Medical-Surgical Nursing: Concepts & Practice 3rd Edition Test Bank

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Chapter01:CaringforMedical-SurgicalPatientsMULTIPLECHOICE1.Thenewnursedemonstratesanunderstandingoftheprimarypurposeofthestatenursepracticeact(NPA)byexplainingthatitactsto:a.test and license LPN/LVNs.b.define the scope of LPN/LVN practice.c.improve the quality of care provided by the LPN/LVN.d.limit the LPN/LVN employment placement.ANS:BWhileimprovingqualityofcareprovidedbytheLPN/LVNmaybearesultoftheNPA,theprimarypurposeoftheNPAofeachstatedefinesthescopeofnursingpracticeinthatstate.DIF:CognitiveLevel:ComprehensionREF:1-2OBJ:1(theory)TOP:NPAKEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare2.Thechargenurseasksthenewvocationalnursetostartanintravenousinfusion.Becausethevocationalnursehasnotbeentaughtthisskillduringhereducationalprogram,thevocationalnurseshould:a.ask a more experienced nurse to demonstrate the procedure.b.look up the procedure in the procedure manual.c.attempt to perform the procedure with supervision.d.inform the charge nurse of her lack of training in this procedure.ANS:DThechargenurseshouldbeinformedofthelackoftrainingtoperformtheprocedure,andthevocationalnurseshouldseekfurthertrainingtogainproficiency.Althoughtheotheroptionsmightbehelpful,theyarenotsafe.DIF:CognitiveLevel:ApplicationREF:2OBJ:1(theory)TOP:ProvidingSafeCareKEY:NursingProcessStep:NA

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MSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare3.Thenurserecognizestheneedforfurtherdischargeeducationwhenthepatientsays:a.“I have no idea of how this drug will affectme.”b.“Do you know if my physician is coming backtoday?”c.“Will my insurance pay for mystay?”d.“Am I going to have to go to a nursinghome?”ANS:ALackofknowledgeatdischargeaboutmedicationeffectsandsideeffectsisaconcernthatshouldbeaddressedbythevocationalnurse.Theotherconcernsintheoptionsaretheresponsibilityofotherdepartmentstowhichthenursemightreferthepatient.DIF:CognitiveLevel:AnalysisREF:2OBJ:1(theory)TOP:TeachingKEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare4.AccordingtomoststateNPAs,thevocationalnurseactingaschargenurseinalong-termcarefacilityisactinginwhichcapacity?a.Under direct supervision of an RN on the unitb.With the RN in the buildingc.Under general supervision by the RN available on site or by phoned.As an independent vocational nurseANS:CThevocationalnurseinthecapacityofthechargenurseinalong-termcarefacilityactswiththegeneralsupervisionofanRNavailableonsiteorbyphone.DIF:CognitiveLevel:ComprehensionREF:3OBJ:1(theory)TOP:ChargeNurse/ManagerKEY:NursingProcessStep:NAMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare5.Thenurseremindsthepatientwhoisamemberofahealthmaintenanceorganizationthatpriortotreatmenthewillneedto:

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a.seek the opinion of another physician.b.have medical services approved by his insurance.c.provide documentation of all care received for his condition.d.wait 6 months to see a specialist.ANS:BMostHMOsrequirepreprocedureauthorizationfortreatment.Patientsarenotrequiredtoseekasecondopinion,providedocumentationofcare,orwaitaspecifictimeperiodbeforevisitingaspecialist.DIF:CognitiveLevel:ApplicationREF:5OBJ:3(theory)TOP:ChargeNurse/ManagerKEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare6.Thepatientcomplainstothenursethatheisconfusedabouthis“deductible”thatheowesthehospital.Thenurseexplainsthatthedeductibleisa(n):a.amount of money put aside for the payment of future medical bills.b.one-time fee for service.c.amount of money deducted from the bill by the insurance company.d.annual amount of money the patient must pay out-of-pocket for medical care.ANS:DThedeductibleistheannualamounttheinsuredmustpayout-of-pocketpriortotheinsurancecompanyassumingthecost.Thispracticeimprovestheprofitoftheinsurancecompany.DIF:CognitiveLevel:ApplicationREF:4OBJ:5(theory)TOP:HealthCareFinancingKEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare7.Thenursecomparesthecharacteristicsofahealthmaintenanceorganization(HMO)andapreferredproviderorganization(PPO),pointingoutthatanHMO:a.requires a set fee of each member monthly.b.allows the member to select his health care provider.

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c.permits admission to any facility the member prefers.d.offers unlimited diagnostics tests and treatments.ANS:AHMOsrequireasetfeefromeachmembermonthly(capitation).ThepatientwillbetreatedbytheHMOstaffinHMO-approvedfacilities.ExcessiveuseofdiagnostictestsandtreatmentsisdiscouragedbytheHMO.DIF:CognitiveLevel:ApplicationREF:5OBJ:3(theory)TOP:ManagedCareKEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare8.WhenthepatientasksthenursewhathisMedicarePartAcovers,thenurserespondsthatitcovers:a.inpatient hospital costs.b.reimbursement to the physician.c.outpatient hospital services.d.ambulance transportation.ANS:AMedicarePartAcoversinpatienthospitalexpenses,drugs,x-rays,labwork,andintensivecare.MedicarePartBpaysthephysician,ambulancetransport,andoutpatientservices.DIF:CognitiveLevel:ComprehensionREF:5|Box1-3OBJ:4(theory)TOP:Government-SponsoredHealthInsuranceKEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare9.Thenurseexplainsthatthemaincostcontainmentcomponentofdiagnosis-relatedgroups(DRGs)isthat:a.hospitals focus only on the specific diagnosis.b.hospitals treat and discharge patients quickly.

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c.reduced-cost drugs are ordered for the specific diagnosis.d.diagnostic group classification streamlines care.ANS:BDRGsareaprospectivepaymentplaninwhichhospitalsreceiveaflatfeeforeachpatient’sdiagnosticcategoryregardlessofthelengthoftimeinthehospital.Ifhospitalscantreatanddischargepatientsbeforetheallottedtime,hospitalsgettokeeptheexcesspayment;costiscontained,andthepatientisdischargedsooner.DIF:CognitiveLevel:ComprehensionREF:6OBJ:5(theory)TOP:Government-SponsoredHealthInsuranceKEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare10.Whileassessingagroupofpatients,thenurserecognizesthepatientwhocouldqualifyforMedicaidbenefitsisthe:a.35-year-old unemployed single mother with diabetes.b.70-year-old Medicare recipient with retirement income who needs to be in a long-term carefacility.c.80-year-old blind woman living in her own home who has inadequate private insurance.d.67-year-old stroke victim with Medicare Part A and an income from investments.ANS:AMedicaidisajointeffortoffederalandstategovernmentsgearedprimarilyforlow-incomepeoplewithnoinsurance.DIF:CognitiveLevel:ComprehensionREF:6|Box1-5OBJ:4(theory)TOP:Government-SponsoredHealthInsurance–MedicaidKEY:NursingProcessStep:AssessmentMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare11.ThenurseexplainsthatthemajorfocusofHealthyPeople2020istoimprovethehealthofAmericansintheseconddecadeofthecenturyby:

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a.funding research.b.distributing health information.c.encouraging healthy lifestyles.d.designing programs for health improvement.ANS:CHealthyPeoplefocusesonhelpingongoingprogramstoincorporatesupportandinformationtoreduceinfantmortality,cancer,cardiovasculardisease,andHIV/AIDSandtoincreaseeffectiveimmunizations,healthyeatinghabits,andhealthyweight.DIF:CognitiveLevel:ComprehensionREF:6-7OBJ:7(theory)TOP:HealthyPeople2020KEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare12.Thenursewhoplansinterventionsforalldimensionsofthepatient’slifeispracticing_____care.a.focusedb.generalc.directedd.holisticANS:DHolisticcareaddressesthephysiologic,psychological,social,cultural,andspiritualneedsofthepatient.DIF:CognitiveLevel:ComprehensionREF:7OBJ:8(theory)TOP:HolisticCareKEY:NursingProcessStep:PlanningMSC:NCLEX:PsychosocialIntegrity:CopingandAdaptation13.Thepatientfuriouslysays,“Mydoctorwassobusygivingmeinstructionsthathedidn’thearwhatIwastryingtoaskhim.”Themostempatheticresponsewouldbe:a.“Boy! When people do that to me, I really getmad.”b.“I’msure the doctor was rushed and unaware of yourneeds.”

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c.“I’llbet that made you feel veryfrustrated.”d.“Take a deep breath and plan what you will say to himtomorrow.”ANS:CEmpathydemonstratesthatthenurseperceivesthepatient’sfeelingsbutdoesnotsharetheemotion.Belittlingthepatient’sfeelings,showingsympathy,ordefendingthedoctormakesthepatientfeeldevalued.DIF:CognitiveLevel:AnalysisREF:8OBJ:9(theory)TOP:Nurse–PatientRelationshipKEY:NursingProcessStep:ImplementationMSC:NCLEX:PsychosocialIntegrity14.Thenurseexplainsthatatherapeuticrelationshipdiffersfromasocialrelationshipinthatthetherapeuticrelationship:a.has no boundaries.b.is goal directed.c.meets the needs of each person in the relationship.d.extends past the hospitalization period.ANS:BThetherapeuticrelationshipisfocusedonthepatientandisgoaldirectedanddesignedtomeetonlytheneedsofthepatientanddoesnotextendpasttheperiodofhospitalization.DIF:CognitiveLevel:ApplicationREF:8OBJ:9(theory)TOP:TherapeuticRelationshipKEY:NursingProcessStep:ImplementationMSC:NCLEX:PsychosocialIntegrity15.Themosteffectivenursingapproachincaringforadepressed80-year-oldnewlyadmittedresidenttoalong-termcarefacilitywouldbeto:a.encourage the resident to engage in an activity.b.remind the resident of reasons to be positive.c.point out episodes of negative behavior.d.present a bright and cheerful behavior.

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ANS:AActivityandsocialinteractionarehelpfultodepressedpatients.Presentingacheeryapproachandpointingoutnegativebehaviorandreasonstobepositivearenottherapeuticatthisstageoftherelationship.DIF:CognitiveLevel:ApplicationREF:8OBJ:11(theory)TOP:DepressedBehaviorKEY:NursingProcessStep:ImplementationMSC:NCLEX:PsychosocialIntegrity16.Thepatientwhohasbeenonantidepressantsfor3daystearfullysays,“Istillfeelrotten.Idon’tthinkanythingcanhelphowIfeel.”Whichisthebestresponsebythenurse?a.“I will tell the charge nurse how you arefeeling.”b.“You will need to be patient and give your medicine some time towork.”c.“Look how much you have improved since you were admitted to thefacility.”d.“It must be frustrating to be going through this difficulttime.”ANS:DThisresponseisanempatheticresponsewhichallowsforfurtherexplorationofthepatient’sfeelings.Theotherresponseswillblockcommunicationwiththispatient.DIF:CognitiveLevel:ApplicationREF:8-9OBJ:11(theory)TOP:TherapeuticCommunicationKEY:NursingProcessStep:ImplementationMSC:NCLEX:PsychosocialIntegrity17.Anoverweightmalepatientripsoffhishospitalgown,throwsitoutthedoor,andshouts,“I’mnotwearingthisstupidgown.Itistoosmall,tooshort,andexposesmybacksidetotheworld.”Thenurse’sbestapproachwouldbeto:a.remind patient of the need to wear the gown for convenience in care.b.confer with the patient for methods to acquire a larger gown.c.replace the torn gown with another.d.inform the charge nurse of the hostile behavior.ANS:B

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Allowinghostilepatientstomakereasonablerequestsdefusestheangerandallowspatientstoventtheirfeelings.DIF:CognitiveLevel:ApplicationREF:9OBJ:11(theory)TOP:HostileBehaviorKEY:NursingProcessStep:ImplementationMSC:NCLEX:PsychosocialIntegrity:CopingandAdaptation18.Amanipulativepatientstates,“Youaretheonlynursewhounderstandsaboutmypain.Can’tyougivemeanextradoseofpainmedication?”Thenurseshould:a.be matter-of-fact and explain that dosage schedules are byphysician’sorders.b.ignore the request.c.point out that such manipulative behavior is ineffective.d.give the extra dose.ANS:AAmatter-of-factresponsetoamanipulativerequestlimitstheeffectofthemanipulation,therebyhelpingthenursetoavoidbecomingdefensiveorbeingswayedbyflattery.DIF:CognitiveLevel:ApplicationREF:9OBJ:11(theory)TOP:ManipulativeBehaviorKEY:NursingProcessStep:ImplementationMSC:NCLEX:PsychosocialIntegrity19.Afemalepatientwhohasrecentlybeendiagnosedwithaninoperablebraintumorasksthenurse,“DoyouthinkGodpunishesus?”Thenurse’smosthelpfulapproachwouldbeto:a.sit down with the patient and ask,“Whatdo youthink?”b.touch thepatient’sshoulder and say,“Godlovesyou.”c.ask the patient if she would like to speak with the chaplain.d.say,“Godwill not give you more than you canbear.”ANS:ASittingwiththepatientandofferingoneselftolistentothepatient’sconcernsandencouragingreflectionisthebestapproachratherthanrespondingwithaclichéorsuggestingspeakingwiththechaplain.

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DIF:CognitiveLevel:AnalysisREF:8-9OBJ:11(theory)TOP:SpiritualCareKEY:NursingProcessStep:ImplementationMSC:NCLEX:PsychosocialIntegrity20.Thenurseiscommunicatingwithapatientwhohasvoicedconcernregardinganupcominghigh-riskprocedure.Thenursedemonstratesempathybystating:a.“Would you like to talk about your feelings regarding theprocedure?”b.“My mother had the same procedure and did verywell.”c.“Ican’timagine how youfeel.”d.“It must be difficult preparing for the procedure; how are youfeeling?”ANS:DThisstatementbythenursedisplaysempathybytryingtoplaceoneselfinthepatient’scircumstanceandvalidatingthepatient’sfeelings.Simplyaskingpatientsiftheywouldliketotalkabouttheirfeelingsdoesnotshowempathyandmayelicita“yes”or“no”response.Tellingthepatientone’smotherhadtheprocedureorstating“Ican’timaginehowyoufeel”doesnotshowempathytowardthepatient.DIF:CognitiveLevel:ApplicationREF:7-8OBJ:9(theory)TOP:Nurse–PatientRelationshipKEY:NursingProcessStep:ImplementationMSC:NCLEX:PsychosocialIntegrityMULTIPLERESPONSE21.ThenewLPN/LVNremindsacoworkerthatclearguidelinesforupholdingclinicalstandardsforsafeandcompetentcarecanbefoundininformationfrom:(Selectallthatapply.)a.thestate’snurse practice act (NPA).b.the State Board of Nurse Examiners (BNE).c.the National Association for Practical Nurse Education and Service (NAPNES).d.institutional policies.e.the National Federation of Licensed Practical Nurses, Inc. (NFLPN).ANS:C,E

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NAPNESandtheNFLPNgiveclearguidelinesforclinicalstandardsthatcanbeusedasabasisforcourtdecisions.TheNPAhasbroadguidelines,andinstitutionalpoliciesmaynotbecomplete.TheBNEenforcestheNPA.DIF:CognitiveLevel:ComprehensionREF:2OBJ:1(theory)TOP:UpholdingClinicalStandardsKEY:NursingProcessStep:NAMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare22.TheLPN/LVNclarifiesthattheroleoftheLPN/LVN,regardlessofemploymentplacement,isto:(Selectallthatapply.)a.uphold clinical standards.b.educate patients.c.communicate effectively.d.collaborate with the health care team.e.initiate a care plan immediately after admission.ANS:A,B,C,DTheLPN/LVNhastheaccountabilitytoupholdclinicalstandards,educatepatients,communicateeffectively,andcollaboratewiththehealthcareteam.Dependingonthetypeoffacility,initiationofacareplanisoftentheroleoftheregisterednurse.DIF:CognitiveLevel:ComprehensionREF:2-3OBJ:2(theory)TOP:RolesofLPN/LVNsKEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare23.ThenewlylicensedLPN/LVNdemonstratesanunderstandingofemploymentopportunitieswhenapplyingtoapositioninwhichofthefollowingareas?(Selectallthatapply.)a.An outpatient clinicb.A home health care agencyc.An intravenous therapy teamd.A long-term care facilitye.An ambulatory care unitANS:A,B,D,E

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Withtheexceptionofanintravenoustherapyteam,whichrequirespostgraduateeducationand/orcertification,theotheroptionsareopentonewlygraduatedvocationalnurses.DIF:CognitiveLevel:ApplicationREF:3|Box1-1OBJ:2(theory)TOP:EmploymentOpportunitiesforLPN/LVNsKEY:NursingProcessStep:NAMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare24.WhenanLPN/LVNdelegatesatasktounlicensedassistivepersonnel(UAP),thereis:(Selectallthatapply.)a.a need for the UAP to voluntarily accept the task delegated.b.continued accountability for the task by the LPN/LVN.c.no further need for supervision of the UAP.d.the understanding that the task is in the job description of the UAP.e.a transfer of authority to the UAP.ANS:A,B,D,EDelegationisaconsideredactinvolvingtheconditionofthepatientandthecompetencyoftheUAP.DelegationrequiresthattheUAPvoluntarilyacceptthetask,whichisinthejobdescriptionoftheUAP.Thevocationalnursehastransferredauthorityforthecompletionofthetaskbutisstillaccountableandshouldsupervise.DIF:CognitiveLevel:ApplicationREF:3-4OBJ:2(theory)TOP:DelegationKEY:NursingProcessStep:NAMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare25.Followinganin-serviceregardingcostcontainmentwithinthehealthcarefacility,theLPN/LVNdemonstratesunderstandingby:(Selectallthatapply.)a.telling patients that they must limit the amount of supplies they use.b.asking the UAP to be sure to correctly charge for patient care items.c.using only necessary items for patient care.d.using and charging for extra patient care items that the patient may take home upondischarge.e.documenting supplies used for patients in their patient care record.

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ANS:B,C,ETheUAPmustcorrectlychargepatientsutilizingthefacility’schargingsystem,onlynecessarysuppliesshouldbeusedforpatientcare,anddocumentingsuppliesusedassistsinreimbursement.Itisinappropriateandnotthepatient’sresponsibilitytomonitortheirsupplyuse,andexcesschargeswouldbeincurredifitemsweregiventothepatientupondischarge.DIF:CognitiveLevel:ApplicationREF:6OBJ:6(theory)TOP:CostContainmentKEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:ManagementofCareCOMPLETION26.Whenaninsurancecompanydirectlyreimbursesalicensedhealthcareproviderforservices,theformoffinancingiscalled______________.ANS:feeforserviceFeeforserviceisthedirectreimbursementbyaninsurancecompanytoahealthcareprovider.DIF:CognitiveLevel:ComprehensionREF:4-5OBJ:6(theory)TOP:HealthCareFinancingKEY:NursingProcessStep:NAMSC:NCLEX:NA27.Thenurseexplainsthattheterm_____________referstotheseverityofillness.ANS:acuityAcuityisthetermreferringtotheseverityofillnessorconditionofapatient.DIF:CognitiveLevel:KnowledgeREF:3OBJ:6(theory)TOP:AcuityKEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCareChapter02:CriticalThinkingandNursingProcessMULTIPLECHOICE

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1.Basictotheabilitytoapplycriticalthinking,thenursemusthave: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:BAnopenattitudenotcloudedbyunshakablebeliefsandvaluesorpresetgoalsallowstheapplicationofcriticalthinking.Acceptancethattheremaynotbeaperfectsolutionleavesthefieldopentonewideas.DIF:CognitiveLevel:ComprehensionREF:14-15OBJ:2(theory)TOP:FactorsInfluencingCriticalThinkingKEY:NursingProcessStep:NAMSC:NCLEX:HealthPromotionandMaintenance2.Thenurseexplainsthatafundamentalbasisforthenursingprocessis: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 withouttheir input.c.a focus on disease control.d.that all persons have worth and dignity.ANS:DThenursingprocessisbasedonthebeliefthatallpeoplehaveworthanddignity.Patient-centeredcarethatisappliedtoallaspectsofthepatient’shealth,andisnotjustdiseaseoriented,isappreciatedbythefamilyandpatient.Holisticcareapproachcansupportthepatienttomeetbasicneeds.DIF:CognitiveLevel:ApplicationREF:16OBJ:5(theory)TOP:BasicBeliefsPertinenttotheNursingProcessKEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare

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3.Uponapatient’sadmissiontothefacility,thenursecollectsthefollowingdata:patient’stemperatureis100°F,oxygensaturationis89%,frothymucusisexpectorated,andthepatient’schestfeelstight.Thenursecorrectlyidentifiestightnessinthechestas:a.judgmental.b.objective data.c.subjective data.d.drawing a conclusion.ANS:CSubjectivedataisinformationgivenbythepatientthatcannotbemeasuredotherwise.Theotherdataareconsideredobjectivedata.Objectivedataarepiecesofinformationthatcanbemeasuredbytheexaminer.Thenurseshouldavoidmakingjudgmentsorconclusionswhenobtainingdata.DIF:CognitiveLevel:ApplicationREF:18OBJ:2(clinical)TOP:AssessmentDataKEY:NursingProcessStep:PlanningMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare4.Thenewlyadmittedpatientisdescribinghisrecentsymptomstothenurse.Thenurseisawarethatthesourceofthisinformationisconsidered:a.primary.b.objective.c.secondary.d.complete.ANS:AThepatientistheprimarysourceofinformation.Objectivereferstoatypeofdataobtainedbythenursethatismeasuredorcanbeverifiedthroughassessmenttechniques,secondaryinformationisobtainedfromrelativesorsignificantothers,andinformationisnotnecessarilycompletewhenthepatientisthesource.DIF:CognitiveLevel:ApplicationREF:19OBJ:2(clinical)TOP:SourcesofInformationKEY:NursingProcessStep:AssessmentMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare

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5.Thenurseperforminganintakeinterviewonanewresidenttothelong-termcarefacilitydetectstheodorofacetonefromthepatient’sbreath.Theassessmentisdoneby:a.inspection.b.observation.c.auscultation.d.olfaction.ANS:DOlfactionisanassessmentmethodofsmells.Inspectionandobservationusethesenseofvision.Auscultationreferstouseofthesenseofhearing.DIF:CognitiveLevel:ComprehensionREF:20OBJ:3(clinical)TOP:OlfactionKEY:NursingProcessStep:AssessmentMSC:NCLEX:HealthPromotionandMaintenance6.Thenurse’sassessmentrevealsedemaofbothfeetandankles.Thebestdocumentationofthesefindingsis: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:DEdemashouldberecordedastolocation,depthofpitting,andtimeforresolution.DIF:CognitiveLevel:ApplicationREF:20OBJ:3(theory)TOP:PalpationKEY:NursingProcessStep:AssessmentMSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort7.Toassessskinturgor,thenursewould:a.examine mucous membranes of the mouth.b.compare limbs for similar color.

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c.pinch skinfold on chest for tenting.d.palpate ankles for evidence of pitting edema.ANS:CSkinturgorcanbeassessedbytentingtheskinonthechestandrecordingthespeedatwhichthe“tent”subsides.DIF:CognitiveLevel:ComprehensionREF:21OBJ:3(clinical)TOP:PracticalAssessmentKEY:NursingProcessStep:AssessmentMSC:NCLEX:HealthPromotionandMaintenance:PreventionandEarlyDetectionofDisease8.ThenursingstudentdemonstratesanunderstandingoftheHealthInsurancePortabilityandAccountabilityAct(HIPAA)by:a.using thepatient’sfull 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 patientinformation before leaving the clinical facility.d.asking the patient for permission to copy lab and diagnostic reports for educationalpurposes.ANS:CHIPAAforbidsanyinformationusedforeducationalpurposestohaveanyidentifyinginformation;therefore,shreddingdocumentswouldbeappropriate.Fullnamesondocuments,printingcopiesofchartforms,andaskingthepatientforpermissiontocopyformswouldbeviolationsofHIPAAregulations.DIF:CognitiveLevel:ApplicationREF:22OBJ:1(clinical)TOP:HIPAAKEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare9.ThediabeticpatientwhohadblooddrawnforanHbA1clevelsays,“Idon’tknowwhytheywanttolookatmyhemoglobin.”Themosthelpfulreplybythenursewouldbe:a.“The test is to evaluate your present level of bloodsugar.”

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b.“The HbA1c provides information relative to blood sugar levels from the past 2 to 3months.”c.“Hemoglobin levels and blood sugar levels are closelyrelated.”d.“The HbA1c tells if you have type 1 or type 2diabetes.”ANS:BHbA1cevaluatestheaveragebloodglucoselevelforthelast2to3months.DIF:CognitiveLevel:ComprehensionREF:24OBJ:2(clinical)TOP:DiagnosticStudiesKEY:NursingProcessStep:ImplementationMSC:NCLEX:HealthPromotionandMaintenance10.TheRNhaschosenthenursingdiagnosisofRiskforimpairedskinintegrityrelatedtoimmobility.Thecorrectgoal/outcomestatementforthediagnosiswouldbe: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:AThegoal/outcomestatementisdirectedattheetiologyandshouldbepatientoriented.Thestatementshouldberealisticandmeasurableandreflectwhatthepatientwilldo.DIF:CognitiveLevel:ApplicationREF:26OBJ:5(clinical)TOP:GoalsKEY:NursingProcessStep:PlanningMSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort11.ThenursewhohasrecentlymovedfromLouisianatoTexasisuncertainabouttheLPN/LVN’sroleinapplyingthenursingprocess.Themostappropriatesourceforthenursetoconsultis:a.hospital policies.b.the Texas State Board of Nursing.c.rules and regulations of the Louisiana Nurse Practice Act.

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d.the National Association of Practical Nurse Education and Service.ANS:BEachstatehasdifferentguidelinesforareasofcareplanning,intravenoustherapy,teaching,anddelegation.TheTexasStateBoardofNursingisthemostreliablesource.DIF:CognitiveLevel:ApplicationREF:16OBJ:6(theory)TOP:NursingProcessKEY:NursingProcessStep:NAMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare12.ThenurseaddsanursingordertothecareplanrelatedtoapatientwithanursingdiagnosisofNutrition:lessthanbodyrequirementrelatedtonauseaandvomiting.Thestatementthatisanursingorderis: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:BOfferingcrackersandiceddrinksarewithinthescopeofnursing;theotheroptionswouldrequireamedicalordertocomplete.DIF:CognitiveLevel:AnalysisREF:26OBJ:6(clinical)TOP:NursingOrdersKEY:NursingProcessStep:PlanningMSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort13.Becausetheevaluationofthenursingcareplanreflectslackofprogresstowardthegoal,thenursewillconferwiththepatienttoplana:a.more accessible goal.b.revision of interventions.c.different nursing diagnosis.d.new evaluation.

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ANS:BWhenlackofprogresstoreachthegoalisseenonevaluation,theinterventionsarereviewedand/orrevised.DIF:CognitiveLevel:ApplicationREF:27OBJ:2(clinical)TOP:EvaluationKEY:NursingProcessStep:PlanningMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare14.Duringtheintakeinterview,thenursenoticesthat,althoughthepatientdeniespain,heisgrimacingandholdinghishandoverhisstomach.Thenurse’sbestapproachwouldbeto: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 thepatient’sabdomen.ANS:BThenurseshouldtrytoresolveanyincongruencebetweenbodylanguageandverbalresponses.DIF:CognitiveLevel:ApplicationREF:17-20OBJ:1(clinical)TOP:PatientInterviewKEY:NursingProcessStep:AssessmentMSC:NCLEX:HealthPromotionandMaintenance15.Duringtheadmissioninterview,whenaskedaboutpain,thepatientresponds,“No.I’mprettywobbly.”Whichactionbythenursewouldbemostappropriate?a.Ask,“Didyou hear me? I asked you aboutpain.”b.Say,“Whatdo you mean‘wobbly’?”c.Record the patient denied pain.d.Record the patient stated he was wobbly.ANS:BThenurseshouldaskforclarificationifunsureofwhatismeantbyoneofthepatient’sresponses.

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DIF:CognitiveLevel:ApplicationREF:17-20OBJ:1(clinical)TOP:PatientInterviewKEY:NursingProcessStep:AssessmentMSC:NCLEX:HealthPromotionandMaintenance16.Thenursewritesaninterventionforthegoal:Patientwillsleepfor5hoursuninterruptedeachnight.Thebestnursinginterventionis:a.medicate with sedative each night.b.offer warm fluids frequently.c.arrange for a large meal at supper.d.discourage daytime napping.ANS:DDiscouragingdaytimenappingincreasestheprobabilityofsleep.Givingmedicationisacollaborativeinterventionasitrequiresanorder.Largemealandlargefluidintakesmayinterruptsleep.DIF:CognitiveLevel:AnalysisREF:26-27OBJ:2(clinical)TOP:NursingInterventionKEY:NursingProcessStep:PlanningMSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort17.Thenursingteamprioritizingthenursingdiagnosesofanoverweighthospitalpatientwillselectasthehighestprioritythenursingdiagnosisof: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:BActivityintoleranceisthehighestpriorityasithastodowithactivitiesthatareessentialtolife.ThesecondisKnowledgedeficitrelatedtoweightreductiondiet,followedbyAlteredself-imagerelatedtoexcessiveweight,andthelastisRiskfordehydrationrelatedtovomiting.DIF:CognitiveLevel:AnalysisREF:24-27OBJ:2(clinical)

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TOP:SettingPrioritiesKEY:NursingProcessStep:PlanningMSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort18.Thenurseexplainsthat,inadditiontotheNANDAstemandetiology,thecompletenursingdiagnosisshouldinclude: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:CAcompletenursingdiagnosismusthaveaNANDAstem,etiology,andsignsandsymptoms(etiology)oftheproblem.DIF:CognitiveLevel:ComprehensionREF:24-25OBJ:7(clinical)TOP:NursingDiagnosisKEY:NursingProcessStep:PlanningMSC:NCLEX:HealthPromotionandMaintenance19.Thenurseexplainstoapatientthatinclusionofpotentialproblemsinthenursingcareplan: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:AAddressingpotentialproblemspreventscomplicationsbyearlyactionratherthanwaitingforaproblemtomaterialize.DIF:CognitiveLevel:ApplicationREF:24-25OBJ:7(clinical)TOP:PotentialHealthProblemsKEY:NursingProcessStep:PlanningMSC:NCLEX:HealthPromotionandMaintenance

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20.Duringtheadmissionprocess,thenursereceivesordersforthepatienttohavearterialbloodgases(ABGs)drawn.Whichfindingfromthepatient’shistorymaycauseconcern?a.Taking ginkgo biloba for the last 6 monthsb.Having an increased hematocrit (Hct) level during the last physical examc.Being diabetic for 10 yearsd.Having a decreased white blood cell (WBC) countANS:AGinkgobilobamaylowertheplateletcountandcausebleeding.Therefore,thenursewouldbeconcernedaboutarterialbleedingoccurringfollowingABGsbeingdrawn.IncreasedHct,ahistoryofdiabetes,andadecreasedWBCcountwouldnotposeanyproblemswithdrawingasampleforABGs.DIF:CognitiveLevel:ApplicationREF:23OBJ:2(clinical)TOP:AlternativeMedicineKEY:NursingProcessStep:AssessmentMSC:NCLEX:PhysiologicalIntegrity:ReductionofRiskPotential21.TheLPN/LVNadherestofacilitypolicyregardingcoremeasuresbyperformingwhichinterventionsduringpatientcare?a.Administering the ordered amount of insulin to a patient with type 1 diabetesb.Performing a thorough patient assessment upon admission to the health care facilityc.Documenting accurately and at appropriate intervals in thepatient’srecordd.Providing patient teaching regarding proper diet for the patient diagnosed with renal failureANS:ACoremeasuresareinterventionsthatarebasedonscientificallyresearched,evidenced-basedstandardsofcareandareusedtotreatthemajorityofpatientswithaspecificillnesswhichoftendevelopscomplications.Insulinadministrationfordiabeticsisevidence-basedresearchedpractice.Theremainingoptionsaregoodpracticebutarenotconsideredcoremeasures.DIF:CognitiveLevel:AnalysisREF:17OBJ:10(clinical)TOP:CoreMeasuresKEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:ManagementofCare

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22.Thenurseiscaringforapatientdiagnosedwithpneumonia.ThepatienthasaBP160/94,P102,R28,cracklesinposteriorlowerlobesbilaterally,oxygensaturation89%,andcomplainsofshortnessofbreathuponexertion.Thehighestprioritynursingdiagnosisforthispatientis:a.Activity intoleranceb.Impaired gas exchangec.Ineffective cardiopulmonary tissue perfusiond.Self-care deficit: Bathing and hygieneANS:BWhileallnursingdiagnosesmayapplytothispatient,Impairedgasexchangeisthehighestprioritybecausethisistheunderlyingproblemfortheothernursingdiagnoses,aswellasphysiologicallythehighestpriority.DIF:CognitiveLevel:ApplicationREF:24-27OBJ:2(clinical)TOP:NursingDiagnosisKEY:NursingProcessStep:PlanningMSC:NCLEX:Safe,EffectiveCareEnvironment:ManagementofCareMULTIPLERESPONSE23.Thenurseexplainstothenursingstudentthattheapplicationofcriticalthinkingtopatientcareinvolves:(Selectallthatapply.)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,ECriticalthinkingasappliedtonursingcarerequiressettingprioritiesofpatientproblemsandneedsbyusinglogicandintuition.Inclusionofthefamilyinthecaremakestheapproachfamilyoriented.Criticalthinkingshouldgobeyondtheobvious.DIF:CognitiveLevel:ComprehensionREF:14-16OBJ:2(theory)TOP:CriticalThinkingKEY:NursingProcessStep:Implementation

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MSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare24.Thenursedemonstratesapplicationofthenursingprocessby:(Selectallthatapply.)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 progresstoward meeting goals.e.ensuring that all personnel caring for the patient are implementing the care plan andworking toward the same goals.ANS:A,C,D,EThenursingcareplanshouldbeupdatedasnecessary,notjustonaweeklybasis.Conceptsofthenursingprocessaredemonstratedbyperformingorderly,logicalhead-to-toeassessments,aswellasongoingevaluationofpatientgoalsandinterventionstomeetthosegoals.DIF:CognitiveLevel:ComprehensionREF:16OBJ:1(clinical)TOP:NursingProcessKEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare25.ThenursedemonstratesknowledgeoftheNationalPatientSafetyGoalsbyperformingpatientcarethatincludes:(Selectallthatapply.)a.identifying the patient prior to medication administration by asking the patient to state his orher name.b.reporting any sentinel event to thefacility’squality assurance team.c.assessing thepatient’sheart 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,EAssessingthepatient’sheartratepriortoadministrationofdigoxindemonstratesknowledgeofmedicationactionsandpreventionofadverseeffects;handhygieneisrequiredbeforeanypatientcare,includingassessment;anddocumentationofthetimeofmedicationadministrationisnecessarytopreventmedicationerrors.TomeetNationalPatientSafetyGoals,thenursemust

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useatleasttwomethodsofpatientidentificationpriortomedicationadministration.ReportingasentineleventisrequiredbutdemonstratesthatNationalPatientSafetyGoalswerenotmet.DIF:CognitiveLevel:ApplicationREF:17|Box2-3OBJ:9(clinical)TOP:NationalPatientSafetyGoalsKEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:SafetyandInfectionControlCOMPLETION26.Thenursingstudentdemonstratesknowledgeoftheproperuseofthe___________whendeterminingthatitissafetoadministermeperidine(Demerol)andpromethazine(Phenergan)together.ANS:MedicationReconciliationFormTheMedicationReconciliationFormtracksallmedicationsthepatientistakingasprescribedbydifferentphysiciansandcanidentifyoverdosesordrugsthatarenotcompatible.DIF:CognitiveLevel:ApplicationREF:19-20OBJ:2(clinical)TOP:MedicationReconciliationFormKEY:NursingProcessStep:ImplementationMSC:NCLEX:Safe,EffectiveCareEnvironment:CoordinatedCare27.Shortnessofbreathduetoemphysemawouldbeamajorcomponentofthe_________careplan.ANS:interdisciplinaryAninterdisciplinarycareplaninvolvesallmembersofthehealthcareteamandisbasedonthemedicaldiagnosisratherthananursingdiagnosis.DIF:CognitiveLevel:ApplicationREF:27OBJ:2(clinical)TOP:InterdisciplinaryCarePlanKEY:NursingProcessStep:PlanningMSC:NCLEX:HealthPromotionandMaintenanceMATCHINGPlacethestepsofthenursingprocessintheirpropersequence.

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a.Evaluationb.Assessmentc.Implementationd.Planninge.Nursing diagnosis28.Step129.Step230.Step331.Step432.Step528.ANS:BDIF:CognitiveLevel:ComprehensionREF:17OBJ:7(clinical)TOP:ApplyingtheNursingProcessKEY:NursingProcessStep:PlanningMSC:NCLEX:HealthPromotionandMaintenance29.ANS:EDIF:CognitiveLevel:ComprehensionREF:17OBJ:7(clinical)TOP:ApplyingtheNursingProcessKEY:NursingProcessStep:PlanningMSC:NCLEX:HealthPromotionandMaintenance30.ANS:DDIF:CognitiveLevel:ComprehensionREF:17OBJ:7(clinical)TOP:ApplyingtheNursingProcessKEY:NursingProcessStep:PlanningMSC:NCLEX:HealthPromotionandMaintenance31.ANS:CDIF:CognitiveLevel:ComprehensionREF:17OBJ:7(clinical)TOP:ApplyingtheNursingProcessKEY:NursingProcessStep:PlanningMSC:NCLEX:HealthPromotionandMaintenance32.ANS:ADIF:CognitiveLevel:ComprehensionREF:17OBJ:7(clinical)TOP:ApplyingtheNursingProcessKEY:NursingProcessStep:PlanningMSC:NCLEX:HealthPromotionandMaintenance

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Chapter03:Fluid,Electrolytes,Acid-BaseBalance,andIntravenousTherapyMULTIPLECHOICE1.Thenurseusesadiagramtodemonstratehowindehydrationthewaterisdrawnintotheplasmafromthecellsbytheprocessof:a.distillation.b.diffusion.c.filtration.d.osmosis.ANS:DTheprocessofosmosisaccomplishesthemovementofwaterfromthecellsintotheplasma,causingdehydration.DIF:CognitiveLevel:ComprehensionREF:32-33OBJ:3(theory)TOP:DehydrationKEY:NursingProcessStep:ImplementationMSC:NCLEX:PhysiologicalIntegrity:PhysiologicalAdaptation2.Thenurseassessingapatientwithvomitinganddiarrheaobservesthattheurineisscantandconcentrated.Thenurseexplainsthatthecompensatoryreabsorptionofwateriscontrolledby:a.osmoreceptors in the hypothalamus.b.antidiuretic hormone in the posterior pituitary.c.baroreceptors in the carotid sinus.d.insulin from the pancreas.ANS:BTheantidiuretichormonecontrolshowmuchwaterleavesthebodybyreabsorbingwaterintherenaltubules.DIF:CognitiveLevel:KnowledgeREF:31-32OBJ:2(theory)TOP:RegulationofBodyFluidsKEY:NursingProcessStep:ImplementationMSC:NCLEX:PhysiologicalIntegrity:PhysiologicalAdaptation

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3.Thenurseusesapicturetoshowhowionsequalizetheirconcentrationbythepassivetransportprocessof:a.osmosis.b.filtration.c.titration.d.diffusion.ANS:DDiffusionistheprocessbywhichsubstancesmovebackandforthacrosscompartmentmembranesuntiltheyareequallydivided.DIF:CognitiveLevel:ComprehensionREF:32OBJ:3(theory)TOP:DiffusionKEY:NursingProcessStep:ImplementationMSC:NCLEX:PhysiologicalIntegrity:PhysiologicalAdaptation4.Thenurseexplainsthattheactivetransportprocessthatisabletomovesodiumandpotassiumintooroutofcellsis:a.filtration.b.sodium pump.c.diffusion.d.osmosis.ANS:BThesodiumpumpisthemechanismbywhichsodiumandpotassiumaremovedintooroutofcellsregardlessoftheconcentration.DIF:CognitiveLevel:ComprehensionREF:33OBJ:3(theory)TOP:ActiveTransportKEY:NursingProcessStep:ImplementationMSC:NCLEX:PhysiologicalIntegrity:PhysiologicalAdaptation5.Thepatienttakingfurosemide(Lasix)tocorrectexcessedemashowsaweightlossof5.5poundsin24hours.Thenursecalculatesthisweightlosstobetheexcretionofapproximately_____litersoffluid.

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a.1.0b.1.5c.2.0d.2.5ANS:DEachkilogram(2.2pounds)ofweightlossisequivalentto1literoffluid.Therefore,5.5pounds÷2.2pounds=2.5liters.DIF:CognitiveLevel:ApplicationREF:35OBJ:1(clinical)TOP:FluidLossKEY:NursingProcessStep:AssessmentMSC:NCLEX:PhysiologicalIntegrity:PhysiologicalAdaptation6.Whenthenurseassessesapotassiumlevelof2.9mEq/Linthepatientwithvomitinganddiarrhea,thenursewillbealertfor:a.excessive urinary output.b.abdominal distention.c.increased reflexes.d.hyperactive bowel sounds.ANS:BApotassiumlevellowerthan3.5mEq/Lresultsinreducedurineoutput,cardiacdysrhythmia,muscleweakness,abdominalpainanddistention,paralyticileus,lethargy,andconfusion.DIF:CognitiveLevel:ApplicationREF:42|Table3-4OBJ:4(theory)TOP:HypokalemiaKEY:NursingProcessStep:AssessmentMSC:NCLEX:PhysiologicalIntegrity:BasicCareandComfort7.Whilethenurseiswashingthefaceofapatientinrenalfailure,thepatientdemonstratesaspasmofthelipsandface.Thenurseexaminestherecentelectrolytelevelstoassessthelevelof:a.potassium.

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