Nursing Consultation and Evidence-Based Practices: Case Studies, Exams of Nursing

Download Nursing Consultation and Evidence-Based Practices: Case Studies and more Exams Nursing in PDF only on Docsity! Certified Medical-Surgical Registered Nurse Sample Questions ,Answers and Rationales Christine Warren, 45 years old, has a long history of ulcerative colitis, and non-surgical treatment no longer relieved her symptoms. She underwent a total proctocolectomy and a permanent ileostomy 12 hours ago. The nurse should contact the physician immediately if Mrs. Warren has which of these findings? 1) The stoma appears pale and dry. 2) The stoma appears red and shiny. 3) There is 200 mL of dark green output from the stoma. 4) There is 50 mL of serosanguinous drainage from the stoma. - answers 1) The stoma appears pale and dry. Rationale: If there is an adequate blood supply to the stoma, the color is pink or red, and the stoma is moist as a result of mucous production. A pale dry color suggests ischemia of the stoma or bowel and must be reported immediately to the physician. With an ileostomy initially after surgery, the output is a loose, dark green liquid that may contain some blood. The ileostomy usually begins to drain within 24 of surgery at more than one liter per day. When changing Mrs. Warren's ileostomy bag, the nurse notices that the peristomal skin is irritated. Which of these actions by the nurse would be appropriate before reapplying the appliance? 1) Wash the area with antiseptic soap and water. 2) Clean the site with Dakin's solution. 3) Use a solid skin barrier. 4) Obtain an order for a topical antibiotic. - answers 3) Use a solid skin barrier. Rationale: The drainage from the stoma can quickly irritate the surrounding tissue. Therefore, a solid skin barrier, with a pectin base or karaya wafer that has a measurable thickness and hydrocolloid adhesive properties, should be applied. Which of these comments, if made by Mrs. Warren before her surgery, would indicate that she had concerns about her body image? 1) "I will have to stop my aerobics classes." 2) "I'm so afraid I may not survive the surgery." 3) "I need to go shopping for some loose, baggy clothes." 4) "I'm concerned that this may be only the first of many surgeries." - answers 3) "I need to go shopping for some loose, baggy clothes." Rationale:Body image refers to a person's perception of self and determines how the person interacts with others. One does not need to purchase special clothing after ileostomy surgery, although some minor adjustments may be needed for comfort, e.g., stretch underwear or pantyhose for support. Lewis Palmer, 45 years old, has a history of multiple myocardial infarctions and is a heavy smoker. He takes warfarin sodium (Coumadin) daily. Two weeks ago, he had a right femoral-popliteal bypass, which became occluded 24 hours ago. He is admitted following an angioplasty of the femoral-popliteal bypass graft. Mr. Palmer is receiving continuous IV heparin. Because Mr. Palmer is receiving heparin, it is essential for the nurse to 1) monitor his prothrombin time. 2) observe him for signs of pulmonary embolism. 3) limit his intake of foods high in vitamin K. 4) check the femoral puncture site at frequent intervals. - answers 4) check the femoral puncture site at frequent intervals. Rationale: Since bleeding is a common side effect of heparin, it is vital to check the operative site, the femoral puncture area, for signs of bleeding. Attempts to revascularize Mr. Palmer's leg are unsuccessful, and Mr. Palmer has a below-knee amputation (BKA) of his right extremity and is returned to the medical-surgical unit with an intravenous infusion in place. His orders include: heparin drip, morphine sulfate 10 mg IV push q4h prn for pain, and ampicillin sodium g 1 IV q6h. Twelve hours postoperatively, Mr. Palmer is found to be short of breath and diaphoretic. He says, "My chest hurts." His pulse is 140/min, compared to a baseline of 80/min. His blood pressure is105/60 mm Hg, compared to a Rationale: It is not unusual for a patient who has had a prostatectomy, to complain of not having complete bladder control after catheter removal. To help the patient regain urinary control, pelvic floor strengthening exercises are recommended. A patient's wife is visibly upset and says to the nurse, "I thought my husband only broke his hip, but the doctor thinks he might have had a stroke." Which of the following would be an appropriate response by the nurse? 1) "It's really too early to be concerned about that. Let's wait until the test results come back." 2) "If it is a stroke, your husband is in the right hospital for treatment." 3) "Yes, he does have symptoms of a stroke. That's what the tests will help us find out." 4) "I'm going to get you some information to read about strokes and their treatment." - answers 3) "Yes, he does have symptoms of a stroke. That's what the tests will help us find out." Rationale: Symptoms of stroke vary greatly and the initial diagnosis is made after a non-contrast CT scan is done to determine if the event was ischemic or hemorrhagic. Then, further tests are done to confirm the diagnosis and decide on treatment. In the event of a fire in a hospital's dialysis unit, which of these actions should the nurse take first? 1) Extinguish the fire if possible. 2) Activate the fire response system. 3) Confine the fire by closing all fire doors. 4) Remove patients or staff in danger. - answers 4) Remove patients or staff in danger. Rationale: When a fire occurs in a patient area within the hospital, the nurses' first actions are to protect patients and staff. This usually involves removing the patients and staff from exposure to the fire. An 80-year-old male who has mild dementia is readmitted for the third time with multiple pressure ulcers. During the nursing assessment, multiple bruises are also observed on his body. He lives with his son and daughter- in-law. The nurse suspects elder abuse/neglect. Which of these actions should the nurse take? 1) Have a staff member present during family visits. 2) Report the findings. 3) Discuss the situation with the family. 4) Ask the patient who is providing his care. - answers 2) Report the findings. Rationale: Most states require that health care workers report suspected elder abuse to an official agency, such as Adult Protective Services. A patient who has active pulmonary tuberculosis (TB) states, "I'm not going to take these TB pills!" Which of these responses by the nurse would be appropriate? 1) "You have a legal right to refuse to take this medication." 2) "You need to sign a Refusal of Treatment Form." 3) "You need to ask your doctor about the possibility of discontinuing the medication." 4) "You should know that the health department can require you to take the medication." - answers 4) "You should know that the health department can require you to take the medication." Rationale: Tuberculosis (TB) is a public health problem that requires reporting of the disease to the health department. It is essential that the patient understand the need to take prescribed TB medications as directed. Patients who are unwilling or unable to adhere to treatment may be required to do so by law or may be quarantined or isolated until noninfectious. State governments have legal responsibility for TB control activities, including treatment protocols for nonadherent patients. Health care workers should be familiar with the law in their particular states for these procedures. When a patient is having a chest tube removed, which of these instructions would be appropriate? 1) "Take short quick breaths with your mouth open." 2) "Take a deep breath and hold it." 3) "Breathe only through your mouth." 4) "Breathe as you normally do." - answers 2) "Take a deep breath and hold it." Rationale: Taking a deep breath and holding it (or performing the Valsalva maneuver) will prevent air from being pulled back into the pleural space as the tube is removed. Using the average cost of a problem and the cost of intervention to demonstrate savings is: A. A cost-benefit analysis B. An efficacy study C. A product evaluation D. A cost-effective analysis - answers A. A cost-benefit analysis uses average cost of a problem (such as wound infections) and the average cost of intervention to demonstrate savings. For example, if a surgical unit averaged 10 surgical site infections annually at an additional average cost of $27,000 each, the total annual cost would be $270,000. If the total cost for interventions, (new staff person, benefits, education, and software) totals $92,000, and the goal is to reduce infections by 50% (0.5 X $270,000 for a total projected savings of $135,000), cost benefit is demonstrated by subtracting the proposed savings from the intervention costs ($135,000 - $92,000) for a savings of $43,000 annually. In Erikson's psychosocial model of development, which stage is typical of those entering young adulthood? A.Identify vs role confusion B.Initiative vs guilt C.Ego integrity vs despair D.Intimacy vs isolation - answers D. Erickson's psychosocial development model focuses on conflicts at each stage of the lifespan and the virtue that results from finding balance in the conflict. The first 5 stages refer to infancy and childhood and the last 3 stages to adulthood: Intimacy vs isolation (Young adulthood): Love/intimacy or lack of close relationships. Generativity vs stagnation (Middle age): Caring and achievements or stagnation. 2. Place the patient in a high Fowler position and administer oxygen. 3. Place the patient in a reverse Trendelenburg position and open the IV line. 4. Report the findings to the provider. - answers 1. Medicate the patient for pain. To prevent a common, adverse effect of prolonged use of phenytoin sodium (Dilantin), patients taking the drug are instructed to: 1. Avoid crowds and obtain an annual influenza vaccination. 2. Drink at least 2 L of fluids daily, including 8 to 10 glasses of water. 3. Eat a potassium-rich, low sodium diet. 4. Practice good dental hygiene and report gum swelling or bleeding. - answers 4. Practice good dental hygiene and report gum swelling or bleeding. The most common, preventable complication of abdominal surgery is: 1. Atelectasis. 2. Fluid and electrolyte imbalance. 3. Thrombophlebitis. 4. Urinary retention. - answers 1. Atelectasis. A 78-year-old patient is scheduled for transition to home after treatment for heart disease. The patient's spouse, who has chronic obstructive pulmonary disease, plans to care for the patient at home. The spouse says that their grown children, who live nearby, will help. The best approach to discharge planning is to: 1. Arrange nursing home placement for the couple. 2. Consult the spouse's healthcare provider about the spouse's ability to care for the patient. 3. Contact the children to ascertain their commitment to help. 4. Discuss community resources with the spouse and offer to make referrals. - answers 4. Discuss community resources with the spouse and offer to make referrals. During an assessment of a patient who sustained a head injury 24 hours ago, the medical-surgical nurse notes the development of slurred speech and disorientation to time and place. The nurse's initial action is to: 1. Continue the hourly neurologic assessments. 2. Inform the neurosurgeon of the patient's status. 3. Prepare the patient for emergency surgery. 4. Recheck the patient's neurologic status in 15 minutes. - answers 2. Inform the neurosurgeon of the patient's status. For the evaluation feedback process to be effective, a manager: 1. Conducts weekly meetings with staff members. 2. Considers staff members' interests and abilities when delegating tasks. 3. Informs staff members regularly of how well they are performing their jobs. 4. Provides goals for staff members to meet. - answers 3. Informs staff members regularly of how well they are performing their jobs. An 80-year-old patient is placed in isolation when infected with methicillin- resistant Staphylococcus aureus. The patient was alert and oriented on admission, but is now having visual hallucinations and can follow only simple directions. The medical-surgical nurse recognizes that the changes in the patient's mental status are related to: 1. A fluid and electrolyte imbalance. 2. A stimulating environment. 3. Sensory deprivation. 4. Sundowning. - answers 3. Sensory deprivation. To prepare a patient on the unit for a bronchoscopic procedure, a medical- surgical nurse administers the IV sedative. The medical-surgical nurse then instructs the licensed practical nurse to: 1. Educate the patient about the pending procedure. 2. Give the patient small sips of water only. 3. Measure the patient's blood pressure and pulse readings. 4. Take the patient to the bathroom one more time. - answers 3. Measure the patient's blood pressure and pulse readings. Which physiological response is often associated with surgery-related stress? 1. Bronchial constriction 2. Decreased cortisol levels 3. Peripheral vasodilation 4. Sodium and water retention - answers 4. Sodium and water retention A patient's family does not know the patient's end-of-life care preferences, but assumes that they know what is best for the patient under the circumstances. This assumption reflects: 1. Justice. 2. Paternalism. 3. Pragmatism. 4. Veracity. - answers 2. Paternalism. Which statement by a patient with diabetes mellitus indicates an understanding of the medication insulin glargine (Lantus)? 1. "Lantus causes weight loss." 2. "Lantus is used only at night." 3. "The duration of Lantus is six hours." 4. "There is no peak time for Lantus." - answers 4. "There is no peak time for Lantus." Which action occurs primarily during the evaluation phase of the nursing process? 1. Data collection 2. Decision-making and judgment 3. Priority-setting and expected outcomes 4. Reassessment and audit - answers 4. Reassessment and audit Which action best describes a sentinel event alert? 1. Documenting the breakdown in communication during a shift report 2. Indicating that a community or institution is unsafe 3. Recording the harm done when a medication error occurs 4. Signaling the need for immediate investigation and response - answers 4. Signaling the need for immediate investigation and response Which is primarily a developmental task of middle age? After completing a thorough neurological and physical assessment of a patient who is admitted for a suspected stroke, a medical-surgical nurse anticipates the next step in the immediate care of this patient to include: 1. Administering tissue plasminogen activator. 2. Obtaining a computed tomography scan of the head without contrast. 3. Obtaining a neurosurgical consultation. 4. Preparing for carotid Doppler ultrasonography. - answers 2. Obtaining a computed tomography scan of the head without contrast. The first step in applying the quality improvement process to an activity in a clinical setting is to: 1. Assemble a team to review and revise the activity. 2. Collect data to measure the status of the activity. 3. Select an activity for improvement. 4. Set a measurable standard for the activity. - answers 3. Select an activity for improvement. The registered nurse has an unlicensed assistant working with her for the shift. When delegating tasks, the nurse understands that the unlicensed assistant: A. interprets clinical data. B. collects clinical data. C. is trained in the nursing process. D. can function independently - answers B. collects clinical data. Rationale: Unlicensed personnel make observations, collect clinical data, and report findings to the nurse. Option A is incorrect because the registered nurse, who has learned critical thinking skills, interprets the data. Option C is incorrect because although unlicensed assistants are trained to perform skills, they don't learn the nursing process. Option D is incorrect because unlicensed assistants don't function independently; they're assigned tasks by a registered nurse who retains overall responsibility for the patient. When performing an assessment, the nurse identifi es the following signs and symptoms: impaired coordination, decreased muscle strength, limited range of motion, and reluctance to move. These signs and symptoms indicate which nursing diagnosis? A. Health-seeking behaviors B. Impaired physical mobility C. Disturbed sensory perception D. Deficient knowledge - answers B. Impaired physical mobility Rationale:Impaired physical mobility is a limitation of physical movement and is defined by the patient's signs and symptoms. Options A, C, and D are nursing diagnoses with different defining signs and symptoms. When prioritizing a patient's care plan based on Maslow's hierarchy of needs, the nurse's fi rst priority would be: A. allowing the family to see a newly admitted patient. B. ambulating the patient in the hallway. C. administering pain medication. D. using two nurses to transfer the patient. - answers C. administering pain medication. Rationale: In Maslow's hierarchy of needs, pain relief is on the first layer. Activity (Option B) is on the second layer. Safety (Option D) is on the third layer. Love and belonging (Option A) are on the fourth layer When a nurse asks another nurse for advice on handling a particular patient problem, she's seeking what type of consultation? A. Patient-centered case consultation B. Consultee-centered case consultation C. Program-centered administrative consultation D. Consultee-centered administrative consultation - answers A. Patient- centered case consultation Rationale: Patient-centered case consultation (Option A) provides expert advice on handling a particular patient or group of patients. Consultee-centered case consultation (Option B) focuses on work difficulties with patients, which are used as a learning opportunity. Program-centered administrative consultation (Option C) provides expert advice on developing new programs or improving existing ones. Consultee-centered administrative consultation (Option D) considers work problems in the areas of program development and organization. When implementing an evidence-based nursing program to decrease the incidence of pressure ulcers on a medical-surgical unit, which of the following is the most important to ensure its success? A. Obtaining support from management, administration, and physicians B. Determining and documenting patient outcomes C. Identifying a significant problem that needs to be addressed D. Evaluating research based on its validity and reliability - answers A. Obtaining support from management, administration, and physicians Rationale: To successfully implement an evidence-based nursing program, it's important to obtain the support of management, administration, and physicians. Option B is part of evaluating evidence-based nursing program implementation. Option C is part of the first step of the evidence-based nursing program process. Option D is part of the critical evaluation of resources. When planning the implementation of evidence-based practices to prevent falls, which of the following steps should the nurse take fi rst? A. Identify the common causes of falls. B. Gather and review currently existing literature and guidelines for the prevention of falls. C. Identify fall prevention practices that are applicable to the patient care setting. D. Gather data to identify the effectiveness of the new practice guidelines. - answers B. Gather and review currently existing literature and guidelines for the prevention of falls. Rationale: Options A, B, and C are correct steps in planning for the implementation of evidence-based practices; however, Option B would be D. arranged for continual care of the patient. - answers D. arranged for continual care of the patient. Rationale: By leaving the patient, the nurse is at fault for abandonment. The better courses of action are to turn on the call bell or elicit help on the way to the patient's room. Options A and C are incorrect because neither excuses the nurse from her responsibility for ensuring the patient's safety. Option B is incorrect because restraints are only to be used as a last resort, when all other alternatives for ensuring patient safety have been tried and have failed; moreover, restraints won't ensure the patient's safety. The nurse is caring for a patient admitted to the emergency department after a motor vehicle accident. Under the law, the nurse must obtain informed consent before treatment unless the patient: A. is mentally ill. B. refuses to give informed consent. C. is in an emergency situation. D. asks the nurse to give substituted consent - answers C. is in an emergency situation. Rationale: The law doesn't require informed consent in an emergency situation when the patient can't give consent and no next of kin is available. Option A is incorrect because even though a patient who is declared mentally incompetent can't give informed consent, mental illness doesn't by itself indicate that the patient is incompetent to give such consent. Option B is incorrect because a mentally competent patient may refuse or revoke consent at any time. Option D is incorrect because although the nurse may act as a patient advocate, the nurse can never give substituted consent. Which of the following acts committed by a nurse is an intentional tort? A. Battery B. Breach of confidentiality C. Negligence D. Abandonment - answers A. Battery Rationale: Battery, touching a patient without justifi cation or permission, is an intentional tort. Option B is incorrect because although a nurse who breaches a patient's confidentiality can be subject to a lawsuit or disciplinary action, the act isn't an intentional tort. Option C is incorrect because negligence, the failure to exercise the degree of care that a person of ordinary prudence would exercise under the same circumstances, is an unintentional tort. Option D is incorrect because although abandonment is a liability for nurses, the act isn't an intentional tort. OSHA is responsible for: A. compensating workers injured in the workplace. B. providing rehabilitation for workers injured in the workplace. C. inspecting high-hazard workplaces for compliance with protective standards. D. disciplining workers injured in the workplace. - answers C. inspecting high-hazard workplaces for compliance with protective standards. Rationale: OSHA is responsible for preventing work-related injuries, illnesses, and deaths. Options A and B are incorrect because it's the responsibility of workers' compensation to compensate workers for injuries occurring in the workplace and to provide rehabilitative services. Option D is incorrect because it's the employer's responsibility to improve the safety and health of employees. Employers who violate OSHA standards are subject to fines and penalties A patient became seriously ill after a nurse gave him the wrong medication. After his recovery, he fi led a lawsuit. Who is most likely to be held liable? A. No one because it was an accident B. The hospital C. The nurse D. The nurse and the hospital - answers D. The nurse and the hospital Rationale: Nurses are always responsible for their actions. The hospital is liable for negligent conduct of its employees within the scope of employment. Consequently, the nurse and the hospital are liable. Therefore, Options B and C are incorrect. Option A is incorrect because although the mistake wasn't intentional, standard procedure wasn't followed. Which of the following is incorrect about informed consent? A. It can be revoked by the state, especially when the benefits outweigh the risks. B. A person has to be mentally competent to sign an informed consent. C. Physicians can waive informed consents in emergency situations. D. The name of the procedure, its risks and benefits, and other alternative procedures make up all the essential elements of informed consent - answers D. The name of the procedure, its risks and benefits, and other alternative procedures make up all the essential elements of informed consent Rationale: An informed consent should also contain the name of the health care professional who will be performing the procedure. The other options are correct statements about informed consent. Which of the following is considered identifi able health information? A. A photograph of a patient's leg showing a unique tattoo B. A patient's chart listing his history of a stroke last year C. A blank menu for a regular diet on the patient's over-bed table D. A laboratory report with the patient's name, address, Social Security number, date of birth, and room number deleted - answers A. A photograph of a patient's leg showing a unique tattoo Rationale: Any information that can identify the person or that relates to a past, present, or future physical or mental condition is considered identifiable health information. Options B, C, and D don't contain information that can identify the patient. In a negligence suit against a nurse, what must the plaintiff prove? A. The nurse intended to cause harm. altering bowel sounds with palpation before auscultation. The correct sequence for all other assessments is inspection, palpation, percussion, and auscultation. To maintain a therapeutic environment with a patient and his family, the nurse can use communication techniques such as clarifi cation. An example of clarifi cation is: A. "How is it going?" B. "You say you aren't concerned, but you've asked me many questions on this same subject." C. "What do you mean when you say...?" D. "For now, I would like to concentrate on..." - answers C. "What do you mean when you say...?" Rationale: Option C is an example of clarification or seeking validation. Option A isn't an example of clarification but is instead an example of a broad-opening technique. Option B is an example of confrontation, which calls attention to discrepancies in what the patient is saying. Option D is an example of focusing or helping the patient direct his thoughts. In the stages of death and dying as defi ned by Elisabeth Kübler-Ross, loss, grief, and intense sadness are symptoms of: A. depression. B. denial. C. anger. D. acceptance. - answers A. depression. Rationale: Loss, grief, and intense sadness indicate depression. Denial (Option B) is indicated by the refusal to admit the truth or reality. Anger (Option C) is manifested by rage and resentment. Acceptance (Option D) is evidenced by a gradual, peaceful withdrawal from life. In the levels of basic human needs as defi ned by Abraham Maslow, which of the following levels is most basic? A. Physiologic B. Safety and security C. Love, affection, and belonging D. Esteem - answers A. Physiologic Rationale: Physiologic needs (Option A) are the most basic needs and essential for sustaining life. Once physiologic needs are met, needs for safety and security (Option B) can be met, followed by love, affection, and belonging (Option C), and esteem (Option D). According to the stages of development, what confl ict does the older adult experience? A. Intimacy versus isolation B. Generativity versus stagnation C. Identity versus role confusion D. Integrity versus despair - answers D. Integrity versus despair Rationale: The key confl ict the older adult (age 66 and older) faces is integrity versus despair. Intimacy versus isolation (Option A) is the key conflict in young adulthood; generativity versus stagnation (Option B), the key conflict in middle adulthood; and identity versus role confusion (Option C), the key conflict of adolescence The nurse is caring for a patient who has just been diagnosed with a terminal illness. The patient says to her, "I can't believe this! I feel..." and pauses. The nurse allows the patient time to gather his thoughts. What type of therapeutic communication is this? A. Clarification B. Empathy C. Reflection D. Silence - answers D. Silence Rationale: The nurse allows the patient time to gather his thoughts by using silence. Clarifi cation (Option A) would be seeking validation for what the patient said. Empathy (Option B) would be the nurse placing herself temporarily in the patient's position. Reflection (Option C) would be paraphrasing what the patient said. A patient becomes angry attending a treatment group and complains about it to the nurse. Which response could the nurse give that would best demonstrate clarifi cation? A. "Can you tell me what about the treatment group made you angry?" B. "Why are you upset? Attending the treatment group will help you get well." C. "It sounds like group today was pretty upsetting." D. "Treatment groups have been carefully planned by the staff to help patients." - answers A. "Can you tell me what about the treatment group made you angry?" Rationale: Option A uses clarifi cation to seek validation of what the patient said. Using "why," as in Option B, is accusatory and can hinder self-disclosure. Option C is an example of empathy, and Option D is a destructive sentence that negates the patient's importance. Which of Piaget's cognitive developmental stages takes place from ages 7 to 11? A. Formal operations B. Concrete operations C. Preoperational D. Sensorimotor - answers B. Concrete operations Rationale: The concrete operations stage takes place between ages 7 and 11. The formal operations stage (Option A) occurs at age 11 and above. The preoperational stage (Option C) takes place between ages 2 to 7, and the sensorimotor stage (Option D) occurs from birth to age 2 years. Which interaction style describes a nurse who cannot clearly separate her own emotional responses from the patient's needs and wants? A. Holistic B. Defensive C. Sympathetic D. Silence - answers C. Sympathetic B. Maceration C. Sloughing D. Angiogenesis - answers B. Maceration Rationale: Maceration is the softening of tissue by wetting or soaking. Eschar (Option A) is thick, leathery, necrotic, devitalized tissue. Sloughing (Option C) is the separation of necrotic tissue from viable tissue. Angiogenesis (Option D) is the formation of new granulation vessels. After assessing a patient's pressure ulcer, you note that subcutaneous fat is visible but that bone, tendon, and muscle are not exposed. You observe slough, but it does not obscure the depth of tissue loss. You also note some undermining and tunneling. What stage pressure ulcer is this? A. Stage II B. Suspected deep tissue injury C. Stage III D. Stage IV - answers C. Stage III Rationale: A Stage III pressure ulcer involves full-thickness tissue loss, possibly with visible subcutaneous fat but with no exposer of bone, tendon, or muscle; slough may be present but doesn't obscure the depth of tissue loss, and undermining and tunneling may also be present. A Stage II pressure ulcer (Option A) involves a partial-thickness tissue loss presenting as a shallow, open ulcer with a red-pink wound bed without slough. A suspected deep tissue injury (Option B) involves a purple or maroon localized area of discolored intact skin or blood-filled blister resulting from damage of underlying soft tissue from pressure, shear, or both. A stage IV pressure ulcer (Option D) involves full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present on some parts of the wound bed. During which stage of healing does granulation tissue form and epithelialization occur? A. The maturation phase B. The epithelial closure phase C. The infl ammatory phase D. The proliferative phase - answers D. The proliferative phase Rationale: During the proliferative stage of wound healing, granulation tissue forms and epithelialization occurs. In the final maturation phase (Option A), collagen reorganizes and strengthens. In the epithelial closure phase (Option B), the wound contracts and begins to close. The inflammatory phase (Option C) starts right after injury and doesn't involve granulation tissue formation or epithelialization. Which of the following are external factors that subject the skin to injury? A. Emaciation and infections B. Allergens and radiation C. Radiation and emaciation D. Allergens and infections - answers B. Allergens and radiation Rationale: Allergens and radiation are external factors that subject the skin to injury. Emaciation (included in Options A and C) and infection (included in Options A and D) are internal factors. Where is a venous ulcer typically found on a patient? A. The medial lower leg and ankle B. The plantar aspect of foot C. On a bony prominence D. Under the heels - answers A. The medial lower leg and ankle Rationale: A venous ulcer is typically found on the medial lower leg and ankle. A diabetic ulcer is usually found on the plantar aspect of the foot (Option B) or under the heels (Option D). A pressure ulcer is usually found on a bony prominence (Option C). Which substance enables the transport of oxygen during wound healing? A. Zinc B. Vitamin B6 C. Folate D. Vitamin C - answers C. Folate Rationale: Folate enables the transport of oxygen during wound healing. Zinc (Option A) enables protein synthesis and tissue repair. Vitamin B6 (Option B) decreases collagen and protein synthesis, and vitamin C (Option D) is needed for collagen synthesis The nurse is teaching a group of patient care attendants about infectioncontrol measures. The nurse tells the group that the fi rst line of intervention for preventing the spread of infection is: A. wearing gloves. B. administering antibiotics. C. hand hygiene. D. assigning private rooms for patients. - answers C. hand hygiene. Rationale: Hand hygiene is the fi rst line of intervention for preventing the spread of infection. Option B is incorrect because antibiotics should be initiated only when an organism is identifi ed. Although wearing gloves (Option A) and assigning private rooms (Option D) can also decrease the spread of infection, they should be implemented according to standard precautions when indicated. The nurse is caring for a patient who was given pain medication before leaving the recovery room. Upon returning to his room, the patient states that he is still experiencing pain and requests more pain medication. Of the following actions, which is the first for the nurse to take? A. Tell the patient that he must wait 4 hours for more pain medication. B. Give half of the ordered as-needed dose. C. Document the patient's pain. D. Notify the practitioner that the patient is still experiencing pain - answers D. Notify the practitioner that the patient is still experiencing pain Rationale: The practitioner should be notifi ed that the patient is still experiencing pain so that new medication orders can be established. Option A is incorrect because patients who have recently undergone surgery shouldn't have to wait 4 hours for pain relief. Option B is incorrect because a nurse Rationale: A low-residue diet is used to avoid GI tract irritation and decrease fecal volume, appropriate measures for a patient with ulcerative colitis. Such a patient doesn't need to follow a lowfat diet (Option A) or to consume additional calories (Option C). A patient with ulcerative colitis should avoid a high-fiber diet (Option D), which contains such foods as whole grain cereals and fruit. The nurse performs a nutritional assessment on a patient with lung cancer who is in the postoperative period after a lobectomy. Which of the following could be an early sign of malnutrition? A. A retinal-binding protein level of 2.0 mg/dL B. Dry, fl aky, discolored skin and brittle nails C. A body mass index (BMI) of 20 D. An albumin level of 3.0 g/dL - answers A. A retinal-binding protein level of 2.0 mg/dL Rationale: Retinal-binding protein has a half-life of 12 hours, so a decrease from the normal values of 2.6 to 7.6 mg/dL could be an early sign of malnutrition. Dry, fl aky, discolored skin and brittle nails (Option B) are later signs of malnutrition. A BMI of 20 (Option C) falls in the normal range. Albumin has a half-life of 20 days so, although a value of 3.0 g/dL (Option D) would be a decrease from the normal values of 3.5 to 5 g/dL, it would be a later sign of malnutrition The two types of surgery primarily used to promote weight loss are restrictive and malabsorptive-restrictive. Which of the following is an example of restrictive weight-loss surgery? A. Gastric bypass B. Adjustable gastric banding C. Roux-en-Y D. Biliopancreatic diversion - answers B. Adjustable gastric banding Rationale: Adjustable gastric banding is a type of gastric restriction weight- loss surgery. Malabsorptive-restrictive procedures include gastric bypass (Option A) (also known as a Roux-en-Y bypass [Option C]) and biliopancreatic diversion (Option D). In what type of electrolyte imbalance would the nurse observe tall, tented T waves; a widened QRS complex; and a prolonged PR interval on the patient's ECG? A. Hypokalemia B. Hypocalcemia C. Hypercalcemia D. Hyperkalemia - answers D. Hyperkalemia Rationale: In hyperkalemia, the patient's ECG will show tall, tented T waves; a widened QRS complex; and a prolonged PR interval. In hypokalemia (Option A) the ECG will show a fl at ST segment and Q wave. Hypocalcemia (Option B) and hypercalcemia (Option C) won't show T wave, QRS, or PR interval changes on the ECG. While auscultating the heart sounds of a patient with mitral insuffi ciency, the nurse hears an extra heart sound immediately after the second heart sound (S2 ). The nurse should document this extra heart sound as: A. a first heart sound (S1). B. a third heart sound (S3). C. a fourth heart sound (S4). D. a mitral murmur - answers B. a third heart sound (S3). Rationale: An S3 is heard following an S2 , indicating that the patient is experiencing heart failure and results from increased filling pressures. Option A (S1) is a normal heart sound made by the closing of the mitral and tricuspid valves. Option C (S4) is heard before S1 and is caused by resistance to ventricular filling. Option D (murmur of mitral insufficiency) occurs during systole and is heard when there's turbulent blood fl ow across the valve. A 55-year-old black male is found to have a blood pressure of 150/90 mm Hg during a work site health screening. What should the nurse do? A. Consider this to be a normal finding for his age and race. B. Recommend he have his blood pressure rechecked in 1 year. C. Recommend he have his blood pressure rechecked within 2 weeks. D. Recommend he go to the emergency department for further evaluation. - answers C. Recommend he have his blood pressure rechecked within 2 weeks. Rationale: A BP of 150/90 mm Hg should be rechecked within 2 weeks according to current recommendations. If confirmed, assessment and treatment should be initiated by the practitioner. Option A is incorrect because although hypertension is more prevalent among blacks, a BP of 150/90 mm Hg isn't considered normal. Option B is incorrect because a person with a BP of 150/90 mm Hg shouldn't wait as long as 1 year to have it rechecked. Option D is incorrect because he doesn't need to be treated on an emergency basis, but he should have his BP monitored. The nurse is administering warfarin (Coumadin) to a patient with deep vein thrombophlebitis. Which laboratory value indicates warfarin is at therapeutic levels? A. PTT 1½ to 2 times the control B. PT 1½ to 2 times the control C. INR of 3 to 4 D. Hematocrit of 32% - answers B. PT 1½ to 2 times the control Rationale: Warfarin is at therapeutic levels when the patient's PT is 1½ to 2 times the control. Higher values indicate increased risk of bleeding and hemorrhage, and lower values indicate increased risk of blood clot formation. Option A is incorrect because heparin, not warfarin, prolongs PTT. Option C is incorrect because although the INR may also be used to determine if warfarin is at a therapeutic level, an INR should be 2-3. Option D is incorrect because hematocrit doesn't provide information on the effectiveness of warfarin; however, a falling hematocrit in a patient taking warfarin may be a sign of hemorrhage. A patient is receiving captopril for heart failure. The nurse should notify the practitioner that the medication therapy is ineffective if an assessment reveals: A. a skin rash. B. peripheral edema. C. a dry cough. Rationale: ACE inhibitors reduce preload and afterload. Antiplatelet drugs minimize platelet aggregation (Option A). Nitrates reduce myocardial oxygen consumption (Option C). Beta-adrenergic blockers reduce the workload of the heart and myocardial oxygen demand (Option D). Which of the following conditions can cause right-sided heart failure? A. A ventricular septal defect B. An anterior MI C. An atrial septal defect D. Constrictive pericarditis - answers C. An atrial septal defect Rationale: An atrial septal defect can lead to right-sided heart failure. Left- sided heart failure can result from a ventricular septal defect (Option A), an anterior MI (Option B), or constrictive pericarditis (Option D). When assessing a patient with anemia from acute blood loss, the nurse would expect to fi nd which of the following? A. Sudden onset of symptoms, hypotension, and tachycardia B. Exertional dyspnea, poor nutrition, and hypotension C. Sudden onset of symptoms, glossitis, and tachycardia D. Fatigue, neuropathy, and tachycardia - answers A. Sudden onset of symptoms, hypotension, and tachycardia Rationale: Acute blood loss occurs suddenly. Hypotension and tachycardia are compensatory mechanisms in response to rapid loss of blood volume. Although anemia may produce exertional dyspnea and hypotension, Option B is incorrect because poor nutrition is neither a symptom nor a cause of anemia due to blood loss. Options C and D are incorrect because anemia due to acute blood loss produces neither glossitis nor neuropathy. When teaching safety precautions to a patient with thrombocytopenia, the nurse should include which of the following directives? A. Eat foods high in iron. B. Avoid products that contain aspirin. C. Avoid people with respiratory tract infections. D. Eat only cooked vegetables - answers B. Avoid products that contain aspirin. Rationale: Patients with a low platelet count should avoid products that contain aspirin because they increase the tendency to bleed. Option A would be important to teach the patient with anemia. Options C and D are correct for the patient with leukopenia. When assessing the patient, the nurse knows that the body system least affected by multiple myeloma is the: A. skeletal system. B. renal system. C. nervous system. D. cardiovascular system. - answers D. cardiovascular system. Rationale: Multiple myeloma usually doesn't have a direct effect on the heart. Options A, B, and C are incorrect because multiple myeloma usually affects the skeletal, renal, and nervous systems. The nurse is reviewing assessment data for a patient with a diagnosis of stage III Hodgkin's disease. This diagnosis is most strongly supported by lymphatic involvement on both sides of the: A. blood-brain barrier. B. diaphragm. C. descending aorta. D. spinal column - answers B. diaphragm. Rationale: With stage III Hodgkin's disease, malignant cells are widely disseminated to lymph nodes on both sides of the diaphragm. Options A, B, and D are incorrect because these structures aren't involved in the staging of Hodgkin's disease. A 50-year-old male with a diagnosis of leukemia is responding poorly to treatment. He is tearful and trying to express his feelings, but he is having diffi culty. The nurse should fi rst: A. tell him that she will leave for now but she will be back. B. offer to call pastoral care. C. ask if he would like her to sit with him while he collects his thoughts. D. tell him that she can understand how he is feeling. - answers C. ask if he would like her to sit with him while he collects his thoughts. Rationale: The patient needs to feel that people are concerned with his situation. Option A is incorrect because leaving the patient doesn't show acceptance of his feelings. Option B is incorrect because offering to call pastoral care may be helpful for some patients but should be done after the nurse has spent time with the patient. Option D is incorrect because telling the patient that she understands how he's feeling is inappropriate because it doesn't help him express his feelings. A patient with blood type B can receive a transfusion of what type of RBCs? A. Type A or type O B. Type B or type O C. Type AB or type O D. Type A or type B - answers B. Type B or type O Rationale: Type B blood contains B antigens and anti-A antibodies, but no anti-B antibodies. Therefore, a patient with type B blood can receive type B or type O RBCs, which contain neither anti-A nor anti-B antibodies. Options A, C, and D are incorrect because blood type B contains anti-A antibodies Which type of anemia results from defi ciency of all the blood's formed elements, caused by failure of the bone marrow to generate enough new cells? A. Sickle cell anemia B. Folic acid deficiency anemia C. Aplastic anemia D. Iron deficiency anemia - answers C. Aplastic anemia Rationale: Aplastic anemia usually develops when damaged or destroyed stem cells inhibit RBC production. Sickle cell anemia (Option A) is a genetic disorder that causes malformation of RBCs. Folic acid deficiency anemia Impaired gas exchange is the priority nursing diagnosis for the patient with P. jiroveci pneumonia. Airway,breathing, and circulation take top priority for any patient. A patient has chronic bronchitis. The nurse is teaching him breathing exercises. Which point should the nurse include in her teaching? A. Make inhalation longer than exhalation. B. Exhale through an open mouth. C. Use diaphragmatic breathing. D. Use chest breathing. - answers C. Use diaphragmatic breathing. Rationale: In patients with chronic bronchitis, the diaphragm is fl at and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Option A is incorrect because exhalation should be no longer than inhalation to prevent collapse of the bronchioles. Because a patient with chronic bronchitis should exhale through pursed lips to prolong expiration, keep the bronchioles from collapsing, and prevent air trapping, Option B is incorrect. Option D is incorrect because diaphragmatic breathing, not chest breathing, increases lung expansion A patient with ARDS is intubated and placed on mechanical ventilation. His Pao2 is 60 mm Hg on 1.0 Fio2 To improve his Pao2 without ra ising the Fio2,the patient will most likely be placed on: A. time-cycled ventilation. B. volume-cycled ventilation. C. pressure support. D. PEEP. - answers D. PEEP. Rationale: PEEP is widely used during mechanical ventilation of the patient with ARDS to improve gas exchange over the alveolar capillary membrane. Time- or volume-cycled ventilation, Options A and B, are less likely to be used for a patient with ARDS than pressure-cycled ventilation. Pressure support, Option C, depends on the patient's inspiratory effort and isn't as effective as PEEP in treating ARDS. When auscultating the chest of a patient with pneumonia, the nurse should expect to hear which type of sounds over areas of consolidation? A. Bronchial B. Bronchovesicular C. Tubular D. Vesicular - answers A. Bronchial Rationale: Chest auscultation reveals bronchial breath sounds over areas of consolidation. Bronchovesicular breath sounds (Option B) are normal over midlobe lung regions, tubular sounds (Option C) are commonly heard over large airways, and vesicular breath sounds (Option D) are commonly heard in the bases of the lung fields. A patient's history reveals that he suffers from daytime symptoms of asthma that occur 3 to 6 days a week. How would his asthma severity be described? A. Mild intermittent B. Mild persistent C. Moderate persistent D. Severe persistent - answers B. Mild persistent Rationale: In mild persistent asthma, the patient's daytime symptoms of asthma occur 3 to 6 days a week. In mild intermittent asthma (Option A), the patient's daytime symptoms occur no more than twice a week. In moderate persistent asthma (Option C), the patient has daily daytime symptoms. In severe persistent asthma (Option D), the patient has continual daytime symptoms. A 66-year-old patient has marked dyspnea at rest, is thin, and uses accessory muscles to breathe. He is tachypneic, with a prolonged expiratory phase. He has no cough. He leans forward with his arms braced on his knees to support his chest and shoulders for breathing. This patient has signs and symptoms of which respiratory disorder? A. ARDS B. Asthma C. Chronic obstructive bronchitis D. Emphysema - answers D. Emphysema Rationale: These are classic signs and symptoms of a patient with emphysema. Patients with ARDS (Option A) are acutely short of breath and require emergency care; those with asthma (option B) are also acutely short of breath during an attack and appear very frightened. Patients with chronic obstructive bronchitis (Option C) appear bloated and cyanotic A nurse is preparing to reinforce the teaching plan for a patient who has recently been diagnosed with squamous cell carcinoma of the left lung. Which statement by the nurse is correct? A. "You have a slow-growing cancer that rarely spreads." B. "In terms of prognosis, you may have only a few months to live." C. "Squamous cell cancer is a very rapidly growing cancer." D. "The cancer has generally metastasized by the time diagnosis is made." - answers A. "You have a slow-growing cancer that rarely spreads." Rationale: Squamous cell carcinoma is a type of cancer that grows slowly and rarely metastasizes. It has the best prognosis of all lung cancer types. It's not appropriate for the nurse to tell the patient how long he has to live (Option B). Squamous cell carcinoma does not grow rapidly (Option C) and rarely metastasizes (Option D). Which respiratory disorder is most common in the fi rst 24 to 48 hours after surgery? A. Atelectasis B. Bronchitis C. Pneumonia D. Pneumothorax - answers A. Atelectasis Rationale: Atelectasis develops when there's interference with the normal negative pressure that promotes lung expansion. Patients in the postoperative phase often splint their breathing because of pain and positioning, which causes hypoxia. It's uncommon for any of the other respiratory disorders (Options B, C, and D) to develop. A patient with acute asthma showing inspiratory and expiratory wheezes and a decreased forced expiratory volume should be treated immediately with which class of medication? A. Beta-adrenergic blockers Rationale: Staying with the patient and encouraging him to feed himself will ensure adequate food intake. A patient with Alzheimer's disease can forget to eat. Filling out the patient's menu (Option B), allowing privacy during meals (Option C), or fi lling out the menu for the patient (Option D) don't ensure adequate nutritional intake. The nurse is teaching a patient and his family about dietary practices related to Parkinson's disease. A priority for the nurse to address is risk of: A. fluid overload and drooling. B. aspiration and anorexia. C. choking and diarrhea. D. dysphagia and constipation - answers D. dysphagia and constipation Rationale: Eating problems associated with Parkinson's disease include aspiration, choking, constipation, and dysphagia. Option A is incorrect since fluid overload isn't specifically related to Parkinson's disease and, although drooling occurs with Parkinson's disease, it doesn't take priority. Anorexia (Option B) and diarrhea (Option C) aren't specifically associated with Parkinson's disease. An elderly patient has just suffered a stroke that has left him with amnesia. Amnesia is a symptom associated with damage to which vessel? A. Carotid artery B. Anterior cerebral arteries C. Vertebrobasilar artery D. Middle cerebral artery - answers C. Vertebrobasilar artery Rationale: Damage to the vertebrobasilar artery can produce amnesia. Damage to the other arteries (Options A, B, and D) doesn't produce amnesia. Which condition places a patient at risk for an embolic stroke? A. Atrial fibrillation B. Bradycardia C. Deep vein thrombosis D. A history of MI - answers A. Atrial fibrillation Rationale: Atrial fi brillation results from the irregular and rapid discharge from multiple ectopic atrial foci that causes quivering of the atria without atrial systole. This asynchronous atrial contraction predisposes the patient to mural thrombi, which may embolize, leading to a stroke. Bradycardia (Option B), deep vein thrombosis (Option C), and a history of MI (Option D) don't lead to arterial embolization. After a patient experiences a brain stem infarction, the nurse should observe for which condition? A. Aphasia B. Bradypnea C. Contralateral hemiplegia D. Numbness and tingling to the face or arm - answers B. Bradypnea Rationale: The brain stem contains the medulla and the vital cardiac, vasomotor, and respiratory centers. A brain stem infarction leads to vital sign changes such as bradypnea. Aphasia (Option A) is associated with lobar strokes in the cerebral hemispheres. Although contralateral hemiplegia (Option C) and numbness and tingling in the face or arm (Option D) may occur with certain types of strokes, they generally don't occur with brain stem infarction. A patient with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which reason? A. To reduce intraocular pressure B. To prevent acute tubular necrosis C. To promote osmotic diuresis to decrease ICP D. To draw water into the vascular system to increase blood pressure - answers C. To promote osmotic diuresis to decrease ICP Rationale: Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol also reduces intraocular pressure (Option A), helps prevent acute tubular necrosis (Option B), and draws water into the vascular system to increase blood pressure (Option D), its most pressing use for this patient is to reduce ICP. In a patient with meningitis, irritation to which CN could cause photophobia? A. III B. IV C. V D. VI - answers C. V Rationale: Irritation to CN V may cause photophobia. Irritation to CN III (Option A), IV (Option B), and VI (Option D) may cause diplopia, impaired ocular movement, ptosis, and unequal pupils - answers Rationale: - answers Rationale: