Nursing Care and Collaboration in Medical-Surgical Units, Exams of Nursing

Download Nursing Care and Collaboration in Medical-Surgical Units and more Exams Nursing in PDF only on Docsity! NUR 2032 EVOLVE EXAM QUESTIONS WITH CORRECT ANSWERS GRADED A 2023-24 Chapter one Evolve  Which important aspect of coordinating care within the interdisciplinary team is facilitated by use of the “SBAR” and “PACE” procedures? a. Communication b. Implementation c. Policymaking d. Protocol development  The nurse educator is instructing newly hired registered nurses about patient- centered care. Which competency categories are included in this content? a. Attitudes b. Environments c. Judgements d. Knowledge e. Skills f. Values  Bedside computers are an example of informatics used in health care primarily for which purpose? a. Documenting interdisciplinary care b. Enhancing collaboration and coordination of care c. Offering client access to e-mail and the internet d. Retrieving data from evidence-based practice  The nurse has recently been assigned to a medical-surgical clinical rotation. According to the scope of medical-surgical nursing, what type of client assignment does the nurse expect to see? a. Hospitalized children with acute and chronic illnesses b. Hospitalized adults with acute and chronic illnesses c. Older adult in a nursing home d. Working adults in a corporate setting  Which of these hospital staff members will the nurse manager assign to coordinate the discharge of a client who will need community-based rehabilitation services after a traumatic injury? a. The nurse responsible for the client’s case management b. The physical therapist who developed the client’s exercise program c. The health care provider assigned as the client’s medial resident d. The unit-based RN who has cared for the client during the hospital stay  The nurse is asked to collaborate with other to implement an interdisciplinary plan of care for a client. Which health care team members are essential for the client’s daily care regimen? a. Anesthesiologist b. Case manager c. Health care provider d. Occupational therapist e. Chaplain  Which principal nursing action best support a focus on client safety? a. Client restraints b. Handwashing c. Preoperative checklist d. Respect of others e. Five rights of drug administration  The nurse is appointed to a hospital committee whose goal is to “improve the safety of nursing practice.” Which areas of practice are included in the committee’s task? a. Attentiveness/surveillance of client b. Mandatory reporting c. Medication administration d. Participation in professional organizations e. Prevention of errors or complications f. Teaching clients about the care regimens  An older client who has had a total hip replacement will be transferred to rehabilitation center for continuing care before going home the joint commission, along with national patient safety goal standards, mandates communication between hospital nurses and other providers to ensure adequate transition management. Which aspects of this client’s care plan are most important for the nurse to communicate to the rehabilitation center care team? a. Third-party payer information b. Pain medication needs c. Primary care provider d. Medical history of osteoarthritis  The nurse supports the client and family in deciding on the “Do Not Resuscitate” order. Which ethical principle that guides nursing clinical decision making is demonstrated in this situation? a. Beneficence b. Justice c. Legality d. Self-determination  The nursing student asks the supervising nurse whether a certain fall protocol used on the nursing unit is effective. To demonstrate effectiveness, what does the supervising nurse identify? a. Information about how to implement a fall protocol and what nurses need to document b. Data about the number of falls after the protocol was introduced compared with previous fall rates c. The number of clients who currently have a fall protocol in place d. National statistics about the use of fall protocols to prevent serious injury from falls  A previously stable postoperative client on the medical-surgical unite now has a blood pressure of 88/40 mm Hg and a heart rate of 124 beats/min. after placing the client in Trendelenburg position, which action does the nurse perform next? a. Activate the rapid response team b. Call for a code blue c. Determine the cause of the changes d. Re-check the vital signs in 5 minutes 6. The nurse on a medical unit just received report. Which client should the nrue anticipate on order for arterial blood gases? a. Admitted with chronic pancreatitis b. Admitted for excessive salicylate ingestion c. History of type 2 diabetes with a blood glucose of 180 mg/dL (10 mmol/L) d. History of chronic obstructive lung disease, respiratory rate 20, O2 93 on room air 7. The nurse prepares a presentation on healthy defecation for health fair. Which information should the nurse include when discussing constipation? Select all that apply a. Do not ignore the urge to defecate b. Establish a regular exercise routine c. Decrease the amount of fiber in diet d. Maintain fluid intake of at least 2000 mL/day e. Increase the amount of fresh fruits and vegetables in diet f. Use over the counter constipation medication frequently 8. The nurse obtains the health history of a client admitted to the hospital with difficulty breathing and chronic obstructive pulmonary disease (COPD). Which factors from the client’s history are related to developing COPD? Select all that apply a. Has history of asthma b. Drinks six cans of beer a day c. Had two myocardial infarctions (MIs) d. Worked as a coal miner for 20 years e. Works on a grain farm for last 8 years f. Smoked ½ pack of cigarettes per day for 30 years 9. The nurse is teaching a health and wellness class. What will the nurse include in the discussion of common risk factors for impaired cellular regulation? select all that apply a. Smoking b. Poor nutrition c. Drinking alcohol d. Physical inactivity e. Over the age of 70 10. The nurse cares for a client diagnosed with bowel and bladder incontinence. Which is a priority nursing diagnosis for this client? a. Imbalanced nutrition b. Impaired skin integrity c. Decreased fluid volume d. Altered level of consciousness Chapter 3 evolve 1. The RN has delegated nursing actions to experienced unlicensed assistive personnel (UAP) working in a long-term care facility. Which action require direct supervision by the RN? Select all that apply a. Assisting a 70-year-old client who has new-onset leg pain when ambulating b. Feeding an 82-year-old client who has severe joint disease in both hands c. Helping a 66-year-old client complete her personal hygiene d. Repositioning a 69-year-old client who has recently became unconscious e. Assisting a 72-year-old client who has chronic arthritis of the knee to the restroom 2. The RN manager of a skilled nursing facility wants to assign a staff member to assess the nutritional needs of an emaciated client with pressure ulcers. Which of these team members is appropriate? a. The LPN/LVN treatment nurse responsible for the client’s wound care b. The LPN/LVN medication nurse for this client c. The nurse assistant caring for this client for the past 2 weeks d. The RN team leader responsible for care planning 3. The nurse is conducting a medication assessment on an older adult client who is being admitted to a long-term care facility for rehabilitation following a hip replacement. With Beers criteria used as a resource, which drug poses a potential risk for this client? a. Acetaminophen (Tylenol) b. Celecoxib (Celebrex) c. Digoxin (Lanoxin) d. Mesalamine (Asacol) 4. The RN at a skilled nursing facility is supervising a staff of LPN/LVNs and nursing assistants. Which of these nursing actions does the RN delegate to a nursing assistant? a. Admitting a new client with multiple bruises over the upper thighs b. Assisting a client with chronic joint stiffness to ambulate c. Making hourly assessments on a client with delirium and dementia d. Monitoring a confused client who has been placed in a jacket restraint 5. The nurse is assessing an older adult client’s alcohol use. Which client statement warrants a follow-up collection of more data? a. I am a “teetotaler”; I never drink anything alcoholic b. I had three glasses of champagne at my granddaughter’s wedding last month c. I like to have a glass of wine every once in a while d. I usually drink two vodkas to help me get to sleep each night 6. Which is the fastest-growing subgroup of older adults? a. Young old b. Middle old c. Old old d. Elite old 7. A 70-year-old client whose spouse died the previous year says to the nurse “life is not fun anymore.” How does the nurse respond? a. Are you getting enough sleep? That makes me feel better b. Tell me about your support network, such as friends and family c. How are you feeling about death of your spouse after this length of time? d. Why don’t you go on a vacation? A change of scenery will do you good 8. Which older adult client’s living situation typically presents highest risk for abuse? a. At home alone b. At home with a spouse c. In a long-term care facility d. With adult daughter and grandchildren 9. The RN is arriving for night duty at an acute care hospital. Which client does the RN assess first? a. A 65-year-old scheduled for next-day surgery b. A 68-year-old with chronic protein-calorie malnutrition c. A 70-year-old with a history of gout and joint pain d. A 72-year-old admitted with postoperative delirium 10. The nurse is assessing the nutritional status of an older adult client. Which statement made by the client needs to be explored further? a. Although I enjoy eating sweets and desserts, I need to balance them with heathier foods b. For protein in my diet, I like to get the fish sandwich and first at the fast food drive through at least 3 times a week c. To keep my bowel movement regular, I try to eat some fresh fruits and vegetables each day d. With less activity and exercise in my life these days, I should reduce my total calorie intake 11. An older adult client who lives with her daughter is admitted to the hospital. During the admission assessment, the nurse notes strong body odor, several large pressure ulcers, and limb contractures. What does the nurse do first? a. Ask the daughter about the ulcers and contractures b. Contact the hospital social worker c. Gives the client a bath d. Notifies the health care provider 12. The nurse is teaching a class of older adults about ways to promote their cognitive health. Which collaborative intervention will be most helpful for them? Select all that apply a. Allowing for increased rest and relaxation time b. Having solitary time to reminisce about life experiences c. Joining a peer group with a common learning goal d. Learning a new skill e. Meditating for 30 minutes each day f. Starting a new physical activity 13. The nurse is talking to a group of active senior citizens about making healthy lifestyle choices. Which suggestion is most important in promoting health and safety? a. Continue to eat healthy foods, especially protein b. Seek counseling for depression because it is not a normal part of aging c. Enroll in a safe driving refresher course and avoid risky diving situations d. Walk 30 minutes three to five times a week 14. At a follow-up home-care visit after repair of a fractured radial bone, an older adult client states “I am not sleeping at all during the night.” The client partner reports that the client is sleeping all day. Which intervention does the nurse suggest? a. Increasing the client’s daytime activities b. Placing a “Do not disturb” sign on the door a night c. Taking additional pain medication (analgesic) during the day d. Taking herbal remedies to enhance the effects of prescribed medication 15. A client with end-stage lung cancer and metastasis to the brain has been admitted to the medical-surgical unit. After trying all options to provide a safe environment, the nursing staff is required to apply restraints. Which nursing intervention is required for this client? a. Checking the restraints every 1 to 2 hours b. Releasing the restraints at least every 2 hours c. Using chemical sedation instead of restraints a. Case managers b. Client and family c. Medical-surgical nurses d. Rehabilitation nurses 6. An 82-year-old client is being discharged after successful bladder and bowel training. Before going home, the client ask what food can be eaten to prevent constipation. What is the best response by the nurse? a. Continue on a soft diet b. Decrease your fluid intake c. Eat at least 2 slices of whole wheat bread daily d. Increase your fiber intake with fruits, vegetables, beans, and unsalted nuts 7. A client has been hospitalized with a non-life-threatening C-spine neck injury. The interdisciplinary rehabilitation team has worked with the quadriplegic client for 4 months. Which outcome indicates that the team’s efforts are effective? a. Constipation now occurs only 3 days a week b. Mobility requires multiple assistive devices c. Personal care is performed with help from the family d. Skin is intact, with no evidence of skin impairment 8. A client has just received a bisacodyl (Dulcolax) suppository. How soon after administration does the nurse expect results to be evident? a. 5 to 10 minutes b. 10 to 15 minutes c. 15 to 30 minutes d. 30 to 45 minutes 9. A client in rehabilitation says “this is too hard. My life will never be the same again!” what is the nurse’s BEST response? a. How did you handle challenges before you were injured? b. Should I call a family member to help c. Why don’t you try a relaxation exercise d. You will be fine, don’t worry so much 10. The client is struggling with use of eating utensils. Which rehabilitation team member is brought in to help the client with this problem? a. Activity therapist b. Occupational therapist c. Physiatrist d. Physical therapist 11. An 80-year-old client is bedridden after having a cerebral vascular accident. Which nursing intervention does the nurse use to help prevent skin breakdown? a. Applying moist packs to the skin every shift b. Ensuring the client’s skin remains dry and clean c. Decreasing calories consumed, avoiding weight gain d. Turning and repositioning at least every 4 hours 12. An 82-year-old client with medication-controlled hypertension has altered bladder and bowel patterns as a result of an uninhibited bowel and bladder. Bowel training has been unsuccessful despite consistent toileting and dietary modifications. Why is bisacodyl (Dulcolax) prescribed for this client? Select all that apply a. For its action as an effective bladder antispasmodic b. To promote bladder emptying c. To enhance the action of prescribed antihypertensive medication d. To effectively reestablish defecation patterns e. To promote rectal emptying 13. The partner of a newly diagnosed paraplegic client says, “I don’t know how I am going to manage a job, car for my partner, and take care of the family.” How does the nurse respond? a. Can you quit your job? b. How did you handle challenges before your partner was injured? c. Let’s see what resources are available to help d. Things will get better and you will be fine 14. A rehabilitation nurse is teaching the client with a spastic bladder to perform intermittent catheterizations. Which client statement shows the need for further education? a. Before I catharize myself, I will try to urinate b. I can wait from 9 AM until 6 PM between catheterizations c. I will use the Valsalva and Crede maneuvers before trying to urinate d. You can teach my son to help me with my catheterizations 15. The rehabilitation nurse in a medical-surgical setting is assessing the client’s ability to perform activities of daily living (ADLs). Which test does the nurse use? a. Confusion assessment method (CAM) b. Functional independence measures c. Minimum data set d. Shift change assessment 16. A paraplegic client with injury to the sixth thoracic vertebra has urinary incontinence that is assessed as “sudden and gushing.” When catheterized after being incontinent, urine remains in the client’s bladder. Which bladder training technique does the nurse recommend for this client? a. Providing a high-fiber diet b. Scheduling intermittent catheterizations c. Taking an antispasmodic medication as prescribed d. Using the Valsalva and Crede maneuvers 17. Which nursing intervention does the rehabilitation nurse delegte to the nursing assistant who is caring for a 70-year-old client with ride-side weakness following a stroke? a. Arrange for family members to participate in planning for discharge b. Determine whether the client’s passive range-of-motion (ROM) exercises should be increased c. Reinforce the client’s placing the right arm in the sleeve first when dressing d. Teaching the client to use an extended shoehorn when putting on shoes 18. What role does the rehabilitation nurse have in the functioning of the rehabilitation team? Select all that apply. a. Coordinates holistic care b. Coordinates rehabilitation team activities c. Develop the client’s fine motor skills d. Plans continuity of care for discharge e. Retrains clients with swallowing challenges 19. A rehabilitation client is being discharged home. Which nursing intervention provides the best assessment for home modifications, while helping diminish the client’s anxiety about the process of discharge? a. Doing discharge teaching b. Having a home visit made by the case manager c. Making a leave of absence (LOA) visit possible d. Performing a pre-discharge assessment 20. An 82-year-old woman is admitted to the transitional care unit for stroke rehabilitation with a history of uncontrolled hypertension, coronary artery disease, and elevated cholesterol levels. Her blood pressure (BP) is currently controlled with antihypertensive medications. The UAP reports that the client’s systolic blood pressure drops by 20 mm Hg when the client gets out of bed. What is the likely cause of this client’s change in blood pressure? a. Her stroke is worsening, becoming more acute b. Orthostatic hypotension is exacerbated by antihypertensive medication c. The dose of her antihypertensive medication is to high d. The does of her antihypertensive medication is to low 21. A client has a priority problem of skin breakdown related to immobility and incontinence. Which nursing intervention does the rehabilitation RN delegate to a nursing assistant? a. Assessing the client’s skin for areas of breakdown b. Developing a schedule for turning the client c. Planning a diet high in protein and calories d. Re-positioning the client every 2 hours 22. The nurse is mentoring a nursing student about best practices for safe client handling. What practice does the nurse teach the student? a. Keep the client at arm’s length to maximize your leverage in moving him or her b. Place your feet at right angles to the client’s feet to stabilize yourself c. Put the bed at waist level for care and hip level for movement of the client d. Try to keep the client positioned to your side so that you can benefit from a rotating motion when moving him or her 23. The hospital nurse is assigned to establish a rehabilitation milieu on the unit. What elements does the nurse include? Select all that apply a. Allowing time for clients to practice self-management skills b. Encouraging clients and providing emotional support c. Keeping to a structured hospital schedule (e.g., medication administration) d. Making the inpatient unit a more homelike environment e. Carefully monitoring fluid and dietary intake f. Protecting clients from embarrassment (e.g., bowel training) 24. Following a fall, a 62-year-old client is admitted to the rehabilitation unit with a broken collarbone and a full leg brace. Which transfer technique is indicated for this client? a. Bear-hug technique b. Cane-assisted transfer c. Mechanical lift d. Slide board b. Advance directives allow a client to convey his or her wishes about health care ahead of time c. Most Americans have an advance directive in place; you will need to see a lawyer d. You should have completed the paperwork before you were admitted 8. A dying client exhibits signs of agitation. The foley catheter has drained 100 mL in the last 3 hours, and the client’s last bowel movement was yesterday evening. What does the nurse do first? a. Administer an analgesic b. Arrange for a consultation with a bereavement counselor c. Assess the client for impaction d. Change the foley catheter to ensure adequate drainage 9. The nurse is coordinating interdisciplinary palliative care interventions for the dying client. Which goal is the nurse seeking to meet? a. Avoiding symptoms of client distress b. Ensuring an expedited death c. Meeting all of the client’s needs d. Facilitating a peaceful death for the client 10. The daughter of a dying client says, “I don’t want my father to be uncomfortable.” How does the nurse respond? a. Do you want to talk to the bereavement nurse? b. Your father will be closely monitored and cared for c. Your father will be kept sedated d. We will send him to hospice when the time comes 11. The nurse working on an inpatient hospice unit has received the change-of-shift report. Which client does the nurse assess first? a. A 26-year-old with metastatic breast cancer who is experiencing pain related at 10 (0-to-10 scale) and anxiety b. A 30-year-old with AIDS-associated dementia and agitation who is asking for assistance with calling family members c. A 62-year-old with lung cancer who has cool, clammy, dusky skin, and blood pressure of 64/20 mm Hg d. A 70-year-old with cancer of the colon who has a respiratory rate of 8 with loud, wet-sounding respirations 12. A hospice client has just died. Which of these postmortem nursing tasks is most appropriate to delegate to a nursing assistant? a. Assessing the client for cessation of respiratory effort and lack of pulse b. Documenting the time of death and required assessment data on the chart c. Notifying the spouse and other family members about the client’s death d. Removing all IV lines or tubes according to the hospice policy 13. The family of an unconscious dying client realizes that their mother will die soon. The client’s children are having a difficult time letting go. How does the nurse respond to the needs of this family? a. “don’t be upset; she wouldn’t want it that way.” b. She will soon be in a better place.” c. “things will be fine, try not to worry so much.” d. “this must be difficult for you.” 14. The nurse manager for home health and hospice is scheduling daily client visits. Which client is appropriate for the nursing assistant to visit? a. Advanced cirrhosis of the liver and just called the hospice agency reporting nausea b. Aggressive brain tumor and needs daily assistance with ambulation and bathing c. Inoperable lung cancer and considering whether to have radiation and chemotherapy d. Prostate cancer and bone metastases and how new-onset leg weakness and tingling 15. A hospice client becomes to weak to swallow. What does the nurse do initially to increase the client’s comfort? a. Administer nutrition and fluids though a nasogastric tube b. Explains to the family that aspiration may be a concern c. Obtains a physician order to initiate an IV line d. Teachers the family how to provider oral care 16. A dying client says to the nurse “I am afraid to die. I did a lot of wrong things in my life.” How does the nurse respond? a. “don’t worry, God will forgive you.” b. “I’m sure it is nothing to worry about.” c. Tell me more about that d. Why? What did you do wrong? 17. A client diagnosed with lung cancer 6 months ago is now ventilator-dependent and unresponsive. The family wants to remove the ventilator and stop antibiotics and IV fluids. What does the nurse do next? a. Facilitates a meeting between the family and health care team b. Removes the interventions, per the family’s wishes c. Tells the family that removing the interventions is illegal d. Waits to obtain information on the client’s wishes 18. A client with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order does the nurse implement first? a. Albuterol (Proventil) 0.5% solution per nebulizer b. Morphine sulfate (Roxanol) 5 to 10 mg sublingually as needed c. Oxygen 2 to 6 L/min per nasal cannula d. Prednisone (deltasone) elixir 10 mg orally 19. In which newly admitted client situation does the nurse initiate a conversation about advance directives? Select all that apply a. A client with a non-life-threatening illness b. A person who currently has advance directives c. The client with end-stage kidney disease d. The comatose client who was injured in an automobile crash e. The laboring mother expecting her first child 20. A Christian client is struggling with a diagnosis of cancer and says “why is life so unfair?” what health care team member does the nurse ask to provide support? a. Client’s family b. Physician c. Hospital chaplain d. Psychiatrist 21. A dying client is having difficulty swallowing oral medications. Which intervention does the nurse implement for this client? a. Asks the pharmacy to substitute intramuscular (IM) equivalents for the medications b. Asks the provider if the medications can be discontinued or substituted c. Crushes the pills, open the sustained-release capsules, and mixes them with a spoonful of applesauce d. Does not give the medication and documents: “unable to swallow” 22. A client has died after a long hospital stay. The family was present at the time of the client’s death. Which postmortem action does the nurse implement? a. Asks the family if they wish to help wash the client b. Asks the family to leave during post-death care c. Raises the head of the bed and opens the client’s eyes d. Removes dentures and any prosthetics 23. A dying client cannot swallow and is accumulating audible mucus in the upper airway (Death rattles). The nursing assistant reports that these noises are upsetting to the family members. What does the nurse tell the assistant to do? a. Assist the family in leaving the room so that they can compose themselves b. Place the client in a side-lying position so secretion can drain c. Position the client in a high-fowler’s position to minimize secretions d. Use a Yankauer suction tip to remove secretion from the client’s upper airway 24. The nurse recognizes signs and symptoms of delirium in an 80-year-old client who is dying from metastatic breast cancer. What does the nurse do initially for this client? a. Requests an order for an antipsychotic medication to control these symptoms b. Collaborates with the end-of-life (EOL) care team to evaluate possible medication-induced causes c. Discontinues all medications that have central nervous system adverse effects d. Assures the client’s family that this terminal delirium indicates that death is imminent 25. A client dying of cancer is receiving high doses of opioids. In addition, which intervention is the most effective for this client? a. Classical music b. Deep muscle massage c. More pain medication d. Short, light massage 26. A nurse who is skilled in complementary and alternative medicine (CAM) therapies works on a cancer unit with clients who are terminally ill. For which client symptoms does the nurse use these therapies? a. Constipation b. Cool extremities c. Increased pain d. Memory loss Chapter 14 Evolve b. “I drink a glass of wine a night” c. “I had a heart attack 4 months ago” d. “I quit smoking 10 years ago” 14. A diabetic client who is scheduled for vascular surgery is admitted on the day of surgery with several orders. Which order does the nurse accomplish first? a. Use electric clippers to cut hair at the surgical site b. Start an infusion of lactated ringer’s solution at 75 ml/hr c. Administer one-half of the client’s usual lispro insulin dose d. Draw blood for glucose, electrolyte, and complete blood count values. 15. An older client’s adult child tells the nurse that the client does not want life support. What does the nurse do first? a. Call the legal department to draft the paperwork b. Document this in the chart c. Thank the person and do nothing else d. Talk to the client Chapter 15 evolve 1. During surgery, who is most responsible for monitoring for possible breaks in sterile technique? a. Circulating nurse b. Holding nurse c. Anesthesiologist d. Surgeon 2. A surgical client has signed do-not-resuscitate (DNR) orders before going to the operating room (OR). A complication requiring resuscitation occurs during surgery. What is the nurse’s proper action? a. Call the legal department b. Call the client’s primary health care provider c. Honor the DNR order d. Resuscitate per OR procedure 3. The nurse anesthetist notices that a surgical client has an unexpected rise in the end- tidal carbon dioxide level, with a decrease in oxygen saturation and sinus tachycardia. What is the nurse anesthetist’s initial action? a. Administer cardiopulmonary resuscitation b. Continue as normal c. Immediately stop all inhalation anesthetic agents and succinylcholine d. Inform the surgeon 4. The charge nurse for a hospital operating room is making client assignments for the day. Which client is mot appropriate to assign to the least-experienced circulating nurse? a. The 20-year-old client who has a ruptured appendix and is having an emergency appendectomy b. The 28-year-old client with a fracture femur who is having an open reduction and internal fixation c. The 45-year-old client with coronary artery disease who is having coronary artery bypass grafting d. The 52-year-old client with stage 1 breast cancer who is having tunneled central venous catheter placed 5. As the unit nurse is about to give a preoperative medication to a client going into surgery, it is discovered that the surgical consent form is not signed. What does the nurse do after verifying the procedure with the client? a. Calls the surgeon b. Calls the anesthesiologist c. Gives the medication as ordered d. Asks the client to sign the consent form 6. A client is having an arthroscopy of the left knee and has just been moved to the surgical holding area. Which statement by the nurse properly identifies the client while the nurse checks the identification label? a. “are you Mr. smith?” b. “Good morning, Mr. smith” c. “what is your name, and when were you born? d. “What surgery are you having today?” 7. Which intervention does the nurse implement for an older adult client to minimize skin breakdown related to surgical positioning? a. Apply elastic stocking to lower extremities b. Monitor for excessive blood loss c. Pad bony prominences d. Secure joints on a board in anatomic positions 8. Who is most likely person to administer blood products in an operating suite? a. Circulating nurse b. Holding nurse c. Scrub nurse d. Specialty nurse 9. A preoperative client wears a hearing aid and is extremely hard of hearing without it. What does the nurse do to help reduce this client’s anxiety? a. Actively listen to this client’s concerns b. Allow the client to wear the hearing aid to surgery c. Ask if the client may wear the hearing aid until anesthesia is given d. Explain that it is hospital policy to remove a hearing aid before surgery 10. A client has undergone an 8-hour surgical procedure under general anesthesia. In assessing the client for complications related to positioning, the nurse is most concerned with which finding? a. Decreased sensation in the lower extremities b. Diminished peripheral pulses in the lower extremities c. Pale, cool extremities d. Reddened areas over bony prominences 11. Which staff member will be best for the nurse manager to assign to update standard nursing care plans and polices for care of the client in the operating room (OR)? a. Surgical technologist with 10 years of experience in the OR at this hospital b. Certified registered nurse first assistant (CRNFA) who has worked for 5 years in the ORs of multiple hospitals c. Holding room RN who has worked in the hospital holding room for longer than 15 years d. Circulating RN who has been employed in the hospital OR for 7 years 12. A client who is preparing to undergo a vaginal hysterectomy is concerned about being exposed. How does the nurse ensure that this client’s privacy will be maintained? a. Remind the client that she will be asleep b. Ensure that drapes will minimize perianal exposure c. Explain postoperative expectations d. Restrict the number of technicians in the procedure 13. If sterile gauze falls to the ground and hits the front of the ssurgeon’s gown on the way down, what does the nurse do to ensure proper infection control? a. Helps the surgeon change the gown b. Picks the gauze up with a pair of sterile gloves c. Pick the gauze up without touching the surgeon d. Sprays an antimicrobial on the surgeon’s gown 14. Which statement by a nursing student indicates a need for further teaching about operating room (OR) surgical attire? a. “I must cover my facial hair” b. “I don’t need a sterile gown to be in the OR” c. “If I go into the OR, I must wear a protective mask” d. “My scrubs will be sterile” Chapter 16 evolve 1. The nurse is performing a dressing change on a client who underwent abdominal surgery 6 days prior. The nurse notes a moderate amount of serosanguineous drainage on the old dressing. What will the nurse do? a. Apply extra gauze to the new dressing b. Contact the surgeon to discuss the need for antibiotics c. Notify the surgeon about possible wound dehiscence c. Intravenous nonopioid analgesics d. Intravenous opioid analgesics 15. An RN and an LPN/LVN are working together in caring for a client who need all of these intervention after orthopedic surgery. Which action (s) would be best for the RN to accomplish? a. Reinforce the need to cough and deep-breathe every 2 to 4 hours b. Develop the discharge teaching plan in conjunction with the client c. Administer narcotic pain medication before assisting the client with ambulation d. Listen for bowel sounds and monitor the abdomen for distention and pain Chapter 17 evolve 1. Which home health nurse should the nurse manager assign to care for an 18-year-old client with kidney transplant who has many questions about the prescribed cyclosporine (Sandimmune)? a. RN who has worked for the home health agency for 5 years in maternal- child health b. RN who has extensive critical care nursing experience and has worked in home health for a year c. RN who transferred to the home health agency after working for 10 years in an outpatient dialysis unit d. RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency 2. A client who is exposed to invading organisms recovers rapidly after the invasion without damage to health body cells. How has the immune response protected the client? a. Intact skin and mucous membrane b. Self-tolerance c. Inflammatory response against invading foreign proteins d. Antibody-antigen interaction 3. Which nursing activity can the nurse delegate to a home health aide? a. Changing the dressing for a client with a low absolute neutrophil count b. Assisting with bathing for a client with chronic rejection of a liver transplant c. Teaching a client with bacterial pneumonia how to take the prescribed antibiotic d. Assessing incisional tenderness for a client who had a recent kidney transplant 4. The nurse is teaching a client about cyclosporine (Sandimmune) therapy after liver transplantation. Which client statement indicates the need for further teaching? a. “I will be on this medicine for the rest of my life” b. “I must undergo regular kidney function tests” c. I must regularly monitor my blood sugar” d. My gums may become swollen because of this drug” 5. Because of the flu epidemic, the respiratory floor of a hospital does not have any open beds. Which client does the nurse determine is ready for discharge at the request of the discharge planner? a. Older adult client with history of congestive heart failure, oxygen saturation of 91%, and on O2 at 2 L, with white blood cell count (WBC) 150,000 mm3 (15.5 x 109/L), segmented neutrophils (segs)(8.0 x 109/L), bands 5% (0.5 x 109/L), lungs with slight crackles in bases, able to assist with activities of daily living, and afebrile b. Middle-aged client with history of multiple sclerosis, decreased ability to ambulate since hospitalization, lungs clear WBC count 9,500 mm3 (9.5 x 109/L), segs (6.o x 109/L), bands 1.0% (0.1 x 109/L), oxygen saturation of 93% on room air, and afebrile c. Young adult client with crackles in all lung lobes, with productive cough of copious amounts of thick yellow sputum, WBC count 20,000 mm3 (20.0 x 109/L), segs (7.0 x 109/L), bands 10.0% (1.1 x 109/L), oxygen saturation of 95% on O2 at 2 L, and temperature of 100.4 F (38C) d. Older adult client with recent history of rip hip replacement, with productive cough, WBC count 3,400 mm3 (3.4 x 109/L), segs (6.2 x 109/L), bands 5% (0.5 x 109/L), lungs with crackles right mid-lobe posterior chest wall, oxygen saturation of 89% with O2 at 2 L, and afebrile 6. Which statement accurately explain otitis media? a. The inflammatory response is triggered by the invasion of foreign proteins b. Phagocytosis by macrophages and neutrophils destroy and eliminates foreign invaders c. In is caused by a left shift or increase in immature neutrophils d. Many immune system cells release into the blood have specific effects 7. The nurse is preparing a client for discharge on postoperative day 1 after a modified radical mastectomy. Which instruction is most important for the nurse to include in this client’s discharge plan? a. Please report any increased redness, swelling, warmth, or pain to your health care provider b. Do not allow anyone to take your blood pressure or draw blood on the side where you had your breast removed c. A referral has been made to the American Cancer society’s reach to recovery program, and a volunteer will call you next week d. Avoid the prone and hunchback positions, and ask your health care provider for any other needed activity restrictions 8. Which statement best exemplifies a client’s protection from cancer provided by cell- mediated immunity (CMI) after exposure to asbestos? a. Cytotoxic and cytolytic T cells destroy cells that contain the major histocompatibility complex of a processed antigen b. Helper and inducer T cells recognize self-cells versus non-self-cells and secrete lymphokines that can enhance the activity of white blood cells c. Suppressors T cells prevent hypersensitivity when a client is exposed to non- self- cells or to proteins d. Balance elicits protection when helper or inducer T cells outnumber suppressor T cells by a ratio of 2:1 9. Which postoperative kidney transplantation client does the nurse asses first for signs and symptoms of hyperacute rejection? a. Older adult with Parkinson disease receiving a donation from an identical twin b. Grand multipara female with a history of subsequent blood transfusions c. Middle-aged man with a 20-pack-year history d. Young adult with type 1 diabetes 10. A complete blood count with differential is performed on a client with chronic sinusitis. Which finding does the nurse expect? a. Segmented neutrophils, 62% b. Lymphocytes, 28% c. Bands, 5% d. Basophils, 4% Chapter 18 Evolve 1. A client diagnosed with exacerbation of systemic sclerosis (SSc) asks the nurse why a foot board and a bed cradle have been placed on the bed. The nurse explains that they are used for what purpose? a. Inspect skin for lesions or changes b. Promote comfort from Raynaud’s phenomenon c. Prevent foot drop and contractures d. Decrease chilling of the extremities 2. The home health nurse conducts a community presentation of Lyme disease for the resident of an assisted living facility. Which statement from the audience indicates to the home health nurse that further instruction is needed? a. I will gently remove the tick with tissue and then burn it to prevent the spread of the disease b. It is best to walk in the center of an outside trial c. I should wait 4 to 6 weeks after being bitten by a tick to be tested for Lyme disease d. I’ll wear light-colored clothes with long sleeves, long pants, closed shoes, and a hat when I am walking in the woods 3. The nurse is caring for a middle aged client diagnosed with rheumatoid arthritis. Which client statement requires further assessment for unproductive cooping strategies? a. I’m letting my husband do most of the cooking, but I help plan the menus b. Since I started taking etanercept (Enbrel), I can walk up and down the stairs of my house easier c. My husband is getting used to having sex only once a month d. I worry about what is going to happen to me if my husband cannot take care of me, but he says he will hire someone if he must 4. Which statement indicates to the nurse that a client with fibromyalgia syndrome is using a complementary therapy to help relieve symptoms? a. My thera-band really helps me loosen up my arms b. The brace on my lower leg is helping me walk better c. Focusing on the slow stretching movement and my breathing in tai chi helps me relax d. Water aerobic exercises have helped me sleep better 5. In teaching a client with acute secondary gout, which instruction about preventing recurrence is most important for the nurse to include? a. Use long-handled device such as a Reacher b. When getting out of bed, use fingers to push off c. Sit in a low back chair d. Bend at the waist while keeping the back straight e. Use adaptive device such as Velcro closures f. Turn a doorknob clockwise 19. The nurse is developing a teaching plan for a client diagnosed with osteoarthritis (OA). The nurse includes which instruction in the teaching plan? a. Begin a running program b. Take up knitting to slow down joint degeneration c. Eat at least 2 cups (17 ounces) of yogurt per day d. Wear supportive shoes 20. The nurse is caring for an older, alert adult client diagnosed with osteoarthritis. Which client statement indicates to the nurse that the client is using effective coping strategies? a. I do not know how long my wife will be able to take care of me at home b. The bus is coming to pick me up from senior center three time a week so I can play cards c. I am helping with the dishes and laundry, but I hurt so badly when I am doing it d. I do not know how much longer my neighbor can continue to help clean my house Chapter 19 Evolve 1. The nurse is assigned to care for four clients. Which client does the nurse assess first? a. Client with human immune deficiency virus (HIV) and Kaposi’s sarcoma who has increased swelling of a sarcoma lesion on the right arm b. Client with a history of liver transplantation who is currently taking cyclosporine (Sandimmune) and has an elevated temperature c. Client who has been admitted receiving a monthly dose of serum immune globulin to treat Bruton’s agammaglobulinemia d. Client who has been receiving radiation to the abdomen and has a decreased total lymphocyte count 2. A client is receiving highly active antiretroviral therapy (HAART). Which statement by the client indicates a need for further teaching by the nurse? a. With this treatment, I probably cannot spread this virus to others b. This treatment does not kill the virus c. This medication prevents the virus from replicating in my body d. research has shown the effectiveness of this therapy if I do not forget to take any doses 3. in discharging a client diagnosed with acquired immune deficiency syndrome (AIDS), which statement by the nurse uses a nonjudgmental approach in discussing sexual practices and behaviors? a. Have you had sex with men or women or both b. I hope you use condoms to protect your partners c. You must tell me all of your partners’ names, so I can let them know about possibly having AIDS d. You must tell me if you have a history of any sexually transmitted disease because the public health department needs to know 4. A client diagnosed with human immune deficiency virus is concerned about getting opportunistic infections and asks the nurse how to prevent them. Which intervention does the nurse recommend to the client? a. Clean toothbrushes once a week b. Bathe daily using an antimicrobial soap c. Eat salad at least once a day d. Wash dishes in cool water 5. Which intervention does the home health nurse teach to family members to reduce confusion in a client diagnosed with acquired immune deficiency syndrome (AIDS)- related dementia? Select all that apply a. Change the decorations in the home according to the season b. Put the bed close to the window c. Write out detailed instructions, and have the client read them over before performing a task d. Ask the client what time he or she prefers to shower or bathe e. Mark off the day of the calendar, leaving open the current date 6. In planning care for a client with an acquired secondary immune deficiency with Candida albicans, which problem has the highest priority? a. Loss of social contact related to misunderstanding of transmission of acquired secondary immune deficiency and the social stigma b. Mouth sore related to candida albicans secondary to acquired secondary immune deficiency c. Potential for infection transmission related to recurring opportunistic infections d. High risk for inadequate nutrition related to acquired secondary immune deficiency and candida albicans 7. The nurse is conducting a health assessment interview with a client diagnosed with human immune deficiency virus (HIV). Which statement by the client does the nurse immediately address? a. When I injected heroin, I was exposed to HIV b. I don’t understand how the antiretroviral drugs work c. I remember to take my antiretroviral drugs almost every day d. My sex drive is weaker than it used to be since I started taking my antiretroviral medications 8. The nurse is instructing an unlicensed health care worker on the care of a client with human immune deficiency herpes. Which statement by the health care worker indicates effective teaching of Standard precautions? a. I need to know my HIV status, so I must get tested before caring for any clients b. Putting a gown and glove will cover up the itchy sores on my elbows c. Washing my hands and putting on a gown and gloves is what I must do before starting care d. I will wash my hands before going into the room, and then will put on a gown and gloves only for direct contact with the client’s genitals 9. A client who is human immune deficiency virus positive is experiencing anorexia and diarrhea. Which nursing actions does the nurse delegate to a nursing assistant? a. Collaborate with the client to select foods that are high in calories b. Provide oral care to the client before meals to enhance appetite c. Assess the perianal area every 8 hours for signs of skin breakdown d. Discuss the need to avoid foods that are spicy or irritating 10. Which factor relates most directly to a diagnosis of primary immune deficiency? a. History of viral infection b. Full-term infant surfactant deficiency c. Contact with anthrax toxin d. Corticosteroid therapy 11. The home health nurse is making an initial home visit to a client currently living with family members after being hospitalized with pneumonia and newly diagnosed with acquired immune deficiency syndrome (AIDS). Which statement by the nurse best acknowledges the client’s fear of discovery of hi AIDS by his family? a. Do you think that I could post a sign on your bedroom door for everything about the need to wash their hands? b. Is there somewhere private in the home where we can go and talk? c. I hope that all of your family members know about your disease and how you need to be protected, because you have been so sick. d. It is your duty to protect your family members from getting AIDS 12. Which statement made to the nurse by a health care worker assigned to care for a client with human immune deficiency virus (HIV) indicates a breach of confidentiality and requires further education by the nurse? a. I told family members they need to wash their hands when they enter and leave the room b. The other health care worker and I were out in the hallway discussing our concern about getting HIV from our client c. Yes, I understand the reasons why I have to wear gloves when I bathe the client d. The client spouse told me she got HIV from a blood transfusion 13. Which factors are possible transmission routes for human immune deficiency virus (HIV)? Select all that apply a. Breast-feeding b. Anal intercourse c. Mosquito bites d. Toileting facilities e. Oral sex 14. The nurse is providing care to a client with impaired oxygenation related to anemia. Which nursing intervention has the highest priority? a. Administer antibiotics as prescribed b. Transfuse ordered packed red blood cells c. Teach pursed-lip breathing d. Encourage increased fluid intake 15. Which member of the health care team demonstrates reducing the risk for infection for a client with acquired immune deficiency syndrome (AIDS)? a. The dietary worker hands the disposable meal trays to the LPN assigned to the clients b. The social worker encourages the client to verbalize about stressors at home