Medical-Surgical Nursing- Concepts & Practice, 3rd Edition by Susan C. deWit, Candice K. Kumagai Test Bank
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Sample Test
Chapter 03: Fluid, Electrolytes, Acid-Base Balance, and
Intravenous Therapy
deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd
Edition
MULTIPLE CHOICE
1. The
nurse uses a diagram to demonstrate how in dehydration the water is drawn into
the plasma from the cells by which process?
|
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.
PTS:
1
DIF: Cognitive Level:
Knowledge
REF: 32
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. Which controlling factor is responsible for
compensatory reabsorption of water?
|
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.
PTS:
1
DIF: Cognitive Level: Comprehension
REF: 30
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 which
passive transport process?
|
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.
PTS:
1
DIF: Cognitive Level:
Knowledge
REF: 31
OBJ: 2 (theory)
TOP: Diffusion KEY:
Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
4. Which
term describes the active transport process that moves sodium and potassium
into or out of cells?
|
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.
PTS:
1
DIF: Cognitive Level: Knowledge
REF: 32
OBJ: 2 (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 that this weight loss is
equivalent to how many liters (L) of fluid?
|
a. |
1 L |
|
b. |
1.5 L |
|
c. |
2.0 L |
|
d. |
2.5 L |
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.
PTS:
1
DIF: Cognitive Level:
Application REF:
33, Clinical Cues
OBJ: 1 (clinical)
TOP: Fluid Loss KEY: Nursing
Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
6. The
nurse is caring for a patient with a potassium level of 2.9 mEq/L. The nurse
should carefully monitor the patient for which potential problem?
|
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.
PTS:
1
DIF: Cognitive Level:
Application REF:
41, Table 3-4
OBJ: 15 (clinical)
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. Which laboratory value corresponds
with the nurse’s assessment findings?
|
a. |
Potassium of 3.4 mEq/L |
|
b. |
Calcium of 7.9 mg/dL |
|
c. |
Sodium of 140 mEq/L |
|
d. |
Phosphorus of 2.8 mg/dL |
ANS: B
Chvostek 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. Hypocalcemia occurs when the
calcium level drops below 8.4. A potassium level of 3.4 mEq/L and a sodium
level of 140 mEq/L are findings within normal limits. A patient in renal
failure is most likely to have a high phosphorus level rather than a low phosphorus
level, and 2.8 mg/dL is within the range consistent with hypophosphatemia.
PTS:
1
DIF: Cognitive Level:
Analysis
REF: 43, Table 3-4
OBJ: 4 (theory)
TOP: Chvostek Sign
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention
and Early Detection of Disease
8. Which
finding is most important for the nurse to confirm prior to hanging an
intravenous (IV) bag containing potassium?
|
a. |
Verify a blood pressure of
at least 60 mm Hg diastolic. |
|
b. |
Check for urine output of
at least 30 mL/hr. |
|
c. |
Ensure filter placement on
the IV line. |
|
d. |
Verify a 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.
PTS:
1
DIF: Cognitive Level:
Application REF:
43, Safety Alert
OBJ: 10 (theory)
TOP: Administration of IV Potassium
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk
Potential
9. Which
statement demonstrates that the patient accurately understands the nurse’s
teaching related to a low-sodium diet?
|
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 ketchup.” |
ANS: C
Avocado and oranges have no significant sodium content. Dried
fruits, tomato juice, cheese, and ketchup are foods with high sodium content
that should be limited or avoided.
PTS:
1
DIF: Cognitive Level:
Application REF:
43, Nutrition Considerations
OBJ: 4 (clinical)
TOP: Low-Sodium Diet
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
10. The
nurse is caring for an 80-year-old patient. Which finding is the best early
indicator of dehydration in this patient?
|
a. |
Reduced skin turgor |
|
b. |
Constipation |
|
c. |
Increased temperature |
|
d. |
Thirst |
ANS: B
The nurse understands that this patient’s age places him at
greater risk for dehydration.
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.
PTS:
1
DIF: Cognitive Level:
Analysis
REF: 33-34
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. These laboratory values are consistent with
which acid-base imbalance?
|
a. |
Respiratory alkalosis |
|
b. |
Metabolic alkalosis |
|
c. |
Respiratory acidosis |
|
d. |
Metabolic acidosis |
ANS: D
These results are indicative of metabolic acidosis.
PTS:
1
DIF: Cognitive Level:
Application REF:
46
OBJ: 15 (clinical)
TOP: Respiratory Acidosis
KEY: Nursing Process Step: Assessment MSC:
NCLEX: Health Promotion and Maintenance
12. The
nurse is caring for a young patient with asthma. Which activity should the
nurse encourage in order to help prevent respiratory acidosis?
|
a. |
Engage in deep-breathing
exercises every 2 hours. |
|
b. |
Drink 8 ounces of fluid
every 4 hours. |
|
c. |
Ambulate for 15 minutes
twice a day. |
|
d. |
Sleep 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.
PTS:
1
DIF: Cognitive Level: Analysis
REF: 46
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. These laboratory values are consistent with
which acid-base imbalance?
|
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.
PTS:
1
DIF: Cognitive Level:
Application REF:
46
OBJ: 8 (theory)
TOP: Metabolic Acidosis
KEY: Nursing Process Step: Assessment MSC:
NCLEX: Health Promotion and Maintenance
14. The
nurse is caring for a patient with metabolic acidosis. Which assessment finding
reveals that the compensatory mechanism to correct this imbalance is in effect?
|
a. |
Increased urinary output |
|
b. |
Reduced abdominal
distention |
|
c. |
Kussmaul respirations |
|
d. |
Decreased blood pressure |
ANS: C
Kussmaul respirations, or deep and rapid respirations, are
blowing off carbon dioxide to reduce an acidotic state.
PTS: 1
DIF: Cognitive Level:
Application
REF: 47
OBJ: 7 (theory)
TOP: Metabolic Acidosis
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
15. The
nurse assesses the patient’s IV insertion site and observes that the vein is
hard, the skin is red and tender, and a blood return in the IV line. After
removing the IV catheter, which action should the nurse take next?
|
a. |
Obtain an arm board to
properly secure the IV. |
|
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. The IV has been
discontinued, so an arm board for stabilization is unnecessary. Elevation of
the arm would be helpful to reduce swelling. A cool compress would be indicated
for other issues related to IV infusion problems, such as extravasation.
PTS:
1
DIF: Cognitive Level:
Application REF:
51
OBJ: 18 (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. Which flow rate is correct?
|
a. |
30 gtt/min |
|
b. |
35 gtt/min |
|
c. |
40 gtt/min |
|
d. |
45 gtt/min |
ANS: A
500 mL to be given in 4 hours equals 125 mL/hr. 125 mL ÷ 60
minutes = 2 mL/min ´ 15 gtt/mL = 30 gtt/min.
PTS:
1
DIF: Cognitive Level:
Application REF:
53
OBJ: 12 (theory)
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. What amount should the nurse record as the IV fluid intake for
the shift?
|
a. |
1000 mL |
|
b. |
1050 mL |
|
c. |
1100 mL |
|
d. |
1150 mL |
ANS: D
800 mL + 350 mL from second bag = 1150 mL.
PTS:
1
DIF: Cognitive Level:
Application REF:
53-54
OBJ: 12 (theory)
TOP: Calculating IV Fluid Intake
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
18. After
selecting an appropriate fluid, which action should the nurse take to correctly
flush a PRN lock?
|
a. |
Flush forcefully to clear
the lumen. |
|
b. |
Use slow, gentle pressure
to clear the lumen. |
|
c. |
Flush hard enough to clear
resistance. |
|
d. |
Aspirate for blood return
prior to flushing. |
ANS: B
The standard of care utilizes slow, gentle pressure. The nurse
should stop the flush if resistance is met. Resistance may indicate a clot and
force would break the clot loose. Aspiration is not necessary.
PTS:
1
DIF: Cognitive Level:
Application REF:
54
OBJ: 18 (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. Which action demonstrates effective nursing care?
|
a. |
Checking the patient’s
blood glucose level according to facility protocol. |
|
b. |
Increasing the infusion
rate 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 it is almost always administered via a central line rather
than a peripheral line.
PTS:
1
DIF: Cognitive Level:
Application REF:
55
OBJ: 19 (clinical)
TOP: TPN
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. Which laboratory abnormality corresponds with
these findings?
|
a. |
Potassium of 3.3 mEq/L |
|
b. |
Sodium of 129 mEq/L |
|
c. |
Calcium of 8.2 mg/dL |
|
d. |
Chloride of 105 mEq/L |
ANS: B
The patient is demonstrating signs and symptoms of hyponatremia;
therefore, the nurse should assess the patient’s sodium level.
PTS:
1
DIF: Cognitive Level:
Application REF:
40, Table 3-4
OBJ: 15 (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. Which action(s)
demonstrates knowledge of proper assessment? (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 four 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.
PTS:
1
DIF: Cognitive Level:
Application REF:
33
OBJ: 13 (clinical)
TOP: Assessment Data: Skin Turgor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and
Comfort
22. The
nurse is caring for a patient that has a potassium level of 5.0. The nurse
should carefully monitor the patient for which signs and symptoms? (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.
PTS:
1
DIF: Cognitive Level:
Application REF:
43
OBJ: 15 (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 IV order(s)? (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 solution |
|
e. |
0.9% sodium chloride |
ANS: B, C
The solution being prescribed is an isotonic solution. 5%
dextrose in water, lactated Ringer 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.
PTS:
1
DIF: Cognitive Level:
Analysis
REF: 48-49
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. After receiving
these orders from the health care provider, which order(s) should the nurse
question? (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), two tabs, by mouth after first occurrence of nausea and
vomiting. |
|
c. |
Administer furosemide
(Lasix) 40 mg by slow IV push. |
|
d. |
Monitor the patient’s
intake and output every 4 hours. |
|
e. |
Obtain patient’s weight every
morning and record. |
ANS: A, B, C
A primary concern in a patient with uncontrolled vomiting
includes monitoring hydration status. Intake and output and daily weights are
indicators of hydration status and should be assessed. 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. Lasix is a powerful loop diuretic that
would exacerbate the patient’s volume depletion.
PTS:
1
DIF: Cognitive Level: Analysis
REF: 33, Box 3-2, 36, Table 3-2, 50, Table
3-6
OBJ: 13 (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.
PTS:
1
DIF: Cognitive Level: Comprehension
REF: 50, 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.
PTS:
1
DIF: Cognitive Level: Comprehension
REF: 32
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
buffer; kidneys; respiratory
respiratory; buffer; kidneys
respiratory; kidneys; buffer
kidneys; respiratory; buffer
kidneys; buffer; respiratory
The buffer system, the respiratory system, and the kidneys
contribute unique compensations to correct an acid-base imbalance.
PTS:
1
DIF: Cognitive Level: Comprehension
REF: 44
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 occurs in which order?
(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 gastrointestinal tract |
28. Step
1
29. Step
2
30. Step
3
31. Step
4
32. Step
5
28. ANS:
D
PTS:
1
DIF: Cognitive Level: Analysis
REF:
43
OBJ: 4 (theory)
TOP: Hypocalcemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
29. ANS:
A
PTS:
1
DIF: Cognitive Level: Analysis
REF:
43
OBJ: 4 (theory)
TOP: Hypocalcemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
30. ANS:
B
PTS:
1
DIF: Cognitive Level: Analysis
REF:
43
OBJ: 4 (theory)
TOP: Hypocalcemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
31. ANS:
E
PTS:
1
DIF: Cognitive Level: Analysis
REF:
43
OBJ: 4 (theory)
TOP: Hypocalcemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological
Adaptation
32. ANS:
C
PTS:
1
DIF: Cognitive Level: Analysis
REF: 43
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
deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd
Edition
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. Which statement best explains the goal for
Epogen administration prior to surgery?
|
a. |
The patient will only
require a single antibiotic immediately prior to surgery. |
|
b. |
The patient will have
greater numbers of white blood cells (WBCs) following surgery. |
|
c. |
The patient will not
require a blood transfusion during surgery. |
|
d. |
The patient will maintain
stable potassium levels 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 affect WBCs or serum potassium levels.
PTS:
1
DIF: Cognitive Level:
Application REF:
62
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 drinking two glasses of wine daily, smoking
one pack of cigarettes daily ´ 20 years, completing a round of corticosteroids
for asthma control 2 days ago, and taking a dose of passion flower extract
yesterday. Which action should the nurse take next?
|
a. |
Supply the patient with
information on a smoking cessation class. |
|
b. |
Educate the patient
regarding the dangers of drinking alcohol on a daily basis. |
|
c. |
Provide the patient with
information regarding the dangers of using herbal medications. |
|
d. |
Notify the physician
immediately regarding the patient’s 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 two 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.
PTS:
1
DIF: Cognitive Level:
Analysis
REF: 65, Table 4-2
OBJ: 2 (theory)
TOP: Perioperative Management
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
Potential
3. The
nurse is caring for a presurgical patient. The patient asks the nurse why her
height and weight are recorded. How should the nurse respond?
|
a. |
“This information helps us
to correctly calculate the anesthesia dose.” |
|
b. |
“Height and weight are
important predictors of blood loss.” |
|
c. |
“This information is used
to assess respiratory volume.” |
|
d. |
“Height and weight help us
anticipate your fluid needs.” |
ANS: A
Height and weight are used to calculate anesthesia dosages.
PTS:
1
DIF: Cognitive Level: Comprehension
REF: 76
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 laboratory reports and notes an
elevated aspartate aminotransferase (AST) and bilirubin. The nurse understands
that this patient is most at risk for which potential complication?
|
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.
PTS:
1
DIF: Cognitive Level:
Analysis
REF: 64, Box 4-2, 65, 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.
Which safety precaution should the nurse take?
|
a. |
Monitor respiratory status. |
|
b. |
Raise the 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.
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