The nurse is using a preoperative checklist to assist in preparing a patient on the day of surgery. What will the checklist include? (Select all that apply.)

The nurse is using a preoperative checklist to assist in preparing a patient on the day of surgery. What will the checklist include? (Select all that apply.)

a. Vital signs

b. Laboratory data

c. Living will

d. NPO

e. Identification (ID) band on

f. Family location





Answer: A, B, D, E

The nurse is providing preoperative education and reviews with the patient what it will be like to be in the surgical environment. What points should the nurse include? (Select all that apply.)

The nurse is providing preoperative education and reviews with the patient what it will be like to be in the surgical environment. What points should the nurse include? (Select all that apply.)

a. The surgical area is cold but warm blankets will be provided.

b. The surgical staff will be dressed in special clothing with hats and masks.

c. The operative suite will be very dark.

d. Families are not allowed in the operating suite.

e. The operating table or bed will be comfortable and soft.

f. The nurses will be there to assist you through this process.





Answer: A, B, D, F

The nurse is caring for a patient in the operating suite. The nurse assists in positioning the patient to (Select all that apply.)

The nurse is caring for a patient in the operating suite. The nurse assists in positioning the patient to (Select all that apply.)

a. Gain access to the operative site.

b. Sustain adequate circulatory and respiratory function.

c. Ensure patient safety and skin integrity.

d. Support the use of equipment.

e. Maintain neuromuscular structures.

f. Provide warmth and comfort.





Answer: A, B, C, E

The nurse is preparing for a patient who will be going to surgery. The nurse screens for risk factors that can increase a persons risks in surgery. What risk factors are included in the nurses screening? (Select all that apply.)

The nurse is preparing for a patient who will be going to surgery. The nurse screens for risk factors that can increase a persons risks in surgery. What risk factors are included in the nurses screening? (Select all that apply.)

a. Age

b. Nutrition

c. Race

d. Obesity

e. Pregnancy

f. Ambulatory surgery






Answer: A, B, D, E

The nurse is caring for a postoperative patient with an incision. Which of the following nursing interventions have been found to decrease wound infections? (Select all that apply.)

The nurse is caring for a postoperative patient with an incision. Which of the following nursing interventions have been found to decrease wound infections? (Select all that apply.)

a. Perform hand hygiene before and after contact with the patient.

b. Maintain normoglycemia.

c. Use hair clippers to remove hair.

d. Administer antibiotics within 30 to 60 minutes of incision time.

e. Provide bath and linen change daily.

f. Perform first dressing change 1 week postoperatively.






Answer: A, B, C, D

The nurse is caring for an ambulatory surgery patient. To be discharged home, what criteria must the patient meet? (Select all that apply.)

The nurse is caring for an ambulatory surgery patient. To be discharged home, what criteria must the patient meet? (Select all that apply.)

a. Able to drink fluids

b. Able to eat crackers

c. Manageable pain

d. Able to void

e. Dry and intact dressing

f. Able to dress self





Answer: A, C, D, E

The nurse is precepting a new nurse in the perioperative area. The nurse explains that perioperative nursing is based on certain principles and includes (Select all that apply.)

The nurse is precepting a new nurse in the perioperative area. The nurse explains that perioperative nursing is based on certain principles and includes (Select all that apply.)

a. Purchasing the correct equipment.

b. Providing high-quality and patient safety focused care.

c. Scheduling the right types of patients.

d. Conducting multidisciplinary teamwork.

e. Ensuring effective therapeutic communication.

f. Providing advocacy for the patient.



Answer: B, D, E, F

The ambulatory surgical nurse calls to check on the patient at home the morning after surgery. The patient is reporting continued nausea and vomiting. Which of the following discharge education points should be reviewed with the patient?

The ambulatory surgical nurse calls to check on the patient at home the morning after surgery. The patient is reporting continued nausea and vomiting. Which of the following discharge education points should be reviewed with the patient?

a. Instruct the patient to take deep breaths.

b. Instruct the patient to drink ginger ale and eat crackers.

c. Instruct and attempt to connect the patient with the physician.

d. Instruct the patient to go to the emergency department.







Answer: C

The nurse is caring for a patient who will undergo a coronary artery bypass graft procedure. What level of care will the patient require immediately post procedure?

The nurse is caring for a patient who will undergo a coronary artery bypass graft procedure. What level of care will the patient require immediately post procedure?

a. Acute caremedical-surgical unit

b. Acute careintensive care unit

c. Ambulatory surgery

d. Ambulatory surgeryextended stay




Answer: B

The postanesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgical floor. Before leaving the floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this nursing action?

The postanesthesia care unit (PACU) nurse transports the inpatient surgical patient to the medical-surgical floor. Before leaving the floor, the medical-surgical nurse obtains a complete set of vital signs. What is the rationale for this nursing action?

a. The first action in a head-to-toe assessment is vital signs.

b. This is done to compare and monitor for vital sign variation during transport.

c. This is done to ensure that the medical-surgical nurse checks on the postoperative patient.

d. This is done to follow hospital policy and procedure for care of the surgical patient.





Answer: B

The nurse is caring for a patient in the postanesthesia care unit. The patient asks for a bedpan and states to the nurse, I feel like I need to go to the bathroom, but I cant. Which of the following nursing interventions would be most appropriate?

The nurse is caring for a patient in the postanesthesia care unit. The patient asks for a bedpan and states to the nurse, I feel like I need to go to the bathroom, but I cant. Which of the following nursing interventions would be most appropriate?

a. Encourage the patient to wait a minute and try again.

b. Call the physician and obtain an order for catheterization.

c. Assess the patients intake and the patient for bladder distention.

d. Inform the patient that everyone feels this way after surgery.






Answer: C

The nurse is monitoring a patient in the postanesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which of the following actions would be most appropriate for this patient?

The nurse is monitoring a patient in the postanesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which of the following actions would be most appropriate for this patient?

a. Encourage copious amounts of water.

b. Weigh the patient and compare with preoperative weight.

c. Measure and record all intake and output.

d. Start an additional intravenous (IV) line.





Answer: C

The nurse is caring for a postoperative patient who has had a carpel tunnel repair. The patient has a temperature of 97 F and is shivering. Which of the following is the best reason for this condition?

The nurse is caring for a postoperative patient who has had a carpel tunnel repair. The patient has a temperature of 97 F and is shivering. Which of the following is the best reason for this condition?

a. The patient is dressed only in a gown.

b. Anesthesia lowers metabolism.

c. The surgical suite has laminar flow.

d. The open body cavity contributed to heat loss.






Answer: B

The nurse is caring for a patient in the operating suite who is experiencing hypercarbia, tachypnea, tachycardia, premature ventricular contractions, and muscle rigidity. The nurse suspects that this patient may be experiencing

The nurse is caring for a patient in the operating suite who is experiencing hypercarbia, tachypnea, tachycardia, premature ventricular contractions, and muscle rigidity. The nurse suspects that this patient may be experiencing

a. Hypoxia.

b. Malignant hyperthermia.

c. Fluid imbalance.

d. Hemorrhage.





Answer: B

The nurse is caring for a postoperative patient with a history of obstructive sleep apnea. The nurse monitors for which of the following?

The nurse is caring for a postoperative patient with a history of obstructive sleep apnea. The nurse monitors for which of the following?

a. Choking and noisy, irregular respirations

b. Shallow respirations

c. Moaning and reports of pain

d. Disorientation





Answer: A

The nurse is concerned about the skin integrity of the patient in the intraoperative phase of surgery. Which of the following actions helps to minimize skin breakdown?

The nurse is concerned about the skin integrity of the patient in the intraoperative phase of surgery. Which of the following actions helps to minimize skin breakdown?

a. Encouraging the patient to bathe before surgery

b. Securing attachments to the operating table with foam padding

c. Periodically adjusting the patient during the surgical procedure

d. Measuring the time a patient is in one position during surgery





Answer: B

The nurse is caring for a patient in the operating suite. Which of the following outcomes would be most appropriate for this patient?

The nurse is caring for a patient in the operating suite. Which of the following outcomes would be most appropriate for this patient?

a. At the end of the intraoperative phase, the patient will be free of burns at the grounding pad.

b. At the end of the intraoperative phase, the patient will be free of infection.

c. At the end of the intraoperative phase, the patient will be free of nausea and vomiting.

d. At the end of the intraoperative phase, the patient will be free of pain.






Answer: A

The nurse is caring for a patient in the preoperative holding area of an ambulatory surgery center. Which nursing action would be most appropriate for this area?

The nurse is caring for a patient in the preoperative holding area of an ambulatory surgery center. Which nursing action would be most appropriate for this area?

a. Monitor vital signs every 15 minutes.

b. Empty the urinary drainage bag.

c. Apply a warm blanket.

d. Check the surgical dressing.





Answer: C

The nurse is caring for a patient intraoperatively. Primary roles of the circulating nurse include

The nurse is caring for a patient intraoperatively. Primary roles of the circulating nurse include

a. Establishing and implementing the plan of care.

b. Maintaining a sterile field.

c. Assisting with applying sterile drapes.

d. Handing sterile instruments and supplies to the surgeon.







Answer: A

The nurse is preparing a patient for a surgical procedure on the right great toe. Which of the following actions would be most important to include in this patients preparation?

The nurse is preparing a patient for a surgical procedure on the right great toe. Which of the following actions would be most important to include in this patients preparation?

a. Ascertain that the surgical site has been correctly marked.

b. Ascertain where the family will be located during the procedure.

c. Place the patient in a clean surgical gown.

d. Ask the patient to remove all hairpins and cosmetics.






Answer: A

The nurse has completed a preoperative assessment for a patient going to surgery and gathers assessment data. Of the following, which would be the most important next step?

The nurse has completed a preoperative assessment for a patient going to surgery and gathers assessment data. Of the following, which would be the most important next step?

a. Notify the operating suite that the patient has a latex allergy.

b. Document that the patient had a bath at home this morning.

c. Ask the nursing assistant to obtain vital signs.

d. Administer the ordered preoperative intravenous antibiotic.





Answer: A

The nurse has administered an anxiolytic as a preoperative medication to the patient going to surgery. Which of the following is the best next step?

The nurse has administered an anxiolytic as a preoperative medication to the patient going to surgery. Which of the following is the best next step?

a. Waste any unused medication according to policy.

b. Notify the operating suite that the medication has been given.

c. Instruct the patient to call for help to go to the restroom.

d. Ask the patient to sign the consent for surgery.





Answer: C

During preoperative assessment for a 7:30 case, the patient indicates to the nurse that he had a cup of coffee this morning. The nurse reports this information to the anesthesia provider anticipating

During preoperative assessment for a 7:30 case, the patient indicates to the nurse that he had a cup of coffee this morning. The nurse reports this information to the anesthesia provider anticipating

a. A delay in or cancellation of surgery.

b. Questions regarding components of the coffee.

c. Additional questions about why the patient had coffee.

d. Instructions to determine what education was provided in the preoperative visit.






Answer: A

The nurse and the nursing assistant are caring for a group of postoperative patients who need turning, coughing, deep breathing, incentive spirometry, and leg exercises. The nurse directs the nursing assistant to

The nurse and the nursing assistant are caring for a group of postoperative patients who need turning, coughing, deep breathing, incentive spirometry, and leg exercises. The nurse directs the nursing assistant to

a. Teach and demonstrate postoperative exercises.

b. Inform the nurse if the patient is unwilling to perform exercises.

c. Document in the medical record when exercises are completed.

d. Do nothing associated with postoperative exercises.






Answer: B

The nurse is reviewing the surgical consent with the patient during preoperative education. The patient indicates that he does not understand what procedure will be completed. What is the nurses best next step?

The nurse is reviewing the surgical consent with the patient during preoperative education. The patient indicates that he does not understand what procedure will be completed. What is the nurses best next step?

a. Notify the physician about the patients question.

b. Explain the procedure that will be completed.

c. Ask the patient to sign the form.

d. Continue with preoperative education.





Answer: A

The nurse is preparing to assist the patient in using the incentive spirometer. Which nursing intervention should the nurse provide first?

The nurse is preparing to assist the patient in using the incentive spirometer. Which nursing intervention should the nurse provide first?

a. Perform hand hygiene.

b. Place in reverse Trendelenburg position.

c. Explain use of the mouthpiece.

d. Instruct the patient to inhale slowly.





Answer: A

The nurse and the nursing assistant are assisting a postoperative patient to turn in the bed. To assist in minimizing discomfort, which instruction should the nurse provide to the patient?

The nurse and the nursing assistant are assisting a postoperative patient to turn in the bed. To assist in minimizing discomfort, which instruction should the nurse provide to the patient?

a. Close your eyes and think about something pleasant.

b. Hold your breath and count to three.

c. Hold my shoulders with your hands.

d. Place your hand over your incision.






Answer: D

The nurse is making a preoperative education appointment with a patient. The patient asks if he should bring family with him to the appointment. What is the best response by the nurse?

The nurse is making a preoperative education appointment with a patient. The patient asks if he should bring family with him to the appointment. What is the best response by the nurse?

a. There is no need for an additional person at the appointment.

b. Your family can come and wait with you in the waiting room.

c. We recommend including family in this appoint to ease everyone's anxiety.

d. It is required that you have a family member at this appointment.





Answer: C

The nurse is encouraging a reluctant postoperative patient to deep breathe and cough. What explanation can the nurse provide that may encourage the patient to cough more effectively?

The nurse is encouraging a reluctant postoperative patient to deep breathe and cough. What explanation can the nurse provide that may encourage the patient to cough more effectively?

a. If you don't deep breathe and cough, you will get pneumonia.

b. Deep breathing and coughing will clear out the anesthesia.

c. Coughing will not harm the incision if done correctly.

d. You will need to cough only a few times during this shift.






Answer: C

The nurse explains the pain relief measures available after surgery during preoperative teaching for a surgical patient. Which of the following comments from the patient indicates the need for additional education on this topic?

The nurse explains the pain relief measures available after surgery during preoperative teaching for a surgical patient. Which of the following comments from the patient indicates the need for additional education on this topic?

a. I will take the pain medication as the physician prescribes it.

b. I will be asked to rate my pain on a pain scale.

c. I will have minimal pain because of the anesthesia.

d. I will take my pain medications before doing postoperative exercises.





Answer: C

The nurse is caring for a postoperative patient with an abdominal incision. A pillow is used during coughing to provide

The nurse is caring for a postoperative patient with an abdominal incision. A pillow is used during coughing to provide

a. Pain relief.

b. Splinting.

c. Distraction.

d. Anxiety reduction.




Answer: B

The nurse is providing preoperative teaching for the ambulatory surgery patient who will be having a cyst removed from the right arm. Which would be the best explanation for diet progression after surgery?

The nurse is providing preoperative teaching for the ambulatory surgery patient who will be having a cyst removed from the right arm. Which would be the best explanation for diet progression after surgery?

a. Start with clear liquids, soup, and crackers. Advance to a normal diet as you tolerate.

b. There is no limitation on your diet. You can have whatever you want.

c. Stay on clear liquids for 24 hours. Then you can progress to a normal diet.

d.Start with clear liquids for 2 hours, then full liquids for 2 hours. Then progress to a normal diet.






Answer: A

Which nursing assessment would indicate that the patient is performing diaphragmatic breathing correctly?

Which nursing assessment would indicate that the patient is performing diaphragmatic breathing correctly?

a. Hands placed on border of rib cage with fingers extended will touch as chest wall contracts.

b. Hands placed on chest wall with fingers extended will separate as chest wall contracts.

c. The patient will feel upward movement of the diaphragm during inspiration.

d. The patient will feel downward movement of the diaphragm during expiration.






Answer: A

The nurse is caring for a preoperative patient. The nurse teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurses best next step?

The nurse is caring for a preoperative patient. The nurse teaches the principles and demonstrates leg exercises for the patient. The patient is unable to perform leg exercises correctly. What is the nurses best next step?

a. Assess for the presence of anxiety, pain, or fatigue.

b. Ask the patient why he does not want to do the exercises.

c. Encourage the patient to practice at a later date.

d. Assess the educational methods used to educate the patient.






Answer: A

The nurse is caring for a postoperative patient on the medical-surgical floor. To prevent venous stasis and the formation of thrombus after general anesthesia, the nurse encourages

The nurse is caring for a postoperative patient on the medical-surgical floor. To prevent venous stasis and the formation of thrombus after general anesthesia, the nurse encourages

a. Coughing.

b. Diaphragmatic breathing.

c. Incentive spirometry.

d. Leg exercises.





Answer: D

The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Reasons for this intervention include

The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Reasons for this intervention include

a. Management of pain.

b. Decreased healing time.

c. Prevention of atelectasis.

d. Decreased thrombus formation.






Answer: C

The nurse is caring for a potential surgical patient in the preadmission testing unit. The medication history indicates that the patient is currently taking warfarin (Coumadin). Which of the following actions should the nurse take?

The nurse is caring for a potential surgical patient in the preadmission testing unit. The medication history indicates that the patient is currently taking warfarin (Coumadin). Which of the following actions should the nurse take?

a. Consult with the physician regarding a radiological examination of the chest.

b. Consult with the physician regarding an international normalized ratio (INR).

c. Consult with the physician regarding blood urea nitrogen (BUN).

d. Consult with the physician regarding a complete blood count (CBC).




Answer: B

The nurse is completing a medication history for the surgical patient in pre admission testing. Which of the following medications should the nurse instruct the patient to hold in preparation for surgery?

The nurse is completing a medication history for the surgical patient in pre admission testing. Which of the following medications should the nurse instruct the patient to hold in preparation for surgery?

a. Ibuprofen

b. Acetaminophen

c. Vitamin C

d. Miconazole





Answer: A

The nurse is preparing a patient for surgery. Aims of assessment before surgery include

The nurse is preparing a patient for surgery. Aims of assessment before surgery include

a. Establishing a patients baseline of normal function.

b. Planning for care after the procedure.

c. Educating the patient and family about the procedure.

d. Gathering appropriate equipment for the patients needs.





Answer: A

The nurse is caring for a patient in the postanesthesia care unit who has undergone a left total knee arthroplasty. The anesthesia provider has indicated that the patient received a left femoral peripheral nerve block. Which assessment would be an expected finding for a patient with this type of regional block?

The nurse is caring for a patient in the postanesthesia care unit who has undergone a left total knee arthroplasty. The anesthesia provider has indicated that the patient received a left femoral peripheral nerve block. Which assessment would be an expected finding for a patient with this type of regional block?

a. Decreased pulse at the left posterior tibia

b. Left toes cool to touch and slightly cyanotic

c. Sensation decreased in the left leg

d. Patient report of pain in the left foot





Answer: C

The patient has presented to the ambulatory surgery center to have a colonoscopy. The patient is scheduled to receive moderate sedation (conscious sedation) during the procedure. Moderate sedation is used routinely for procedures that require

The patient has presented to the ambulatory surgery center to have a colonoscopy. The patient is scheduled to receive moderate sedation (conscious sedation) during the procedure. Moderate sedation is used routinely for procedures that require

a. Performance on an outpatient basis.

b. A depressed level of consciousness.

c. Loss of sensation in an area of the body.

d. The patient to be immobile.





Answer: B

The nurse is caring for a patient in pre admission testing. The patient has been assigned a physical status classification by the American Society of Anesthesiologist of P3. Which of the following assessments would support this classification?

The nurse is caring for a patient in pre admission testing. The patient has been assigned a physical status classification by the American Society of Anesthesiologist of P3. Which of the following assessments would support this classification?

a. Denial of any major illnesses or conditions

b. Normal, healthy patient

c. History of hypertension, 80 pounds overweight, history of asthma

d. History of myocardial infarction that limits activity




Answer: C

The nurse is caring for a patient in the postanesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. This procedure would be classified as

The nurse is caring for a patient in the postanesthesia care unit. The patient has developed profuse bleeding from the surgical site, and the surgeon has determined the need to return to the operative area. This procedure would be classified as

a. Elective.

b. Urgent.

c. Emergency.

d. Major.



Answer: C

The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patients laboratory tests and allergies. In which perioperative nursing phase would this work be completed?

The nurse is caring for a patient who is scheduled to undergo a surgical procedure. The nurse is completing an assessment and reviews the patients laboratory tests and allergies. In which perioperative nursing phase would this work be completed?

a. Perioperative

b.Preoperative

c. Intraoperative

d. Postoperative




Answer: B

The nurse is precepting a student nurse and explains that perioperative nursing care occurs

The nurse is precepting a student nurse and explains that perioperative nursing care occurs

a. Before, during, and after surgery.

b. In preadmission testing.

c. During the surgical procedure.

d. In the postanesthesia care unit.






Answer: A

A nurse is caring for a patient who is experiencing vertigo. Which nursing intervention would assist the patient in controlling the vertigo?

A nurse is caring for a patient who is experiencing vertigo. Which nursing intervention would assist the patient in controlling the vertigo?

a. Increasing fluid intake to 3 liters a day

b. Watching television instead of reading books

c. Avoiding riding in vehicles and making sudden motions

d. Placing several antiemetic patches on the patient





Answer: C

The nurse is developing a plan of care for a patient who is having a prosthetic eye placed. Which nursing diagnosis related to patient safety is the priority for the nurse to include in the plan of care?

The nurse is developing a plan of care for a patient who is having a prosthetic eye placed. Which nursing diagnosis related to patient safety is the priority for the nurse to include in the plan of care?

a. Self-care deficit

b. Risk for injury

c. Anxiety

d. Body image disturbance





Answer: B

A nurse is establishing a relationship with the patient who is visually impaired. Which is the most appropriate method to teach the patient how to contact the nurse for assistance?

A nurse is establishing a relationship with the patient who is visually impaired. Which is the most appropriate method to teach the patient how to contact the nurse for assistance?

a. Place a raised Braille sticker on the call button, and instruct the patient to press for assistance.

b. Instruct the patient to yell at the top of his lungs to get the attention of the staff.

c. Explain to the patient that a staff person will stop by once an hour to see if the patient needs anything.

d. Share cell phone numbers with the patient so he can call the nurse if he needs her.




Answer: A

A nurse is establishing a relationship with the patient who is visually impaired. Which is the most appropriate method to teach the patient how to contact the nurse for assistance?

A nurse is establishing a relationship with the patient who is visually impaired. Which is the most appropriate method to teach the patient how to contact the nurse for assistance?

a. Place a raised Braille sticker on the call button, and instruct the patient to press for assistance.

b. Instruct the patient to yell at the top of his lungs to get the attention of the staff.

c. Explain to the patient that a staff person will stop by once an hour to see if the patient needs anything.

d. Share cell phone numbers with the patient so he can call the nurse if he needs her.




Answer: A

The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except her location. Which nursing intervention would be effective in orienting a patient with neurological deficit?

The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except her location. Which nursing intervention would be effective in orienting a patient with neurological deficit?

a. Assessing the patients level of consciousness and documenting every 4 hours

b. Keeping a day-by-day calendar at the patients bedside and having the patient manage it

c. Placing a patient observer in the patients room for safety

d. Informing the patient that she cannot be discharged unless she is awake, alert, and oriented




Answer: B

The nurse is caring for a patient who is a well-known surgeon at the hospital. Because of his status, all the hospitals physicians want to be sure to pay him a visit. The nurse notices the patient becoming more agitated and withdrawn with each group of visitors. The nurse asks the patient if he would like a Do not disturb sign placed on the door. A few hours later, the nurse notices a physician who is not involved in the patients care attempting to enter the room. Which response by the nurse is most appropriate?

The nurse is caring for a patient who is a well-known surgeon at the hospital. Because of his status, all the hospitals physicians want to be sure to pay him a visit. The nurse notices the patient becoming more agitated and withdrawn with each group of visitors. The nurse asks the patient if he would like a Do not disturb sign placed on the door. A few hours later, the nurse notices a physician who is not involved in the patients care attempting to enter the room. Which response by the nurse is most appropriate?

a. Allowing the physician to enter because he has higher authority than the nurse

b. Calling for security to remove the visitor

c. Firmly explaining that the patient does not wish to have visitors at this time, so do not enter the room

d. Scolding the physician for not obeying the signs on the door and respecting the patients wishes.




Answer: C

What nursing action can the nurse implement to comfort an elderly patient with sensory deprivation to improve meaningful stimuli?

What nursing action can the nurse implement to comfort an elderly patient with sensory deprivation to improve meaningful stimuli?

a. Placing a Do not disturb sign on the patients door

b. Offering the patient a back rub

c. Asking the patient if he would like a newspaper to read

d. Placing the patient in the room farthest from the nurses station





Answer: B

The nurse is aware that which patient is most at risk for sensory deprivation?

The nurse is aware that which patient is most at risk for sensory deprivation?

a. A patient in the ICU under constant monitoring following a myocardial infarction

b. A patient on the unit with tuberculosis on airborne precautions

c. A patient who recently had a stroke and has left-sided weakness

d. A patient receiving hospice care for end-stage brain cancer




Answer: B

The nurse is caring for a patient with expressive aphasia from a traumatic brain injury. Which desired outcome should be included in the plan of care?

The nurse is caring for a patient with expressive aphasia from a traumatic brain injury. Which desired outcome should be included in the plan of care?

a. Patient will recover full use of speech vocabulary in 1 week.

b. Patient will carry a pen and a pad of paper around for communication.

c. Patient will thicken drinks to prevent aspiration.

d. Patient will communicate nonverbally.




Answer: D

The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over inability to sleep. Which action by the nurse is most appropriate for this patient?

The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over inability to sleep. Which action by the nurse is most appropriate for this patient?

a. Provide the patient with a therapeutic back rub.

b. Turn off the alarms on the monitoring devices.

c. Administer an opioid medication to help the patient sleep.

d. Provide the patient with earplugs.




Answer: D

Often blindness occurs during childhood. Which health preventative measure is most appropriate to prevent vision impairment?

Often blindness occurs during childhood. Which health preventative measure is most appropriate to prevent vision impairment?

a. Screen young children early for visual impairments.

b. Instruct parents to report reduced eye contact from their child immediately.

c. Include rubella and syphilis screening in the preconception care plan.

d. Administer prophylactic antibiotics to all newborns.





Answer: C

The home health nurse is caring for a patient with a tactile deficit; the nurse is concerned about injury related to inability to feel harmful stimuli. The nurse evaluates that the patient is able to safely care for himself when the patient demonstrates which action?

The home health nurse is caring for a patient with a tactile deficit; the nurse is concerned about injury related to inability to feel harmful stimuli. The nurse evaluates that the patient is able to safely care for himself when the patient demonstrates which action?

a. Places colored stickers on faucet handles to indicate temperature and keeps a thermometer near the tub

b. Asks the nurse to test the temperature of the water before entering the bath

c. Replaces all lace-up shoes with Velcro ones and purchases shampoo caps

d. Dispenses all medications onto a plate for easy access in the morning




Answer: A

The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient?

The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient?

a. Speaking in a loud voice, enunciating every syllable

b. Having direct conversation with the patient in his affected ear

c. If the patient does not understand what the nurse is saying, repeating the phrase again

d. Speaking with hands, face, and expressions




Answer: D

The nurse is caring for a patient who is having difficulty understanding written and spoken word? The nurse suspects the patient has _____ aphasia.

The nurse is caring for a patient who is having difficulty understanding written and spoken word? The nurse suspects the patient has _____ aphasia.

a. Expressive

b. Receptive

c. Brocas

d. Wernicke's




Answer: B

The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis addresses the complication of the sensory deficit that places the patient at greatest risk for injury?

The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis addresses the complication of the sensory deficit that places the patient at greatest risk for injury?

a. Risk for falls

b. Body image disturbance

c. Social isolation

d. Fear




Answer: A

A new nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient is becoming malnourished because nothing tastes good. Which recommendation by the nurse would be most appropriate for this patient?

A new nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient is becoming malnourished because nothing tastes good. Which recommendation by the nurse would be most appropriate for this patient?

a. Rinse your mouth several times a day to hydrate your taste buds.

b. Blend foods together in interesting flavor combinations.

c. Eat soft foods that are easy to chew and swallow.

d. Avoid adding spices or aromatic ingredients to food to prevent nausea.






Answer: A

The nurse would utilize the Snellen chart for assessment of which patient?

The nurse would utilize the Snellen chart for assessment of which patient?

a. A patient who is having difficulty remembering how to perform familiar tasks

b. A patient who turns the television up as loud as possible

c. A patient who holds his newspaper 2 inches from his face

d. A patient who frequently reports the incorrect time from the clock across the room





Answer: D

Which nursing assessment best measures cognitive functioning?

Which nursing assessment best measures cognitive functioning?

a. Administer a Mini-Mental Status Exam (MMSE).

b. Ask the patient his name, where he is, and what month it is.

c. Ask the patients family if the patient is behaving normally.

d. Evaluate the patients ability to read the newspaper.




Answer: A

Which assessment question should the nurse ask to best understand how visual alterations are affecting the patients self-care ability?

Which assessment question should the nurse ask to best understand how visual alterations are affecting the patients self-care ability?

a. Have you stopped reading books or switched to books on audiotape?

b. Are you able to prepare a meal or write a check?

c. How do you protect yourself from injury at work?

d. How does your vision impairment make you feel?




Answer: B

A home health nurse is assembling a puzzle with an elderly patient and notices that the patient is having difficulty connecting two puzzle pieces. The nurse knows that this is most likely related to which aspect of sensory deprivation?

A home health nurse is assembling a puzzle with an elderly patient and notices that the patient is having difficulty connecting two puzzle pieces. The nurse knows that this is most likely related to which aspect of sensory deprivation?

a. Perceptual

b. Cognitive

c. Affective

d. Social




Answer: A

A patient informs the nurse that she often becomes nauseated when riding in motor vehicles. The nurse knows that this is related to which sensory deficit?

A patient informs the nurse that she often becomes nauseated when riding in motor vehicles. The nurse knows that this is related to which sensory deficit?

a. Neurological deficit

b. Visual deficit

c. Hearing deficit

d. Balance deficit




Answer: D

Which nursing diagnosis addresses psychological concerns for a patient with both hearing and visual sensory impairment?

Which nursing diagnosis addresses psychological concerns for a patient with both hearing and visual sensory impairment?

a. Self-care deficit

b. Risk for falls

c. Social isolation

d. Impaired physical mobility




Answer: C

A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with attempting to eat his meal and is becoming tearful. The nurse includes which intervention in the patients plan of care?

A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with attempting to eat his meal and is becoming tearful. The nurse includes which intervention in the patients plan of care?

a. Teach the patient about special devices used to assist patients with eating meals.

b. Order the patient food that does not require utensils.

c. Place a consult for a home health nurse.

d. Obtain an order for antidepressant medications.




Answer: A

A nurse is caring for an elderly patient who was in a motor vehicle accident because he thought the stop light was green. The patient asks the nurse if he should no longer drive. Which response by the nurse is most therapeutic?

A nurse is caring for an elderly patient who was in a motor vehicle accident because he thought the stop light was green. The patient asks the nurse if he should no longer drive. Which response by the nurse is most therapeutic?

a. Yes, you should stop driving. As you age, your cognitive function declines, and becoming confused puts everyone else on the road at risk.

b. Yes, you should ask family members to drive you around from now on. Your reflex skills have declined so much you cant avoid an accident.

c. No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is illuminated, it means stop, and if the bottom is illuminated, it means go.

d. No, instead you should see your ophthalmologist and get some glasses to help you see better.




Answer: C

Which of the following sensory changes are normal with aging?

Which of the following sensory changes are normal with aging?

a. Impaired night vision

b. Difficulty hearing low pitch

c. Increase in taste discrimination

d. Heightened sense of smell




Answer: A

The nurse would be most concerned about the risk of malnutrition for a patient with which sensory deficit?

The nurse would be most concerned about the risk of malnutrition for a patient with which sensory deficit?

a. Xerostomia

b. Disequilibrium

c. Cataracts

d. Peripheral neuropathy



Answer: A

A nurse is caring for a patient with a nursing diagnosis of Hearing deficit related to presbycusis. Which assessment of the patient would indicate an adaptation to the sensory deficit?

A nurse is caring for a patient with a nursing diagnosis of Hearing deficit related to presbycusis. Which assessment of the patient would indicate an adaptation to the sensory deficit?

a. The patient frequently cleans out his ears with a cotton swab.

b. The patient turns one ear toward the nurse during conversation.

c. The patient isolates himself from social situations.

d. The patient asks the nurse to speak loudly during conversations.




Answer: B

What is the involuntary motion of retracting the body from painful stimuli?

What is the involuntary motion of retracting the body from painful stimuli?

a. Sensation

b. Reception

c. Perception

d. Reaction




Answer: D

A nurse is administering a vaccine to a 4-year-old child who is visually impaired. After the needle enters the arm, the child says, Ow, that was sharp! The nurse knows that the ability to recognize and interpret stimuli is known as

A nurse is administering a vaccine to a 4-year-old child who is visually impaired. After the needle enters the arm, the child says, Ow, that was sharp! The nurse knows that the ability to recognize and interpret stimuli is known as

a. Sensation.

b. Reception.

c. Perception.

d. Reaction.




Answer: C

The nurse is administering ibuprofen (Advil) to an older patient. Which of the following assessment data causes the nurse to hold the medication? (Select all that apply.)

The nurse is administering ibuprofen (Advil) to an older patient. Which of the following assessment data causes the nurse to hold the medication? (Select all that apply.)

a. Past medical history of gastric ulcer

b. Patient states last bowel movement was 4 days ago

c. Stated allergy to aspirin

d. Patient states has 2/10 intermittent joint pain

e. Patient experienced respiratory depression after administration of an opioid medication




Answer: A, C

The nurse is caring for an infant in the intensive care unit. Which of the following is the most accurate description of factors that will influence the perception and management of pain for this patient?

The nurse is caring for an infant in the intensive care unit. Which of the following is the most accurate description of factors that will influence the perception and management of pain for this patient?

a. Infants cannot tolerate analgesics owing to an underdeveloped metabolism.

b. Infants have an increased sensitivity to pain when compared with older children.

c. Pain cannot be accurately assessed in infants.

d. Infants respond behaviorally and physiologically to painful stimuli.




Answer: D

A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. What does type of pain does the nurse document that the patient has?

A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. What does type of pain does the nurse document that the patient has?

a. Visceral pain

b. Somatic pain

c. Peripherally generated pain

d. Centrally generated pain





Answer: B

Which of the following is the best way for the nurse to manage pain for a patient with chronic pain from arthritis?

Which of the following is the best way for the nurse to manage pain for a patient with chronic pain from arthritis?

a. Administer pain medication before any activity.

b. Provide intravascular bolus as needed for breakthrough pain.

c. Give medications around-the-clock.

d. Administer pain medication only when non-pharmacological measures have failed.



Answer: C

The nurse is caring for a patient who recently had surgery to repair a hernia. The patients pain was 7 out of 10 before receiving pain medication. One hour after receiving an oral opioid, the patient ranks his pain at 3 out of 10. The patient asks the nurse why he isn't receiving more pain medication. Which is the nurses best response?

The nurse is caring for a patient who recently had surgery to repair a hernia. The patients pain was 7 out of 10 before receiving pain medication. One hour after receiving an oral opioid, the patient ranks his pain at 3 out of 10. The patient asks the nurse why he isn't receiving more pain medication. Which is the nurses best response?

a. This medication can be given only every 4 hours. It is not time for you to have any other pain medication right now.

b. I will notify the health care provider to come perform an assessment if your pain doesn't improve in 30 minutes.

c. If the pain becomes severe, we may need to transfer you to an intensive care unit.

d. It can take 2 hours for oral pain medication to work, and your pain is going down. Lets try boosting you up in bed and putting an ice pack on the incision to see if that helps.




Answer: D

The nurse is caring for a patient who suddenly experiences chest pain. What is the nurses first priority?

The nurse is caring for a patient who suddenly experiences chest pain. What is the nurses first priority?

a. Call the rapid response team.

b. Ask the patient to rate and describe the pain.

c. Raise the head of the bed.

d. Administer pain relief medications.




Answer: B

A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain. Which part of the patients social history is the nurse most concerned about?

A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain. Which part of the patients social history is the nurse most concerned about?

a. Patient drinks 1 to 2 glasses of wine every night.

b. Patient smokes 2 packs of cigarettes a day.

c. Patient occasionally smokes marijuana.

d. Patient takes anti anxiety medications.




Answer: A

The nurse is assessing a patient for opioid tolerance. Which finding supports the nurses assessment?

The nurse is assessing a patient for opioid tolerance. Which finding supports the nurses assessment?

a. Increasingly higher doses of opioid are needed to control pain.

b. The patient needed a substantial dose of naloxone (Narcan).

c. The patient asks for pain medication close to the time it is due around the clock.

d. The patient no longer experiences sedation from the usual dose of opioid.





Answer: A

The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first?

The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first?

a. The patient who needs to take a scheduled dose of maintenance pain medication

b. The patient who needs to be premedicated before walking

c. The patient with a PCA running who needs to have the syringe replaced

d. The patient who is experiencing 8/10 pain and has a STAT order for pain medication




Answer: D

The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates correct understanding?

The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates correct understanding?

a. You cannot use a pain scale to compare the pain of my patient with the pain of your patient.

b. When patients say they don't need pain medication, they aren't in pain.

c. Pain assessment scales determine the quality of a patients pain.

d. A patients behavior is more reliable than the patients report of pain.




Answer: C

The nurse is assessing how a patients pain is affecting mobility. Which assessment question is most appropriate?

The nurse is assessing how a patients pain is affecting mobility. Which assessment question is most appropriate?

a. Have you considered working with a physical therapist?

b. What activities, if any, has your pain prevented you from doing?

c. Would you please rate your pain on a scale from 1 to 10 for me?

d. What effect does your pain medication typically have on your pain?



Answer: B

A nurse is supervising a student who is caring for a patient with chronic pain. Which statement by the student indicates an understanding of pain management?

A nurse is supervising a student who is caring for a patient with chronic pain. Which statement by the student indicates an understanding of pain management?

a. This patient says her pain is a 5, but she is not acting like it. I am not going to give her any pain medication.

b. The patient is sleeping, so I pushed her PCA button for her.

c. I need to reassess the patients pain 1 hour after administering oral pain medication.

d. It wasnt time for the patients medication, so when she requested it, I gave her a placebo.






Answer: C

Which statement made by a nursing educator best explains why it is important for nurses to determine a patients medical history and recent drug use?

Which statement made by a nursing educator best explains why it is important for nurses to determine a patients medical history and recent drug use?

a. Health care providers have a responsibility to prevent drug seekers from gaining access to drugs.

b. This information is useful in determining what type of pain interventions will most likely be effective in providing pain relief.

c. Some recreational drugs have pharmaceutical counterparts that may be more effective in managing pain.

d. Getting this information gives the nurse an opportunity to provide patient teaching about drug abstinence.





Answer: B

The nurse knows that which technique is best for assessing pain in a child who is 4 years of age?

The nurse knows that which technique is best for assessing pain in a child who is 4 years of age?

a. Ask the parents if they think their child is in pain.

b. Use the FACES scale.

c. Ask the child to rate the level of pain on a 0 to 10 pain scale.

d. Check to see what previous nurses have charted.





Answer: B

A nurse receives an order from a health care provider to administer Vicodin ES, which contains 750 mg acetaminophen and 7.5 mg hydrocodone, to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurses best next action?

A nurse receives an order from a health care provider to administer Vicodin ES, which contains 750 mg acetaminophen and 7.5 mg hydrocodone, to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurses best next action?

a. Give the Vicodin ES to the patient immediately because the patient is experiencing severe pain.

b. Ask the health care provider to verify the dosage and frequency of the medication.

c. Ask the health care provider for an order for a nonsteroidal antiinflammatory drug (NSAID).

d. Ask the health care provider for an order to play music for the patient, in addition to providing the pain medication.




Answer: B

A nurse has brought the patient his scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic?

A nurse has brought the patient his scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic?

a. This medication will still be providing you relief at the time of your dressing change.

b. OK, swallow this pain pill, and I will return in a minute to fill your wound.

c. Would you like medication to be given for dressing changes on top of your regularly scheduled medication?

d. Your medication is scheduled for this time, and I cant adjust the time for you. Im sorry, but you must take your pill right now.






Answer: C

A nurse is providing medication education to a patient who just started taking ibuprofen, a nonselective nonsteroidal antiinflammatory drug (NSAID). Which statement made by the nurse best indicates how ibuprofen works?

A nurse is providing medication education to a patient who just started taking ibuprofen, a nonselective nonsteroidal antiinflammatory drug (NSAID). Which statement made by the nurse best indicates how ibuprofen works?

a. Ibuprofen helps to remove factors that cause or stimulate pain.

b. Ibuprofen reduces anxiety, which will help you better cope with your pain.

c. Ibuprofen helps to decrease the production of prostaglandins.

d. Ibuprofen binds with opiate receptors to reduce your pain.




Answer: C

The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which statement best describes that guided imagery is effectively controlling the patients pain during dressing changes?

The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which statement best describes that guided imagery is effectively controlling the patients pain during dressing changes?

a. The patients need for analgesic medication decreases during the dressing changes.

b. The patient rates pain during the dressing change as a 6 on a scale of 0 to 10.

c. The patients facial expressions are stoic during the procedure.

d. The patient can tolerate more pain, so dressing changes can be performed more frequently.





Answer: A

The nurse recognizes that which of the following is a modifiable contributor to a patients perception of pain?

The nurse recognizes that which of the following is a modifiable contributor to a patients perception of pain?

a. Age and gender

b. Anxiety and fear

c. Culture

d. Previous pain experience




Answer: B

A patient who had a motor vehicle accident 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). How does the nurse know that the patient is experiencing effective pain management with the PCA?

A patient who had a motor vehicle accident 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). How does the nurse know that the patient is experiencing effective pain management with the PCA?

a. The patient is sleeping and is difficult to arouse.

b. The patient rates pain at an acceptable level of 3 on a 0 to 10 scale.

c. Sufficient medication is left in the PCA syringe.

d. The patient presses the control button to deliver pain medication.




Answer: B

A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most. What type of pain does the nurse document that the patient is having at this time?

A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most. What type of pain does the nurse document that the patient is having at this time?

a. Superficial pain

b. Idiopathic pain

c. Chronic pain

d. Visceral pain




Answer: D

A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower legs, which is causing the patient to have a decreased ability to feel pain in the lower extremities. The nurse is providing education to the patient to prevent injury to the feet. The nurse tells the patient to always wear shoes or slippers when walking. Which of the following statements made by the nurse best explains the rationale for this instruction?

A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower legs, which is causing the patient to have a decreased ability to feel pain in the lower extremities. The nurse is providing education to the patient to prevent injury to the feet. The nurse tells the patient to always wear shoes or slippers when walking. Which of the following statements made by the nurse best explains the rationale for this instruction?

a. Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet.

b. Shoes provide non-pharmacological pain relief to people with diabetes and peripheral neuropathy.

c. Since you cannot feel pain as much in your feet, you need to open your neurological gates to allow pain sensations to come through. Wearing shoes helps to open those gates, which protects your feet.

d. You have lost the ability to withdraw from pain because of your peripheral neuropathy. If you step on something and are not wearing shoes, you will not feel it; this could possibly cause injury to your foot.




Answer: D

A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. What nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider?

A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. What nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider?

a. Frequently reassesses the patients pain scores

b. Reassures the patient that the provider will come to the emergency department soon

c. Softly plays music that the patient finds relaxing

d. Teaches the patient how to do yoga






Answer: C

A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with Vicodin (5/325). What important patient education does the nurse provide?

A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with Vicodin (5/325). What important patient education does the nurse provide?

a. Be sure to eat a meal high in fat before taking the medication, to avoid a stomach ulcer.

b. Narcotics can be addictive, so do not take them unless you are in severe pain.

c. You need to drink plenty of fluids and eat a diet high in fiber.

d. As your pain severity lessens, you will begin to give yourself once-daily intramuscular injections.




Answer: C

A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patients behavior and response to surgery?

A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patients behavior and response to surgery?

a. The surgery successfully cured the patients pain.

b. The patients culture is possibly influencing the patients experience of pain.

c. The patient is experiencing urinary retention because of manipulation of the spine during surgery; this is preventing the patient from experiencing pain.

d. The nurse is allowing personal beliefs about pain to influence pain management at this time.



Answer: B

A nurse is caring for a patient who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the patient when providing patient education about effective pain management?

A nurse is caring for a patient who is experiencing pain following abdominal surgery. What information is important for the nurse to tell the patient when providing patient education about effective pain management?

a. To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain.

b. You should take your medication after you walk to make sure you do not fall while you are walking.

c. We should work together to create a regular schedule of medications that does not allow for breakthrough pain.

d. You need to take oral pain medications when you experience severe pain.




Answer: C

Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective?

Which of the following statements made by the patient indicates to the nurse that teaching on a patient-controlled analgesia (PCA) device has been effective?

a. This is the only pain medication I will need to be on.

b. I can administer the pain medication as frequently as I need to

c. I feel less anxiety about the possibility of overdosing.

d. I will need the nurse to notify me when it is time for another dose.



Answer: C

A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient?

A 24-year-old Asian woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient?

a. Relaxation and guided imagery

b. Transcutaneous electrical nerve stimulation (TENS)

c. Herbal supplements with analgesic effects

d. Pudendal block




Answer: A

What nursing intervention is most effective in preventing injury to a patient following administration of epidural anesthesia?

What nursing intervention is most effective in preventing injury to a patient following administration of epidural anesthesia?

a. Keeping the reversal agent in a syringe in the patients bedside table

b. Applying a gauze dressing to the epidural catheter insertion site

c. Labeling the tubing that leads to the epidural catheter

d. Asking the nursing assistive personnel to check on the patient at least once every 2 hours




Answer: C

The nurse anticipates administering an opioid fentanyl patch to which patient?

The nurse anticipates administering an opioid fentanyl patch to which patient?

a. A 15-year-old adolescent with a broken femur

b. A 30-year-old adult with cellulitis

c. A 50-year-old patient with prostate cancer

d. An 80-year-old patient with a broken hip




Answer: C

The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients?

The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients?

a. Neurological factors

b. Competency of the surgeon

c. Meaning of pain

d. Postoperative support personnel




Answer: C

A nursing student is planning care for an elderly patient who is experiencing pain. Which of the following statements made by the nursing student indicates the need for the nursing professor to clarify the nursing students knowledge?

A nursing student is planning care for an elderly patient who is experiencing pain. Which of the following statements made by the nursing student indicates the need for the nursing professor to clarify the nursing students knowledge?

a. Older patients often have difficulty determining what is causing their pain.

b. It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patients response to the medication.

c. As adults age, their ability to perceive pain decreases.

d. Patients who have dementia probably experience pain, and their pain is not always well controlled.




Answer: B

Which of the following statements made by a patient reflects that the patient understands the relationship between the gate control theory of pain and the use of meditation to relieve pain?

Which of the following statements made by a patient reflects that the patient understands the relationship between the gate control theory of pain and the use of meditation to relieve pain?

a. Meditation controls pain by blocking pain impulses from coming through the gate.

b. Meditation will help me sleep through the pain because it opens the gate.

c. Meditation stops the occurrence of pain stimuli.

d. Meditation alters the chemical composition of pain neuroregulators, which closes the gate.




Answer: A

A nurse is caring for a patient who recently had an abdominal hysterectomy and states that she is experiencing severe pain. The patients blood pressure is 110/60, and her heart rate is 60. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic?

A nurse is caring for a patient who recently had an abdominal hysterectomy and states that she is experiencing severe pain. The patients blood pressure is 110/60, and her heart rate is 60. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic?

a. Your vitals do not show that you are having pain; can you describe your pain?

b. You do not look like you are in pain.

c. OK, I will go get you some narcotic pain relievers immediately.

d. What would you like to try to alleviate your pain?





Answer: D

What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery?

What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery?

a. Assess the patients body language.

b. Observe cardiac monitor for increased heart rate.

c. Ask the patient to rate the level of pain.

d. Ask the patient to describe the effect of pain on the ability to cope.




Answer: C

A 6-year-old male presents with fever, pain, swelling, and warmth. Tests reveal osteomyelitis In addition to the clinical symptoms, the nurse would expect elevations in which lab tests? (Select all that apply.)

A 6-year-old male presents with fever, pain, swelling, and warmth. Tests reveal osteomyelitis In addition to the clinical symptoms, the nurse would expect elevations in which lab tests? (Select all that apply.)

a. C-reactive protein

b. White blood cell count

c. Red cell count

d. Erythrocyte sedimentation rate (ESR)

e. Liver enzymes




Answer: A, B, D

A major predictor of poor prognosis for Ewing sarcoma is:

A major predictor of poor prognosis for Ewing sarcoma is:

a. Age of onset

b. Size of tumor

c. Presence of metastasis

d. Gender of child





Answer: C

Ewing sarcoma originates from:

Ewing sarcoma originates from:

a. Osteoblasts

b. Epithelial cells

c. The spleen

d. The bone marrow





Answer: D

A 16-year-old male was recently diagnosed with osteosarcoma. The tumor is most likely present in the _____ of long bones.

A 16-year-old male was recently diagnosed with osteosarcoma. The tumor is most likely present in the _____ of long bones.

a. Epiphyses

b. Metaphyses

c. Marrow

d. Osteocytes


Answer: B

In reviewing the history of the patient with osteosarcoma, the nurse might also expect the patient to have:

In reviewing the history of the patient with osteosarcoma, the nurse might also expect the patient to have:

a. Rhabdomyosarcoma

b. Ewing sarcoma

c. Fibroma

d. Retinoblastoma





Answer: D

A 13-year-old female presents with pain at night, cough, and dyspnea. Testing reveals a metastasizing malignant bone tumor. The most likely type of tumor is:

A 13-year-old female presents with pain at night, cough, and dyspnea. Testing reveals a metastasizing malignant bone tumor. The most likely type of tumor is:

a. Nonossifying fibroma

b. Chondrosarcoma

c. Ewing sarcoma

d. Osteosarcoma





Answer: D

A 22-year-old female has a brother with DMD and wants to know if her children will inherit it. A fairly accurate test to identify female carriers of the disease is measurement of serum levels of:

A 22-year-old female has a brother with DMD and wants to know if her children will inherit it. A fairly accurate test to identify female carriers of the disease is measurement of serum levels of:

a. Dystrophin

b. Myoglobin

c. Creatine kinase (CK)

d. Troponin 1





Answer: C

The onset of DMD most often occurs at:

The onset of DMD most often occurs at:

a. 3 to 6 months of age

b. Preschool years

c. School age

d. The onset of puberty




Answer: C

Duchenne muscular dystrophy (DMD) has a(n) _____ inheritance pattern.

Duchenne muscular dystrophy (DMD) has a(n) _____ inheritance pattern.

a. Autosomal recessive

b. X-linked recessive

c. Y-linked dominant

d. Autosomal dominant






Answer: B

The treatment of Osgood-Schlatter disease includes:

The treatment of Osgood-Schlatter disease includes:

a. Steroids

b. Restriction from physical activity

c. High doses of aspirin

d. Knee replacement




Answer: B

A 3-year-old male presents with developmental delay. Testing reveals that the child has muscular dystrophy. Treatment will include:

A 3-year-old male presents with developmental delay. Testing reveals that the child has muscular dystrophy. Treatment will include:

a. Aspirin

b. Antivirals

c. Steroids

d. Chemotherapy





Answer: C

Which of the following types of scoliosis accounts for the majority of the cases of scoliosis?

Which of the following types of scoliosis accounts for the majority of the cases of scoliosis?

a. Idiopathic

b. Infectious

c. Iatrogenic

d. Secondary





Answer: A

Osgood-Schlatter disease causes inflammation of the:

Osgood-Schlatter disease causes inflammation of the:

a. Shoulder joint

b. Patellar tendon

c. Elbow ligaments

d. Hip cartilage





Answer: B

LCP disease affects which of the following joints?

LCP disease affects which of the following joints?

a. Vertebral

b. Shoulder

c. Hip

d. Knee






Answer: C

A 5-year-old female was diagnosed with seropositive juvenile rheumatoid arthritis (RA). The treatment option for this disease is termed:

A 5-year-old female was diagnosed with seropositive juvenile rheumatoid arthritis (RA). The treatment option for this disease is termed:

a. Supportive

b. Curative

c. Antibacterial

d. Experimental




Answer: A

A 1-year-old female was diagnosed with OI. Which of the following is a complication in this patient?

A 1-year-old female was diagnosed with OI. Which of the following is a complication in this patient?

a. Congestive heart failure

b. Liver failure

c. Aortic aneurysm

d. Pulmonary emboli






Answer: C

Children with OI suffer from frequent:

Children with OI suffer from frequent:

a. Bone fractures

b. Dislocations

c. Bone infections

d. Joint injuries




Answer: A

A 9-month-old male was diagnosed with OI following recurrent fractures and findings of osteopenia. This disease is caused by errors in the synthesis of:

A 9-month-old male was diagnosed with OI following recurrent fractures and findings of osteopenia. This disease is caused by errors in the synthesis of:

a. Elastin

b. Glycoproteins

c. Collagen

d. Calcium salts





Answer: C

A 9-month-old male was diagnosed with osteogenesis imperfecta (OI) following recurrent fractures and findings of osteopenia. This disease is caused by:

A 9-month-old male was diagnosed with osteogenesis imperfecta (OI) following recurrent fractures and findings of osteopenia. This disease is caused by:

a. Uterine teratogens

b. A genetic defect

c. Malnutrition

d. Trauma




Answer: B

While performing an assessment of a 2-month-old, the nurse notes a positive Ortolani click. The nurse would suspect the child has:

While performing an assessment of a 2-month-old, the nurse notes a positive Ortolani click. The nurse would suspect the child has:

a. A hip fracture

b. Hip dysplasia

c. Osteogenesis imperfecta

d. Osteomyelitis




Answer: B

While giving a lecture on attention-deficit/hyperactivity disorder, the nurse encourages which of the following to reduce children's stress regarding homework assignments?

While giving a lecture on attention-deficit/hyperactivity disorder, the nurse encourages which of the following to reduce children's stress regarding homework assignments?

a. Time management skills

b. Prevention of iron deficiency anemia

c. Routine preventative health visits

d. Speech articulation skill





Answer: A

Identify a socio cultural factor that can lead to developmental problems.

Identify a socio cultural factor that can lead to developmental problems.

a. Family relocation

b. Childhood obesity

c. Prolonged poverty

d. Loss of stamina






Answer: C

The purpose of unconscious ego defense mechanisms is to do which of the following for the individual?

The purpose of unconscious ego defense mechanisms is to do which of the following for the individual?

a. Protect against feelings of worthlessness and anxiety.

b. Facilitate the use of problem-focused coping.

c. Evaluate an event for its personal meaning.

d. Trigger the stress control functions of the medulla oblongata.





Answer: A

An adult who was in a motor vehicle accident is brought into the emergency department by paramedics, who report the following in-transit vital signs:

An adult who was in a motor vehicle accident is brought into the emergency department by paramedics, who report the following in-transit vital signs:

Oral temperature: 99.0 F

Pulse: 102 beats per minute

Respiratory rate: 26 breaths per minute

Blood pressure: 140/106

The nurse can identify that which hormones are the likely causes of the abnormal vital signs?



a. ADH and ACTH

b. ACTH and epinephrine

c. ADH and norepinephrine

d. Epinephrine and norepinephrine






Answer: D

The nursing student gave a wellness lecture on the importance of accurate assessment and intervention from a personal, family, and community perspective. The other nursing students enjoyed the lecture about which nursing theory?

The nursing student gave a wellness lecture on the importance of accurate assessment and intervention from a personal, family, and community perspective. The other nursing students enjoyed the lecture about which nursing theory?

a. Ego defense model

b. Situational model

c. Evidence-based practice model

d. Neuman systems model





Answer: D

A young adults chief complaint is seizure fits. A chart review shows a negative EEG report and a normal neurological consultation report. A psychosocial history reveals increased family stress, bankruptcy, and a recent divorce. The nurse recognizes that this young mans pseudo-seizures most likely are an example of which unconscious coping mechanism?

A young adults chief complaint is seizure fits. A chart review shows a negative EEG report and a normal neurological consultation report. A psychosocial history reveals increased family stress, bankruptcy, and a recent divorce. The nurse recognizes that this young mans pseudo-seizures most likely are an example of which unconscious coping mechanism?

a. Compensation

b. Conversion

c. Dissociation

d. Denial




Answer: B

An assessment finding example for caregiver strain would be which of the following?

An assessment finding example for caregiver strain would be which of the following?

a. Caregiver routinely creates a weekly menu plan.

b. Caregiver has not received medical care when ill.

c. Caregiver can identify respite care provider.

d. Caregiver attends religious service.






Answer: B

A person states that he was not shoplifting from the store despite very clear evidence on the store surveillance tape. This person is demonstrating which ego defense mechanism?

A person states that he was not shoplifting from the store despite very clear evidence on the store surveillance tape. This person is demonstrating which ego defense mechanism?

a. Dissociation

b. Conversion

c. Denial

d. Compensation





Answer: C

A trauma survivor is requesting sleep medication because of bad dreams. Concerned about posttraumatic stress disorder, the nurse asks

A trauma survivor is requesting sleep medication because of bad dreams. Concerned about posttraumatic stress disorder, the nurse asks

a. Are you reliving your trauma?

b. Are you having chest pain?

c. Can you describe your phobias?

d. Can you tell me when you wake up?






Answer: A

A teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. Given appropriate tertiary level interventions, the nursing intervention would be to

A teen with celiac disease continues to eat food she knows will make her ill several hours after ingestion. Given appropriate tertiary level interventions, the nursing intervention would be to

a. Teach the patient about the food pyramid.

b. Administer antidiarrheal medications with meals.

c. Assist the teen in meeting dietary restrictions while eating foods similar to those eaten by her friends.

d. Admonish the teen and her parents regarding her consistently poor diet choices.





Answer: C

Despite working in a highly stressful nursing unit and accepting additional shifts, a new nursing graduate has a strategy to prevent burnout. The best strategy would be for the new nurse to

Despite working in a highly stressful nursing unit and accepting additional shifts, a new nursing graduate has a strategy to prevent burnout. The best strategy would be for the new nurse to

a. Identify limits and scope of work responsibilities.

b. Write for 10 minutes in a journal every day.

c. Use progressive muscle relaxation.

d. Delegate complex nursing tasks to licensed professional nurses.






Answer: A

A senior college student contacts the college health clinic about a freshman student living on the same dormitory floor. The senior student reports that the freshman is crying and is not adjusting to college life. The clinic nurse recognizes this as a combination of situational and maturational stress factors. The best comment to the senior student would be

A senior college student contacts the college health clinic about a freshman student living on the same dormitory floor. The senior student reports that the freshman is crying and is not adjusting to college life. The clinic nurse recognizes this as a combination of situational and maturational stress factors. The best comment to the senior student would be

a. Id better call 911 because your friend is suicidal.

b. Give her this list of university and community resources.

c. You must make an appointment for the student to obtain medications.

d. Id recommend you help the student pack her bags to go home.






Answer: B

An adult male reports new-onset seizure like activity. An EEG and a neurology consultants report rule out a seizure disorder. When considering the ego defense mechanism of conversion, the nurses next best action would be to

An adult male reports new-onset seizure like activity. An EEG and a neurology consultants report rule out a seizure disorder. When considering the ego defense mechanism of conversion, the nurses next best action would be to

a. Recommend acupuncture.

b. Confront the patient on malingering.

c. Obtain history of any recent life stressors.

d. Recommend a regular exercise program.






Answer: C

During the evaluation stage of the critical thinking model applied to a patient coping with stress, the nurse will

During the evaluation stage of the critical thinking model applied to a patient coping with stress, the nurse will

a. Select nursing interventions to promote the patients adaptation to stress.

b. Establish short- and long-term goals with the patient experiencing stress.

c. Identify stress management interventions for achieving expected outcomes.

d. Reassess patients stress-related symptoms and compare with expected outcomes.






Answer: D

Pediatric stressors related to self-esteem and changes in family structure reflect which maturational school age category?

Pediatric stressors related to self-esteem and changes in family structure reflect which maturational school age category?

a. Elementary school age

b. Preadolescence

c. Adolescence

d. Early adulthood





Answer: B

After a natural disaster occurred, an emergency worker referred a family for crisis intervention services. One family member refused to attend the services, stating No way, I'm not crazy. The best response the nurse can give is which of the following?

After a natural disaster occurred, an emergency worker referred a family for crisis intervention services. One family member refused to attend the services, stating No way, I'm not crazy. The best response the nurse can give is which of the following?

a. Many times disasters can create mental health problems, so you really should participate with your family.

b. Crisis intervention is a short-term problem-solving type of help, and seeking this help does not mean that you have a mental illness.

c. Don't worry now. The psychiatrists are well trained to help.

d. Crisis intervention will help your family communicate better.







Answer: B

A nurse is teaching guided imagery to a prenatal class. Identify an example of guided imagery from the options below.

A nurse is teaching guided imagery to a prenatal class. Identify an example of guided imagery from the options below.

a. Singing

b. Back massage

c. Sensory peaceful words

d. Listening to music






Answer: C

The nurse teaches stress reduction and relaxation training to a health education group of patients after cardiac bypass surgery. The nurse is performing which level of intervention?

The nurse teaches stress reduction and relaxation training to a health education group of patients after cardiac bypass surgery. The nurse is performing which level of intervention?

a. Primary

b. Secondary

c. Tertiary

d. Quad level






Answer: C

A woman who was sexually assaulted a month ago presents to the emergency department with complaints of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. The nurse recognizes the signs and symptoms of which medical problem?

A woman who was sexually assaulted a month ago presents to the emergency department with complaints of recurrent nightmares, fear of going to sleep, repeated vivid memories of the sexual assault, and inability to feel much emotion. The nurse recognizes the signs and symptoms of which medical problem?

a. General adaptation syndrome

b. Posttraumatic stress disorder

c. Developmental crisis

d.Alarm reaction





Answer: B

In a natural disaster relief facility, the nurse observes that an elderly man has a recovery plan, while a 25-year-old man is still overwhelmed by the disaster situation. These different reactions to the same situation would be explained best by which of the following?

In a natural disaster relief facility, the nurse observes that an elderly man has a recovery plan, while a 25-year-old man is still overwhelmed by the disaster situation. These different reactions to the same situation would be explained best by which of the following?

a. Restorative care

b. Strong financial resources

c. Maturational and sociocultural factors

d. Immaturity and intelligence factors





Answer: C

To make a diagnosis of fibromyalgia, tenderness must be present in ____ of the 18 points necessary for diagnosis.

To make a diagnosis of fibromyalgia, tenderness must be present in ____ of the 18 points necessary for diagnosis.

Answer: 11 (eleven).

The pattern of bone destruction indicative of an aggressive malignant tumor is known as J_____ pattern. (Select all that apply.)

The pattern of bone destruction indicative of an aggressive malignant tumor is known as J_____ pattern. (Select all that apply.)

a. Moth-eaten

b. Permeative

c. Geographic

d. Radial

e. Selective





Answer: A, B, C

A 29-year-old male was recently diagnosed with AS. He is interested in obtaining more information about his disease. Patient teaching would include which of the following? (Select all that apply.)

A 29-year-old male was recently diagnosed with AS. He is interested in obtaining more information about his disease. Patient teaching would include which of the following? (Select all that apply.)

a. A diagnosis is made from history, physical examination, x-rays, and genetic analysis.

b. Inflammation of the fibrocartilage in cartilaginous joints results in the erosion of bone structure, scar tissue formation, and joint fusion.

c. The more common signs and symptoms of early disease include restricted joint movement and increased pain after physical activity.

d. The usual treatment includes anti-inflammatory and analgesic medications, exercises, and physical therapy.

e. The spine becomes bent forward as the normal convex curve of the lower spine diminishes.






Answer: A, B, D, E

Signs and symptoms of subluxation include (select all that apply):

Signs and symptoms of subluxation include (select all that apply):

a. Pain

b. Swelling

c. Hemorrhage

d. Limitation of movement

e. Joint deformity





Answer: A, B, D, E

A 35-year-old female presents with impaired motor function and visual disturbances. The diagnosis is Paget disease. What additional symptoms would be expected? (Select all that apply.)

A 35-year-old female presents with impaired motor function and visual disturbances. The diagnosis is Paget disease. What additional symptoms would be expected? (Select all that apply.)

a. Skull thickness

b. Dementia

c. Deafness

d. Headache

e. Hypertension





Answer: A, B, C, D

A malignant tumor of striated muscle tissue origin is called:

A malignant tumor of striated muscle tissue origin is called:

a. Myelogenic tumor

b. Giant cell tumor

c. Rhabdomyosarcoma

d. Rhabdomyoma






Answer: C

The most common cause of toxic myopathy is:

The most common cause of toxic myopathy is:

a. Infection

b. A tumor

c. Alcoholism

d. Osteoporosis





Answer: C

A 60-year-old male presents with swelling and pain in the knee. CT reveals a tumor of spongy bone. His diagnosis would be:

A 60-year-old male presents with swelling and pain in the knee. CT reveals a tumor of spongy bone. His diagnosis would be:

a. Chondrosarcoma

b. Rhabdomyoma

c. Rhabdomyosarcoma

d. Fibrosarcoma





Answer: A

A 13-year-old female is admitted to the hospital for evaluation and treatment of an osteosarcoma in her left distal femur. Which statement best describes osteosarcoma?

A 13-year-old female is admitted to the hospital for evaluation and treatment of an osteosarcoma in her left distal femur. Which statement best describes osteosarcoma?

a. Myelogenic, develops in red bone marrow only

b. Benign, develops in spongy bone tissue

c. Collagenic, originates in the periosteum

d. Osteogenic, most often develops in the bone marrow





Answer: D

Myotonia is characterized by:

Myotonia is characterized by:

a. Prolonged depolarization of muscle cell membranes

b. Absence of adenosine triphosphate (ATP) for muscle contraction

c. Delayed muscle contraction

d. Hyperactive reflexes





Answer: A

Fibromyalgia is a chronic musculoskeletal disorder characterized by:

Fibromyalgia is a chronic musculoskeletal disorder characterized by:

a. Pain resulting from joint and muscle inflammation

b. Muscle pain in the back and gastrointestinal symptoms

c. Neurologic pain in the skeletal muscles

d. Diffuse pain, fatigue, and tender points





Answer: D

A 32-year-old male was injured in a motor vehicle accident and confined to bed for 3 weeks. During this time, the size and strength of muscle fibers decreased, a condition referred to as:

A 32-year-old male was injured in a motor vehicle accident and confined to bed for 3 weeks. During this time, the size and strength of muscle fibers decreased, a condition referred to as:

a. Myelodysplasia

b. Ischemic atrophy

c. Disuse atrophy

d. Deconditioning hypoplasia






Answer: C

The final stage of gout, characterized by crystalline deposits in cartilage, synovial membranes, and soft tissue, is called:

The final stage of gout, characterized by crystalline deposits in cartilage, synovial membranes, and soft tissue, is called:

a. Monoarticular arthritis

b. Tophaceous gout

c. Asymptomatic hyperuricemia

d. Complicated gout






Answer: B

A 51-year-old male experienced severe acute gouty arthritis. Which of the following is the most common trigger for the symptoms?

A 51-year-old male experienced severe acute gouty arthritis. Which of the following is the most common trigger for the symptoms?

a. Trauma

b. Anemia

c. High-fat foods

d. Lack of exercise






Answer: A