Test Bank For Medical-Surgical Nursing: Concepts and Practice, 2nd Edition

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Chapter 01: Caring for Medical-SurgicalPatientsChapter 01: Caring for Medical-Surgical PatientsMULTIPLE CHOICE1.The new nurse demonstrates an understanding of the primary purpose of the statenurse practice act (NPA) by explaining that it acts to:a.testandlicenseLPN/LVNs.b.definethescopeofLPN/LVNpractice.c.improvethequalityofcareprovidedbytheLPN/LVN.d.limittheLPN/LVNemploymentplacement.ANS: BWhile improving quality of care provided by the LPN/LVN may be a result of theNPA, the primary purpose of the NPA of each state defines the scope of nursingpractice in that state.DIF: Cognitive Level: Comprehension REF: 1-2 OBJ: 1 (theory)TOP: NPA KEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care2.The charge nurse asks the new vocational nurse to start an intravenous infusion.Because the vocational nurse has not been taught this skill during her educationalprogram, the vocational nurse should:a.askamoreexperiencednursetodemonstratetheprocedure.b.lookuptheprocedureintheproceduremanual.c.attempttoperformtheprocedurewithsupervision.d.informthechargenurseofherlackoftraininginthisprocedure.ANS: DThe charge nurse should be informed of the lack of training to perform the procedure,and the vocational nurse should seek further training to gain proficiency. Although theother options might be helpful, they are not safe.DIF: Cognitive Level: Application REF: 2 OBJ: 1 (theory)TOP: Providing Safe Care KEY: Nursing Process Step: NAMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

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3.The nurse recognizes the need for further discharge education when the patientsays:a.“Ihavenoideaofhowthisdrugwillaffectme.”b.“Doyouknowifmyphysicianiscomingbacktoday?”c.“Willmyinsurancepayformystay?”d.“AmIgoingtohavetogotoanursinghome?”ANS: ALack of knowledge at discharge about medication effects and side effects is a concernthat should be addressed by the vocational nurse. The other concerns in the optionsare the responsibility of other departments to which the nurse might refer the patient.DIF: Cognitive Level: Analysis REF: 2 OBJ: 1 (theory)TOP: Teaching KEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care4.According to most state NPAs, the vocational nurse acting as charge nurse in along-term care facility is acting in which capacity?a.UnderdirectsupervisionofanRNontheunitb.WiththeRNinthebuildingc.UndergeneralsupervisionbytheRNavailableonsiteorbyphoned.AsanindependentvocationalnurseANS: CThe vocational nurse in the capacity of the charge nurse in a long-term care facilityacts with the general supervision of an RN available on site or by phone.DIF: Cognitive Level: Comprehension REF: 3 OBJ: 1 (theory)TOP: Charge Nurse/Manager KEY: Nursing Process Step: NAMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care5.The nurse reminds the patient who is a member of a health maintenanceorganization that prior to treatment he will need to:a.seektheopinionofanotherphysician.b.havemedicalservicesapprovedbyhisinsurance.c.providedocumentationofallcarereceivedforhiscondition.d.wait6monthstoseeaspecialist.ANS: B

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Most HMOs require preprocedure authorization for treatment. Patients are notrequired to seek a second opinion, provide documentation of care, or wait a specifictime period before visiting a specialist.DIF: Cognitive Level: Application REF: 5 OBJ: 3 (theory)TOP: Charge Nurse/Manager KEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care6.The patient complains to the nurse that he is confused about his“deductible”that heowes the hospital. The nurse explains that the deductible is a(n):a.amountofmoneyputasideforthepaymentoffuturemedicalbills.b.one-timefeeforservice.c.amountofmoneydeductedfromthebillbytheinsurancecompany.d.annualamountofmoneythepatientmustpayout-of-pocketformedicalcare.ANS: DThe deductible is the annual amount the insured must pay out-of-pocket prior to theinsurance company assuming the cost. This practice improves the profit of theinsurance company.DIF: Cognitive Level: Application REF: 4 OBJ: 5 (theory)TOP: Health Care Financing KEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care7.The nurse compares the characteristics of a health maintenance organization (HMO)and a preferred provider organization (PPO), pointing out that an HMO:a.requiresasetfeeofeachmembermonthly.b.allowsthemembertoselecthishealthcareprovider.c.permitsadmissiontoanyfacilitythememberprefers.d.offersunlimiteddiagnosticstestsandtreatments.ANS: AHMOs require a set fee from each member monthly (capitation). The patient will betreated by the HMO staff in HMO-approved facilities. Excessive use of diagnostictests and treatments is discouraged by the HMO.DIF: Cognitive Level: Application REF: 5 OBJ: 3 (theory)

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TOP: Managed Care KEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care8.When the patient asks the nurse what his Medicare Part A covers, the nurseresponds that it covers:a.inpatienthospitalcosts.b.reimbursementtothephysician.c.outpatienthospitalservices.d.ambulancetransportation.ANS: AMedicare Part A covers inpatient hospital expenses, drugs, x-rays, lab work, andintensive care. Medicare Part B pays the physician, ambulance transport, andoutpatient services.DIF: Cognitive Level: Comprehension REF: 5 | Box 1-3 OBJ: 4 (theory)TOP: Government-Sponsored Health InsuranceKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care9.The nurse explains that the main cost containment component of diagnosis-relatedgroups (DRGs) is that:a.hospitalsfocusonlyonthespecificdiagnosis.b.hospitalstreatanddischargepatientsquickly.c.reduced-costdrugsareorderedforthespecificdiagnosis.d.diagnosticgroupclassificationstreamlinescare.ANS: BDRGs are a prospective payment plan in which hospitals receive a flat fee for eachpatient’sdiagnostic category regardless of the length of time in the hospital. Ifhospitals can treat and discharge patients before the allotted time, hospitals get to keepthe excess payment; cost is contained, and the patient is discharged sooner.DIF: Cognitive Level: Comprehension REF: 6 OBJ: 5 (theory)TOP: Government-Sponsored Health InsuranceKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care10.While assessing a group of patients, the nurse recognizes the patient who couldqualify for Medicaid benefits is the:

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a.35-year-oldunemployedsinglemotherwithdiabetes.b.70-year-oldMedicarerecipientwithretirementincomewhoneedstobeinalong-termcarefacility.c.80-year-oldblindwomanlivinginherownhomewhohasinadequateprivateinsurance.d.67-year-oldstrokevictimwithMedicarePartAandanincomefrominvestments.ANS: AMedicaid is a joint effort of federal and state governments geared primarily for low-income people with no insurance.DIF: Cognitive Level: Comprehension REF: 6 | Box 1-5 OBJ: 4 (theory)TOP: Government-Sponsored Health Insurance–MedicaidKEY: Nursing Process Step: AssessmentMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care11.The nurse explains that the major focus ofHealthy People 2020is to improve thehealth of Americans in the second decade of the century by:a.fundingresearch.b.distributinghealthinformation.c.encouraginghealthylifestyles.d.designingprogramsforhealthimprovement.ANS: CHealthy Peoplefocuses on helping ongoing programs to incorporate support andinformation to reduce infant mortality, cancer, cardiovascular disease, and HIV/AIDSand to increase effective immunizations, healthy eating habits, and healthy weight.DIF: Cognitive Level: Comprehension REF: 6-7 OBJ: 7 (theory)TOP: Healthy People 2020 KEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care12.The nurse who plans interventions for all dimensions of thepatient’slife ispracticing _____ care.a.focusedb.generalc.directedd.holistic

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ANS: DHolistic care addresses the physiologic, psychological, social, cultural, and spiritualneeds of the patient.DIF: Cognitive Level: Comprehension REF: 7 OBJ: 8 (theory)TOP: Holistic Care KEY: Nursing Process Step: PlanningMSC: NCLEX: Psychosocial Integrity: Coping and Adaptation13.The patient furiously says,“Mydoctor was so busy giving me instructions that hedidn’thear what I was trying to askhim.”The most empathetic response would be:a.“Boy!Whenpeopledothattome,Ireallygetmad.”b.“I’msurethedoctorwasrushedandunawareofyourneeds.”c.“I’llbetthatmadeyoufeelveryfrustrated.”d.“Takeadeepbreathandplanwhatyouwillsaytohimtomorrow.”ANS: CEmpathy demonstrates that the nurse perceives thepatient’sfeelings but does notshare the emotion. Belittling thepatient’sfeelings, showing sympathy, or defendingthe doctor makes the patient feel devalued.DIF: Cognitive Level: Analysis REF: 8 OBJ: 9 (theory)TOP: Nurse–Patient Relationship KEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity14.The nurse explains that a therapeutic relationship differs from a social relationshipin that the therapeutic relationship:a.hasnoboundaries.b.isgoaldirected.c.meetstheneedsofeachpersonintherelationship.d.extendspastthehospitalizationperiod.ANS: BThe therapeutic relationship is focused on the patient and is goal directed anddesigned to meet only the needs of the patient and does not extend past the period ofhospitalization.DIF: Cognitive Level: Application REF: 8 OBJ: 9 (theory)TOP: Therapeutic Relationship KEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity

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15.The most effective nursing approach in caring for a depressed 80-year-old newlyadmitted resident to a long-term care facility would be to:a.encouragetheresidenttoengageinanactivity.b.remindtheresidentofreasonstobepositive.c.pointoutepisodesofnegativebehavior.d.presentabrightandcheerfulbehavior.ANS: AActivity and social interaction are helpful to depressed patients. Presenting a cheeryapproach and pointing out negative behavior and reasons to be positive are nottherapeutic at this stage of the relationship.DIF: Cognitive Level: Application REF: 8 OBJ: 11 (theory)TOP: Depressed Behavior KEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity16.The patient who has been on antidepressants for 3 days tearfully says,“Istill feelrotten. Idon’tthink anything can help how Ifeel.”Which is the best response by thenurse?a.“Iwilltellthechargenursehowyouarefeeling.”b.“Youwillneedtobepatientandgiveyourmedicinesometimetowork.”c.“Lookhowmuchyouhaveimprovedsinceyouwereadmittedtothefacility.”d.“Itmustbefrustratingtobegoingthroughthisdifficulttime.”ANS: DThis response is an empathetic response which allows for further exploration of thepatient’sfeelings. The other responses will block communication with this patient.DIF: Cognitive Level: Application REF: 8-9 OBJ: 11 (theory)TOP: Therapeutic Communication KEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity17.An overweight male patient rips off his hospital gown, throws it out the door, andshouts,“I’mnot wearing this stupid gown. It is too small, too short, and exposes mybackside to theworld.”Thenurse’sbest approach would be to:a.remindpatientoftheneedtowearthegownforconvenienceincare.

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b.conferwiththepatientformethodstoacquirealargergown.c.replacethetorngownwithanother.d.informthechargenurseofthehostilebehavior.ANS: BAllowing hostile patients to make reasonable requests defuses the anger and allowspatients to vent their feelings.DIF: Cognitive Level: Application REF: 9 OBJ: 11 (theory)TOP: Hostile Behavior KEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity: Coping and Adaptation18.A manipulative patient states,“Youare the only nurse who understands about mypain.Can’tyou give me an extra dose of painmedication?”The nurse should:a.bematter-of-factandexplainthatdosageschedulesarebyphysician’sorders.b.ignoretherequest.c.pointoutthatsuchmanipulativebehaviorisineffective.d.givetheextradose.ANS: AA matter-of-fact response to a manipulative request limits the effect of themanipulation, thereby helping the nurse to avoid becoming defensive or being swayedby flattery.DIF: Cognitive Level: Application REF: 9 OBJ: 11 (theory)TOP: Manipulative Behavior KEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity19.A female patient who has recently been diagnosed with an inoperable brain tumorasks the nurse,“Doyou think God punishesus?”Thenurse’smost helpful approachwould be to:a.sitdownwiththepatientandask,“Whatdoyouthink?”b.touchthepatient’sshoulderandsay,“Godlovesyou.”c.askthepatientifshewouldliketospeakwiththechaplain.d.say,“Godwillnotgiveyoumorethanyoucanbear.”ANS: A

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Sitting with the patient and offering oneself to listen to thepatient’sconcerns andencouraging reflection is the best approach rather than responding with a cliché orsuggesting speaking with the chaplain.DIF: Cognitive Level: Analysis REF: 8-9 OBJ: 11 (theory)TOP: Spiritual Care KEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial Integrity20.The nurse is communicating with a patient who has voiced concern regarding anupcoming high-risk procedure. The nurse demonstrates empathy by stating:a.“Wouldyouliketotalkaboutyourfeelingsregardingtheprocedure?”b.“Mymotherhadthesameprocedureanddidverywell.”c.“Ican’timaginehowyoufeel.”d.“Itmustbedifficultpreparingfortheprocedure;howareyoufeeling?”ANS: DThis statement by the nurse displays empathy by trying to place oneself in thepatient’scircumstance and validating thepatient’sfeelings. Simply asking patients ifthey would like to talk about their feelings does not show empathy and may elicit a“yes”or“no”response. Telling the patientone’smother had the procedure or stating“Ican’timagine how youfeel”does not show empathy toward the patient.DIF: Cognitive Level: Application REF: 7-8 OBJ: 9 (theory)TOP: Nurse–Patient Relationship KEY: Nursing Process Step: ImplementationMSC: NCLEX: Psychosocial IntegrityMULTIPLE RESPONSE21.The new LPN/LVN reminds a coworker that clear guidelines for upholdingclinical standards for safe and competent care can be found in information from:(Select all that apply.)a.thestate’snursepracticeact(NPA).b.theStateBoardofNurseExaminers(BNE).c.theNationalAssociationforPracticalNurseEducationandService(NAPNES).d.institutionalpolicies.e.theNationalFederationofLicensedPracticalNurses,Inc.

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(NFLPN).ANS: C, ENAPNES and the NFLPN give clear guidelines for clinical standards that can be usedas a basis for court decisions. The NPA has broad guidelines, and institutional policiesmay not be complete. The BNE enforces the NPA.DIF: Cognitive Level: Comprehension REF: 2 OBJ: 1 (theory)TOP: Upholding Clinical Standards KEY: Nursing Process Step: NAMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care22.The LPN/LVN clarifies that the role of the LPN/LVN, regardless of employmentplacement, is to: (Select all that apply.)a.upholdclinicalstandards.b.educatepatients.c.communicateeffectively.d.collaboratewiththehealthcareteam.e.initiateacareplanimmediatelyafteradmission.ANS: A, B, C, DThe LPN/LVN has the accountability to uphold clinical standards, educate patients,communicate effectively, and collaborate with the health care team. Depending on thetype of facility, initiation of a care plan is often the role of the registered nurse.DIF: Cognitive Level: Comprehension REF: 2-3 OBJ: 2 (theory)TOP: Roles of LPN/LVNs KEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care23.The newly licensed LPN/LVN demonstrates an understanding of employmentopportunities when applying to a position in which of the following areas? (Select allthat apply.)a.Anoutpatientclinicb.Ahomehealthcareagencyc.Anintravenoustherapyteamd.Along-termcarefacilitye.AnambulatorycareunitANS: A, B, D, E

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With the exception of an intravenous therapy team, which requires postgraduateeducation and/or certification, the other options are open to newly graduatedvocational nurses.DIF: Cognitive Level: Application REF: 3 | Box 1-1 OBJ: 2 (theory)TOP: Employment Opportunities for LPN/LVNs KEY: Nursing Process Step: NAMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care24.When an LPN/LVN delegates a task to unlicensed assistive personnel (UAP), thereis: (Select all that apply.)a.aneedfortheUAPtovoluntarilyacceptthetaskdelegated.b.continuedaccountabilityforthetaskbytheLPN/LVN.c.nofurtherneedforsupervisionoftheUAP.d.theunderstandingthatthetaskisinthejobdescriptionoftheUAP.e.atransferofauthoritytotheUAP.ANS: A, B, D, EDelegation is a considered act involving the condition of the patient and thecompetency of the UAP. Delegation requires that the UAP voluntarily accept the task,which is in the job description of the UAP. The vocational nurse has transferredauthority for the completion of the task but is still accountable and should supervise.DIF: Cognitive Level: Application REF: 3-4 OBJ: 2 (theory)TOP: Delegation KEY: Nursing Process Step: NAMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care25.Following an in-service regarding cost containment within the health care facility,the LPN/LVN demonstrates understanding by: (Select all that apply.)a.tellingpatientsthattheymustlimittheamountofsuppliestheyuse.b.askingtheUAPtobesuretocorrectlychargeforpatientcareitems.c.usingonlynecessaryitemsforpatientcare.d.usingandchargingforextrapatientcareitemsthatthepatientmaytakehomeupondischarge.e.documentingsuppliesusedforpatientsintheirpatientcarerecord.ANS: B, C, E

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The UAP must correctly charge patients utilizing thefacility’scharging system, onlynecessary supplies should be used for patient care, and documenting supplies usedassists in reimbursement. It is inappropriate and not thepatient’sresponsibility tomonitor their supply use, and excess charges would be incurred if items were given tothe patient upon discharge.DIF: Cognitive Level: Application REF: 6 OBJ: 6 (theory)TOP: Cost Containment KEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Management of CareCOMPLETION26.When an insurance company directly reimburses a licensed health care providerfor services, the form of financing is called ______________.ANS:fee for serviceFee for service is the direct reimbursement by an insurance company to a health careprovider.DIF: Cognitive Level: Comprehension REF: 4-5 OBJ: 6 (theory)TOP: Health Care Financing KEY: Nursing Process Step: NAMSC: NCLEX: NA27.The nurse explains that the term _____________ refers to the severity of illness.ANS:acuityAcuityis the term referring to the severity of illness or condition of a patient.DIF: Cognitive Level: Knowledge REF: 3 OBJ: 6 (theory)TOP: Acuity KEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Coordinated CareChapter 02: Critical Thinking and NursingProcessChapter 02: Critical Thinking and Nursing ProcessMULTIPLE CHOICE1.Basic to the ability to apply critical thinking, the nurse must have:a.unshakablebeliefsandvalues.b.anopenattitude.

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c.theabilitytodisregardevidenceinconsistentwithsetgoals.d.theabilitytorecognizetheperfectsolution.ANS: BAn open attitude not clouded by unshakable beliefs and values or preset goals allowsthe application of critical thinking. Acceptance that there may not be a perfect solutionleaves 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: NAMSC: NCLEX: Health Promotion and Maintenance2.The nurse explains that a fundamental basis for the nursing process is:a.thatbasicneedsmustbemetbytheindividualwithoutassistance.b.thatpatientsandfamiliesappreciateanefficienthealthcaresystemthatfunctionswithouttc.afocusondiseasecontrol.d.thatallpersonshaveworthanddignity.ANS: DThe nursing process is based on the belief that all people have worth and dignity.Patient-centered care that is applied to all aspects of thepatient’shealth, and is notjust disease oriented, is appreciated by the family and patient. Holistic care approachcan support the patient to meet basic needs.DIF: Cognitive Level: Application REF: 16 OBJ: 5 (theory)TOP: Basic Beliefs Pertinent to the Nursing ProcessKEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care3.Upon apatient’sadmission to the facility, the nurse collects the following data:patient’stemperature is 100° F, oxygen saturation is 89%, frothy mucus isexpectorated, and thepatient’schest feels tight. The nurse correctly identifiestightness in the chest as:a.judgmental.b.objectivedata.c.subjectivedata.d.drawingaconclusion.ANS: C

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Subjective datais information given by the patient that cannot be measured otherwise.The other data are considered objective data. Objective data are pieces of informationthat can be measured by the examiner. The nurse should avoid making judgments orconclusions when obtaining data.DIF: Cognitive Level: Application REF: 18 OBJ: 2 (clinical)TOP: Assessment Data KEY: Nursing Process Step: PlanningMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care4.The newly admitted patient is describing his recent symptoms to the nurse. Thenurse is aware that the source of this information is considered:a.primary.b.objective.c.secondary.d.complete.ANS: AThe patient is the primary source of information. Objective refers to a type of dataobtained by the nurse that is measured or can be verified through assessmenttechniques, secondary information is obtained from relatives or significant others, andinformation 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: AssessmentMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care5.The nurse performing an intake interview on a new resident to the long-term carefacility detects the odor of acetone from thepatient’sbreath. The assessment is doneby:a.inspection.b.observation.c.auscultation.d.olfaction.ANS: DOlfaction is an assessment method of smells. Inspection and observation use the senseof vision. Auscultation refers to use of the sense of hearing.DIF: Cognitive Level: Comprehension REF: 20 OBJ: 3 (clinical)

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TOP: Olfaction KEY: Nursing Process Step: AssessmentMSC: NCLEX: Health Promotion and Maintenance6.Thenurse’sassessment reveals edema of both feet and ankles. The bestdocumentation of these findings is:a.pittingedemapresentinbothfeetandankles.b.edemainbothfeetandanklesapproximately4mmdeep.c.4mmpittingedemaquicklyresolving.d.bilateralpittingedemainfeetandankles:4mmdeepresolvingin3seconds.ANS: DEdema 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: AssessmentMSC: NCLEX: Physiological Integrity: Basic Care and Comfort7.To assess skin turgor, the nurse would:a.examinemucousmembranesofthemouth.b.comparelimbsforsimilarcolor.c.pinchskinfoldonchestfortenting.d.palpateanklesforevidenceofpittingedema.ANS: CSkin turgor can be assessed by tenting the skin on the chest and recording the speed atwhich the“tent”subsides.DIF: Cognitive Level: Comprehension REF: 21 OBJ: 3 (clinical)TOP: Practical Assessment KEY: Nursing Process Step: AssessmentMSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease8.The nursing student demonstrates an understanding of the Health InsurancePortability and Accountability Act (HIPAA) by:a.usingthepatient’sfullnameonlyonclinicalassignmentssubmittedtotheinstructor.b.usingthefacilityprintertocopylabreportsonanassignedpatient.c.shreddinganydocumentsthatthestudenthasbeenusingthatcontainidentifyingpatientinleavingtheclinicalfacility.d.askingthepatientforpermissiontocopylabanddiagnosticreportsforeducationalpurposeANS: C

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HIPAA forbids any information used for educational purposes to have any identifyinginformation; therefore, shredding documents would be appropriate. Full names ondocuments, printing copies of chart forms, and asking the patient for permission tocopy forms would be violations of HIPAA regulations.DIF: Cognitive Level: Application REF: 22 OBJ: 1 (clinical)TOP: HIPAA KEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care9.The diabetic patient who had blood drawn for an HbA1c level says,“Idon’tknowwhy they want to look at myhemoglobin.”The most helpful reply by the nurse wouldbe:a.“Thetestistoevaluateyourpresentlevelofbloodsugar.”b.“TheHbA1cprovidesinformationrelativetobloodsugarlevelsfromthepast2to3monthc.“Hemoglobinlevelsandbloodsugarlevelsarecloselyrelated.”d.“TheHbA1ctellsifyouhavetype1ortype2diabetes.”ANS: BHbA1c 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: ImplementationMSC: NCLEX: Health Promotion and Maintenance10.The RN has chosen the nursing diagnosis of Risk for impaired skin integrityrelated to immobility. The correct goal/outcome statement for the diagnosis would be:a.patientwillsitinchairatbedsidefor15minutesaftereachmeal.b.nursewillassistpatienttochaireveryshift.c.nursewillassessskinandrecordconditioneveryshift.d.patientwillchangepositionfrequently.ANS: AThe 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: PlanningMSC: NCLEX: Physiological Integrity: Basic Care and Comfort

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11.The nurse who has recently moved from Louisiana to Texas is uncertain about theLPN/LVN’srole in applying the nursing process. The most appropriate source for thenurse to consult is:a.hospitalpolicies.b.theTexasStateBoardofNursing.c.rulesandregulationsoftheLouisianaNursePracticeAct.d.theNationalAssociationofPracticalNurseEducationandService.ANS: BEach state has different guidelines for areas of care planning, intravenous therapy,teaching, and delegation. The Texas State Board of Nursing is the most reliablesource.DIF: Cognitive Level: Application REF: 16 OBJ: 6 (theory)TOP: Nursing Process KEY: Nursing Process Step: NAMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care12.The nurse adds a nursing order to the care plan related to a patient with a nursingdiagnosis of Nutrition: less than body requirement related to nausea and vomiting.The statement that is a nursing order is:a.medicatewithanantiemeticbeforeeachmeal.b.offercrackersandiceddrinkbeforeeachmeal.c.changediettoclearliquids.d.givenothingbymouthuntilnauseasubsides.ANS: BOffering crackers and iced drinks are within the scope of nursing; the other optionswould require a medical order to complete.DIF: Cognitive Level: Analysis REF: 26 OBJ: 6 (clinical)TOP: Nursing Orders KEY: Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity: Basic Care and Comfort13.Because the evaluation of the nursing care plan reflects lack of progress toward thegoal, the nurse will confer with the patient to plan a:a.moreaccessiblegoal.b.revisionofinterventions.c.differentnursingdiagnosis.

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d.newevaluation.ANS: BWhen lack of progress to reach the goal is seen on evaluation, the interventions arereviewed and/or revised.DIF: Cognitive Level: Application REF: 27 OBJ: 2 (clinical)TOP: Evaluation KEY: Nursing Process Step: PlanningMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care14.During the intake interview, the nurse notices that, although the patient deniespain, he is grimacing and holding his hand over his stomach. Thenurse’sbestapproach would be to:a.examinethehistorycloselyforetiologyofpain.b.questionthepatientabouthavingfeelingsofpain.c.recordthatpatientdeniespainbutseemstobehavingabdominaldiscomfort.d.physicallyexaminethepatient’sabdomen.ANS: BThe nurse should try to resolve any incongruence between body language and verbalresponses.DIF: Cognitive Level: Application REF: 17-20 OBJ: 1 (clinical)TOP: Patient Interview KEY: Nursing Process Step: AssessmentMSC: NCLEX: Health Promotion and Maintenance15.During the admission interview, when asked about pain, the patient responds,“No.I’mprettywobbly.”Which action by the nurse would be most appropriate?a.Ask,“Didyouhearme?Iaskedyouaboutpain.”b.Say,“Whatdoyoumean‘wobbly’?”c.Recordthepatientdeniedpain.d.Recordthepatientstatedhewaswobbly.ANS: BThe nurse should ask for clarification if unsure of what is meant by one of thepatient’sresponses.DIF: Cognitive Level: Application REF: 17-20 OBJ: 1 (clinical)TOP: Patient Interview KEY: Nursing Process Step: AssessmentMSC: NCLEX: Health Promotion and Maintenance

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16.The nurse writes an intervention for the goal: Patient will sleep for 5 hoursuninterrupted each night. The best nursing intervention is:a.medicatewithsedativeeachnight.b.offerwarmfluidsfrequently.c.arrangeforalargemealatsupper.d.discouragedaytimenapping.ANS: DDiscouraging daytime napping increases the probability of sleep. Giving medication isa collaborative intervention as it requires an order. Large meal and large fluid intakesmay interrupt sleep.DIF: Cognitive Level: Analysis REF: 26-27 OBJ: 2 (clinical)TOP: Nursing Intervention KEY: Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity: Basic Care and Comfort17.The nursing team prioritizing the nursing diagnoses of an overweight hospitalpatient will select as the highest priority the nursing diagnosis of:a.Riskfordehydrationrelatedtovomiting.b.Activityintolerancerelatedtoshortnessofbreath.c.Knowledgedeficitrelatedtoweightreductiondiet.d.Alteredself-imagerelatedtoexcessiveweight.ANS: BActivity intolerance is the highest priority as it has to do with activities that areessential 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 fordehydration related to vomiting.DIF: Cognitive Level: Analysis REF: 24-27 OBJ: 2 (clinical)TOP: Setting Priorities KEY: Nursing Process Step: PlanningMSC: NCLEX: Physiological Integrity: Basic Care and Comfort18.The nurse explains that, in addition to the NANDA stem and etiology, thecomplete nursing diagnosis should include:a.atimereferenceformeetingtheneed.b.adesignationofwhatthepatientshoulddo.c.signsandsymptomsoftheproblemassessed.

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d.aspecificallywordedmedicaldiagnosis.ANS: CA complete nursing diagnosis must have a NANDA stem, etiology, and signs andsymptoms (etiology) of the problem.DIF: Cognitive Level: Comprehension REF: 24-25 OBJ: 7 (clinical)TOP: Nursing Diagnosis KEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance19.The nurse explains to a patient that inclusion of potential problems in the nursingcare plan:a.alertsnursingstafftopreventpotentialcomplications.b.remindsthefamilyofpotentialproblems.c.broadenstheassessmentofthecaregiver.d.educatesthepatienttoaspectsofherhealth.ANS: AAddressing potential problems prevents complications by early action rather thanwaiting for a problem to materialize.DIF: Cognitive Level: Application REF: 24-25 OBJ: 7 (clinical)TOP: Potential Health Problems KEY: Nursing Process Step: PlanningMSC: NCLEX: Health Promotion and Maintenance20.During the admission process, the nurse receives orders for the patient to havearterial blood gases (ABGs) drawn. Which finding from the patient’shistory maycause concern?a.Takingginkgobilobaforthelast6monthsb.Havinganincreasedhematocrit(Hct)levelduringthelastphysicalexamc.Beingdiabeticfor10yearsd.Havingadecreasedwhitebloodcell(WBC)countANS: AGinkgo biloba may lower the platelet count and cause bleeding. Therefore, the nursewould be concerned about arterial bleeding occurring following ABGs being drawn.Increased Hct, a history of diabetes, and a decreased WBC count would not pose anyproblems with drawing a sample for ABGs.DIF: Cognitive Level: Application REF: 23 OBJ: 2 (clinical)

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TOP: Alternative Medicine KEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity: Reduction of Risk Potential21.The LPN/LVN adheres to facility policy regarding core measures by performingwhich interventions during patient care?a.Administeringtheorderedamountofinsulintoapatientwithtype1diabetesb.Performingathoroughpatientassessmentuponadmissiontothehealthcarefacilityc.Documentingaccuratelyandatappropriateintervalsinthepatient’srecordd.ProvidingpatientteachingregardingproperdietforthepatientdiagnosedwithrenalfailureANS: ACore measures are interventions that are based on scientifically researched,evidenced-based standards of care and are used to treat the majority of patients with aspecific illness which often develops complications. Insulin administration fordiabetics is evidence-based researched practice. The remaining options are goodpractice but are not considered core measures.DIF: Cognitive Level: Analysis REF: 17 OBJ: 10 (clinical)TOP: Core Measures KEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Management of Care22.The nurse is caring for a patient diagnosed with pneumonia. The patient has a BP160/94, P 102, R 28, crackles in posterior lower lobes bilaterally, oxygen saturation89%, and complains of shortness of breath upon exertion. The highest priority nursingdiagnosis for this patient is:a.Activityintoleranceb.Impairedgasexchangec.Ineffectivecardiopulmonarytissueperfusiond.Self-caredeficit:BathingandhygieneANS: BWhile all nursing diagnoses may apply to this patient, Impaired gas exchange is thehighest priority because this is the underlying problem for the other nursingdiagnoses, as well as physiologically the highest priority.DIF: Cognitive Level: Application REF: 24-27 OBJ: 2 (clinical)TOP: Nursing Diagnosis KEY: Nursing Process Step: PlanningMSC: NCLEX: Safe, Effective Care Environment: Management of Care

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MULTIPLE RESPONSE23.The nurse explains to the nursing student that the application of critical thinking topatient care involves: (Select all that apply.)a.identificationofapatientproblem.b.settingpriorities.c.concentratingonthepatientratherthanfamilyneeds.d.useoflogicandintuition.e.expansionofthoughtbeyondtheobvious.ANS: A, B, D, ECritical thinking as applied to nursing care requires setting priorities of patientproblems and needs by using logic and intuition. Inclusion of the family in the caremakes 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: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care24.The nurse demonstrates application of the nursing process by: (Select all thatapply.)a.performingahead-to-toeassessment.b.updatingthepatientcareplanonaweeklybasis.c.evaluatingifpatientgoalshavebeenmet.d.determiningifnursinginterventionsneedtobechangedbasedonlackofpatientprogresstgoals.e.ensuringthatallpersonnelcaringforthepatientareimplementingthecareplanandworkinsamegoals.ANS: A, C, D, EThe nursing care plan should be updated as necessary, not just on a weekly basis.Concepts of the nursing process are demonstrated by performing orderly, logicalhead-to-toe assessments, as well as ongoing evaluation of patient goals andinterventions to meet those goals.DIF: Cognitive Level: Comprehension REF: 16 OBJ: 1 (clinical)TOP: Nursing Process KEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

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25.The nurse demonstrates knowledge of the National Patient Safety Goals byperforming patient care that includes: (Select all that apply.)a.identifyingthepatientpriortomedicationadministrationbyaskingthepatienttostatehisob.reportinganysentineleventtothefacility’squalityassuranceteam.c.assessingthepatient’sheartratepriortoadministrationofdigoxin.d.performinghandhygienepriortoperformingapatientassessment.e.documentingtheappropriatetimeofmedicationadministration.ANS: C, D, EAssessing thepatient’sheart rate prior to administration of digoxin demonstratesknowledge of medication actions and prevention of adverse effects; hand hygiene isrequired before any patient care, including assessment; and documentation of the timeof medication administration is necessary to prevent medication errors. To meetNational Patient Safety Goals, the nurse must use at least two methods of patientidentification prior to medication administration. Reporting a sentinel event isrequired 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: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Safety and Infection ControlCOMPLETION26.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 FormThe Medication Reconciliation Form tracks all medications the patient is taking asprescribed by different physicians and can identify overdoses or drugs that are notcompatible.DIF: Cognitive Level: Application REF: 19-20 OBJ: 2 (clinical)TOP: Medication Reconciliation Form KEY: Nursing Process Step: ImplementationMSC: NCLEX: Safe, Effective Care Environment: Coordinated Care27.Shortness of breath due to emphysema would be a major component of the_________ care plan.ANS:

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interdisciplinaryAn interdisciplinary care plan involves all members of the health care team and isbased 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: PlanningMSC: NCLEX: Health Promotion and MaintenanceMATCHINGPlace the steps of the nursing process in their proper sequence.a.Evaluationb.Assessmentc.Implementationd.Planninge.Nursingdiagnosis28.Step 129.Step 230.Step 331.Step 432.Step 528. ANS: B DIF: Cognitive Level: Comprehension REF: 17OBJ: 7 (clinical) TOP: Applying the Nursing ProcessKEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance29. ANS: E DIF: Cognitive Level: Comprehension REF: 17OBJ: 7 (clinical) TOP: Applying the Nursing ProcessKEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance30. ANS: D DIF: Cognitive Level: Comprehension REF: 17OBJ: 7 (clinical) TOP: Applying the Nursing ProcessKEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance31. ANS: C DIF: Cognitive Level: Comprehension REF: 17OBJ: 7 (clinical) TOP: Applying the Nursing ProcessKEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance32. ANS: A DIF: Cognitive Level: Comprehension REF: 17OBJ: 7 (clinical) TOP: Applying the Nursing ProcessKEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

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Chapter 03: Fluid, Electrolytes, Acid-BaseBalance, and Intravenous TherapyChapter 03: Fluid, Electrolytes, Acid-Base Balance, and Intravenous TherapyMULTIPLE CHOICE1.The nurse uses a diagram to demonstrate how in dehydration the water is drawn intothe plasma from the cells by the process of:a.distillation.b.diffusion.c.filtration.d.osmosis.ANS: DThe process of osmosis accomplishes the movement of water from the cells into theplasma, causing dehydration.DIF: Cognitive Level: Comprehension REF: 32-33 OBJ: 3 (theory)TOP: Dehydration KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation2.The nurse assessing a patient with vomiting and diarrhea observes that the urine isscant and concentrated. The nurse explains that the compensatory reabsorption ofwater is controlled by:a.osmoreceptorsinthehypothalamus.b.antidiuretichormoneintheposteriorpituitary.c.baroreceptorsinthecarotidsinus.d.insulinfromthepancreas.ANS: BThe antidiuretic hormone controls how much water leaves the body by reabsorbingwater in the renal tubules.DIF: Cognitive Level: Knowledge REF: 31-32 OBJ: 2 (theory)TOP: Regulation of Body Fluids KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation3.The nurse uses a picture to show how ions equalize their concentration by thepassive transport process of:a.osmosis.

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b.filtration.c.titration.d.diffusion.ANS: DDiffusion is the process by which substances move back and forth acrosscompartment membranes until they are equally divided.DIF: Cognitive Level: Comprehension REF: 32 OBJ: 3 (theory)TOP: Diffusion KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation4.The nurse explains that the active transport process that is able to move sodium andpotassium into or out of cells is:a.filtration.b.sodiumpump.c.diffusion.d.osmosis.ANS: BThe sodium pump is the mechanism by which sodium and potassium are moved intoor out of cells regardless of the concentration.DIF: Cognitive Level: Comprehension REF: 33 OBJ: 3 (theory)TOP: Active Transport KEY: Nursing Process Step: ImplementationMSC: NCLEX: Physiological Integrity: Physiological Adaptation5.The patient taking furosemide (Lasix) to correct excess edema shows a weight lossof 5.5 pounds in 24 hours. The nurse calculates this weight loss to be the excretion ofapproximately _____ liters of fluid.a.1.0b.1.5c.2.0d.2.5ANS: DEach kilogram (2.2 pounds) of weight loss is equivalent to 1 liter of fluid. Therefore,5.5 pounds ÷ 2.2 pounds = 2.5 liters.DIF: Cognitive Level: Application REF: 35 OBJ: 1 (clinical)

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TOP: Fluid Loss KEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity: Physiological Adaptation6.When the nurse assesses a potassium level of 2.9 mEq/L in the patient withvomiting and diarrhea, the nurse will be alert for:a.excessiveurinaryoutput.b.abdominaldistention.c.increasedreflexes.d.hyperactivebowelsounds.ANS: BA potassium level lower than 3.5 mEq/L results in reduced urine output, cardiacdysrhythmia, muscle weakness, abdominal pain and distention, paralytic ileus,lethargy, and confusion.DIF: Cognitive Level: Application REF: 42 | Table 3-4OBJ: 4 (theory) TOP: HypokalemiaKEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity: Basic Care and Comfort7.While the nurse is washing the face of a patient in renal failure, the patientdemonstrates a spasm of the lips and face. The nurse examines the recent electrolytelevels to assess the level of:a.potassium.b.calcium.c.sodium.d.magnesium.ANS: BChvostek’ssign is a signal of hypocalcemia. It occurs when the facial nerve is tappedor stroked about an inch in front of the earlobe and results in unilateral twitching ofthe face.DIF: Cognitive Level: Analysis REF: 44 OBJ: 4 (theory)TOP:Chvostek’sSign KEY: Nursing Process Step: AssessmentMSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease8.Prior to hanging an IV containing potassium, the nurse will confirm that there is a:a.bloodpressureofatleast60mmHgdiastolic.

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b.urineoutputofatleast30mL/hr.c.filterontheIVline.d.pulseofatleast50beats/min.ANS: BAn adequate urine output must be present prior to the administration of potassium toensure adequate excretion of potassium, preventing hyperkalemia.DIF: Cognitive Level: Application REF: 44 | Safety AlertOBJ: 10 (theory) TOP: Administration of IV PotassiumKEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity: Reduction of Risk Potential9.The nurse determines there is no need for further instruction related to a low-sodium diet when the patient says:a.“IcanhaveallthedriedfruitsIwant.”b.“I’mlookingforwardtoatallglassoftomatojuice.”c.“I’mgoingtoeatmyfavoriteavocadoandorangesalad.”d.“I’mgoingtoeatacheeseburgerwithextracatsup.”ANS: CAvocado and oranges have no significant sodium content. Dried fruits, tomato juice,cheese, and catsup are high in sodium.DIF: Cognitive Level: Application REF: 41 | Nutrition ConsiderationsOBJ: 4 (clinical) TOP: Low-Sodium DietKEY: Nursing Process Step: EvaluationMSC: NCLEX: Physiological Integrity: Basic Care and Comfort10.Because the 80-year-old patient is prone to dehydration related to the age-relatedchange of decreased thirst and kidney function, the nurse monitors for the earliest signof dehydration, which is:a.reducedskinturgor.b.constipation.c.increasedtemperature.d.thirst.ANS: B

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Constipation is the best early indicator of dehydration in the older adult. Older adultshave age-related poor skin turgor. Increased temperature and thirst are later signs ofdehydration.DIF: Cognitive Level: Analysis REF: 35 OBJ: 5 (theory)TOP: Dehydration in the Older Adult KEY: Nursing Process Step: AssessmentMSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease11.The patient with long-term obstructive pulmonary disease has a pH of 7, HCO3–of 18 mEq/L, and a PaCO2 of 40 mm Hg. From this laboratory information, the nurseassesses the patient is in:a.respiratoryalkalosis.b.metabolicalkalosis.c.respiratoryacidosis.d.metabolicacidosis.ANS: DThese results are indicative of metabolic acidosis.DIF: Cognitive Level: Analysis REF: 47-48 | Table 3-5OBJ: 3 (clinical) TOP: Respiratory AcidosisKEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance12.To help prevent respiratory acidosis in a young person with asthma, the nursewould encourage:a.deep-breathingexercisesevery2hours.b.drinking8ouncesoffluidevery4hours.c.ambulatingfor15minutestwiceaday.d.sleepingwiththeheadofthebedelevated45degrees.ANS: ADeep breathing blows off CO2, which reduces the acid ions, thus preventingrespiratory acidosis. Drinking fluids prevents dehydration and keeps secretions moistand thin, and sleeping with the head of the bed elevated will ease breathing andimprove gas exchange. Ambulating 15 minutes twice a day does not have an impacton respiratory acidosis.DIF: Cognitive Level: Analysis REF: 47-48 | Table 3-5OBJ: 8 (theory) TOP: Respiratory Acidosis

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KEY: Nursing Process Step: ImplementationMSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease13.The patient who has had diarrhea for the last 3 days has blood gases of pH of 7.1,HCO3–of 20 mEq/L, and PCO2 of 36 mm Hg. The nurse recognizes these valuesindicate:a.respiratoryalkalosis.b.metabolicalkalosis.c.respiratoryacidosis.d.metabolicacidosis.ANS: DMetabolic acidosis shows a low pH, low HCO3–, and normal CO2.DIF: Cognitive Level: Application REF: 47-48 | Table 3-5OBJ: 8 (theory) TOP: Metabolic AcidosisKEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance14.The nurse can record that the compensatory mechanism for the correction ofmetabolic acidosis is in effect when the nurse observes:a.increasedurinaryoutput.b.reducedabdominaldistention.c.Kussmaul’srespirations.d.decreasedbloodpressure.ANS: CKussmaul’srespirations, or deep and rapid respirations, are blowing off carbondioxide to reduce an acidotic state.DIF: Cognitive Level: Application REF: 48 OBJ: 3 (clinical)TOP: Metabolic Acidosis KEY: Nursing Process Step: AssessmentMSC: NCLEX: Physiological Integrity: Physiological Adaptation15.The nurse assessing the IV insertion site finds the vein hard, the skin red andtender, and a blood return in the IV line. The most effective intervention afterremoving the IV catheter is to:a.notifythechargenurse.b.elevatethearmabovetheleveloftheheart.c.cleanthesitewithalcoholandapplycoolcompresses.

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