TEST BANK FOR MEDICAL SURGICAL NURSING CRITICAL THINKING EXAM QUESTIONS WITH DETAILED VE, Exams of Nursing

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TEST BANK FOR MEDICAL SURGICAL NURSING

CRITICAL THINKING EXAM QUESTIONS WITH

DETAILED VERIFIED ANSWERS

100%COMPLETE GRADED A+ LATEST 2024

CHAPTER 1-CHAPTER 51

Chapter 1

1. The nurse is caring for four clients on a medical–surgical unit. Which client should the nurse see initially? 1. (^) A client admitted with hepatitis A who has had severe diarrhea for the last 24 hours 2. (^) A client admitted with pneumonia who is has small amounts of yellow productive sputum 3. (^) A client admitted with fever of unknown origin (FUO) who has been without fever for the last 48 hours 4. (^) A client admitted with a wound infection whose WBC is 8,500 mm 3 Answer: 1 Rationale: The nurse must decide which client should be seen on the initial rounds of the day. The nurse must remember that the first client to be seen should be the client who needs the attention of the nurse initially. A client with hepatitis A does experience diarrhea, but diarrhea for the last 24 hours could cause the client to have a problem with dehydration and experience a state of fluid volume deficit. Cognitive Level: Application Client Needs: Safe, Effective Care Environment Nursing Process: Planning

1. The nurse is preparing to administer influenza vaccines to a mass drive-through clinic. Which statement by a client would indicate further questioning prior to giving the client the influenza vaccine?
2. “I am allergic to horse hair.”
3. “I try to get my vaccine every year.”
4. “I am not allergic to anything except eggs.”
5. “My husband had a severe allergic reaction after he received his influenza vaccine.” Answer: 3

Rationale: Influenza vaccines are recommended for person at high risk for serious sequelae of influenza. The nurse should be aware that client with a sensitivity to eggs should not receive the vaccine. Vaccines prepared from chicken or duck embryos are contraindicated in clients who are allergic to eggs. Cognitive Level: Application Client Needs: Safe, Effective Care Environment

Nursing Process: Assessment

2. The nurse is caring for four clients on a medical–surgical unit. The secretary gives the nurse the morning labs. Which of the following labs would require that the nurse call the physician and inform the healthcare provider about the client’s abnormalities?
   1. (^) WBC 14,600 mm 3
   2. (^) Serum protein 6.9 g/dL
   3. (^) I & D (incision and drainage) showing no growth for the last 24 hours
   4. (^) Albumin 4.2 g/dL Answer: 1 Rationale: When the nurse is caring for several clients, all of the labs should be checked frequently throughout the shift to assess for any abnormalities. The WBC in option 1 is abnormal. (Normal WBC 4,000–10,000 mm^3 .) All of the other lab results are within acceptable range; therefore, the results should not be called in to the physician. Cognitive Level: Application Client Needs: Physiologic Integrity Nursing Process: Assessment
3. The nurse is orienting a new graduate. The nurse is reinforcing the importance of standard precautions. Which of the following observations by the nurse would require further education regarding standard precautions?
   1. The graduate nurse understands to wash hands when entering and exiting the client’s room.
   2. The graduate nurse wears gloves when serving breakfast trays to various clients.
   3. The graduate nurse wears a gown, gloves, and goggles when suctioning a client.
   4. The graduate nurse leaves all supplies in the room of a client who is in contact isolation. Answer: 2 Rationale: The nurse must have an understanding of standard precautions. Prevention is the most important measure to prevent nosocomial infections. Standard precautions were published in 1996 that provide guidelines for the handling of blood and other body fluids. These guidelines are used with all clients, regardless of whether they have a known infectious disease. Standard precautions are used by all healthcare workers who have direct contact with clients or with their body

fluids. It is not necessary for the nurse to wear gloves while delivering food trays to the client, because there is not contact with the client. Cognitive Level: Application Client Needs: Safe, Effective Care Environment Nursing Process: Evaluation

5. The admitting department alerts the nurse on a medical–surgical unit that a client with active tuberculosis (TB) is being admitted to the unit. Which type of isolation is appropriate based on the client’s diagnosis?
   1. Standard precautions
   2. Airborne precautions
   3. Droplet precautions
   4. Contact precautions Answer: 2 In addition to handwashing and standard precautions, the nature and spread of some infectious diseases require that special techniques be used to protect uninfected clients and workers. The client with pulmonary tuberculosis will be placed in airborne precautions. The client should be placed in a private room with special ventilation that does not allow air to circulate to general hospital ventilation; a mask or special filter respirators will be used for everyone entering the room. Cognitive Level: Application Client Needs: Safe, Effective Care Environment Nursing Process: Assessment
6. A client is receiving IV vancomycin for the treatment of Clostridium difficile. The nurse understands that the client who develops flushing, tachycardia, and hypotension during the infusion of vancomycin indicates:
   1. Ototoxicity effect.
   2. Superinfection.
   3. Red man syndrome.
   4. Hives. Answer: 3 Rationale: Vancomycin inhibits cell wall synthesis, and is used for serious infections. It is only effective against gram-positive bacteria, especially Staphylococcus aureus and Staphylococcus epidermidis. The nurse should infuse this medication slowly over 60 minutes or more to avoid “red man” syndrome. The syndrome is characterized by

erythematous rash, flushing, tachycardia, and hypotension. Clients can become dizzy and agitated. Cognitive Level: Application Client Needs: Physiological Integrity Nursing Process: Evaluation

7. The physician has ordered for the client to receive a trough blood level to evaluate the therapeutic effect of an antibiotic. The nurse understands that the trough should be ordered:
   1. A few minutes before the next scheduled dose of medication.
   2. 1 – 2 hours after the oral administration of the medication.
   3. 30 minutes after the IV administration.
   4. During the infusion of the antibiotic. Answer: 1 Rationale: Antibiotic peak and trough levels monitor therapeutic blood levels of the prescribed medication. The therapeutic range—the minimum and maximum blood levels at which the drug is effective—is known for a given drug. By measuring blood levels at the predicted peak (1–2 hours after oral administration, 1 hour after intramuscular administration, and 30 minutes after IV administration) and trough (usually a few minutes before the next scheduled dose), it is also possible to determine whether the drug is reaching a toxic or harmful level during therapy, increasing the likelihood of adverse effects. Cognitive Level: Application Client Needs: Safe, Effective Care Environment Nursing Process: Assessment
8. The nurse needs to change a dressing on the client’s abdomen. Which of the following techniques should be implemented?
   1. Contact precautions
   2. Standard precautions
   3. Droplet precautions
   4. Airborne precautions Answer: 2 Rationale: Standard precautions are used on all clients, regardless of whether they have a know infectious disease. Standard precautions are used by all healthcare workers who

have direct contact with clients or with their body fluids. Since the client has an abdominal dressing, the nurse will use standard precautions. Cognitive Level: Application Client Needs: Safe, Effective Care Environment Nursing Process: Planning

9. The physician has ordered for the nurse to obtain a sputum specimen. The nurse understands that the sputum specimen should be collected:
   1. Immediately after the first dose of antibiotic is administered.
   2. 30 minutes after the first dose of antibiotics is administered.
   3. During the first dose of antibiotics.
   4. Before the first dose of antibiotics is administered. Answer: 4 Rationale: When the physician orders a specimen to be collected, the nurse should collect the specimen before the first dose of antibiotics is administered, to ensure adequate organisms for culture. Cognitive Level: Comprehension Client Needs: Safe, Effective Care Environment Nursing Process: Planning
10. Which of the following manifestations indicates a systemic reaction associated with an inflammatory response?
    1. Erythema
    2. Pain
    3. Tachypnea (RR 26)
    4. Edema Answer: 3 Rationale: If the nurse observes a systemic reaction, the client will exhibit manifestations including temperature, increased pulse, tachypnea, and leukocytosis. Erythema, warmth, pain, edema, and functional impairment indicate a local reaction. Cognitive Level: Application Client Needs: Physiological Integrity Nursing Process: Assessment

11. A client develops hyperthermia related to a diagnosis of Pneumonia. Which of the following nursing interventions would be effective in the treatment of hyperthermia? Select all that apply.
    1. Increase the temperature of the room environment to prevent shivering.
    2. Use ice packs and a tepid bath as needed.
    3. Administer antipyretic medications per physician’s orders.
    4. Promote frequent rest periods to increase energy reserve.
    5. Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance. Answer: 2; 3; 4 Rationale: Hyperthemia is an expected consequence of the infectious disease process. Fever can produce mild, short-term effects or, when prolonged, can cause life- threatening effects. The nurse should administer antipyretic medications as indicated for elevated temperatures. The nurse should use ice packs, cool/tepid baths, or hypothermia blanket with caution. The nurse should enforce frequent rest periods because rest increases energy reserve, which is depleted by an increased metabolic, heart, and respiratory rate. The nurse should encourage fluids rather than restrict fluids because of the risk of electrolyte imbalance. Cognitive Level: Assessment Client Needs: Physiological Integrity Nursing Process: Implementation
12. The nurse is assessing a client’s wound for signs and symptoms of inflammation. Which of the following would alert the nurse that the client is exhibiting signs of inflammation? Select all that apply.
    1. Leg edema
    2. Leg cool to touch
    3. Severe pain from swelling
    4. Decreased peripheral pulses
    5. Severe erythema of leg Answer: 1; 3; 5 Rationale: Regardless of the cause, location, or extent of the injury, the acute inflammatory response follows the sequence of vascular response, cellular and phagocytic response, and healing. Many manifestations of inflammation are produced by inflammatory mediators such as histamines and prostaglandins released when tissue is damaged. The cardinal signs of inflammation include erythema, local heat caused by the

increased blood flow to the injured area (hyperemia), swelling due to accumulated fluid at site, pain from tissue swelling and chemical irritation of nerve endings, and loss of function caused by the swelling and pain. Cognitive Level: Application Client Needs: Physiological Integrity Nursing Process: Assessment Alternate item format – Select all that apply Which of the following manifestations would the nurse expect to see with a client who has had previous knee surgery who suffered a surgical infection with signs of systemic manifestations? Select all that apply.

1. (^) Erythema
2. (^) WBC 14,200 mm 3
3. (^) Pain at the surgical site
4. (^) 10% Bands
5. (^) Respiratory rate of 16
6. (^) Pulse 114 Answer: 2; 3; 6 Rationale: The client is post–surgical repair of the knee. The nurse should be able to distinguish between local reactions and system reactions. An elevated WBC and 10% bands are indicative of an infection. Vital sign changes typically associated with an infection include an elevation in temperature and tachycardia. Local manifestations include erythema, warmth, pain, edema, and functional impairment, whereas systemic manifestations include elevated temperature above 100.4°F, pulse greater than 90/min., respiratory rate greater than 20, and WBC greater than 12,000 mm^3 or > 10% bands. Cognitive Level: Application Client Needs: Physiological Integrity Nursing Process: Assessment Chapter 2
7. When collecting data at the immunization clinic, which of the following disclosures by the client would cause the nurse to hold administration of the varicella vaccine?

a. History of an allergic reaction to yeast bread b. Itching and swelling on the face and hands after ingesting eggs c. A low grade temperature within the past two days d. A blood transfusion after undergoing surgery three months ago Answer: d Rationale: Contradictions for the varicella vaccine include pregnancy, suppressed immunity, and a recent history of a blood transfusion. Recent hyperthermia and allergies to yeast or eggs do not indicate a potential difficulty with the administration of the varicella vaccine. Nursing Process Step: Assessment Client Needs Category: Health Promotion and Maintenance Client Needs Subcategory: Prevention and/or Early Detection of Health Problems Cognitive Level: Analysis

2. The nurse is planning an in-service to discuss primary levels of disease prevention. Which of the following topics should be included in this presentation? a. A discussion concerning the use of available community rehabilitation facilities b. Available locations for diabetes screening c. The need for annual colonoscopy examinations d. The elimination of smoking and alcohol use Answer: d Rationale: Primary prevention involves activities geared toward the prevention of illness and disease. Screening activities such as glucose testing and colonoscopy examinations are a form of secondary prevention. Rehabilitation activities are considered a tertiary level of prevention. Nursing Process Step: Planning Client Needs Category: Health Promotion and Maintenance Client Needs Category: Prevention and/or Early Detection of Health Problems Cognitive Level: Application
3. A 45 - year-old client voices concerns about gaining 12 pounds over the past two years. The client reports no change in dietary habits. Which response by the nurse is most appropriate? a. “Age-related changes in metabolism can result in weight gain despite consistent dietary intake.” b. “Are you exercising?” c. “You might be eating more than you think.” d. “You are getting older.” Answer: a Rationale: A reduction in metabolic rate often accompanies aging. This will cause weight gain despite not eating more calories. Asking the client about exercise fails to provide the

needed information to the client. It also assumes the client is sedentary. Implying the client is overeating is judgmental, and will do little to establish a therapeutic rapport. The client is aware of aging. Pointing this out does little to meet the client’s obvious interest in more information. Nursing Process Step: Diagnosis Client Needs Category: Physiological Integrity Client Needs Category: Physiological Adaptation Cognitive Level: Application

4. The nurse is assisting an 18 - year-old female client to plan a healthy diet to support recent weight loss. Which of the following should be included in the dietary plan? Select all that apply. a. 200 mg folic acid are recommend in the daily diet. b. Eat at least six servings of grains. c. To avoid constipation, keep daily iron intake below 21 mg. d. Fat intake should be limited to less than 30% of the daily caloric intake. Answer: b; d Rationale: Grain intake should include at least six servings daily. To maintain a healthy weight and reduce incidence of cardiovascular disease, fat intake should not exceed 30% of the daily intake. Folic acid intake should be at 400 mg daily. Iron is a vital ingredient in the daily diet. 18 mg daily is reflective of the desired amount. Constipation should be managed by an adequate fluid and fiber intake. Nursing Process Step: Planning Client Needs Category: Health Promotion and Maintenance Client Needs Subcategory: Prevention and/or Detection of Early Health Problems Cognitive Level: Application
5. During a routine physical examination for a 52-year-old Caucasian male, the client declines to have his prostate gland examined. He states he does not have a family history and does not feel he is at risk. What initial response by the nurse is most appropriate? a. “You may refuse any screening test you wish.” b. “I will need to tell the physician about your refusal.” c. “Your risk factors increase with aging.” d. “You are right, Caucasian men have less incidence of prostate cancer.” Answer: c Rationale: The need for prostate screening begins at age 50. Individuals with risk factors should begin screening at age 45. The client’s age places him at an increased risk, so he should begin the screening process. While the client may refuse any testing, this does not allow the client to engage in secondary levels of prevention. The client’s refusal should be recorded in the medical record but not used as a means to coerce the client.

Nursing Process Step: Implementation Client Needs Category: Health Promotion and Maintenance Client Needs Subcategory: Growth and Development through the Lifespan Cognitive Level: Analysis

6. The nurse is preparing to teach a class for a group of new parents. The nurse is attempting to determine what topic would be of the greatest interest to the audience. What selection would be most appropriate? a. Safety b. Chronic illness prevention c. Problem-solving skills d. Interventions to manage depression Answer: a Rationale: The parents of small children are interested in information geared toward keeping them safe. Household safety is a priority for children of all ages. The families attending the session likely will have limited interest in preventing illness, as they typically represent a healthy segment of the population. Depression is a greater concern for older adults. Nursing Process Step: Assessment Client Needs Category: Health Promotion and Maintenance Client Needs Subcategory: Growth and Development through the Lifespan Cognitive Level: Analysis
7. An African-American male is discussing his dietary intake with the nurse. The nurse encourages the client to keep sodium intake below 1,500 mg per day. The client reports he does not have any known risk for the development of hypertension and feels this is too restrictive. How should the nurse respond? a. “African-Americans typically have higher sodium levels than their Caucasian counterparts.” b. “This is the amount of sodium intake recommended for everyone.” c. “This is what will be best for you.” d. “Do you eat a great deal of salt?” Answer: a Rationale: After generations of conditioning, African-Americans frequently have higher sodium levels. The recommended sodium intake for African-Americans is slightly lower than are the levels for their Caucasian peers. Simply telling the client the recommendation is “best” does not provide an adequate level of information. The amount of salt ingested by the client should be recorded, but this is not the best response. Nursing Process Step: Implementation Client Needs Category: Physiological Integrity

Client Needs Subcategory: Physiological Adaptation Cognitive Level: Analysis

8. A 45-year-old woman presents to the ambulatory clinic for a gynecological examination. The health history reveals no significant personal or family medical history. What information concerning health-promotion behaviors should be presented to the client? a. It is time to begin having mammograms every other year. b. If the client is in a monogamous relationship, Pap smears will not be needed. c. Bone density examinations are indicated every year. d. Recommended calcium intake is at least 1,200 mg per day. Answer: d Rationale: The recommended calcium intake is at least 1,200 mg per day. This will be beneficial in the prevention of osteoporosis. Women should begin having annual mammograms by age 40. Pap smears are continued for women in monogamous relationships. For women with no significant risk for the development of osteoporosis, bone density examinations should be done every other year. Nursing Process Step: Implementation Client Needs Category: Health Promotion and Maintenance Client Needs Subcategory: Prevention and/or Early Detection of Health Problems Cognitive Level: Analysis
9. A 75-year-old client seeks care at an ambulatory clinic. The client reports having experienced extreme drowsiness after recently taking dosages of an over-the-counter cold medication. When collecting data, the nurse notes the client reports taking only the prescribed amount of the preparation. What inferences can be made by the nurse concerning the events? a. The client likely has taken more of the preparation than stated. b. The client likely has experienced a reaction between the cold medication and other routine medications. c. The client’s age has influenced his response to the medication. d. The client is allergic to the cold medication. Answer: c Rationale: Older clients often experience altered responses to medications. These changes are in response to age-related developments in the kidneys and liver. There is no evidence the client has taken too much medication. There is no information provided to indicate the client is taking other medications. Allergic reactions typically manifest with integumentary- or respiratory-related symptoms. Nursing Process Step: Evaluation Client Needs Category: Physiological Integrity Client Needs Subcategory: Pharmacological and Parental Therapies

Cognitive Level: Analysis Chapter 3

1. A nursing student is reading about the concept of parish nursing. Which of the following statements indicates understanding of the key concepts of parish nursing?

1. “You must practice a certain faith to be involved in parish nursing.”
2. “Parish nurses are independent practitioners providing care to members of a selected church.”
3. “Parish nursing is reserved for nurse practitioners.”
4. “Parish nurses may be employed by a hospital.” Answer: 4 Rationale: Parish nursing seeks to provide health care to traditionally underserved populations. Involvement in parish nursing is not limited to select faiths. The parish nurse may work directly for the church involved or be contracted by the church to provide nursing services and perform referrals. Parish nursing is not limited to nurse practitioners. Nursing Process Step: Evaluation Client Needs Category: Health Promotion and Maintenance Client Needs Subcategory: Prevention and/or Early Detection of Health Problems Cognitive Level: Application
5. The mother of a severely handicapped child states she is exhausted and voices the need to “take a break” to the nurse. What type of referral would best benefit the client?
6. A respite care provider
7. Hospice care agency
8. Home care
9. Ambulatory clinic Answer: 1 Rationale: Individuals who are faced with caring for ill or handicapped family members might need to have a “break.” The best option would be for a respite care provider. Respite care offers short in-home services in which the care provider would be freed from her duties for a short time. Hospice care is designed to assist the dying client and family members. Home health care is best for clients who are unable to leave their home for care services. Ambulatory clinics are used for clients who are in need of limited point-of-care medical services. Nursing Process Step: Implementation Clients Needs Category: Psychological Integrity Client Needs Subcategory: Coping and Adaptation Cognitive Level: Application
10. The client who lives alone indicates concerns about their ability to perform the necessary dressing changes after discharge. Which action by the nurse is indicated at this time?
11. Explain to the client that she will need to seek the assistance of a friend or neighbor to help as needed.
12. Make a referral to the home healthcare agency preferred by the client.

3. Contact the hospital social worker.
4. Discuss the client’s anticipated needs with the physician. Answer: 4 Rationale: The client will likely need home health care. Home care requires a physician’s order. The nurse will need to initiate the referral process. In some facilities, a discharge planner might be involved. The services of the hospital social worker are not indicated by the information provided. The client has already indicated the absence of assistance. If the client lacks the social resources for it, it will be up to the healthcare team to locate community-based resources. Nursing Process Step: Implementation Client Needs Category: Safe, Effective Care Environment Client Needs Subcategory: Management of Care Cognitive Level: Application
5. The nurse is evaluating a group of clients for referral to a home health agency. Each of the clients is on the Medicare program. Which client is most likely to qualify for home health services?
6. The postoperative client needing reevaluated by the physician six weeks postoperatively
7. The client having a moderate-sized stage III pressure ulcer requiring daily dressing changes
8. The bedridden client who’s physician has prescribed oral antibiotic therapy for two weeks
9. The client having large stage I pressure ulcer Answer: 2 Rationale: Home care is indicated for clients for whom travel to the healthcare provider would be impossible or quite difficult. A large stage III pressure ulcer would be painful for the client during travel. Daily dressing changes would not be a typical function of the physician’s office, and would ideally be completed in the home. The client requiring a postoperative assessment in six weeks does not appear to have any limitations presented. Oral antibiotic therapy does not present challenges to the client that signal the need for home care. The stage I pressure ulcer does not have skin breakdown or require professional healthcare services. Nursing Process Step: Planning Client Needs Category: Safe, Effective Care Environment Client Needs Subcategory: Management of Care Cognitive Level: Analysis

5. During a home care visit, the nurse notices the client’s dressing supplies are not being kept in a readily assessable environment. The nurse has discussed this with the client and family in previous visits. What action by the nurse is indicated?
6. Document the activities relating to the situation.
7. Continue to discuss the issues each visit.
8. Notify the physician.
9. Take the supplies and arrange to bring them back with each visit. Answer: 1 Rationale: The nurse has attempted to address the concerns with the client and family. The client’s failures to make changes in routine indicate a lack of intent to change. Continued discussion likely will prove futile. There is no need to notify the physician at this time. Taking custody of the supplies, carrying them around and bringing them back each time, is not feasible for the nurse. Goals of the nurse are not necessarily shared by the client. Nursing Process Step: Planning Client Needs Category: Psychological Integrity Client Needs Subcategory: Coping and Adaptation Cognitive Level: Application
10. While conducting a home health care visit, the nurse is asked to administer insulin to the client’s ailing husband. What action by the nurse is indicated?
11. The nurse should refuse to administer the medication.
12. The nurse may agree to assist with the administration of the insulin this time only but should caution the client and family that this is not the purpose for their visit.
13. The nurse should contact the physician for the husband for an order for the medication.
14. The nurse should contact his supervisor to obtain permission to administer the medication. Answer: 1 Rationale: The home healthcare nurse is there to care for the client. Providing nursing services for the other members of the household is not appropriate. Legal issues would preclude the nurse from providing care without an order. Making contact with the physician is not appropriate, as the client’s husband is not a client of the home health agency. Nursing Process Step: Implementation Client Needs Category: Safe, Effective Care Environment Client Needs Subcategory: Management of Care Cognitive Level: Analysis

7. The home health nurse observes several small, round bruises on the back side of an elderly client’s arms. What action by the nurse is indicated first?
8. Question the client about the cause of the bruises.
9. Discuss the bruises with the client’s spouse.
10. Document the bruises, with plans to review them for changes on the next visit.
11. Contact the home health supervisor to report the findings. Answer: 1 Rationale: The client should be asked about the cause of the bruises. Nurses suspecting abuse are legally required to report it. Pending the client’s response, the supervisor will likely require notification. The client’s spouse should not be the first contact concerning the bruises, as he might be the source of the injury. Documentation about the findings is indicated. Delaying action until the next visit does not meet the legal responsibilities of the nurse. Nursing Process Step: Assessment Client Needs Category: Safe, Effective Care Environment Client Needs Subcategory: Safety and Infection Control Cognitive Level: Analysis
    8. A home health nurse is preparing to begin a series of visits with a client. Based upon the client’s condition, the client is expected to require home care visits weekly for the next two months. Which of the following tasks should take place first?
12. Set priorities.
13. Assess the home environment.
14. Establish trust and rapport.
15. Promote learning. Answer: 3 Rationale: The basis for a successful long-term relationship between the nurse and the client is founded in trust. Once a rapport is established, it will be possible to begin to identify priorities that are of mutual interest. A review of the home environment will be needed to determine needs for all aspects of care and to promote and maintain safety. Learning is an ongoing process. The client will be more receptive to interventions by the nurse once a rapport is established. Nursing Process Step: Planning Client Needs Category: Psychological Integrity Client Needs Subcategory: Coping and Adaptation Cognitive Level: Application
16. A postoperative client is preparing for discharge. A home health nurse has been scheduled to call on the client in two days. The client tires easily and voices an inability

to concentrate on all of the information the nurse is attempting to review. Which of the subjects concerning the client’s condition and home care may be deferred for the home health nurse?

1. The recommended diet after discharge
2. The activities that will take place during the four-week checkup with the physician
3. Potential adverse reactions of the prescribed medications
4. The actions of the prescribed medications Answer: 2 Rationale: The client must be discharged with the needed information to safely manage until the home healthcare nurse has the first visit in two days. Information concerning prescribed medications and the recommended diet are of the greatest priority, as they will require action by the client prior to the health nurse’s visit. A discussion involving activities planned four weeks in the future can wait until the client is better able to tolerate the information. Nursing Process Step: Evaluation Client Needs Category: Physiological Integrity Client Needs Subcategory: Physiological Adaptation Cognitive Level: Analysis
5. The home health nurse has identified a series of concerns while providing services to a client. During one of the visits, the nurse becomes concerned about criminal activity in the home. What initial action by the nurse is most appropriate?
6. Dial 911 to obtain assistance in removing the client from the home.
7. Contact the physician to discuss the situation.
8. Leave the home.
9. Advise the client to leave the home as soon as possible. Answer: 3 Rationale: The nurse working in the client’s home must always be aware of personal safety. Leaving the home in the presence of criminal activity would be the safest alternative. Removing the client from the home is beyond the scope of the nurse’s responsibility. Contact with the physician might be indicated, but it does not have a higher priority than leaving the scene to ensure personal safety. Nursing Process Step: Implementation Client Needs Category: Safe, Effective Care Environment Client Needs Subcategory: Management of Care Cognitive Level: Analysis

11. The nurse is teaching the client about ways to increase personal safety in the home. During the interaction, the client advises the nurse that he has no plans to make the recommended changes. What response by the nurse is most appropriate?
12. “You might not get well if you do not follow my recommendations.”
13. “I will need to tell your physician the home is not safe enough.”
14. “If you need more information about what we have discussed, please let me know.”
15. “I might not be able to continue my visits if you do not conform.” Answer: 3 Rationale: When providing patient teaching, the nurse must be aware that not all recommendations considered important by the nurse will be held at the same priority by the client. A failure to have the same goals does not mean the interaction is without merit. Telling the client he might not recover might not be true. At no time should the client feel threatened by the nurse’s responses. Implying that the visits will stop or that the physician will be called could be considered threatening. Nursing Process Step: Implementation Client Needs Category: Safe, Effective Care Environment Client Needs Subcategory: Safety and Infection Control Cognitive Level: Analysis
16. During a home health visit, the client indicates he feels he might need physical therapy to facilitate his recovery. What action by the nurse is indicated?
17. The nurse should contact the client’s insurance carrier to determine benefit eligibility.
18. The nurse should provide the client with the contact information for a local agency that offers physical therapy services.
19. The nurse should contact the physician to discuss the client’s concerns.
20. The nurse should advise the client to contact the physician to discuss his concerns. Answer: 3 Rationale: The home health nurse is responsible for making contact with needed agencies. Contact with the physician will be needed to initiate physical therapy. Nursing Process Step: Implementation Client Needs Category: Safe, Effective Care Environment Client Needs Subcategory: Management of Care Cognitive Level: Application
21. The nurse is assessing the client’s perception of safety issues in the home. Which of the following questions and statements will best assist the nurse in obtaining the needed data?
22. “Do you feel safe at home?”
23. “Can you see room for improving safety at home?”
24. “Please tell me some safety concerns you have.”
25. “Have you ever fallen at home?”

Answer: 3 Rationale: Open-ended questions or statements will yield the most information. Encouraging the client to share safety concerns will allow the greatest exchange of information directly related to the identified topic. Asking the client about feeling safe at home is broad, and might not yield the desired information. Nursing Process Step: Assessment Client Needs Category: Safe, Effective Care Environment Client Needs Subcategory: Safety and Infection Control Cognitive Level: Application CHAPTER 4

1. When preparing a client for surgery, the nurse observes that the client has been crying. When the nurse asks the client to sign the surgery consent form, the client states “I guess

I should just go ahead and sign it, even though I’m not really sure about doing this.” The best response by the nurse would be: a. “Most people are usually nervous before surgery.” b. “The surgeon is waiting, so you should decide.” c. “What concerns are you having?” d. “Should we just cancel your surgery?” Correct answer: c Rationale: The nurse has a responsibility to assess further what the client is upset/concerned about prior to surgery. If the nurse was present when the physician gave informed consent, he can reinforce any information. If he was not present, or there are still questions, the surgeon should be notified to make any other clarifications. The surgery should not just be cancelled. Telling the client that others are usually nervous does not address this client’s individual needs. The client has a right to have all questions answered prior to signing a consent for surgery, and should not be pressured for any reason. Application; Implementation; Safe, Effective Care Environment

2. Upon review of the medical history prior to surgery, the nurse notes that a client has a history of alcoholism. The nurse makes a point to bring this to the surgeon’s attention when informed consent is being provided. The rationale for this action would be: a. The client could be at risk for depression postoperatively. b. The client will be at greater risk for respiratory complications postoperatively. c. The client could be dehydrated. d. The client might require more general anesthesia. Correct answer: d Rationale: Clients need to be assessed for surgical risk factors preoperatively for planning. There is no reason to anticipate depression, respiratory complications, or dehydration simply due to a history of alcoholism. Damage to the client’s liver might have occurred, and this could affect how the client metabolizes medications. Analysis; Planning; Safe, Effective Care Environment
3. The nurse is providing preoperative teaching to a client with diabetes. The client states “I know I won’t need as much insulin after surgery, since I haven’t had anything to eat or drink since midnight.” Which response by the nurse would be most appropriate? a. “You are right, the insulin need will be less postoperatively.”

b. “Your insulin need will be adjusted and most likely will increase due to the stress of surgery on your body.” c. “We will give you your usual dose of insulin just prior to surgery.” d. “You will be given insulin during surgery to avoid complications postoperatively.” Correct answer: b Rationale: The stress of surgery, not of being n.p.o. preoperatively, often increases rather than decreases blood sugar, and thus insulin needs. Insulin is not typically given just prior to or during surgery. Analysis; Implementation; Physiological Integrity

4. A client has a history of malignant hyperthermia. A bowel resection with colostomy placement surgery is scheduled. The nurse anticipates which type of anesthesia will be used with this client? a. Regional anesthesia b. Inhaled anesthesia c. Conscious sedation d. Total intravenous anesthesia Correct answer: d Rationale: The client is having a major surgery. General anesthesia would be indicated. Inhaled and total intravenous anesthesia are general anesthesia options. The use of inhaled anesthesia in a client with a history of malignant hyperthermia would be avoided, as it can trigger malignant hyperthermia. Total intravenous anesthesia would be used in this situation. Analysis; Planning; Physiological Integrity
5. A client reports a pain level of 6 on a 0–10 pain scale. The nurse offers to review the orders for additional pain medication. The client states “I really don’t want to take any more pain medication, because I am afraid I will become addicted.” The nurse’s response should focus on which concept? a. Physical dependence on pain medication is uncommon during the short-term postoperative use. b. This client already might have an addiction problem. c. This client might benefit from a placebo dose. d. The physician should be notified to discuss pain management. Correct answer: a Rationale: Clients might fear “addiction” or physical dependence on pain medications, especially opioids, postoperatively. The duration of use is typically short-term, and this concern should be discussed, but is not anticipated to occur. The client who already has an addiction problem most likely would be requesting more medication, not refusing it.

The client is verbalizing pain, so administration of a placebo is unethical, against client rights for pain management, and should not be administered. It is within the scope of the nurse to review and make decisions with the client regarding safe use of pain medications that have been ordered by the physician. The physician does not need to be called at this time unless the nurse’s interventions with the client are unsuccessful. Analysis; Implementation; Physiological Integrity

6. The nurse has many teaching responsibilities preoperatively. From the following list, select all topics that would be within the nurse’s scope to provide instructions about preoperatively: a. Diaphragmatic breathing b. Positioning/turning in bed c. Coughing exercises d. Potential risks of the surgery Correct answers: a; b; c Rationale: Measures to ensure respiratory, circulatory, and gastrointestinal functioning are important for the nurse to teach the client preoperatively. The physician would discuss the potential risks and benefits of the surgery during the informed consent process. Application; Implementation; Physiological Integrity
7. Assessment findings that would alert the nurse that a client might be at greater risk for deep vein thrombosis include: (Select all that apply.) a. Client is 35 years old. b. Client has varicose veins. c. Client is obese. d. Client is on an anticoagulant medication. Correct answers: b; c Rationale: The development of a blood clot is an increased risk in the client with an impaired circulatory system; as evidenced by varicose veins, a client who is obese, and over the age of 40 years, has an infection or malignancy. Anticoagulant medications are given to dissolve clots, and do not increase the risk of development. Analysis; Planning; Physiological Integrity
8. Following a coughing episode, a client who is 12 hours postoperative from abdominal surgery notifies the nurse of “a feeling of pressure in the surgical wound.” The nurse observes that the surgical wound is open. The initial response by the nurse should be: a. Check the client’s vital signs, then notify the physician.

b. Cover the wound with a sterile dressing moistened with normal saline, then notify the physician. c. Notify the physician. d. Place the client in the Trendelenburg position. Correct answer: b Rationale: When the wound dehiscence occurs, the site must be covered immediately and be kept sterile. The physician should then be notified. The client will be returning to surgery. Vital signs can be taken after the wound is covered and the physician notified. Client positioning is not the priority. Analysis; Implementation; Physiological Integrity Chapter 5

1. The hospice nurse is working with the family of a 30 - year-old client who is dying. The client voices concerns about how her death will be perceived by her 7-year-old child. What advice from the nurse would be most beneficial?
2. Advise the client that children that age emotionally distance themselves from the death.
3. Explain to the client that children of this age recognize death is permanent.
4. Encourage the client to begin to prepare the child by explaining that death is permanent, as the child fears separation, and might lack comprehension of permanent separation.
5. Advise the client that children at this age fear death. Answer: 2 Rationale: Age is a great determinant of beliefs about death. Children at this age understand the finality of death. At the age of 7, children do not have the emotional maturity to distance themselves from death. The ability to understand separation has been mastered by the age of 7. The fear of death is typically seen in children this young. Nursing Process Step: Implementation Client Needs Category: Psychological Integrity Client Needs Subcategory: Cognitive Level: Application
6. A client has reported to the physician’s office with complaints of an inability to sleep at night. During the data collection, the client reports her estranged husband died a little over a year ago. She states “I am not sure why this is so difficult, I really couldn’t stand him near the end.” Which response by the nurse is most appropriate?
7. “You seem angry.”
8. “You should contact a therapist.”
9. “Sometimes a rocky relationship with someone at the time of their death can impact your ability to grieve.”
10. “You are just entering the grief process, things will get better.” Answer: 3 Rationale: Unresolved conflict at the time of death can impact the ability of survivors to successfully grieve the deceased. The client’s demeanor does not seem angry. It is inappropriate for the nurse to refer the client to a therapist. Referrals must be initiated by the physician. The death occurred more than a year ago. The client’s continued inability to sleep indicates impaired grieving. Nursing Process Step: Implementation Client Needs Category: Psychological Integrity Client Needs Subcategory: Cognitive Level: Analysis