapter 03: Fluid, Electrolytes, Acid-Base Balance, and
Intravenous Therapy
MULTIPLE CHOICE
1. The
nurse uses a diagram to demonstrate how in dehydration the water is drawn into
the plasma from the cells by the process of:
|
a. |
distillation. |
|
b. |
diffusion. |
|
c. |
filtration. |
|
d. |
osmosis. |
ANS: D
The process of osmosis accomplishes the movement of water from
the cells into the plasma, causing dehydration.
DIF: Cognitive Level:
Comprehension REF:
32-33
OBJ: 3 (theory)
TOP: Dehydration KEY: Nursing
Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
2. The
nurse assessing a patient with vomiting and diarrhea observes that the urine is
scant and concentrated. The nurse explains that the compensatory reabsorption
of water is controlled by:
|
a. |
osmoreceptors in the
hypothalamus. |
|
b. |
antidiuretic hormone in the
posterior pituitary. |
|
c. |
baroreceptors in the
carotid sinus. |
|
d. |
insulin from the pancreas. |
ANS: B
The antidiuretic hormone controls how much water leaves the body
by reabsorbing water in the renal tubules.
DIF: Cognitive Level: Knowledge
REF:
31-32
OBJ: 2 (theory)
TOP: Regulation of Body
Fluids
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
3. The
nurse uses a picture to show how ions equalize their concentration by the
passive transport process of:
|
a. |
osmosis. |
|
b. |
filtration. |
|
c. |
titration. |
|
d. |
diffusion. |
ANS: D
Diffusion is the process by which substances move back and forth
across compartment membranes until they are equally divided.
DIF: Cognitive Level:
Comprehension REF:
32
OBJ: 3 (theory)
TOP: Diffusion
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
4. The
nurse explains that the active transport process that is able to move sodium
and potassium into or out of cells is:
|
a. |
filtration. |
|
b. |
sodium pump. |
|
c. |
diffusion. |
|
d. |
osmosis. |
ANS: B
The sodium pump is the mechanism by which sodium and potassium
are moved into or out of cells regardless of the concentration.
DIF: Cognitive Level:
Comprehension REF:
33
OBJ: 3 (theory)
TOP: Active
Transport
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
5. The
patient taking furosemide (Lasix) to correct excess edema shows a weight loss
of 5.5 pounds in 24 hours. The nurse calculates this weight loss to be the
excretion of approximately _____ liters of fluid.
|
a. |
1.0 |
|
b. |
1.5 |
|
c. |
2.0 |
|
d. |
2.5 |
ANS: D
Each kilogram (2.2 pounds) of weight loss is equivalent to 1
liter of fluid. Therefore, 5.5 pounds ÷ 2.2 pounds = 2.5 liters.
DIF: Cognitive Level:
Application
REF: 35
OBJ: 1 (clinical)
TOP: Fluid Loss
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
6. When
the nurse assesses a potassium level of 2.9 mEq/L in the patient with vomiting
and diarrhea, the nurse will be alert for:
|
a. |
excessive urinary output. |
|
b. |
abdominal distention. |
|
c. |
increased reflexes. |
|
d. |
hyperactive bowel sounds. |
ANS: B
A potassium level lower than 3.5 mEq/L results in reduced urine
output, cardiac dysrhythmia, muscle weakness, abdominal pain and distention,
paralytic ileus, lethargy, and confusion.
DIF: Cognitive Level:
Application
REF: 42 | Table 3-4
OBJ: 4 (theory)
TOP: Hypokalemia
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
7. While
the nurse is washing the face of a patient in renal failure, the patient
demonstrates a spasm of the lips and face. The nurse examines the recent
electrolyte levels to assess the level of:
|
a. |
potassium. |
|
b. |
calcium. |
|
c. |
sodium. |
|
d. |
magnesium. |
ANS: B
Chvostek’s sign is a signal of hypocalcemia. It occurs when the
facial nerve is tapped or stroked about an inch in front of the earlobe and
results in unilateral twitching of the face.
DIF: Cognitive Level:
Analysis
REF:
44
OBJ: 4 (theory)
TOP: Chvostek’s
Sign
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention
and Early Detection of Disease
8. Prior
to hanging an IV containing potassium, the nurse will confirm that there is a:
|
a. |
blood pressure of at least
60 mm Hg diastolic. |
|
b. |
urine output of at least 30
mL/hr. |
|
c. |
filter on the IV line. |
|
d. |
pulse of at least 50
beats/min. |
ANS: B
An adequate urine output must be present prior to the
administration of potassium to ensure adequate excretion of potassium,
preventing hyperkalemia.
DIF: Cognitive Level: Application
REF: 44 | Safety Alert
OBJ: 10 (theory)
TOP: Administration of IV Potassium
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk
Potential
9. The
nurse determines there is no need for further instruction related to a
low-sodium diet when the patient says:
|
a. |
“I can have all the dried
fruits I want.” |
|
b. |
“I’m looking forward to a
tall glass of tomato juice.” |
|
c. |
“I’m going to eat my
favorite avocado and orange salad.” |
|
d. |
“I’m going to eat a
cheeseburger with extra catsup.” |
ANS: C
Avocado and oranges have no significant sodium content. Dried
fruits, tomato juice, cheese, and catsup are high in sodium.
DIF: Cognitive Level:
Application
REF: 41 | Nutrition Considerations
OBJ: 4 (clinical)
TOP: Low-Sodium Diet
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
10. Because
the 80-year-old patient is prone to dehydration related to the age-related
change of decreased thirst and kidney function, the nurse monitors for the
earliest sign of dehydration, which is:
|
a. |
reduced skin turgor. |
|
b. |
constipation. |
|
c. |
increased temperature. |
|
d. |
thirst. |
ANS: B
Constipation is the best early indicator of dehydration in the
older adult. Older adults have age-related poor skin turgor. Increased
temperature and thirst are later signs of dehydration.
DIF: Cognitive Level:
Analysis
REF:
35
OBJ: 5 (theory)
TOP: Dehydration in the Older
Adult KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention
and Early Detection of Disease
11. The
patient with long-term obstructive pulmonary disease has a pH of 7, HCO3– of
18 mEq/L, and a PaCO2 of 40 mm Hg. From this laboratory information, the nurse
assesses the patient is in:
|
a. |
respiratory alkalosis. |
|
b. |
metabolic alkalosis. |
|
c. |
respiratory acidosis. |
|
d. |
metabolic acidosis. |
ANS: D
These results are indicative of metabolic acidosis.
DIF: Cognitive Level:
Analysis
REF: 47-48 | Table 3-5
OBJ: 3 (clinical)
TOP: Respiratory Acidosis
KEY: Nursing Process Step: Assessment MSC:
NCLEX: Health Promotion and Maintenance
12. To
help prevent respiratory acidosis in a young person with asthma, the nurse
would encourage:
|
a. |
deep-breathing exercises
every 2 hours. |
|
b. |
drinking 8 ounces of fluid
every 4 hours. |
|
c. |
ambulating for 15 minutes
twice a day. |
|
d. |
sleeping with the head of
the bed elevated 45 degrees. |
ANS: A
Deep breathing blows off CO2,
which reduces the acid ions, thus preventing respiratory acidosis. Drinking
fluids prevents dehydration and keeps secretions moist and thin, and sleeping
with the head of the bed elevated will ease breathing and improve gas exchange.
Ambulating 15 minutes twice a day does not have an impact on respiratory
acidosis.
DIF: Cognitive Level:
Analysis
REF: 47-48 | Table 3-5
OBJ: 8 (theory)
TOP: Respiratory Acidosis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention
and Early Detection of Disease
13. The
patient who has had diarrhea for the last 3 days has blood gases of pH of 7.1,
HCO3– of 20 mEq/L, and
PCO2 of 36 mm Hg. The nurse recognizes these values indicate:
|
a. |
respiratory alkalosis. |
|
b. |
metabolic alkalosis. |
|
c. |
respiratory acidosis. |
|
d. |
metabolic acidosis. |
ANS: D
Metabolic acidosis shows a low pH, low HCO3–, and
normal CO2.
DIF: Cognitive Level: Application
REF: 47-48 | Table 3-5
OBJ: 8 (theory)
TOP: Metabolic Acidosis
KEY: Nursing Process Step: Assessment MSC:
NCLEX: Health Promotion and Maintenance
14. The
nurse can record that the compensatory mechanism for the correction of
metabolic acidosis is in effect when the nurse observes:
|
a. |
increased urinary output. |
|
b. |
reduced abdominal
distention. |
|
c. |
Kussmaul’s respirations. |
|
d. |
decreased blood pressure. |
ANS: C
Kussmaul’s respirations, or deep and rapid respirations, are
blowing off carbon dioxide to reduce an acidotic state.
DIF: Cognitive Level:
Application
REF:
48
OBJ: 3 (clinical)
TOP: Metabolic
Acidosis
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
15. The
nurse assessing the IV insertion site finds the vein hard, the skin red and
tender, and a blood return in the IV line. The most effective intervention
after removing the IV catheter is to:
|
a. |
notify the charge nurse. |
|
b. |
elevate the arm above the
level of the heart. |
|
c. |
clean the site with alcohol
and apply cool compresses. |
|
d. |
apply a warm moist pack. |
ANS: D
These are signs and symptoms of phlebitis and should be treated
with a warm moist pack to increase blood flow to the area. Notifying the charge
nurse is not the most effective intervention and may not be necessary according
to facility policy, elevation of the arm would be helpful for swelling, and a
cool compress would be indicated for other issues related to IV infusion
problems such as extravasation.
DIF: Cognitive Level:
Application
REF: 54 | Table 3-7
OBJ: 6 (clinical)
TOP: Phlebitis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
16. Because
there are no IV pumps available for the immediate infusion of an IV medication,
the nurse must calculate the flow rate for 500 mL to run for 4 hours, using a
set that delivers 15 gtt/mL. The flow rate should be _____ gtt/min.
|
a. |
30 |
|
b. |
35 |
|
c. |
40 |
|
d. |
45 |
ANS: A
500 mL to be give in 4 hours equals 125 mL/hr. 125 mL ¸ 60
minutes = 2 mL/min ´ 15 gtt/mL = 30 gtt/min.
DIF: Cognitive Level:
Application
REF: 53-55
OBJ: 10 (clinical)
TOP: Calculation of IV Flow
Rate KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
17. The
count of the solution in the IV container at the beginning of the shift is 800
mL. A new 1000-mL bag was hung during the shift and has 650 mL left at the end
of the shift. The nurse reports the IV fluid intake for the shift as _____ mL.
|
a. |
1000 |
|
b. |
1050 |
|
c. |
1100 |
|
d. |
1150 |
ANS: D
800 mL + 350 mL from second bag = 1150 mL.
DIF: Cognitive Level:
Comprehension REF:
55
OBJ: 9 (theory)
TOP: Calculating IV Fluid
Intake
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
18. The
nurse flushing a PRN lock will select the appropriate fluid and will clear the
lumen by:
|
a. |
flushing forcefully to
clear. |
|
b. |
using slow, gentle
pressure. |
|
c. |
flushing hard enough to
clear resistance. |
|
d. |
aspirating prior to flushing. |
ANS: B
The use of slow, gentle pressure and stopping the flush if
resistance is met is the standard of care. Resistance may indicate a clot and
force would break the clot loose. Aspiration is not necessary.
DIF: Cognitive Level: Application
REF:
55-56
OBJ: 6 (clinical)
TOP: Flushing PRN
Lock
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
19. The
nurse is caring for a patient who has been on total parenteral nutrition (TPN)
for 48 hours. The nurse demonstrates the most effective nursing care by:
|
a. |
checking the patient’s
blood glucose level according to facility protocol. |
|
b. |
speeding up the solution if
the prescribed intake falls behind. |
|
c. |
informing the patient that
TPN can only be administered via a central line for 1 week. |
|
d. |
monitoring the peripheral
IV site of TPN infusion for signs of infiltration at least every 8 hours. |
ANS: A
The hypertonic solution causes difficulty with glucose
tolerance, so monitoring of blood glucose level is imperative. The infusion
rate should never be increased to “catch up” because of the likelihood of fluid
overload caused by the hypertonicity of the TPN. TPN can be administered for
more than 1 week, and TPN is almost always administered via a central line
rather than a peripheral line.
DIF: Cognitive Level:
Application
REF:
57
OBJ: 7 (clinical)
TOP: Total Parenteral
Nutrition
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
20. The
nurse is assessing a patient with renal failure and notes fatigue, muscle
cramps, confusion, and headache. The nurse will monitor the patient’s _____
level.
|
a. |
potassium |
|
b. |
sodium |
|
c. |
calcium |
|
d. |
chloride |
ANS: B
The patient is demonstrating signs and symptoms of hyponatremia;
therefore, the nurse should assess the patient’s sodium level.
DIF: Cognitive Level:
Application
REF: 42 | Table 3-4
OBJ: 7 (clinical)
TOP: Hyponatremia
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Management
of Care
MULTIPLE RESPONSE
21. The
nurse is assessing the hydration status of the patient. The nurse demonstrates
knowledge of proper assessment techniques by: (Select all that apply.)
|
a. |
monitoring the patient’s
daily weight. |
|
b. |
assessing the patient’s
skin turgor on the back of the hand. |
|
c. |
checking the patient’s
blood glucose level 4 times a day. |
|
d. |
assessing for skin tenting
on the patient’s forehead. |
|
e. |
asking the patient if he is
experiencing thirst. |
ANS: A, D, E
The skin of the abdomen, forearm, sternum, forehead, and thigh
can be “tented” as a test for skin turgor by gently pinching up a fold of skin
and observing the delay in return to normal. Assessment of skin turgor is not
reliable on the back of the hand. Weight and experiencing thirst can be
indicators of hydration status, along with further assessment. The patient’s blood
glucose level is not an assessment parameter for hydration status.
DIF: Cognitive Level:
Application
REF: 34 | Box 3-2 OBJ: 1 (clinical)
TOP: Assessment Data: Skin
Turgor KEY: Nursing Process
Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
22. The
patient has a potassium level of 5.0. The nurse closely monitors the patient
for: (Select all that
apply.)
|
a. |
muscle weakness. |
|
b. |
cardiac dysrhythmias. |
|
c. |
decreased reflexes. |
|
d. |
urinary retention. |
|
e. |
hypotension. |
ANS: A, B, E
Normal potassium level is 3.5 to 5.0 mEq/L. Because the patient
is on the highest end of normal, the nurse should monitor for signs of
hyperkalemia. Muscle weakness, cardiac dysrhythmias, and hypotension are signs
of hyperkalemia. Decreased reflexes and urinary retention are signs of
hypokalemia.
DIF: Cognitive Level:
Application
REF: 42-44 | Table 3-4
OBJ: 3 (clinical)
TOP: Hyperkalemia
KEY: Nursing Process Step: Assessment MSC:
NCLEX: Health Promotion and Maintenance
23. The
primary care provider writes an order for the patient to receive an IV of a
solution that has the same osmotic pressure as intracellular fluid. The nurse
would correctly question which of the following IV orders? (Select all that apply.)
|
a. |
5% dextrose in water |
|
b. |
0.45% sodium chloride |
|
c. |
5% dextrose in 0.9% sodium
chloride |
|
d. |
Lactated Ringer’s solution |
|
e. |
0.9% sodium chloride |
ANS: B, C
The solution being prescribed is an isotonic solution. 5%
dextrose in water, Lactated Ringer’s solution, and 0.9% sodium chloride are all
isotonic solutions, whereas 0.45% sodium chloride is a hypotonic solution, and
5% dextrose in 0.9% sodium chloride is a hypertonic solution.
DIF: Cognitive Level:
Analysis
REF: 50 | 52 | Table 3-6
OBJ: 11 (theory)
TOP: Isotonic Solutions
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
24. The
nurse is caring for a newly admitted patient with uncontrolled nausea and
vomiting. The patient has a history of alcoholism and diabetes. Upon obtaining
orders from the primary care provider, the nurse would question which orders: (Select all that apply.)
|
a. |
Administer 10 mg prochlorperazine
maleate (Compazine), IM every 4 to 6 hours for nausea and vomiting. |
|
b. |
Administer diphenoxylate
atropine (Lomotil), 2 tabs, by mouth after first occurrence of nausea and
vomiting. |
|
c. |
Administer Lactated
Ringer’s solution, IV, at 100 mL/hr. |
|
d. |
Monitor the patient’s
intake and output every 4 hours. |
|
e. |
Obtain patient’s weight
every morning and record. |
ANS: A, B, C
The patient’s intake and output and weight are indicators of
hydration status and should be monitored. Prochlorperazine maleate (Compazine)
should not be given with alcohol intake. Because the patient has a history of
alcoholism, it would be best to administer an antiemetic that is not
contraindicated with possible alcohol intake. Diphenoxylate atropine (Lomotil)
is an antidiarrheal, not an antiemetic.
DIF: Cognitive Level:
Analysis
REF: 34 | Box 3-2, 37 | Table 3-2, 52 | Table 3-6
OBJ: 4 (clinical)
TOP: Hydration Status
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
COMPLETION
25. The
nurse demonstrates knowledge of IV solutions by identifying that the IV
solution which provides free water, as well as 340 calories/L, is
______________.
ANS:
10% dextrose in water
10% dextrose in water provides free water with no electrolytes
and 340 calories/L.
DIF: Cognitive Level:
Comprehension REF: 50 | 52 | Table 3-6
OBJ: 12 (theory)
TOP: IV Fluids KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
26. The
nurse explains to the 85-year-old patient with a temperature that, with each
degree of fever, the body loses _____% of water.
ANS:
10
With each degree of fever, the body has an insensible loss of
10% of its water.
DIF: Cognitive Level:
Comprehension REF:
34
OBJ: 5 (theory)
TOP: Insensible
Loss
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
27. The
nurse reminds the patient that the three body mechanisms that attempt to
compensate to correct acid-base imbalances are the __________ system, the
__________ system, and the __________.
ANS:
buffer; respiratory; kidneys
respiratory; buffer; kidneys
The buffer system, the respiratory system, and the kidneys
contribute unique compensations to correct an acid-base imbalance.
DIF: Cognitive Level:
Comprehension REF:
46
OBJ: 8 (theory)
TOP: Acid-Base Compensatory Mechanisms
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
MATCHING
The nurse explains that the chain of events that results in
hypocalcemia for the patient in early renal failure is: (Match the events to
the proper sequence.)
|
a. |
loss of calcium ions. |
|
b. |
vitamin D not activated. |
|
c. |
bone loss. |
|
d. |
retention of phosphates. |
|
e. |
loss of absorption of
calcium from the GI tract. |
28. Step
1
29. Step
2
30. Step
3
31. Step
4
32. Step
5
28. ANS:
D
DIF: Cognitive Level:
Analysis
REF: 44
OBJ: 4 (theory)
TOP: Hypocalcemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
29. ANS:
A
DIF: Cognitive Level:
Analysis
REF: 44
OBJ: 4 (theory)
TOP: Hypocalcemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
30. ANS:
B
DIF: Cognitive Level:
Analysis
REF: 44
OBJ: 4 (theory)
TOP: Hypocalcemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
31. ANS:
E
DIF: Cognitive Level:
Analysis
REF: 44
OBJ: 4 (theory)
TOP: Hypocalcemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
32. ANS:
C
DIF: Cognitive Level:
Analysis
REF: 44
OBJ: 4 (theory)
TOP: Hypocalcemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
Chapter 04: Care of Preoperative and Intraoperative Surgical
Patients
MULTIPLE CHOICE
1. The
nurse is caring for a patient who has received epoetin alfa (Epogen) 2 to 3
weeks prior to a scheduled surgery. The nurse understands that this patient
will likely:
|
a. |
require an antibiotic
immediately prior to surgery. |
|
b. |
have difficulty with blood
clotting following surgery. |
|
c. |
not require a blood
transfusion during surgery. |
|
d. |
develop an electrolyte
imbalance during surgery. |
ANS: C
Epoetin alfa (Epogen) is given to increase red blood cell
production prior to surgery with the goal of having a bloodless surgery.
Epoetin alfa (Epogen) will not affect the need for an antibiotic
preoperatively, nor will it cause difficulty with clotting or cause an
electrolyte imbalance.
DIF: Cognitive Level:
Application
REF:
64
OBJ: 1 (theory)
TOP: Bloodless
Surgery
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
2. The
nurse is performing a preoperative assessment on a patient scheduled for
surgery today. The patient reports a history of drinking 2 glasses of wine
daily, smoking cigarettes for 20 years, completing a round of corticosteroids
for asthma control 2 days ago, and taking the last dose of passion flower
extract yesterday. The nurse’s best action is:
|
a. |
supply the patient with
information on a smoking cessation class. |
|
b. |
warn the patient regarding
the dangers of drinking alcohol on a daily basis. |
|
c. |
provide the patient with
information regarding the use of herbal medications. |
|
d. |
notify the physician
immediately regarding the recent use of corticosteroids. |
ANS: D
The use of corticosteroids reduces the body’s response to
infection and delays healing. Surgery may need to be delayed until the patient
has been off the drug approximately 7 days. Providing the patient with
information regarding smoking cessation is advisable but is not a priority at
this time. Drinking 2 glasses of wine daily may not be a problem if not contraindicated
by the patient’s health status. Passion flower extract does not interfere with
the surgery and poses no apparent problems.
DIF: Cognitive Level:
Analysis
REF: 65-67 | Table 4-2
OBJ: 2 (theory)
TOP: Perioperative Management
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
Potential
3. The
presurgical patient asks why it is that her height and weight are recorded. The
nurse replies that the information is essential for:
|
a. |
calculating anesthesia
dose. |
|
b. |
predicting blood loss. |
|
c. |
assessing respiratory
volume. |
|
d. |
anticipating fluid needs. |
ANS: A
Height and weight are used to calculate anesthesia dosages.
DIF: Cognitive Level:
Comprehension REF: 64
OBJ: 3 (theory)
TOP: Presurgical
Assessment
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
Potential
4. The
nurse is reviewing the presurgical patient’s lab reports and notes an elevated
aspartate aminotransferase (AST) and bilirubin. The nurse is most concerned
that this patient is at risk for:
|
a. |
excessive bleeding during
or after surgery. |
|
b. |
an increased serum albumin
level. |
|
c. |
postsurgical respiratory infection. |
|
d. |
delayed wound healing. |
ANS: A
The AST and bilirubin are liver studies. Elevated levels may
indicate a dysfunctional liver. The liver is directly involved with clotting
factors; therefore, this patient would be at risk for excessive bleeding. The
serum albumin level would most likely be decreased if the liver is not
functioning properly. Postsurgical wound infection and delayed wound healing
risks are not directly related to liver function.
DIF: Cognitive Level: Analysis
REF: 66 | Box 4-2, 67 | Table 4-2
OBJ: 2 (theory)
TOP: Preoperative Lab Studies
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
Potential
5. The
patient received a preoperative dose of lorazepam (Ativan) 20 minutes ago. The
safety precaution the nurse should take in regard to this drug is to:
|
a. |
monitor respiratory status. |
|
b. |
raise bed rails. |
|
c. |
elevate the head of the bed
30 degrees. |
|
d. |
take seizure precautions. |
ANS: B
Raising the bed rails is a safety precaution against the
dizziness and hypotension caused by this drug.
DIF: Cognitive Level:
Application
REF: 72 | Safety Alert
OBJ: 4 (clinical)
TOP: Preoperative Medication
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
Potential
6. The
nurse is aware that the 82-year-old patient returning from surgery will need
special attention relative to:
|
a. |
combating thirst. |
|
b. |
maintaining respiratory
status. |
|
c. |
stabilizing blood pressure. |
|
d. |
maintaining core body
temperature. |
ANS: D
Thirst, respiratory status, and blood pressure are all important
considerations when caring for the postsurgical patient; however, maintaining
core body temperature is a major concern with the older adult postsurgical
patient.
DIF: Cognitive Level:
Application
REF:
66
OBJ: 2 (theory)
TOP: Assessment of Surgical Risk Factors
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
7. The
patient refuses to take off her diamond wedding band prior to going to the
operating room. The nurse should first:
|
a. |
record in the chart that
the patient refused to remove jewelry. |
|
b. |
tape the ring to finger,
covering the ring. |
|
c. |
request that the patient
sign a waiver to release the hospital from responsibility. |
|
d. |
alert the surgery team to
the presence of the jewelry. |
ANS: B
Taping the ring will protect the ring and secure it to the
finger. Care must be taken not to wrap the tape too tightly. The nurse will
also need to document the presence of the ring on the preoperative checklist or
in the nurse’s notes. There is no need for a signature on a waiver. Most
facilities have policies in which the patient signs a release of responsibility
for valuables. There is no need to notify the surgical team of the presence of
the ring.
DIF: Cognitive Level:
Comprehension REF: 72
OBJ: 3 (theory)
TOP: Immediate Preoperative
Care KEY: Nursing
Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated
Care
8. Noting
that the Asian patient was given atropine as a preoperative drug, the nurse
will closely monitor for:
|
a. |
oliguria. |
|
b. |
hyperventilation. |
|
c. |
hypotension. |
|
d. |
tachycardia. |
ANS: D
Asians often metabolize atropine differently from other
populations. The drug can greatly accelerate the heart rate in the Asian
patient.
DIF: Cognitive Level:
Application
REF: 72 | Cultural Considerations
OBJ: 2 (theory)
TOP: Immediate Preoperative Care
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological
Therapies
9. The
nurse recognizes a need for further instruction about the emotional preparation
for surgery when a patient says:
|
a. |
“I’m going to hug my
surgeon tomorrow.” |
|
b. |
“My fate is in the hands of
my surgeon. I’m frightened about the outcome.” |
|
c. |
“I’ll be ready for a
cheeseburger when I get back.” |
|
d. |
“I know I may have some
pain, but this gallbladder will be gone when I wake up.” |
ANS: B
This response demonstrates the patient’s fear and insecurity,
which warrant further discussion. Providing additional information or answering
patient questions may help alleviate the patient’s emotional unpreparedness for
surgery. The plan for a cheeseburger indicates a potential need to further
review nutrition in the postoperative period. The other responses demonstrate
positive statements regarding the upcoming postsurgical period.
DIF: Cognitive Level:
Analysis
REF:
67-72
OBJ: 3 (theory)
TOP:
Planning KEY: Nursing
Process Step: Evaluation
MSC: NCLEX: Psychosocial Integrity: Psychosocial
Adaptation
10. Prior
to administering the preoperative medication of Demerol and atropine, the nurse
should confirm that:
|
a. |
a family member is present. |
|
b. |
underwear is removed. |
|
c. |
a consent form is signed. |
|
d. |
bed rails are up. |
ANS: C
Consent forms must be signed prior to giving any sedative or
preoperative drug. Removal of underwear and the raising of the side rails can
be done after the administration of the drug. The family member does not have to
present.
DIF: Cognitive Level:
Comprehension REF:
68
OBJ: 4 (clinical)
TOP: Obtaining
Consent
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Coordinated
Care
11. The
nurse explains that the person responsible for verifying that the consent form
is signed and that the surgical site is marked is the:
|
a. |
scrub nurse. |
|
b. |
surgeon. |
|
c. |
anesthesiologist. |
|
d. |
circulating nurse. |
ANS: D
The circulating nurse is responsible for confirming a signature
on the consent form and marking the site for surgery.
DIF: Cognitive Level:
Comprehension REF: 76 | Box 4-4
OBJ: 6 (theory)
TOP: Circulating Nurse
Duties
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated
Care
Comments
Post a Comment