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Medical Surgical Nursing Concepts & Practice, 2nd Edition by Susan C. – Test Bank
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Chapter 02: Critical Thinking and Nursing Process
MULTIPLE CHOICE
- Basic to the ability to apply critical thinking, the nurse must have:
| a. | unshakable beliefs and values. |
| b. | an open attitude. |
| c. | the ability to disregard evidence inconsistent with set goals. |
| d. | the ability to recognize the perfect solution. |
ANS: B
An open attitude not clouded by unshakable beliefs and values or preset goals allows the application of critical thinking. Acceptance that there may not be a perfect solution leaves the field open to new ideas.
DIF: Cognitive Level: Comprehension REF: 14-15 OBJ: 2 (theory)
TOP: Factors Influencing Critical Thinking KEY: Nursing Process Step: NA
MSC: NCLEX: Health Promotion and Maintenance
- The nurse explains that a fundamental basis for the nursing process is:
| a. | that basic needs must be met by the individual without assistance. |
| b. | that patients and families appreciate an efficient health care system that functions without their input. |
| c. | a focus on disease control. |
| d. | that all persons have worth and dignity. |
ANS: D
The nursing process is based on the belief that all people have worth and dignity. Patient-centered care that is applied to all aspects of the patient’s health, and is not just disease oriented, is appreciated by the family and patient. Holistic care approach can support the patient to meet basic needs.
DIF: Cognitive Level: Application REF: 16 OBJ: 5 (theory)
TOP: Basic Beliefs Pertinent to the Nursing Process
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- Upon a patient’s admission to the facility, the nurse collects the following data: patient’s temperature is 100° F, oxygen saturation is 89%, frothy mucus is expectorated, and the patient’s chest feels tight. The nurse correctly identifies tightness in the chest as:
| a. | judgmental. |
| b. | objective data. |
| c. | subjective data. |
| d. | drawing a conclusion. |
ANS: C
Subjective data is information given by the patient that cannot be measured otherwise. The other data are considered objective data. Objective data are pieces of information that can be measured by the examiner. The nurse should avoid making judgments or conclusions when obtaining data.
DIF: Cognitive Level: Application REF: 18 OBJ: 2 (clinical)
TOP: Assessment Data KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- The newly admitted patient is describing his recent symptoms to the nurse. The nurse is aware that the source of this information is considered:
| a. | primary. |
| b. | objective. |
| c. | secondary. |
| d. | complete. |
ANS: A
The patient is the primary source of information. Objective refers to a type of data obtained by the nurse that is measured or can be verified through assessment techniques, secondary information is obtained from relatives or significant others, and information is not necessarily complete when the patient is the source.
DIF: Cognitive Level: Application REF: 19 OBJ: 2 (clinical)
TOP: Sources of Information KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- The nurse performing an intake interview on a new resident to the long-term care facility detects the odor of acetone from the patient’s breath. The assessment is done by:
| a. | inspection. |
| b. | observation. |
| c. | auscultation. |
| d. | olfaction. |
ANS: D
Olfaction is an assessment method of smells. Inspection and observation use the sense of vision. Auscultation refers to use of the sense of hearing.
DIF: Cognitive Level: Comprehension REF: 20 OBJ: 3 (clinical)
TOP: Olfaction KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- The nurse’s assessment reveals edema of both feet and ankles. The best documentation of these findings is:
| a. | pitting edema present in both feet and ankles. |
| b. | edema in both feet and ankles approximately 4 mm deep. |
| c. | 4 mm pitting edema quickly resolving. |
| d. | bilateral pitting edema in feet and ankles: 4 mm deep resolving in 3 seconds. |
ANS: D
Edema should be recorded as to location, depth of pitting, and time for resolution.
DIF: Cognitive Level: Application REF: 20 OBJ: 3 (theory)
TOP: Palpation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- To assess skin turgor, the nurse would:
| a. | examine mucous membranes of the mouth. |
| b. | compare limbs for similar color. |
| c. | pinch skinfold on chest for tenting. |
| d. | palpate ankles for evidence of pitting edema. |
ANS: C
Skin turgor can be assessed by tenting the skin on the chest and recording the speed at which the “tent” subsides.
DIF: Cognitive Level: Comprehension REF: 21 OBJ: 3 (clinical)
TOP: Practical Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
- The nursing student demonstrates an understanding of the Health Insurance Portability and Accountability Act (HIPAA) by:
| a. | using the patient’s full name only on clinical assignments submitted to the instructor. |
| b. | using the facility printer to copy lab reports on an assigned patient. |
| c. | shredding any documents that the student has been using that contain identifying patient information before leaving the clinical facility. |
| d. | asking the patient for permission to copy lab and diagnostic reports for educational purposes. |
ANS: C
HIPAA forbids any information used for educational purposes to have any identifying information; therefore, shredding documents would be appropriate. Full names on documents, printing copies of chart forms, and asking the patient for permission to copy forms would be violations of HIPAA regulations.
DIF: Cognitive Level: Application REF: 22 OBJ: 1 (clinical)
TOP: HIPAA KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- The diabetic patient who had blood drawn for an HbA1c level says, “I don’t know why they want to look at my hemoglobin.” The most helpful reply by the nurse would be:
| a. | “The test is to evaluate your present level of blood sugar.” |
| b. | “The HbA1c provides information relative to blood sugar levels from the past 2 to 3 months.” |
| c. | “Hemoglobin levels and blood sugar levels are closely related.” |
| d. | “The HbA1c tells if you have type 1 or type 2 diabetes.” |
ANS: B
HbA1c evaluates the average blood glucose level for the last 2 to 3 months.
DIF: Cognitive Level: Comprehension REF: 24 OBJ: 2 (clinical)
TOP: Diagnostic Studies KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
- The RN has chosen the nursing diagnosis of Risk for impaired skin integrity related to immobility. The correct goal/outcome statement for the diagnosis would be:
| a. | patient will sit in chair at bedside for 15 minutes after each meal. |
| b. | nurse will assist patient to chair every shift. |
| c. | nurse will assess skin and record condition every shift. |
| d. | patient will change position frequently. |
ANS: A
The goal/outcome statement is directed at the etiology and should be patient oriented. The statement should be realistic and measurable and reflect what the patient will do.
DIF: Cognitive Level: Application REF: 26 OBJ: 5 (clinical)
TOP: Goals KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- The nurse who has recently moved from Louisiana to Texas is uncertain about the LPN/LVN’s role in applying the nursing process. The most appropriate source for the nurse to consult is:
| a. | hospital policies. |
| b. | the Texas State Board of Nursing. |
| c. | rules and regulations of the Louisiana Nurse Practice Act. |
| d. | the National Association of Practical Nurse Education and Service. |
ANS: B
Each state has different guidelines for areas of care planning, intravenous therapy, teaching, and delegation. The Texas State Board of Nursing is the most reliable source.
DIF: Cognitive Level: Application REF: 16 OBJ: 6 (theory)
TOP: Nursing Process KEY: Nursing Process Step: NA
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- The nurse adds a nursing order to the care plan related to a patient with a nursing diagnosis of Nutrition: less than body requirement related to nausea and vomiting. The statement that is a nursing order is:
| a. | medicate with an antiemetic before each meal. |
| b. | offer crackers and iced drink before each meal. |
| c. | change diet to clear liquids. |
| d. | give nothing by mouth until nausea subsides. |
ANS: B
Offering crackers and iced drinks are within the scope of nursing; the other options would require a medical order to complete.
DIF: Cognitive Level: Analysis REF: 26 OBJ: 6 (clinical)
TOP: Nursing Orders KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- Because the evaluation of the nursing care plan reflects lack of progress toward the goal, the nurse will confer with the patient to plan a:
| a. | more accessible goal. |
| b. | revision of interventions. |
| c. | different nursing diagnosis. |
| d. | new evaluation. |
ANS: B
When lack of progress to reach the goal is seen on evaluation, the interventions are reviewed and/or revised.
DIF: Cognitive Level: Application REF: 27 OBJ: 2 (clinical)
TOP: Evaluation KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- During the intake interview, the nurse notices that, although the patient denies pain, he is grimacing and holding his hand over his stomach. The nurse’s best approach would be to:
| a. | examine the history closely for etiology of pain. |
| b. | question the patient about having feelings of pain. |
| c. | record that patient denies pain but seems to be having abdominal discomfort. |
| d. | physically examine the patient’s abdomen. |
ANS: B
The nurse should try to resolve any incongruence between body language and verbal responses.
DIF: Cognitive Level: Application REF: 17-20 OBJ: 1 (clinical)
TOP: Patient Interview KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- During the admission interview, when asked about pain, the patient responds, “No. I’m pretty wobbly.” Which action by the nurse would be most appropriate?
| a. | Ask, “Did you hear me? I asked you about pain.” |
| b. | Say, “What do you mean ‘wobbly’?” |
| c. | Record the patient denied pain. |
| d. | Record the patient stated he was wobbly. |
ANS: B
The nurse should ask for clarification if unsure of what is meant by one of the patient’s responses.
DIF: Cognitive Level: Application REF: 17-20 OBJ: 1 (clinical)
TOP: Patient Interview KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- The nurse writes an intervention for the goal: Patient will sleep for 5 hours uninterrupted each night. The best nursing intervention is:
| a. | medicate with sedative each night. |
| b. | offer warm fluids frequently. |
| c. | arrange for a large meal at supper. |
| d. | discourage daytime napping. |
ANS: D
Discouraging daytime napping increases the probability of sleep. Giving medication is a collaborative intervention as it requires an order. Large meal and large fluid intakes may interrupt sleep.
DIF: Cognitive Level: Analysis REF: 26-27 OBJ: 2 (clinical)
TOP: Nursing Intervention KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- The nursing team prioritizing the nursing diagnoses of an overweight hospital patient will select as the highest priority the nursing diagnosis of:
| a. | Risk for dehydration related to vomiting. |
| b. | Activity intolerance related to shortness of breath. |
| c. | Knowledge deficit related to weight reduction diet. |
| d. | Altered self-image related to excessive weight. |
ANS: B
Activity intolerance is the highest priority as it has to do with activities that are essential to life. The second is Knowledge deficit related to weight reduction diet, followed by Altered self-image related to excessive weight, and the last is Risk for dehydration related to vomiting.
DIF: Cognitive Level: Analysis REF: 24-27 OBJ: 2 (clinical)
TOP: Setting Priorities KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- The nurse explains that, in addition to the NANDA stem and etiology, the complete nursing diagnosis should include:
| a. | a time reference for meeting the need. |
| b. | a designation of what the patient should do. |
| c. | signs and symptoms of the problem assessed. |
| d. | a specifically worded medical diagnosis. |
ANS: C
A complete nursing diagnosis must have a NANDA stem, etiology, and signs and symptoms (etiology) of the problem.
DIF: Cognitive Level: Comprehension REF: 24-25 OBJ: 7 (clinical)
TOP: Nursing Diagnosis KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
- The nurse explains to a patient that inclusion of potential problems in the nursing care plan:
| a. | alerts nursing staff to prevent potential complications. |
| b. | reminds the family of potential problems. |
| c. | broadens the assessment of the caregiver. |
| d. | educates the patient to aspects of her health. |
ANS: A
Addressing potential problems prevents complications by early action rather than waiting for a problem to materialize.
DIF: Cognitive Level: Application REF: 24-25 OBJ: 7 (clinical)
TOP: Potential Health Problems KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
- During the admission process, the nurse receives orders for the patient to have arterial blood gases (ABGs) drawn. Which finding from the patient’s history may cause concern?
| a. | Taking ginkgo biloba for the last 6 months |
| b. | Having an increased hematocrit (Hct) level during the last physical exam |
| c. | Being diabetic for 10 years |
| d. | Having a decreased white blood cell (WBC) count |
ANS: A
Ginkgo biloba may lower the platelet count and cause bleeding. Therefore, the nurse would be concerned about arterial bleeding occurring following ABGs being drawn. Increased Hct, a history of diabetes, and a decreased WBC count would not pose any problems with drawing a sample for ABGs.
DIF: Cognitive Level: Application REF: 23 OBJ: 2 (clinical)
TOP: Alternative Medicine KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
- The LPN/LVN adheres to facility policy regarding core measures by performing which interventions during patient care?
| a. | Administering the ordered amount of insulin to a patient with type 1 diabetes |
| b. | Performing a thorough patient assessment upon admission to the health care facility |
| c. | Documenting accurately and at appropriate intervals in the patient’s record |
| d. | Providing patient teaching regarding proper diet for the patient diagnosed with renal failure |
ANS: A
Core measures are interventions that are based on scientifically researched, evidenced-based standards of care and are used to treat the majority of patients with a specific illness which often develops complications. Insulin administration for diabetics is evidence-based researched practice. The remaining options are good practice but are not considered core measures.
DIF: Cognitive Level: Analysis REF: 17 OBJ: 10 (clinical)
TOP: Core Measures KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
- The nurse is caring for a patient diagnosed with pneumonia. The patient has a BP 160/94, P 102, R 28, crackles in posterior lower lobes bilaterally, oxygen saturation 89%, and complains of shortness of breath upon exertion. The highest priority nursing diagnosis for this patient is:
| a. | Activity intolerance |
| b. | Impaired gas exchange |
| c. | Ineffective cardiopulmonary tissue perfusion |
| d. | Self-care deficit: Bathing and hygiene |
ANS: B
While all nursing diagnoses may apply to this patient, Impaired gas exchange is the highest priority because this is the underlying problem for the other nursing diagnoses, as well as physiologically the highest priority.
DIF: Cognitive Level: Application REF: 24-27 OBJ: 2 (clinical)
TOP: Nursing Diagnosis KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
MULTIPLE RESPONSE
- The nurse explains to the nursing student that the application of critical thinking to patient care involves: (Select all that apply.)
| a. | identification of a patient problem. |
| b. | setting priorities. |
| c. | concentrating on the patient rather than family needs. |
| d. | use of logic and intuition. |
| e. | expansion of thought beyond the obvious. |
ANS: A, B, D, E
Critical thinking as applied to nursing care requires setting priorities of patient problems and needs by using logic and intuition. Inclusion of the family in the care makes the approach family oriented. Critical thinking should go beyond the obvious.
DIF: Cognitive Level: Comprehension REF: 14-16 OBJ: 2 (theory)
TOP: Critical Thinking KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- The nurse demonstrates application of the nursing process by: (Select all that apply.)
| a. | performing a head-to-toe assessment. |
| b. | updating the patient care plan on a weekly basis. |
| c. | evaluating if patient goals have been met. |
| d. | determining if nursing interventions need to be changed based on lack of patient progress toward meeting goals. |
| e. | ensuring that all personnel caring for the patient are implementing the care plan and working toward the same goals. |
ANS: A, C, D, E
The nursing care plan should be updated as necessary, not just on a weekly basis. Concepts of the nursing process are demonstrated by performing orderly, logical head-to-toe assessments, as well as ongoing evaluation of patient goals and interventions to meet those goals.
DIF: Cognitive Level: Comprehension REF: 16 OBJ: 1 (clinical)
TOP: Nursing Process KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- The nurse demonstrates knowledge of the National Patient Safety Goals by performing patient care that includes: (Select all that apply.)
| a. | identifying the patient prior to medication administration by asking the patient to state his or her name. |
| b. | reporting any sentinel event to the facility’s quality assurance team. |
| c. | assessing the patient’s heart rate prior to administration of digoxin. |
| d. | performing hand hygiene prior to performing a patient assessment. |
| e. | documenting the appropriate time of medication administration. |
ANS: C, D, E
Assessing the patient’s heart rate prior to administration of digoxin demonstrates knowledge of medication actions and prevention of adverse effects; hand hygiene is required before any patient care, including assessment; and documentation of the time of medication administration is necessary to prevent medication errors. To meet National Patient Safety Goals, the nurse must use at least two methods of patient identification prior to medication administration. Reporting a sentinel event is required but demonstrates that National Patient Safety Goals were not met.
DIF: Cognitive Level: Application REF: 17 | Box 2-3 OBJ: 9 (clinical)
TOP: National Patient Safety Goals KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
COMPLETION
- The nursing student demonstrates knowledge of the proper use of the ___________ when determining that it is safe to administer meperidine (Demerol) and promethazine (Phenergan) together.
ANS:
Medication Reconciliation Form
The Medication Reconciliation Form tracks all medications the patient is taking as prescribed by different physicians and can identify overdoses or drugs that are not compatible.
DIF: Cognitive Level: Application REF: 19-20 OBJ: 2 (clinical)
TOP: Medication Reconciliation Form KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- Shortness of breath due to emphysema would be a major component of the _________ care plan.
ANS:
interdisciplinary
An interdisciplinary care plan involves all members of the health care team and is based on the medical diagnosis rather than a nursing diagnosis.
DIF: Cognitive Level: Application REF: 27 OBJ: 2 (clinical)
TOP: Interdisciplinary Care Plan KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
MATCHING
Place the steps of the nursing process in their proper sequence.
| a. | Evaluation |
| b. | Assessment |
| c. | Implementation |
| d. | Planning |
| e. | Nursing diagnosis |
- Step 1
- Step 2
- Step 3
- Step 4
- Step 5
- ANS: B DIF: Cognitive Level: Comprehension REF: 17
OBJ: 7 (clinical) TOP: Applying the Nursing Process
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
- ANS: E DIF: Cognitive Level: Comprehension REF: 17
OBJ: 7 (clinical) TOP: Applying the Nursing Process
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
- ANS: D DIF: Cognitive Level: Comprehension REF: 17
OBJ: 7 (clinical) TOP: Applying the Nursing Process
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
- ANS: C DIF: Cognitive Level: Comprehension REF: 17
OBJ: 7 (clinical) TOP: Applying the Nursing Process
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
- ANS: A DIF: Cognitive Level: Comprehension REF: 17
OBJ: 7 (clinical) TOP: Applying the Nursing Process
KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance
Chapter 04: Care of Preoperative and Intraoperative Surgical Patients
MULTIPLE CHOICE
- The nurse is caring for a patient who has received epoetin alfa (Epogen) 2 to 3 weeks prior to a scheduled surgery. The nurse understands that this patient will likely:
| a. | require an antibiotic immediately prior to surgery. |
| b. | have difficulty with blood clotting following surgery. |
| c. | not require a blood transfusion during surgery. |
| d. | develop an electrolyte imbalance during surgery. |
ANS: C
Epoetin alfa (Epogen) is given to increase red blood cell production prior to surgery with the goal of having a bloodless surgery. Epoetin alfa (Epogen) will not affect the need for an antibiotic preoperatively, nor will it cause difficulty with clotting or cause an electrolyte imbalance.
DIF: Cognitive Level: Application REF: 64 OBJ: 1 (theory)
TOP: Bloodless Surgery KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
- The nurse is performing a preoperative assessment on a patient scheduled for surgery today. The patient reports a history of drinking 2 glasses of wine daily, smoking cigarettes for 20 years, completing a round of corticosteroids for asthma control 2 days ago, and taking the last dose of passion flower extract yesterday. The nurse’s best action is:
| a. | supply the patient with information on a smoking cessation class. |
| b. | warn the patient regarding the dangers of drinking alcohol on a daily basis. |
| c. | provide the patient with information regarding the use of herbal medications. |
| d. | notify the physician immediately regarding the recent use of corticosteroids. |
ANS: D
The use of corticosteroids reduces the body’s response to infection and delays healing. Surgery may need to be delayed until the patient has been off the drug approximately 7 days. Providing the patient with information regarding smoking cessation is advisable but is not a priority at this time. Drinking 2 glasses of wine daily may not be a problem if not contraindicated by the patient’s health status. Passion flower extract does not interfere with the surgery and poses no apparent problems.
DIF: Cognitive Level: Analysis REF: 65-67 | Table 4-2
OBJ: 2 (theory) TOP: Perioperative Management
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
- The presurgical patient asks why it is that her height and weight are recorded. The nurse replies that the information is essential for:
| a. | calculating anesthesia dose. |
| b. | predicting blood loss. |
| c. | assessing respiratory volume. |
| d. | anticipating fluid needs. |
ANS: A
Height and weight are used to calculate anesthesia dosages.
DIF: Cognitive Level: Comprehension REF: 64 OBJ: 3 (theory)
TOP: Presurgical Assessment KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
- The nurse is reviewing the presurgical patient’s lab reports and notes an elevated aspartate aminotransferase (AST) and bilirubin. The nurse is most concerned that this patient is at risk for:
| a. | excessive bleeding during or after surgery. |
| b. | an increased serum albumin level. |
| c. | postsurgical respiratory infection. |
| d. | delayed wound healing. |
ANS: A
The AST and bilirubin are liver studies. Elevated levels may indicate a dysfunctional liver. The liver is directly involved with clotting factors; therefore, this patient would be at risk for excessive bleeding. The serum albumin level would most likely be decreased if the liver is not functioning properly. Postsurgical wound infection and delayed wound healing risks are not directly related to liver function.
DIF: Cognitive Level: Analysis REF: 66 | Box 4-2, 67 | Table 4-2
OBJ: 2 (theory) TOP: Preoperative Lab Studies
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
- The patient received a preoperative dose of lorazepam (Ativan) 20 minutes ago. The safety precaution the nurse should take in regard to this drug is to:
| a. | monitor respiratory status. |
| b. | raise bed rails. |
| c. | elevate the head of the bed 30 degrees. |
| d. | take seizure precautions. |
ANS: B
Raising the bed rails is a safety precaution against the dizziness and hypotension caused by this drug.
DIF: Cognitive Level: Application REF: 72 | Safety Alert
OBJ: 4 (clinical) TOP: Preoperative Medication
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
- The nurse is aware that the 82-year-old patient returning from surgery will need special attention relative to:
| a. | combating thirst. |
| b. | maintaining respiratory status. |
| c. | stabilizing blood pressure. |
| d. | maintaining core body temperature. |
ANS: D
Thirst, respiratory status, and blood pressure are all important considerations when caring for the postsurgical patient; however, maintaining core body temperature is a major concern with the older adult postsurgical patient.
DIF: Cognitive Level: Application REF: 66 OBJ: 2 (theory)
TOP: Assessment of Surgical Risk Factors
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- The patient refuses to take off her diamond wedding band prior to going to the operating room. The nurse should first:
| a. | record in the chart that the patient refused to remove jewelry. |
| b. | tape the ring to finger, covering the ring. |
| c. | request that the patient sign a waiver to release the hospital from responsibility. |
| d. | alert the surgery team to the presence of the jewelry. |
ANS: B
Taping the ring will protect the ring and secure it to the finger. Care must be taken not to wrap the tape too tightly. The nurse will also need to document the presence of the ring on the preoperative checklist or in the nurse’s notes. There is no need for a signature on a waiver. Most facilities have policies in which the patient signs a release of responsibility for valuables. There is no need to notify the surgical team of the presence of the ring.
DIF: Cognitive Level: Comprehension REF: 72 OBJ: 3 (theory)
TOP: Immediate Preoperative Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- Noting that the Asian patient was given atropine as a preoperative drug, the nurse will closely monitor for:
| a. | oliguria. |
| b. | hyperventilation. |
| c. | hypotension. |
| d. | tachycardia. |
ANS: D
Asians often metabolize atropine differently from other populations. The drug can greatly accelerate the heart rate in the Asian patient.
DIF: Cognitive Level: Application REF: 72 | Cultural Considerations
OBJ: 2 (theory) TOP: Immediate Preoperative Care
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The nurse recognizes a need for further instruction about the emotional preparation for surgery when a patient says:
| a. | “I’m going to hug my surgeon tomorrow.” |
| b. | “My fate is in the hands of my surgeon. I’m frightened about the outcome.” |
| c. | “I’ll be ready for a cheeseburger when I get back.” |
| d. | “I know I may have some pain, but this gallbladder will be gone when I wake up.” |
ANS: B
This response demonstrates the patient’s fear and insecurity, which warrant further discussion. Providing additional information or answering patient questions may help alleviate the patient’s emotional unpreparedness for surgery. The plan for a cheeseburger indicates a potential need to further review nutrition in the postoperative period. The other responses demonstrate positive statements regarding the upcoming postsurgical period.
DIF: Cognitive Level: Analysis REF: 67-72 OBJ: 3 (theory)
TOP: Planning KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
- Prior to administering the preoperative medication of Demerol and atropine, the nurse should confirm that:
| a. | a family member is present. |
| b. | underwear is removed. |
| c. | a consent form is signed. |
| d. | bed rails are up. |
ANS: C
Consent forms must be signed prior to giving any sedative or preoperative drug. Removal of underwear and the raising of the side rails can be done after the administration of the drug. The family member does not have to present.
DIF: Cognitive Level: Comprehension REF: 68 OBJ: 4 (clinical)
TOP: Obtaining Consent KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- The nurse explains that the person responsible for verifying that the consent form is signed and that the surgical site is marked is the:
| a. | scrub nurse. |
| b. | surgeon. |
| c. | anesthesiologist. |
| d. | circulating nurse. |
ANS: D
The circulating nurse is responsible for confirming a signature on the consent form and marking the site for surgery.
DIF: Cognitive Level: Comprehension REF: 76 | Box 4-4 OBJ: 6 (theory)
TOP: Circulating Nurse Duties KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- The nurse warns the patient that, in order to retard the growth of microorganisms, the operating room is kept at a temperature of _____ to _____ degrees.
| a. | 60; 65 |
| b. | 66; 70 |
| c. | 71; 74 |
| d. | 75; 77 |
ANS: B
The operating suite is kept at a temperature of 66 to 70 degrees to discourage microbial growth.
DIF: Cognitive Level: Knowledge REF: 75 OBJ: 3 (theory)
TOP: The Surgical Suite KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- The nurse explains that the National Patient Safety Goals protocol requires that:
| a. | a licensed caregiver accompany the patient to the operating room. |
| b. | side rails should be raised and head of bed elevated 30 degrees. |
| c. | surgical site be verified and marked. |
| d. | all prosthetic devices be identified. |
ANS: C
The National Patient Safety Goals require that the patient be identified, the surgical consent be signed and correct, and the surgical site be marked.
DIF: Cognitive Level: Application REF: 76 | Box 4-4 OBJ: 3 (theory)
TOP: Immediate Preoperative Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- The nurse clarifies that the difference between regional anesthesia and procedural sedation anesthesia is that procedural sedation anesthesia uses:
| a. | IV sedation and regional anesthesia. |
| b. | general anesthesia and IV sedation. |
| c. | alternative medicine herbs and regional anesthesia. |
| d. | IV sedation and local anesthesia. |
ANS: A
Procedural sedation anesthesia uses both IV sedation and regional anesthesia.
DIF: Cognitive Level: Comprehension REF: 76 OBJ: 5 (theory)
TOP: Types of Anesthesia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- During the course of surgery, a patient exhibits tachycardia, diaphoresis, and rising body temperature. The priority intervention by the circulating nurse is to:
| a. | continue to monitor the patient for any further changes in condition. |
| b. | note the patient’s oxygen saturation and blood pressure. |
| c. | ask the scrub nurse to verify the assessment findings. |
| d. | alert the anesthesiologist and surgeon immediately. |
ANS: D
These are signs of malignant hyperthermia, along with arrhythmias, muscle rigidity, and hypotension. The anesthesiologist and surgeon should be notified immediately because malignant hyperthermia is a medical emergency.
DIF: Cognitive Level: Application REF: 77 OBJ: 6 (clinical)
TOP: Malignant Hyperthermia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
- The nurse is caring for a postsurgical patient whose surgical procedure lasted 3 hours. The nurse anticipates that the patient will experience:
| a. | thrombophlebitis. |
| b. | muscle spasms. |
| c. | joint pain. |
| d. | hyperthermia. |
ANS: C
Long-term immobility places the patient at risk for pressure damage to skin and underlying tissues. Joint complaints are common after a long surgery. Thrombophlebitis, muscle spasms, and hyperthermia are complications that are not expected to occur.
DIF: Cognitive Level: Application REF: 71 | 77 OBJ: 2 (theory)
TOP: Intraoperative Complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
- The patient has just been given medication to reverse neuromuscular blocking agents. The nurse is aware that the patient is in the general anesthetic stage of:
| a. | induction. |
| b. | introduction. |
| c. | emergence. |
| d. | maintenance. |
ANS: C
Emergence is the stage of surgery in which surgery is completed and the patient is prepared to return to consciousness, and neuromuscular blocking agents are reversed.
DIF: Cognitive Level: Comprehension REF: 76 OBJ: 5 (theory)
TOP: Stages of General Anesthesia KEY: Nursing Process Step: NA
MSC: NCLEX: NA
- The nurse is planning care for four postoperative patients. The nurse determines that the patient who is most likely to develop postoperative complications is the patient who is:
| a. | 36 years old with a history of controlled diabetes. |
| b. | 52 years old with a history of hypothyroidism. |
| c. | 45 years old with a history of a myocardial infarction (MI). |
| d. | 79 years old with mild osteoarthritis. |
ANS: D
Patients over the age of 75 are 3 times more likely to experience surgical complications.
The elderly patient is less able to adjust and compensate for the stress of surgery, as physiologic reserves (cardiac, respiratory, renal) have already declined with age.
DIF: Cognitive Level: Application REF: 64 | Elder Care Points
OBJ: 2 (theory) TOP: Postoperative Complications
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
- The LPN/LVN is in the patient’s room while the charge nurse is obtaining the patient’s signature on the surgical consent form. The patient states, “I didn’t really understand what my surgeon explained, but I trust him completely.” Which response by the charge nurse is correct?
| a. | “I need to contact your surgeon so your questions can be answered.” |
| b. | “I can answer any questions that you might have regarding your surgery.” |
| c. | “As long as you are comfortable, then you may sign the consent form.” |
| d. | “Maybe we should call your surgeon to be sure it is okay to sign the consent.” |
ANS: A
An informed consent means that the surgeon has supplied information regarding the procedure itself, as well as the risks and benefits, and that the patient understands this information. The nurse’s responsibility is witnessing the signing of the form and ensuring the patient understands what the surgeon has discussed, not providing information if the patient has no understanding of the procedure.
DIF: Cognitive Level: Application REF: 68 OBJ: 3 (theory)
TOP: Informed Consent KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
MULTIPLE RESPONSE
- The patient questions the nurse about robotics surgery. The nurse correctly responds, “Robotics: (Select all that apply.)
| a. | gives the surgeon greater magnification than the human eye.” |
| b. | allows the surgeon to be more precise than normal.” |
| c. | allows for a smaller incision.” |
| d. | increases healing time.” |
| e. | procedures generally cause less postoperative pain.” |
ANS: A, B, C, E
Robotics have 12 times magnification of the operative site, steady “hands,” and use a smaller incision, which results in less postoperative pain. Healing time is decreased with robotics.
DIF: Cognitive Level: Comprehension REF: 62-63 OBJ: 1 (theory)
TOP: Robotic Surgery KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
- The nurse is aware that the older adult is a greater surgical risk because the older adult has: (Select all that apply.)
| a. | fewer physiologic reserves. |
| b. | more probability of a chronic illness. |
| c. | more vulnerability to fluid loss. |
| d. | less tolerance for pain. |
| e. | less psychological stamina. |
ANS: A, B, C
The older adult does have less physiologic reserves, more probability for a chronic illness, and more vulnerability to fluid loss. There is no indication that the older adult has less tolerance for pain or less psychological stamina.
DIF: Cognitive Level: Comprehension REF: 64 | Elder Care Points
OBJ: 2 (theory) TOP: Older Adult Surgical Patient
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse reinforces that the purpose of preoperative medication is to: (Select all that apply.)
| a. | reduce anxiety. |
| b. | decrease mucus secretion. |
| c. | counteract nausea. |
| d. | synergize anesthesia. |
| e. | enhance ventilation. |
ANS: A, B, C, D
Preoperative medications are given to reduce anxiety, decrease mucus production, counteract nausea, and enhance anesthesia. Many preoperative medications depress ventilation.
DIF: Cognitive Level: Comprehension REF: 72 OBJ: 3 (theory)
TOP: Preoperative Medication KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
- The nurse determines that the patient demonstrates an understanding of preoperative teaching with which responses? (Select all that apply.)
| a. | “I will need to sign a consent form before I am given my medications prior to my surgery.” |
| b. | “The surgeon will want me to ambulate as soon as possible after my surgery.” |
| c. | “My nurse will want me to take the deepest breaths I can tolerate following my surgery.” |
| d. | “I may experience some constipation if I am taking much pain medication after my surgery.” |
| e. | “The general anesthesia will prevent me from having pain for the first 24 hours after surgery.” |
ANS: A, B, C, D
Consent forms must be signed before preoperative pain medications are administered; early ambulation is common with most surgeries; deep breaths prevent postoperative respiratory complications; and constipation is common with the use of narcotic analgesics. General anesthesia does not prevent pain 24 hours after surgery, so this statement demonstrates the need for further preoperative teaching.
DIF: Cognitive Level: Application REF: 70-72 OBJ: 4 (theory)
TOP: Preoperative Teaching KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
- The nurse instructs the presurgical patient that hypothermia may occur during surgery due to: (Select all that apply.)
| a. | warm atmosphere of the operating room. |
| b. | infusion of cool IV fluids. |
| c. | inhalation of cool anesthetic gases. |
| d. | exposure of body surfaces. |
| e. | lowered metabolism. |
ANS: B, C, D, E
The operating room is kept cool to inhibit growth of organisms. All other options listed are potential causes of hypothermia in the operating room.
DIF: Cognitive Level: Application REF: 77 OBJ: 2 (theory)
TOP: Potential Intraoperative Complications
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- The nurse working in a surgeon’s office is providing preoperative teaching to a patient who is scheduled for a needle breast biopsy. Which statement by the patient demonstrates a need for further preoperative teaching? (Select all that apply.)
| a. | “This procedure will help the doctor determine if I have breast cancer.” |
| b. | “I will most likely have general anesthesia since this is a painful procedure.” |
| c. | “The surgeon will need to perform this procedure within the next 24 to 48 hours.” |
| d. | “I will have less breast pain after having this procedure performed.” |
| e. | “I will not require any further treatment after this procedure is performed.” |
ANS: B, C, D, E
A needle breast biopsy is a diagnostic procedure that is used to determine if cancer cells are present. This procedure typically requires only a local or regional anesthetic; procedures that must be performed within 24 to 48 hours are considered urgent procedures for immediate life-threatening conditions; indicating that less pain will be experienced describes a palliative procedure; and indicating that less breast pain will occur describes a curative procedure.
DIF: Cognitive Level: Application REF: 63 | Table 4-1
OBJ: 3 (theory) TOP: Preoperative Teaching
KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance
COMPLETION
- The nurse reminds the patient that in laparoscopic surgery, with the small incision and less tissue trauma, there is less pain because of the diminished ______________.
ANS:
inflammatory response
There is less trauma, therefore less inflammatory response, which reduces pain.
DIF: Cognitive Level: Comprehension REF: 62 OBJ: 1 (theory)
TOP: Laparoscopic Surgery KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
- A(n) ________________ allows a patient to donate her own blood to be used during or after surgery.
ANS:
autologous transfusion
An autologous transfusion is one in which the patient has donated her own blood to be used during or after surgery.
DIF: Cognitive Level: Comprehension REF: 64 OBJ: 1 (theory)
TOP: Autologous Transfusion KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
- The _____________ functions within the sterile area of the operating room and maintains sterile technique.
ANS:
scrub nurse
scrub person
The scrub nurse is a licensed nurse or surgery technician who functions in the sterile area of the operating room and maintains sterility throughout the operative procedure.
DIF: Cognitive Level: Knowledge REF: 75 | Box 4-3 OBJ: 6 (theory)
TOP: Scrub Nurse Duties KEY: Nursing Process Step: NA
MSC: NCLEX: NA
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