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Medical Surgical Nursing Concept & Practices 2nd Edition, deWit Test Bank

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Test Bank For Medical Surgical Nursing Concept & Practices 2nd Edition, deWit. Note: This is not a text book. Description: ISBN-13: 978-1437717075, ISBN-10: 1437717071.

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Test Bank Medical Surgical Nursing Concept Practices 2nd Edition, deWit

MULTIPLE CHOICE
Chapter 01: Caring for Medical-Surgical Patients
1. The new nurse demonstrates an understanding of the primary purpose of the state nurse practice act (NPA) by explaining that it acts to:
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.
2. 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 educational program, the vocational nurse should:
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.
3. The nurse recognizes the need for further discharge education when the patient says:
a. “I have no idea of how this drug will affect me.”
b. “Do you know if my physician is coming back today?”
c. “Will my insurance pay for my stay?”
d. “Am I going to have to go to a nursing home?”
4. According to most state NPAs, the vocational nurse acting as charge nurse in a long-term care facility is acting in which capacity?
a. Under direct supervision of an RN on the unit
b. With the RN in the building
c. Under general supervision by the RN available on site or by phone
d. As an independent vocational nurse
5. The nurse reminds the patient who is a member of a health maintenance organization that prior to treatment he will need to:
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.
6. The patient complains to the nurse that he is confused about his “deductible” that he owes the hospital. The nurse explains that the deductible is a(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.
7. The nurse compares the characteristics of a health maintenance organization (HMO) and a preferred provider organization (PPO), pointing out that an HMO:
a. requires a set fee of each member monthly.
b. allows the member to select his health care provider.
c. permits admission to any facility the member prefers.
d. offers unlimited diagnostics tests and treatments.
8. When the patient asks the nurse what his Medicare Part A covers, the nurse responds that it covers:
a. inpatient hospital costs.
b. reimbursement to the physician.
c. outpatient hospital services.
d. ambulance transportation.
9. The nurse explains that the main cost containment component of diagnosis-related groups (DRGs) is that:
a. hospitals focus only on the specific diagnosis.
b. hospitals treat and discharge patients quickly.
c. reduced-cost drugs are ordered for the specific diagnosis.
d. diagnostic group classification streamlines care.
10. While assessing a group of patients, the nurse recognizes the patient who could qualify for Medicaid benefits is the:
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 care facility.
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.
Chapter 02: Critical Thinking and Nursing Process
1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.”
10. 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.
Chapter 03: Fluid, Electrolytes, Acid-Base Balance, and Intravenous Therapy
1. The nurse uses a diagram to demonstrate how in dehydration the water is drawn into the plasma from the cells by the process of:
a. distillation.
b. diffusion.
c. filtration.
d. osmosis.
2. The nurse assessing a patient with vomiting and diarrhea observes that the urine is scant and concentrated. The nurse explains that the compensatory reabsorption of water is controlled by:
a. osmoreceptors in the hypothalamus.
b. antidiuretic hormone in the posterior pituitary.
c. baroreceptors in the carotid sinus.
d. insulin from the pancreas.
3. The nurse uses a picture to show how ions equalize their concentration by the passive transport process of:
a. osmosis.
b. filtration.
c. titration.
d. diffusion.
4. The nurse explains that the active transport process that is able to move sodium and potassium into or out of cells is:
a. filtration.
b. sodium pump.
c. diffusion.
d. osmosis.
5. The patient taking furosemide (Lasix) to correct excess edema shows a weight loss of 5.5 pounds in 24 hours. The nurse calculates this weight loss to be the excretion of approximately _____ liters of fluid.
a. 1.0
b. 1.5
c. 2.0
d. 2.5
6. When the nurse assesses a potassium level of 2.9 mEq/L in the patient with vomiting and diarrhea, the nurse will be alert for:
a. excessive urinary output.
b. abdominal distention.
c. increased reflexes.
d. hyperactive bowel sounds.
7. While the nurse is washing the face of a patient in renal failure, the patient demonstrates a spasm of the lips and face. The nurse examines the recent electrolyte levels to assess the level of:
a. potassium.
b. calcium.
c. sodium.
d. magnesium.
8. Prior to hanging an IV containing potassium, the nurse will confirm that there is a:
a. blood pressure of at least 60 mm Hg diastolic.
b. urine output of at least 30 mL/hr.
c. filter on the IV line.
d. pulse of at least 50 beats/min.
9. The nurse determines there is no need for further instruction related to a low-sodium diet when the patient says:
a. “I can have all the dried fruits I want.”
b. “I’m looking forward to a tall glass of tomato juice.”
c. “I’m going to eat my favorite avocado and orange salad.”
d. “I’m going to eat a cheeseburger with extra catsup.”
10. Because the 80-year-old patient is prone to dehydration related to the age-related change of decreased thirst and kidney function, the nurse monitors for the earliest sign of dehydration, which is:
a. reduced skin turgor.
b. constipation.
c. increased temperature.
d. thirst.
Chapter 04: Care of Preoperative and Intraoperative Surgical Patients
1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.”
10. 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.
Chapter 05: Care of Postoperative Surgical Patients
1. The postanesthesia care unit (PACU) nurse determines that the patient’s Aldrete score is 9. The nurse on the postoperative unit knows that this means the:
a. patient is at an increased risk for postoperative respiratory complications.
b. patient’s condition warrants close monitoring.
c. patient is experiencing severe pain.
d. patient will soon be transferred to the postoperative unit.
2. The patient recovering in the PACU awakes confused and disoriented. The nurse’s most appropriate intervention is to:
a. take vital signs.
b. encourage the patient to return to sleep.
c. say, “Your surgery is over. You are in the recovery area.”
d. chart, “Patient awake and disoriented.”
3. Following abdominal surgery, the PACU nurse demonstrates the best nursing care by placing the semi-conscious patient in _____ position.
a. the supine
b. semi-Fowler’s
c. the lateral
d. Trendelenburg’s
4. When the PACU nurse assesses diminished breath sounds in the unconscious recovering patient, the nurse should:
a. hyperventilate the patient with an Ambu bag.
b. turn the oxygen up to 3 L/min.
c. elevate the head of bed 45 degrees.
d. chart, “Diminished breath sounds in both lower lobes.”
5. The nurse is caring for a patient during the first postoperative day. An appropriate goal to write in the nursing care plan to avoid atelectasis would be:
a. patient will turn, cough, and deep-breathe every 4 hours.
b. patient will “huff cough” every 2 hours.
c. patient will use the incentive spirometer twice a day.
d. nurse will assist the patient to ambulate in the hall three times a day.
6. The nurse is caring for a 90-year-old postoperative patient. The nurse notes that the oxygen saturation is frequently dropping below 90%. This is most likely related to:
a. prolonged use of a walker.
b. poor fluid intake.
c. weakened respiratory muscles.
d. increased elasticity of costal cartilages.
7. Which assessment finding on a patient who had a right total knee replacement this morning should be reported to the charge nurse immediately?
a. Pain at level of 8 at operative site
b. Capillary refill of right toe of 7 seconds
c. Right foot warm to touch
d. Swelling of right knee
8. Antiembolic stockings are in place on the obese postsurgical patient. The nurse is aware that the standard of care in regard to antiembolic stockings is that the stockings should be:
a. left in place continually for the first 24 hours.
b. fitted tightly at the knee and ankle.
c. removed approximately 20 minutes every shift.
d. removed when ambulating.
9. The nurse has been assigned to care for several postoperative patients. The nurse is aware that the patient most likely to develop thrombophlebitis is the patient:
a. with a history of blood clots who is being discharged following an outpatient cholecystectomy.
b. who is 6 days postoperative for total right hip replacement and has a history of left-sided stroke.
c. who has had major abdominal surgery and was dehydrated upon admission.
d. who is 2 days postoperative for hernia repair with a history of diabetes.
10. The patient’s initial vital signs immediately on return from surgery are BP, 140/90; P, 80; R, 14; T, 98° F. One hour later the vital signs are BP, 130/84; P, 72; R, 16; T, 96.8° F. Based on these assessments, the nurse should:
a. add a blanket for warmth to the patient.
b. notify the charge nurse of probable hemorrhage.
c. raise the head of the bed 45 degrees.
d. note the assessment as normal postoperative recovery.
Chapter 06: Infection Prevention and Control
1. The nurse points out that covering the mouth and nose with a tissue for a sneeze will reduce the probability of infection being spread by the _____ route.
a. droplet
b. airborne
c. direct contact
d. indirect contact
2. The nurse is providing infection control teaching to a patient. Additional patient teaching is warranted by which patient statement?
a. “It is important that I get my whooping cough vaccination as directed by my health care provider.”
b. “Getting plenty of sleep each night will help my immune system.”
c. “I should wash my hands before preparing my food.”
d. “It is important that I take my antibiotic until I feel infection free.”
3. When the patient complains, “If this viral infection I have right now can’t be helped by antibiotics, why am I taking this expensive acyclovir?” The nurse’s best response is, “Acyclovir is:
a. an antiviral drug that kills viruses.”
b. given to many patients with viral infections.”
c. an antiviral drug that prevents your infection from becoming worse.”
d. given to help strengthen your immune system.”
4. The clinic nurse offers suggestions to a patient who is planning a trip to Mexico that will help prevent a protozoan infection. The most helpful suggestion is:
a. “We will ask the doctor for a prophylactic prescription for an antiviral drug.”
b. “Broad-spectrum antibiotics will be most helpful if you contract a protozoan infection.”
c. “Be sure to practice good hand hygiene while on your vacation.”
d. “It would be best if you drank bottled water while on your trip.”
5. While assessing an obese resident in a long-term care facility, the nurse finds a red, moist rash under the patient’s breasts, in the axilla, and in the inguinal fold. Based on this assessment, the nurse reports to the charge nurse that the resident probably has:
a. a fungal infection.
b. a bacterial infection.
c. an allergic reaction.
d. contact dermatitis.
6. The frustrated patient with a fungal infection complains, “Why is the infection taking so long to heal?” The nurse’s most informative response would be that:
a. fungal infections are essentially incurable.
b. fungi form spores, which make them difficult to kill.
c. fungi can be considered natural flora and are protected by the body.
d. fungi can alter the patient’s DNA and RNA.
7. The nurse explains to the patient who is using Prilosec (a proton pump inhibitor) that the drug has reduced the amount of the natural protector _____ in the stomach lining.
a. lactic acid
b. lysozyme
c. cilia
d. fatty acids
8. The home health nurse advises the patient to treat a fever of 100° F with:
a. aspirin.
b. Tylenol.
c. cool baths.
d. nothing at all.
9. The home health nurse is providing dietary recommendations to keep the immune system healthy. The patient demonstrates understanding by increasing which in the diet?
a. Proteins
b. Fluids
c. Carbohydrates
d. Unsaturated fats
10. The nurse is caring for several patients and determines which patient to be at the most risk for developing an infection related to a decreased anti-inflammatory response?
a. A patient who has been experiencing high levels of stress for the last 3 months
b. A patient whose glycosylated Hgb level is 6.7%
c. A patient recently diagnosed with osteoarthritis
d. A patient scheduled for laparoscopic cholecystectomy in 2 weeks related to gallstones
Chapter 07: Care of Patients with Pain
1. In order to provide the optimum nursing care, it is important for the nurse to know that the standard of pain and pain control is best determined by which person?
a. Physician
b. Nurse
c. Patient’s family
d. Patient
2. The nurse clarifies the basics of the gate theory of pain control as:
a. pain is perceived as opening a “gate” to pain symptoms.
b. the “gate” can be closed to pain by the use of nonpainful stimuli.
c. the “gate” swings back and forth, first allowing pain, then blocking it.
d. the patient can be trained to close the “gate” to pain.
3. When giving care to a 30-year-old Hispanic male, the nurse is aware that the young man will most likely:
a. be stoic about pain.
b. prefer a pill to an injection.
c. ignore somatic interventions such as heat and massage.
d. confess to pain, but refuse pain medication.
4. The nurse is caring for a patient who is having constant nociceptor pain. The nurse can best address the patient’s pain during the perception phase of pain with which intervention?
a. Administer nonsteroidal anti-inflammatory drugs (NSAIDs) for moderate pain.
b. Ask the physician if an opioid could be ordered to treat the patient’s pain when severe.
c. Engage the patient in conversation regarding his family, hobbies, and plans following discharge from the facility.
d. Determine if the patient typically takes a neurotransmitter uptake blocker medication for pain control.
5. The patient is experiencing phantom pain following the amputation of her foot. Which type of pain is most associated with phantom pain?
a. Nociceptive
b. Mild
c. Uncontrollable
d. Neuropathic
6. The nurse explains that the pain threshold and pain tolerance are different in that the pain threshold is the point at which:
a. pain is perceived.
b. the person responds to pain.
c. pharmacologic intervention is required.
d. signs such as grimacing or groaning are observed.
7. The patient who had abdominal surgery this morning refuses the opioid pain medication for fear of addiction. The most informative response by the nurse is:
a. “Opioids are addictive, whereas nonsteroidal anti-inflammatory drugs (NSAIDs) are not.”
b. “Addiction is mainly a matter of attitude.”
c. “Fewer than 3% of people become addicted to drugs used for pain relief.”
d. “Although addiction does occur, it is quickly reversed.”
8. The student nurse understands proper documentation of a pain assessment as evidenced by which note in the patient’s record?
a. Pt. complains of local sharp pain (4/5) in lower abdomen upon standing.
b. Pt. complains of stomach pain after eating (3/5).
c. Pt. reports standing makes his stomach hurt.
d. Pt. reports sharp pain in stomach.
9. The nurse stresses to the home health patient that the acetaminophen pain medication should be taken:
a. as frequently as needed.
b. before pain is severe.
c. when pain becomes unbearable.
d. sparingly and with caution.
10. While bathing the patient, the nurse notes that a transdermal patch that was meant to be on the patient for 3 days is now gone on the second day. The nurse should:
a. document the loss and apply a fresh patch to be replaced in 3 days.
b. report the loss to the charge nurse.
c. document the loss, replace the patch, and continue with the original schedule for replacement.
d. remind the patient that, until the patch is replaced in 24 hours, oral pain relief will be available.
Chapter 08: Care of Patients with Cancer
1. The 40-year-old female who was diagnosed with a benign growth in her colon is concerned about the growth spreading. The nurse can allay her anxiety by explaining that benign neoplasms:
a. arrest their growth on their own.
b. never interfere with normal structures or functions.
c. are easily controlled with radiation.
d. are surrounded by fibrous tissue that prevents spread.
2. The 26-year-old patient with a malignant neoplasm has experienced a 10-pound weight loss in 3 weeks. The nurse takes into consideration that the rapid weight loss is most likely related to:
a. disinterest in eating food in general.
b. a fitness and weight-training exercise program.
c. the malignancy’s high nutritional demand.
d. a self-imposed rigid diet regimen.
3. The nurse recognizes the staging T3, N2, M2 of the patient’s cancer to mean that there is a:
a. small tumor with fewer than two lymph nodes involved.
b. large tumor that is localized.
c. small tumor with adjacent nodes involved.
d. large tumor with extensive lymph node involvement.
4. In assessing several patients in the outpatient clinic, the nurse identifies the patient who is at the greatest risk for cancer as the:
a. 23-year-old car repairman who repaints cars.
b. 30-year-old overweight CPA in New York who has smoked for 10 years and rarely exercises.
c. 45-year-old farmer from Texas who has worked on his family’s cotton farm since the age of 12.
d. 60-year-old ski instructor in Colorado.
5. The nurse recognizes a “promoter” that, although not a carcinogen itself, allows cancer to occur faster in the patient that:
a. is more than 25 pounds overweight.
b. works in a hospital lab.
c. abuses cocaine.
d. drinks heavily.
6. The x-ray technician wears a badge that is monitored frequently to measure the amount of radiation he has absorbed. Such occupational exposure to radiation frequently results in a specific cancer, which is:
a. bladder cancer.
b. leukemia.
c. melanoma.
d. lung cancer.
7. The nurse outlines a diet that would be helpful in the prevention of cancer. This diet includes:
a. adequate nitrites.
b. no more than 40% fats.
c. vitamin B complex.
d. citrus fruits.
8. The young college student who wants a tan before spring break asks the nurse what the safest method would be. The nurse’s best response is:
a. take advantage of morning sun while using sunscreen with an SPF of 30.
b. use a spray-on tanning solution.
c. use a sun lamp for only 20 minutes a day.
d. use a tanning salon for no more than 10 minutes per visit.
9. The nurse reminds the 40-year-old female patient that the American Cancer Society (ACS) recommendations for early detection of cancer include that she should:
a. get a Pap smear every year.
b. get an annual fecal occult blood exam.
c. plan a sigmoidoscopy every 5 years.
d. have a mammogram done every year.
10. In assessing a man who is to have a prostate-specific antigen (PSA) test done, the nurse identifies the situation that will delay the test, which is:
a. having eaten shellfish 48 hours previously.
b. identification of an enlarged prostate.
c. recent urinary tract infection.
d. temperature of 100° F.
Chapter 09: Chronic Illness and Rehabilitation
1. The rehabilitation nurse describes a patient who is blind, works full time as a Spanish interpreter, and lives with his wife in a downtown apartment. The nurse classifies this person as:
a. impaired.
b. disabled.
c. handicapped.
d. dependent.
2. A resident with advanced Parkinson’s disease stays in his wheelchair all day because it is too tiring to walk and he is fearful of falling. In order to increase mobility, the best intervention would be to:
a. instruct the resident in crutch walking.
b. assist the resident to walk in the hallway with a gait belt.
c. encourage the resident to rock back and forth in his wheelchair to off load weight.
d. arrange for a walking cane.
3. The obese resident who lies on her back because it is difficult to turn due to her weight has a pressure ulcer on her coccyx that is covered with a dressing. The most effective intervention to encourage independence is:
a. have staff turn the resident every 2 hours.
b. turn the patient on her side and use pillows to stabilize her.
c. arrange for short side rails to be used for positioning.
d. arrange for a trapeze so the patient can assist with positioning.
4. When the nurse assesses reddened heels on the bed-bound stroke patient, the nurse modifies the care plan to include which intervention?
a. Massage heels briskly.
b. Apply socks to feet.
c. Swab heels with alcohol.
d. Elevate feet on pillows.
5. The nurse cautions the 70-year-old patient who just had the cast removed from a broken arm that the immobility during the time he was in a cast can cause:
a. arthritis.
b. phlebitis.
c. frozen shoulder.
d. painful swelling.
6. The nurse assessing an 85-year-old patient who has been on bed rest for a fractured hip finds the patient flushed with a temperature of 100° F, pulse of 100, and respiration rate of 24. The next intervention should be to assess:
a. BP.
b. breath sounds.
c. abdominal distention.
d. amount of urinary output.
7. The 76-year-old stroke patient in a long-term care facility has sent his food tray back to the kitchen untouched for the second time today. The most effective intervention to increase nutrition would be to:
a. take the tray back and offer to feed the patient.
b. request the dietitian to talk with the patient about food preferences.
c. take a high-protein drink to the patient.
d. sit with the patient during meals.
8. When the nurse is assessing a bed-bound resident, a reddened area over the coccyx that does not blanch is discovered. The best intervention to prevent further skin damage is to:
a. cover with a transparent film dressing.
b. apply warm compress.
c. turn the patient every 2 hours.
d. continue to monitor the area.
9. The LPN/LVN making care assignments to nursing assistants would not assign a patient who has:
a. manipulative behavior.
b. an unstable condition.
c. a draining wound.
d. a communicable disease.
Chapter 10: The Immune and Lymphatic Systems
1. The nurse points out that as a result of the aging process, one change in the immune system is:
a. thickened skin.
b. reduced ciliary action.
c. thinned periosteum.
d. reduced saliva.
2. The nurse differentiates the humoral response from the cell-mediated response in that in the cell-mediated response:
a. the sensitized lymphocytes attack the cell for which they were sensitized.
b. cells produce new antibodies.
c. the response does not occur until the white blood cell (WBC) count rises.
d. there is a systemic response of fever and malaise.
3. The nurse clarifies that the lymphocytes that actually produce either sensitized lymphocytes or antibodies are the:
a. B lymphocytes.
b. T cells.
c. suppressor T cells.
d. stem cells.
4. The nurse explains to a patient with a painful toe that the pain is related to the inflammatory response, which causes the discomfort by the:
a. swelling, which compresses nerves.
b. enzyme release, which irritates the area.
c. acidic waste from the destroyed cells.
d. heat of lysis, which affects the nerves.
5. The nurse reviewing lab results notes that the C-reactive protein is elevated in the patient who had surgery 2 days ago. The nurse is aware this is an indication of:
a. impending infection.
b. possible hemorrhage.
c. a drug allergic reaction.
d. fluid deficit.
6. The nurse is preparing a presentation on the inflammatory response. While preparing a cartoon picture of lysis, the nurse correctly draws which scenario?
a. An antibody acting through the process of neutralization
b. An individual’s arm that is red and swollen
c. A phagocyte eating an antigen
d. A cell that is originating in the bone marrow
7. The nurse exemplifies the action of killer T cells as being like a:
a. tiger slowly stalking an antigen to devour it.
b. mad hornet flying through circulating fluids seeking and killing antigens.
c. spider waiting in a web for an antigen to get caught in it.
d. bird dog pointing to an antigen so it can be attacked by phagocytes.
8. The nurse points out that the fact that humans do not contract such diseases as distemper, as dogs do, is due to the human’s _____ immunity.
a. passive
b. acquired
c. innate
d. passive natural
9. The young father tells the industrial nurse at work that he is afraid he will give his 2-week-old baby his cold. The nurse assures him that the baby is protected by _____ immunity.
a. acquired
b. passive
c. active
d. passive natural
10. The nurse reminds the patient that he can be protected by passive artificial immunity by:
a. being injected with immune globulin.
b. receiving immunizations.
c. contracting the disease.
d. consuming sufficient antioxidants.
Chapter 11: Care of Patient with HIV/AIDS
1. The nurse speaking with a student about immunocompetence correctly defines it as occurring when:
a. there has been an overwhelming allergic reaction.
b. the immune system cannot differentiate between foreign cells and the body’s own cells.
c. the individual is exposed to a disease from which he has no immunity.
d. physiologic responses protect the body against invasion from microorganisms or toxins.
2. The nurse recognizes a need for further instruction when the HIV-positive patient says:
a. “My life is over. HIV and AIDS are the same thing.”
b. “I can delay having full-blown AIDS if I change my lifestyle.”
c. “Drug protocols can keep me relatively healthy for many years.”
d. “I am aware that unsafe sex is a risk factor I ignored.”
3. In caring for the patient who is HIV positive, the nurse should:
a. wear gown, gloves, and mask at all times.
b. limit visitors.
c. monitor intake of salt.
d. use Standard Precautions.
4. The nurse is aware that more instruction is needed for the HIV-positive patient when she says:
a. “Latex condoms are the best.”
b. “I could give my partner HIV without practicing safe sex.”
c. “I should avoid pregnancy.”
d. “Oral sex is safer and doesn’t require a barrier.”
5. The nurse clarifies that the HIV virus enters and alters the DNA of the _____ cell lymphocyte.
a. B
b. T
c. CD4
d. killer T
6. When oral thrush, recurrent vaginal yeast infections, or skin disorders appear in the HIV-positive patient, the nurse assesses this as:
a. AIDS.
b. invasion of primary pathogens.
c. a sign of a failing immune system.
d. retrovirus infection.
7. The nurse describes the initial diagnostic test for HIV as the enzyme-linked immunosorbent assay (ELISA), which is performed to detect:
a. human immunodeficiency virus.
b. depleted phagocytes.
c. numbers of T helper cells.
d. HIV antibodies.
8. The nurse uses a visual aid to demonstrate how nonnucleoside reverse transcriptase inhibitors (NNRTIs) and protease inhibitors (PIs) work to combat HIV by:
a. interfering with replication of the virus.
b. stimulating production of CD4 helper cells.
c. making a hostile environment for the virus.
d. dissolving the virus.
9. The nurse caring for a patient with AIDS who is taking cidofovir (Vistide) for a cytomegalovirus retinitis will modify the care plan to include:
a. provision of cool baths to reduce skin irritation.
b. provision of milk-based drinks to reduce gastritis.
c. teaching direction in the use of an incentive spirometer to reduce pleural effusion.
d. increasing fluid intake to reduce possible nephrotoxicity.
10. The hospitalized patient with an HIV infection who is being treated for Mycobacterium tuberculosis (MTb) demonstrates understanding of care when stating:
a. “I am fortunate that I will not need to be in transmission-based precautions for this infection.”
b. “My family will have to get special testing because the normal PPD test is not used to detect exposure to this infection.”
c. “It is important for me to take my rifampin medication for the next year.”
d. “This infection will only cause problems with my lungs.”
Chapter 12: Care of Patients with Immune and Lymphatic Disorders
1. When the patient has an immediate allergic reaction to the injection of radiopaque dye, the nurse is aware that this immediate response is a type ___ response, which is _____ generated.
a. 1, antibody
b. 2, mast cell
c. 1, mast cell
d. 2, antibody
2. After an influenza immunization, the patient complains of shortness of breath, breaks out in hives, and begins to twitch. What should the nurse initially give?
a. Epinephrine by injection
b. O2 by mask at 5 L/min
c. Corticosteroid by injection
d. Bronchodilators per nebulization
3. Education for the patient with systemic lupus erythematosus (SLE) should include what teaching point?
a. Training with weights to increase strength
b. Using alcohol-based skin products
c. Managing pain with opioids
d. Using potent sunscreen
4. The patient reports that he has been diagnosed with stage II Hodgkin’s disease. The nurse interprets this to mean that the infected lymph node involvement could be:
a. spreading outside of the lymph system.
b. in a single node.
c. in both axillae.
d. in two nodes in the left axilla area.
5. MOPP and ABVD therapy for the treatment of Hodgkin’s disease are treatment protocols using:
a. multiple medications given concurrently.
b. a combination of heat and exercise and chemotherapy.
c. alternating radiation and chemotherapy every 4 weeks.
d. chemotherapy and alternative herbal remedies.
6. The nurse caring for the patient with lymphedema of the left arm will implement what intervention?
a. Encourage patient to keep the arms as inactive as possible to reduce further injury.
b. Clean the arm with mild soap and massage gently.
c. Take blood pressure and give injections in the right arm.
d. Keep the arm below the level of the heart to minimize edema.
7. The patient with rheumatoid arthritis is prescribed an immunosuppressant drug. The patient asks the nurse what this drug is for. What is the nurse’s best response?
a. “The doctor prescribes these drugs to strengthen your immune system.”
b. “The drug inhibits your immune system’s normal response.”
c. “These medications are used to prevent organ rejection.”
d. “This medication will strengthen your joints and repair any joint damage.”
8. The patient scheduled for a CT scan with contrast medium questions the nurse why the technologist asked her if she had any food allergies. Which response by the nurse is correct?
a. “The dye used for a CT scan is egg based, so egg allergies would prevent you from having the test.”
b. “People who are allergic to dairy products are likely to be allergic to CT scan dye.”
c. “Allergies to shellfish can be a problem because shellfish and CT scan dye are iodine based.”
d. “Wheat is the preservative used in CT scan dye, so allergies to wheat may cause allergies to the dye.”
9. The nurse is performing an assessment on a patient admitted for diagnostic testing to rule out fibromyalgia. Which assessment finding would indicate that the patient actually may have the disorder?
a. A decreased response to painful stimuli
b. A pain response to nonpainful stimuli
c. No response to painful stimuli
d. Numbness and tingling in response to painful stimuli
10. The patient with cancer has experienced sensitivity to past chemotherapy infusions. The best action to prevent a hypersensitivity reaction is the administration of _____ prior to the chemotherapy infusion.
a. a corticosteroid
b. daclizumab
c. antithymocyte globulin
d. epinephrine
Chapter 13: The Respiratory System
1. The nurse explains that the purpose of mucus is to:
a. warm the air entering the lungs.
b. trap particles and bacteria.
c. protect the cilia.
d. clean the sinus cavity.
2. A patient with emphysema enters the emergency room with severe dyspnea; O2 saturation is 74%, pulse is 120, and respirations are 26. After positioning the patient in high Fowler’s, the nurse should:
a. attempt to help the patient slow her respirations.
b. coach in pursed-lip breathing.
c. give oxygen at 5 L/min by nasal cannula.
d. reposition patient in orthopneic position.
3. The nurse explains that the mechanism that triggers rate and depth of respiration is based on:
a. ease of respiration.
b. alveolar pressure.
c. patency of bronchi.
d. blood pH.
4. The nurse uses a visual aid to show the mechanics of inhaling which correctly illustrates:
a. the diaphragm moves down.
b. the negative pressure of the lung converts to positive pressure.
c. muscles contract, pulling the rib cage down.
d. bronchi enlarge.
5. The nurse explains that the substance that decreases the surface tension of the alveolar walls is:
a. plasma.
b. surfactant.
c. cilia.
d. mucus.
6. Using animation, the nurse demonstrates how most of the inspired oxygen is carried to the tissues by the:
a. plasma.
b. lymphatic system.
c. red blood cells.
d. white blood cells.
7. The nurse points out to the student nurse that one of the patients she is caring for has an obstructive respiratory disorder. The student is correct in identifying the patient diagnosed with __________ as having an obstructive disorder.
a. atelectasis
b. lung cancer
c. Guillain-Barré syndrome
d. chronic bronchitis
8. When reviewing risk factors, the nurse correctly identifies which patient as having the greatest risk of throat cancer?
a. The patient who drinks 4 cups of coffee per day.
b. The patient who smokes 1 pack of cigarettes per week.
c. The patient who drinks several carbonated drinks per day.
d. The patient who drinks 4 vodka tonics per day.
9. The nurse cautions each person prior to giving the influenza immunization that they should not take it if they are allergic to:
a. strawberries.
b. ragweed.
c. penicillin.
d. eggs.
10. After auscultating a coarse low-pitched sonorous rattling in the left lower lobe, the nurse is concerned that the patient may be developing:
a. an accumulation of secretions in the larger air passages.
b. narrowing in the lower lobe of the lung.
c. irritation in the pleurae.
d. crackles in the left lower lobe.
Chapter 14: Care of Patients with Disorders of the Upper Respiratory System
1. The nurse reminds the patient that a cold is contagious for about _____ days.
a. 2
b. 3
c. 4
d. 7
2. The nurse clarifies that the antibiotic given to the patient with a cold is to:
a. cure the cold.
b. reduce the symptoms.
c. prevent a secondary bacterial infection.
d. protect the immune system.
3. When the patient with an upper respiratory infection states that it is difficult to chew due to pain in the upper teeth, the nurse suspects:
a. abscess.
b. caries.
c. sinusitis.
d. pharyngitis.
4. The 20-year-old who has laser surgery to remove the tonsils should be positioned postoperatively in the position of:
a. side-lying.
b. semi-Fowler’s.
c. prone.
d. supine.
5. The patient with sleep apnea complains to the nurse that he is constantly fatigued. The nurse is most accurate in telling the patient that his fatigue is related to which factor?
a. Oxygen deficiency
b. Waking frequently during the night
c. Increased respiratory effort
d. Snoring
6. The nurse is caring for a patient during the immediate postoperative period following a rhinoplasty. The nurse is most concerned with which assessment finding?
a. The patient complains of being cold and chilled.
b. The patient complains of nausea.
c. The nurse notices the patient swallowing frequently.
d. The patient has a decreased fluid intake.
7. The patient has a tracheostomy with a one-way valve box that allows the patient to:
a. drink.
b. eat.
c. cough.
d. speak.
8. To help reduce the anxiety of a new tracheostomy patient, the nurse should:
a. be efficient in giving care quickly.
b. give care with minimal conversation.
c. delay teaching until tracheostomy is healed.
d. offer reassurance of awareness of apprehension.
9. The nurse is developing the care plan for a laryngectomy patient. Which patient need will be of the highest priority for the nurse to address?
a. A method of pain control
b. Family support
c. A method of communication
d. The need for long-term care
10. The nurse instructs the laryngectomized patient that, in order to warm the inspired air during cold weather, the patient should:
a. place hand over stoma.
b. use scarf to cover stoma.
c. wear moist dressing over stoma.
d. stay in area of humidified air.
Chapter 15: Care of Patients with Disorders of the Lower Respiratory System
1. The patient with acute bronchitis asks if antibiotics will be ordered for the condition. The best response by the nurse would be:
a. “Yes. Antibiotics are the best treatment option.”
b. “No. Antibiotics will not help a viral condition.”
c. “Antibiotics will be given if the sputum culture indicates your bronchitis is caused by bacteria.”
d. “I don’t think so because antibiotics will inhibit the inflammatory response of your body to the invasion of this infection.”
2. The nurse is assessing the patient with influenza and notes general malaise and aching muscles, which have continued for 2 weeks. The nurse is aware that the patient may have developed which complication of influenza?
a. Bronchitis
b. Bacterial pneumonia
c. Urinary infection
d. Encephalitis
3. The nurse explains that treatment with amantadine (Symmetrel) will:
a. prevent viral pneumonia if taken regularly.
b. stop viral spread of avian flu if taken at the first signs and symptoms of disease.
c. lessen the severity of type A flu symptoms if taken within 48 hours of exposure.
d. reduce irritation of bronchitis if taken weekly.
4. The nurse differentiates viral from bacterial pneumonia in that viral pneumonia causes:
a. elevation in white count.
b. consolidation of lung tissue.
c. interstitial inflammation.
d. copious exudate.
5. The 79-year-old patient with bacterial pneumonia becomes increasingly restless and confused. Temperature is 100° F and pulse, blood pressure, and respirations are elevated since the last assessment 6 hours ago. The initial intervention by the nurse should be to:
a. take the patient off oral fluids.
b. assess oxygen saturation.
c. give the ordered mild sedative.
d. administer an NSAID for discomfort.
6. The 75-year-old patient asks the nurse if the Pneumovax immunization he took when he was 65 is still protecting him. The nurse’s most helpful reply is:
a. “Yes. Pneumovax protects you for your lifetime.”
b. “No. The immunity afforded you by Pneumovax lasts only 2 years.”
c. “Yes, but it loses strength and may not protect you from all 23 pneumococcal organisms anymore.”
d. “No. A second dose is needed 6 years after the first for full immunity.”
7. The 75-year-old resident in the nursing home who cares for 40 birds in an aviary complains of shortness of breath and fatigue and a dry cough. Based on this information, the nurse suspects the resident may be suffering from:
a. coccidioidomycosis.
b. histoplasmosis.
c. tuberculosis.
d. atypical pneumonia.
8. The 30-year-old American Indian female who is taking Rifater, a drug containing rifampin, isoniazid, and pyrazinamide, complains that she is tired of taking medicine and having to spit in a bottle all the time. She asks, “When can I stop all this and get on with my life?” The nurse’s best response is that she will no longer be considered contagious when:
a. the sputum culture comes back negative.
b. the medication has been taken for 9 months.
c. three consecutive sputum cultures are negative.
d. the tuberculin skin test (TST) is no longer positive.
9. The nurse reading a tuberculin skin test (TST) on a new employee who lives in the Midwest, is 20 years old, and has no known history of contact with any persons with tuberculosis (TB) will record it as positive if the area around the injection site has an area of swelling of _____ mm _____ hours after the injection.
a. 15; 48
b. 10; 72
c. 5; 48
d. 0 to 5; 72
10. The nurse explains that a serious complication of a patient’s chronic obstructive pulmonary disease (COPD) is cor pulmonale, which is exhibited by:
a. distended neck veins.
b. weight loss.
c. confusion and disorientation.
d. excessive coughing.
Chapter 16: The Hematologic System
1. The stem cells in the marrow are stimulated to make blood cells by the erythropoietin- stimulating factor in the:
a. brain.
b. lung.
c. kidney.
d. liver.
2. Red blood cells only live about _____ days.
a. 30
b. 90
c. 100
d. 120
3. The nurse explains that, in the event of a massive hemorrhagic episode, the _____ contracts and adds blood to the circulating volume.
a. spleen
b. liver
c. pancreas
d. bone marrow
4. The nurse evaluates the lab reports for the patients on the unit, and recognizes the report requiring the most immediate attention is for the patient with RBCs, _____ mil/mm3; WBCs, _____ mil/mm3; and Hb, _____ g/dL.
a. 4.2; 4500; 9.1
b. 5.9; 4500; 12.7
c. 6.0; 6000; 13.2
d. 7.6; 8000; 18.0
5. The nurse notes a rise in the eosinophil count and suspects the patient has a(n):
a. bacterial infection.
b. allergy.
c. viral infection.
d. blood dyscrasia.
6. The nurse uses a visual aid to depict the several kinds of hemoglobin. The hemoglobin that changes the shape of the red blood cell (RBC) on which it resides is hemoglobin:
a. A.
b. A1c.
c. F.
d. S.
7. The nurse is assessing an 82-year-old African American male with sickle cell anemia and notes the sclera of his eyes to be yellow. The nurse correctly interprets this finding as:
a. sickle cell crisis.
b. anemia.
c. jaundice.
d. a normal occurrence.
8. The nurse explains that jaundice is present as a result of the release of excessive _____ into the bloodstream.
a. histamine
b. bilirubin
c. plasma
d. platelets
9. When the patient with pernicious anemia says, “I don’t know why I am so tired,” the nurse can clarify by saying that the fatigue is related to:
a. lack of oxygen being carried to cells of the body.
b. enlarged spleen, which makes breathing difficult.
c. proliferation of white cells.
d. excessive red cells that have decreased the blood pressure.
10. When the nurse observes melena, she is aware that a minimum of _____ to _____ mL of blood has been deposited into the GI tract.
a. 25; 50
b. 50; 75
c. 75; 100
d. 100; 120
Chapter 17: Care of Patients with Hematologic Disorders
1. The nurse cautions the 79-year-old male who had a gastrectomy a month ago that he is at risk for _____ anemia.
a. aplastic
b. pernicious
c. iron deficiency
d. nutritional
2. Because of a deficiency of iron, the person with iron deficiency anemia is unable to make sufficient:
a. plasma.
b. WBCs.
c. hemoglobin.
d. antibodies.
3. The nurse is aware that a common cause of reduced amounts of erythropoietin is:
a. renal failure.
b. liver cancer.
c. emphysema.
d. diabetes.
4. The nurse anticipates that the patient with iron deficiency anemia will have red cells that are:
a. normochromic and normocytic.
b. hypochromic and microcytic.
c. hyperchromic and macrocytic.
d. normochromic and microcytic.
5. The home health nurse assesses the patient taking ferrous sulfate (Feosol). Which patient statement alerts the nurse that teaching is necessary regarding this medication?
a. “It tastes better when I take my medicine with milk.”
b. “My wife says I should take my medicine with orange juice.”
c. “I am always careful not to break open the capsule.”
d. “I usually take my iron with my whole-grain toast during breakfast.”
6. Change question stem, answer options, rationale, and cognitive level as follows:
The student nurse is preparing to administer an iron preparation via the intramuscular (IM) route. Which action by the student indicates the need for further instruction?
a. The student changes needles after drawing up the medication.
b. The student chooses a 1 1/2 inch needle.
c. The student chooses a 20-gauge needle.
d. The student uses the Z-track technique when administering the injection.
7. The nurse frequently assesses for signs of infection on the patient with aplastic anemia because the patient will not be able to produce an inflammatory response related to the low level of:
a. leukocytes.
b. erythrocytes.
c. histamine.
d. hemopoietin.
8. The nurse instructs the 20-year-old female patient with sickle cell trait that:
a. the condition will evolve into sickle cell anemia as she ages.
b. all of her children will have sickle cell anemia.
c. the trait will be transmitted to male children only.
d. the trait can be passed on to all children.
9. The nurse stresses to the patient with sickle cell anemia that one of the most elementary home interventions to help prevent sickle cell crisis is to:
a. take iron supplements daily.
b. maintain adequate fluid intake.
c. engage in daily exercise.
d. eat leafy green vegetables.
10. The nurse is conscientious in the care of the feet and legs of a patient with sickle cell anemia because:
a. stasis ulcers are a constant threat.
b. bleeding may occur on the soles of the feet.
c. edema of the feet increases activity intolerance.
d. toenails must be kept short to avoid ingrown nails.
Chapter 18: The Cardiovascular System
1. The nurse encourages a 65-year-old female patient to get a cholesterol study because the best indicator of possible heart disease in women is:
a. low levels of high-density lipoprotein.
b. low levels of triglycerides.
c. high levels of high-density lipoprotein.
d. low levels of low-density lipoprotein.
2. The nurse explaining blood pressure to a patient instructs that, in a blood pressure of 120/80, the 80 indicates the:
a. pulse pressure.
b. pressure in the relaxed ventricles.
c. relative ejection factor.
d. stroke volume.
3. The nurse is aware that the eventual outcome of angiotensin on the circulatory system is:
a. vasoconstriction.
b. release of sodium and water to be excreted.
c. increase in blood pressure.
d. decrease in cardiac output.
4. The 85-year-old patient asks the nurse why he has a heart murmur now after all these years. What is the most likely cause of this patient’s heart murmur?
a. Hypertension
b. Atherosclerosis
c. Insufficient valves
d. Weakened pacemaker
5. The nurse is performing a cardiac assessment on the older adult patient and notices an irregular rhythm when listening to the apical pulse. The nurse knows that this is often due to what cause in the elderly patient?
a. Loss of cells in the sinoatrial (SA) nodes
b. Increased peripheral resistance
c. Hypertension
d. Atherosclerosis
6. The nurse warns a group of college students that atherosclerotic plaque begins to occur after the age of:
a. 18.
b. 20.
c. 25.
d. 30.
7. The nurse is outlining a teaching program for diabetic patients. Which teaching point will the nurse stress when educating this population about strategies to prevent heart disease?
a. Keep blood sugar below 110 mg/dL.
b. Prevent infections.
c. Eat meals at regular times.
d. Use sterile technique in insulin injections.
8. The nurse explains that a Doppler flow study is done to:
a. detect a clot in a coronary artery.
b. visualize obstructions in leg vessels.
c. assess efficiency of blood flow through heart chambers.
d. detect a defective heart valve.
9. Following an angiogram, the nurse will assess and record:
a. allergy to dye.
b. range of motion of lower limbs.
c. presence and strength of pedal pulses.
d. nausea.
10. The patient who is to have a stress echocardiogram is instructed that prior to the test she should:
a. eat a full meal.
b. limit caffeine drinks to 1 cup.
c. abstain from smoking for 8 hours.
d. wear hard-soled shoes.
Chapter 19: Care of Patients with Hypertension and Peripheral Vascular Disease
1. Hypertension is diagnosed by the finding of a blood pressure reading greater than:
a. 120/80 twice, 2 weeks apart.
b. 140/90 twice, 2 weeks apart.
c. 120/80 on 3 consecutive days.
d. 140/90 every day for a week.
2. Because of reduced sensitivity of the baroreceptors in the older adult who is also on a diuretic, the nurse instructs the patient to:
a. walk for 20 minutes a day.
b. reduce sodium in the diet.
c. sit on the side of the bed before standing.
d. use a walker for all ambulation.
3. The home health nurse is alarmed that the hypertensive patient’s blood pressure has risen to 200/160, but he denies any discomfort. The nurse interprets these assessments as being indicative of:
a. malignant hypertension.
b. hypertensive crisis.
c. essential hypertension.
d. secondary hypertension.
4. The nurse adds an intervention to the care plan of a patient who has just been prescribed a thiazide diuretic, which is to increase:
a. intake of foods containing potassium.
b. carbohydrates in the diet.
c. foods high in sodium.
d. fluid intake.
5. The patient has been prescribed a low-sodium diet. Which food omissions from the diet will indicate the patient has an adequate understanding of the recommended diet?
a. Fresh spinach
b. Hot dogs
c. Pasta
d. Grapefruit
6. The patient is instructed that the most common and effective antiplatelet aggregation agent is:
a. warfarin.
b. aspirin.
c. alteplase (Activase).
d. reteplase (Retavase).
7. The patient scheduled for a percutaneous angioplasty (PTA) is instructed that a ________ is left in the artery to keep it patent.
a. bolus of alteplase
b. dose of reteplase
c. stent
d. graft
8. The nurse is providing patient teaching to a pregnant patient who works as a cashier in a grocery store. Which suggestion by the nurse will help most in preventing varicose veins?
a. Add vitamin C to diet.
b. “March in place” while standing at the counter.
c. Avoid tight support hose.
d. Wear supportive shoes.
9. An 86-year-old patient asks why her ankles have a brownish discoloration and the skin looks so thick. Which is the most accurate response by the nurse?
a. “The valves in the vessels in your legs aren’t working as well as they used to, which causes the discoloration and thickening of your skin.”
b. “You probably aren’t getting enough iron in your diet. We should talk to your doctor about adding an iron supplement.”
c. “How many years have you smoked? Nicotine will cause these changes in your skin.”
d. “These are just normal changes seen in most elderly people.”
10. The nurse is planning the care for a patient who is to have a saphenous vein stripping. What will be the priority intervention?
a. Bed rest and leg elevation for the first 12 to 24 hours
b. Assessing the need for significant pain relief
c. Massaging the legs to stimulate sluggish circulation
d. Elevating the legs to prevent hematoma
Chapter 20: Care of Patients with Cardiac Disorders
1. The nurse would anticipate that the patient with right-sided heart failure would exhibit:
a. wheezing.
b. orthopnea.
c. edema.
d. pallor.
2. The nurse anticipates that, on auscultation of the chest of an older adult with left-sided congestive heart failure (CHF), the major adventitious sound will be:
a. wheezing.
b. crackles.
c. rhonchi.
d. friction rub.
3. The nurse explains to the patient that the implanted cardioverter-defibrillator (ICD) will:
a. shock the arrhythmias into sinus rhythm.
b. enhance the heart pumping action.
c. stimulate an extra beat if the heart rate drops.
d. control the rate of the heart at a the present level.
4. The patient with severe congestive heart failure (CHF) does not want to take the morphine ordered, stating that he is not in pain and he is fearful of becoming addicted. The nurse can allay anxiety by explaining that the morphine:
a. is given to many people with CHF.
b. can be omitted and relief can be obtained with NSAIDs.
c. is used to relieve anxiety and air hunger.
d. is the only drug that can be used for CHF patients.
5. The nurse caring for a patient with congestive heart failure (CHF) will include which intervention in the plan of care?
a. Perform all care at one time to allow more time to rest.
b. Keep the patient as flat as possible to prevent venous pooling.
c. Encourage eating large meals at regular times.
d. Alternate rest with activity.
6. The patient with tachycardia who has a heart rate of 115 complains of shortness of breath. The nurse interprets this complaint as being related to which problem?
a. Pulmonary edema
b. Drop in cardiac output
c. Impending pneumonia
d. Increasing anxiety
7. The nurse evaluates the need for further instruction on reduction of caffeine when the patient who has an arrhythmia says:
a. “I’ve cut my coffee from 10 cups to 2 cups a day.”
b. “I don’t drink regular cola drinks anymore.”
c. “I have given up drinking those high-energy drinks.”
d. “I’ve switched from 5 cups of coffee to 5 cups of tea.”
8. If there are several tiny spikes in place of P waves on the ECG, the nurse recognizes the arrhythmia as:
a. premature ventricular contraction (PVC).
b. atrial flutter/fibrillation.
c. ventricular tachycardia (VT).
d. premature atrial contraction (PAC).
9. The patient with atrial fibrillation asks why she needs to take warfarin. The most informative response by the nurse is that warfarin will:
a. thin the blood to increase the ejection fraction.
b. prevent clots from forming in the atria.
c. block the arrhythmia from involving the ventricles.
d. increase the cardiac output.
10. The nurse caring for a patient who is taking amiodarone (Cordarone) will plan to assess the vital signs carefully for which common side effect?
a. Sudden increase in temperature
b. Hypotension
c. Bradycardia
d. Depressed ventilation

AND MUCH MORE