Intro To Nursinhjcfnhgg - Exam 2 Concepts - Modules 5-8

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name
Intro to Nursing - Exam 2 Concepts - Modules 5-8
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description
NUR1020C Pensacola State College Nursing 2014 | Potter:
Fundamentals of Nursing, 8th Edition, Chapters 48, 14, 31, 25 | Ignatavicius: Me
dical-Surgical Nursing: Patient-Centered Collaborative Care, 7th Edition, Chapte
r 27 | Kee: Pharmacology: A Patient-Centered Nursing Process Approach, 8th Editi
on, Chapters 1-6, 8, 10 | Giddens: Concepts for Nursing Practice, 1st Edition, C
hapter 21, Concept 2, Concept 39
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author MedicalPartisan
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Text 1 Text 2 Picture 2
"When repositioning an immobile patient, the nurse notices redness over a bony p
rominence. What is indicated when a reddened area blanches on fingertip touch?
A. A local skin infection requiring antibiotics
B. Sensitive skin that requires special bed linen
C. A stage III pressure ulcer needing the appropriate dressing
D. Blanching hyperemia, indicating the attempt by the body to overcome the ische
mic episode.
(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"
"Answer: D.
When repositioning an immobile patient, it is important to assess all bony promi
nences for the presence of redness, which can be the first sign of impaired skin
integrity. Pressing over the area compresses the blood vessels in the area; and
, if the integrity of the vessels is good, the area turns lighter in color and t
hen returns to the red color. However, if the area does not blanch when pressure
is applied, tissue damage is likely."
"Which type of pressure ulcer is noted to have intact skin and may include chang
es in one or more of the following: skin temperature (warmth or coolness), tissu
e consistency (firm or soft), and/or pain?
A.
B.
C.
D.
Stage
Stage
Stage
Stage
I
II
III
IV

"Answer: A.
A stage I pressure ulcer does not have a break in the skin but has a redness tha
t does not blanch. Depending on the skin color, there may be a discoloration; th
e area may feel warm because of the vasodilation or cool if blood is constricted
in the area; and the tissue may feel firm if there is edema in the area or soft
if the blood flow is compromised. The patient may report pain in the area."
"When obtaining a wound culture to determine the presence of a wound infection,
from where should the specimen be taken?
A.
B.
C.
D.
Necrotic tissue
Wound drainage
Drainage on the dressing
Wound after it has first been cleaned with normal saline

"Answer: D.
Drainage that has been present on the wound surface can contain bacteria from th
e skin, and the culture may not contain the true causative organisms of a wound
infection. By cleaning the area before obtaining the culture, the skin flora is
removed."
"After surgery the patient with a closed abdominal wound reports a sudden ""pop"
" after coughing. When the nurse examines the surgical wound site, the sutures a
re open, and pieces of small bowel are noted at the bottom of the now-opened wou
nd. Which corrective intervention should the nurse do first?
A. Allow the area to be exposed to air until all drainage has stopped
B. Place several cold packs over the area, protecting the skin around the wound
C. Cover the area with sterile, saline-soaked towels and immediately notify the
surgical team; this is likely to indicate a wound evisceration
D. Cover the area with sterile gauze, place a tight binder over it, and ask the
patient to remain in bed for 30 minutes because this is a minor opening in the s
urgical wound and should reseal quickly
"Answer: C.
If a patient has an opening in the surgical incision and a portion of the small
bowel is noted, the small bowel must be protected until an emergency surgical re
pair can be done. The small bowel and abdominal cavity should be maintained in a
sterile environment; thus sterile towels that are moistened with sterile saline
should be used over the exposed bowel for protection and to keep the bowel mois
t."
"Which description best fits that of serous drainage from a wound?
A.
B.
C.
D.
Fresh bleeding
Thick and yellow
Clear, watery plasma
Beige to brown and foul smelling

"Answer: C.
Serous fluid generally is serum and presents as light red, almost clear fluid."
"For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which
wound care product helps prevent edema formation, control bleeding, and anesthe
tize the body part?
A.
B.
C.
D.
Binder
Ice bag
Elastic bandage
Absorptive diaper

"Answer: B.
An ice bag helps to constrict excess fluid in tissues, which prevents edema. The
blood vessels become constricted, help to control bleeding, and can decrease pa
in where the ice bag is placed."
"Which skin care measures are used to manage a patient who is experiencing fecal
and urinary incontinence?
A. Keeping the buttocks exposed to air at all times
B. Using a large absorbent diaper, changing when saturated
C. Using an incontinence cleaner, followed by application of a moisture-barrier
ointment
D. Frequent cleaning, applying an ointment, and covering the areas with a thick
absorbent towel
"Answer: C.
Skin that is in contact with stool and urine can become moist and soft, allowing
it to become damaged. The stool contains bacteria and in some cases enzymes tha
t can harm the skin if in contact for a prolonged period of time. The use of an
incontinence cleaner provides a gentle removal of stool and urine, and the use o
f the moisture-barrier ointment provides a protective layer between the skin and
the next incontinence episode."
"Which of the following describes a hydrocolloid dressing?
A.
B.
C.
D.
A seaweed derivative that is highly absorptive

Premoistened gauze placed over a granulating wound
A debriding enzyme that is used to remove necrotic tissue
A dressing that forms a gel that interacts with the wound surface

"Answer: D.
A hydrocolloid dressing is made of materials that are adhesive and can form a ge
l over the open area of the wound. Since moisture enhances wound healing, the ge
l that forms places the wound in the proper environment for healing."
"Which of the following is an indication for a binder to be placed around a surg
ical patient with a new abdominal wound?
A.
B.
C.
D.
Collection of wound drainage

Reduction of abdominal swelling
Reduction of stress on the abdominal incision
Stimulation of peristalsis (return of bowel function) from direct pressure

"Answer: C.
A binder placed over the abdomen can provide protection to the abdominal incisio
n by offering support and decreasing stress from coughing and movement."
"When is an application of a warm compress indicated? (Select all that apply.)
A.
B.
C.
D.
To relieve edema
For a patient who is shivering
To improve blood flow to an injured part
To protect bony prominences from pressure ulcers

"Answers: A, C.
Warm compresses can improve circulation by dilating blood vessels, and they redu
ce edema. The moisture of the compress conducts heat."
"What is the removal of devitalized tissue from a wound called?
A.
B.
C.
D.
Debridement
Pressure reduction
Negative pressure wound therapy
Sanitization

"Answers: A.
Debridement is the removal of nonliving tissue, cleaning the wound to move towar
d healing."
"What does the Braden Scale evaluate?
A.
B.
C.
D.
Skin integrity at bony prominences, including any wounds

Risk factors that place the patient at risk for skin breakdown
The amount of repositioning that the patient can tolerate
The factors that place the patient at risk for poor healing

"Answer: B.
The Braden Scale measures factors in six subscales that can predict the risk of
pressure ulcer development. It does not assess skin or wounds."
"On assessing your patient's sacral pressure ulcer, you note that the tissue ove
r the sacrum is dark, hard, and adherent to the wound edge. What is the correct
stage for this patient's pressure ulcer?
A.
B.
C.
D.
Stage II
Stage IV
Unstageable
Suspected deep tissue damage

"Answer: C.
To determine the stage of a pressure ulcer you examine the depth of the tissue i
nvolvement. Since the pressure ulcer assessed was covered with necrotic tissue,
the depth could not be determined. Thus this pressure ulcer cannot be staged."
"A contaminated or traumatic wound may show signs of infection within 24 hours.
A surgical wound infection usually develops postoperatively within 14 days.

A. True
B. False
"Answer: B.
A contaminated or traumatic wound may show signs of infection early, within 2 to
3 days. A surgical wound infection usually develops postoperatively within 4 to
5 days."
"Healing by primary intention is expected when the edges of a clean surgical inc
ision are sutured or stapled together, tissue loss is minimal or absent, and the
wound is uncontaminated by microorganisms.
A. True
B. False
"Answer: A.
This is the correct definition of healing by primary intention."
"Which of the following may indicate internal hemorrhage? (Select all that apply
.)
A.
B.
C.
D.
Distention or swelling of the affected body part

An elevated white blood cell count
A decreased blood pressure and increased pulse
A change in the type and amount of drainage from a surgical drain

"Answers: A, C,
D.
The nurse can detect internal bleeding by looking for distention or swelling of
the affected body part, a change in the type and amount of drainage from a surgi
cal drain, or signs of hypovolemic shock such as a decreased blood pressure, inc
reased pulse, and cool, clammy skin. An elevated white blood cell count would be
an indication of infection."
"Which of the following patients has the least risk for developing a wound infec
tion?
A.
B.
C.
D.
E.
An 80-year-old man who has a burn

A 17-year-old patient who has a metal fragment lodged in his thigh
A 30-year-old female who had an episiotomy after childbirth
A patient receiving chemotherapy who has a surgical incision
A patient with peripheral vascular disease and an ulcer on the heel

"Answer: C.
The chances of wound infection are greater when the wound contains dead or necro
tic tissue (as with a burn), there are foreign bodies in or near the wound, and
the blood supply and local tissue defenses are reduced or the patient is immunoc
ompromised."
"When teaching a patient about wound healing, the nurse should tell the patient:
A. Inadequate nutrition delays wound healing and increases risk of infection.
B. Chronic wounds heal more efficiently in a dry, open environment, so leave the
m open to air when possible.
C. Long-term steroid therapy diminishes the inflammatory response and speeds wou
nd healing.
D. Fat tissue heals more readily because there is less vascularization.
"Answer: A.
Inadequate nutrition including proteins, carbohydrates, lipids, vitamins, and minera
ls delays tissue repair and increases risk for infection. Both full-thickness wounds
and partial-thickness wounds heal more efficiently in a moist, protected enviro

nment. Long-term steroid therapy may diminish the inflammatory response and redu
ce the healing potential. Steroids slow collagen synthesis. Fat tissue has less
blood supply, which decreases transport of nutrients and cellular elements requi
red for healing."
"The nurse is caring for a patient who had knee replacement surgery 5 days ago.
The patient's knee appears red and is very warm to the touch. The patient reques
ts pain medication. Which of the following would be a correct explanation of wha
t the nurse has assessed?
A.
B.
C.
D.
These are expected findings for this postoperative time period.

The patient is becoming dependent upon pain medication.
The nurse should observe the patient more closely for wound dehiscence.
The patient is demonstrating signs of a postoperative wound infection.

"Answer: D.
The risk for infection is greatest 4 to 5 days postoperative. Symptoms of wound
infection include fever, tenderness and pain at the wound site, an elevated whit
e blood cell count, and the edges of the wound may appear inflamed. If drainage
is present, it is odorous and purulent, which causes a yellow, green, or brown c
olor, depending on the causative organism."
"The nurse is caring for a patient after major abdominal surgery. Which of the f
ollowing demonstrates correct understanding of wound dehiscence?
A. The nurse should
e wound.
B. Wound dehiscence
r surgery.
C. The nurse should
D. The condition is
be alert for an increase in serosanguineous drainage from th

is most likely to occur during the first 24 to 48 hours afte
administer cough suppressant to prevent wound dehiscence.
an emergency that requires surgical repair.

"Answer: A.
An increase in drainage is a symptom of a potential dehiscence. Wound dehiscence
most commonly occurs before collagen formation (3 to 11 days after injury). To
prevent dehiscence, place a folded thin blanket or pillow over an abdominal woun
d when the patient is coughing. This provides a splint to the area, supporting t
he healing tissue when coughing increases the intra-abdominal pressure. Eviscera
tion is an emergency that requires surgical repair. Dehiscence does not necessar
ily indicate surgery is necessary."
"The nurse reports a patient has a wound on his abdomen that is healing by secon
dary intention. The nurse understands this means the patient:
A.
B.
C.
D.
has a drain.
is at greater risk for infection.
is at greater risk for wound dehiscence.
is healing naturally.

"Answer: B.
Healing by secondary intention indicates the patient has a wound where there is
tissue loss and the wound edges are not well-approximated. There is greater oppo
rtunity for development of infection without the protective epidermal barrier an
d longer healing time."
"A postoperative diabetic patient had an exploratory laparotomy (incision in the
abdomen) 5 days ago. The patient's history indicates obesity with a BMI of 32 a
nd smoking 1 pack/day. Based on this information, the nurse understands the pati
ent should be observed for:
A. Developing a blood clot.
B. Developing a fistula.
C. Wound dehiscence.
D. Hemorrhage.
"Answer: C.
This patient is at risk for poor wound healing due to the chronic illness of dia
betes, being obese (BMI >30), and smoking. Fatty tissue has a poor blood supply
for healing and smoking increases the patient's likelihood of coughing. The nurs
e should observe for an increase in serosanguineous drainage, an indication of p
otential dehiscence. The nurse should teach the patient to splint the abdomen wi
th a pillow when coughing as a sudden strain on the incision could lead to dehis
cence."
"Match the description to the correct term: Thick, yellow, green, tan, or brown.
A.
B.
C.
D.
Purulent
Serous
Serosanguineous
Sanguineous

Answer: A.
"Match the description to the correct term: Clear, watery plasma.
A.
B.
C.
D.
Purulent
Serous
Serosanguineous
Sanguineous

Answer: B.
"Match the description to the correct term: Bright red: indicates active bleedin
g.
A.
B.
C.
D.
Purulent
Serous
Serosanguineous
Sanguineous

Answer: D.
"Match the description to the correct term: Pale, red, watery.
A.
B.
C.
D.
Purulent
Serous
Serosanguineous
Sanguineous

Answer: C.
"The patient asks the nurse what the purpose is for his Hemovac drain. The nurse
's best response is:
A. ""To reduce the need for frequent dressing changes""
B. ""To provide constant suction to remove and collect drainage from your wound
to help it heal""
C. ""To have a more accurate method of determining fluid loss and whether your f
luids need to be increased""
D. ""To prevent infection and crust formation at the wound site""
"Answer: B.
The correct response would be ""To provide constant suction to remove and collec
t drainage from your wound to help it heal."" Although a Hemovac drain will coll
ect drainage, the Hemovac drain is used to provide constant low-pressure suction
to remove and collect drainage from the wound bed to allow the tissues to come
together to heal. Measuring the amount of drainage is used to determine when the
drain may be removed."
"A patient is to go home with a Jackson-Pratt drain. Which of the following stat
ements, if made by the patient, indicates further teaching is required?
A.
B.
C.
D.
""I should empty the drain when it is one-half to two-thirds full.""

""I should keep a record of how much drainage I empty.""
""If drainage suddenly stops, it means the drain is ready to be removed.""
""The bulb of the drain should remain compressed.""

"Answer: C.
If drainage suddenly stops, the drainage tubing may have a blockage. Notify the
health care provider. The drain reservoir should be emptied every 8 hours or les
s if the reservoir becomes one-half to two-thirds full. The patient should keep
a record of the drain's output in 24 hours to aid in determining whether the amo
unt is decreasing as expected and when the drain may be removed. The reservoir s
hould remain compressed to provide a constant low suction."
"When should wound drainage be cultured?
A.
B.
C.
D.
When there is a change in color, amount, or odor of drainage

If the patient complains of pain
When the drain is removed
If the nurse empties the drainage evacuator without applying sterile gloves

"Answer: A.
Wound drainage should be cultured when infection is suspected, as indicated by t
he drainage appearing to be purulent, a change in the amount or color of the wou
nd drainage, or when a foul odor of the drainage is noted. It is appropriate for
the nurse to wear clean gloves to empty the drainage evacuator."
"The nurse is teaching a patient how to empty his Hemovac drain. Which action of
the patient indicates that further instruction is needed? The patient:
A. opens the plug on the port for emptying the drainage reservoir and drains the
contents into the measuring container.
B. presses downward until the bottom and top of the Hemovac are in contact to re
establish the vacuum.
C. holds the surfaces of the Hemovac together with one hand, cleans the opening
and plug with an alcohol swab with the other hand, and immediately replaces the
plug.
D. empties the Hemovac drain, replaces the plug, and records the amount of drain
age.
"Answer: D.
The patient must reestablish the vacuum for the Hemovac to be effective. To re-e
stablish the vacuum, the patient needs to press the bottom and the top of the He
movac together."
"Because a patient has a Penrose drain, the nurse inspects the patient's skin an
d changes the dressing by placing a drainage sponge around the drain. What is th
e rationale for doing this?
A. Because drainage can be irritating to the skin and may cause skin breakdown
B. Because a Penrose drain has to be frequently compressed to create a constant
low-pressure suction
C. To prevent the tubing from migrating into the wound
D. To advance the tube as the wound heals
"Answer: A.
A Penrose drain does not have a collection device. Therefore, the nurse should i
nspect the skin and change the dressings as needed to prevent skin breakdown. A
Penrose drain does not have a reservoir to compress. A safety pin is inserted th
rough a Penrose drain to prevent the tubing from migrating into the wound. Altho
ugh a Penrose drain may be advanced as the wound heals, this is not the rational
e for the nurse's inspection and changing of the drainage sponges."

"Which of the following is inappropriate to delegate to nursing assistive person
nel (NAP)?
A.
B.
C.
D.
Emptying a closed drainage container

Measuring the amount of drainage
Assessment of wound drainage
Reporting the amount on the patient's intake and output record

"Answer: C.
Assessment of wound drainage and maintenance of drains and the drainage system r
equire the critical thinking and knowledge application unique to a nurse and the
refore are inappropriate to delegate to NAP.
***NAPs CANNOT ASSESS***"
"The patient complains ""It feels like the drain is pulling on my surgical site.
"" What is the nurse's best action?
A. Secure the drain above the incision to the dressing with tape and a safety pi
n and instruct the patient to keep the drain above the insertion site when ambul
ating, sitting, and lying.
B. Make sure there is slack in the tubing from the reservoir to the wound, allow
ing the patient movement and avoiding pulling at the insertion site.
C. Instruct the patient that this is the normal sensation of having a drain and
inquire if the patient would like pain medication.
D. Have the patient lie down and advance the drain further into the patient unti
l the sensation is relieved and drainage is noted in tubing; secure a new dressi
ng over insertion site of drain.
"Answer: B.
To avoid pulling at the insertion site, the nurse should be sure there is slack
in the tubing from the reservoir to the wound, allowing the patient movement. To
facilitate drainage, the nurse should secure the drain below the incision to th
e dressing with tape and a safety pin and instruct the patient to keep the drain
below the insertion site when ambulating, sitting, and lying. An order would be
required to administer pain medication. The nurse should not advance the tube i
nto the patient as this would introduce microorganisms."
"Which of the following are functions of dressings? (Select all that apply.)
A.
B.
C.
D.
E.
To promote hemostasis
To keep the wound bed dry
Wound debridement
To prevent contamination
To increase circulation

"Answers: A, C,
D.
Dressings provide several functions, which include debridement, maintaining a mo
ist wound environment, protecting from outside contamination and further injury,
preventing the spread of microorganisms, increased patient comfort, and promoti
ng hemostasis by control of bleeding. Dressings are unable to increase circulati
on."
"Which of the following patients would be expected to benefit from a moist-to-dr
y dressing? (Select all that apply.)
A. A 24-year-old patient with an open
B. A 7-year-old with abrasions on the
C. A 50-year-old with a postoperative
D. A 30-year-old who had a large cyst
resent in the crater-type wound
and infected wound from a spider bite

knees
knee-replacement incision
removed and now has some necrotic tissue p

"Answers: A, D.
Moist-to-dry dressings are best used with necrotic, infected wounds requiring de
bridement. Moist dressings are often used for helping to heal full-thickness wou
nds that look like craters. Dry woven gauze dressings are most often used for ab
rasions and postoperative incisions when minimal drainage is anticipated."
"The nurse is observing the patient's wife perform the moist-to-dry dressing cha
nge. Which actions, if made by the patient's wife, indicate that further instruc
tion is needed? (Select all that apply.)
A. Premedicates for pain
B. Packs wound tightly
C. Leaves contact or primary dressing dripping moist
D. When removing the old dressing the wife leaves the dressing dry, even when it
sticks slightly.
"Answers: B, C.
Inner gauze should be moist to absorb drainage and adhere to debris. The wound s
hould be loosely packed to facilitate wicking of drainage into the absorbent out
er layer of the dressing. The wound should never be over packed because this can
cause wound trauma when the dressing is removed. Premedicating for pain will he
lp provide comfort during the dressing change. If dressing sticks on a moist-todry dressing, the wife should gently free the dressing and alert the patient of
discomfort. The wife was correct in not wetting the dressing as a moist-to-dry d
ressing should debride the wound."
"A patient with a wound vacuum-assisted closure (wound V.A.C.) continues to comp
lain of pain. What measures may be taken? (Select all that apply.)
A.
B.
C.
D.
E.
Switch to the white polyvinyl alcohol (PVA) soft foam.

Decrease the pressure setting.
Administer pain medication.
Switch to the black polyurethane (PU) foam.
Keep the suction in the ""off"" position.

"Answers: A, B,
C.
Patients may experience more pain with the black foam because of excessive wound
contraction. For this reason, they may need to be switched to the PVA soft foam
. Administering pain medication can help alleviate pain, and decreasing the pres
sure setting may also help reduce pain."
"During a sterile dressing change, when are the gloves changed?
A. After the old dressing is removed and before creating a sterile field
B. After the old dressing is removed and before cleansing the wound
C. After the old dressing is removed, after cleansing the wound, and before appl
ying a new dressing
D. It is unnecessary to change gloves for chronic wounds.
"Answer: B.
Gloves are discarded after removing the old dressing. If required, a sterile fie
ld is then prepared, new sterile gloves are applied, and the wound is cleansed.
It is unnecessary to change the gloves frequently unless they are accidentally c
ontaminated. Gloves are changed after removing the old dressing and before clean
ing the wound to reduce transmission of cross-contamination microorganisms. The
same gloves may then be worn for applying a new dressing. Clean gloves may be wo
rn rather than sterile gloves with chronic wounds (check facility policy)."
"A patient states that she is unable to get her transparent dressing to stay in
place. What instruction should the nurse provide the patient?
A. ""If you are having difficulty with your dressing changes, we can see if the
doctor will give you a referral to a home care facility.""

B. ""Make sure that you have a margin of 1 to 1.5 inches (2.5 to 3.75 cm) around
the wound, and that the skin is thoroughly dry before applying the dressing.""
C. ""This type of dressing requires frequent changing because they do not stay i
n place.""
D. ""You probably are applying it incorrectly, or perhaps you are just too anxio
us about having to perform the dressing change.""
E. ""There are many options on the market. Why don't you try to use a non-adhesi
ve-backed transparent dressing instead?""
"Answer: B.
If the transparent dressing does not stay in place, the size of the dressing sho
uld be evaluated for adequate (1 to 1.5 inches or 2.5 to 3.75 cm) margin, and th
e skin should be dried thoroughly before reapplication. The patient requires fur
ther instruction, not necessarily a referral, regarding interventions to aid in
dressing adherence. The dressing coming off is an unexpected outcome. Blaming th
e patient is non-therapeutic."
"A patient asks the nurse why the Montgomery ties are being used instead of regu
lar tape. The nurse's best response is:
A. ""Because Montgomery ties are nonallergenic.""
B. ""Montgomery ties can be tied tighter, providing a more secure dressing and g
reater support of the wound.""
C. ""It allows the wound to breathe.""
D. ""Montgomery ties avoid frequent removal of tape, which is irritating to the
skin during dressing changes.""
"Answer: D.
Frequent removal of tape for dressing changes is irritating to the skin. Montgom
ery straps are wide tapes with holes to use with ties that secure dressings and
facilitate changes without removing the tape each time. Some patients are allerg
ic to adhesive. These patients often benefit from paper or nonallergenic tape. T
ransparent dressings allow the wound to ""breathe."""
"How can the nurse determine that negative pressure is being achieved with a wou
nd V.A.C.?
A. The nurse can inquire about the patient's pain level. If there is a reported
decrease in the level of pain, then the wound is constricting and negative press
ure is being achieved.
B. The nurse can ensure that there is no whistling noise at the wound site and t
hat the wound V.A.C. has not triggered its alarm.
C. The nurse can check for air leaks by listening with a stethoscope or by movin
g the hand around the edges of the wound while applying light pressure.
D. The nurse can ensure that the foam is in contact with the entire wound base,
margins, and tunneled and undermined areas.
"Answer: C.
The nurse should inspect the wound V.A.C. system to verify that negative pressur
e is being achieved: verify that the display screen reads THERAPY ON; be sure th
e clamps are open and tubing is patent; identify air leaks by listening with a s
tethoscope or by moving hand around edges of the wound while applying light pres
sure; and if a leak is present, use strips of transparent film to patch areas ar
ound the edges of the wound. Negative pressure is achieved when an airtight seal
is achieved. The wound V.A.C. will sound an alarm if the canister is improperly
engaged or if the unit is tilted beyond 45 degrees."
"Which of the following is a correct sequence for changing a gauze dressing?
A. Remove old dressing, discard gloves and perform hand hygiene, create sterile
field, apply sterile gloves, clean wound, blot dry, apply new dressing.
B. Remove old dressing, discard gloves, apply new gloves, and apply new dressing
.
C. Remove old dressing, discard gloves, clean wound, apply loose woven gauze, an
d cover with thicker woven pad (e.g., ABD pad).
D. Create sterile field, remove old dressing, discard gloves and perform hand hy
giene, apply new gloves, clean wound, blot dry, apply new dressing.
"Answer: A.
The nurse should remove the old dressing, inspect the wound, dispose of gloves a
nd soiled dressings, and perform hand hygiene. The nurse then creates a sterile
field and applies new sterile gloves and cleans the wound from least contaminate
d (the surgical incision) to the most contaminated (the drain). The nurse dries
the area in the same manner and puts on the new dressing."
"A patient has a 4-day-old postoperative incision. Which would be a normal findi
ng when changing the dressing?
A.
B.
C.
D.
Small amount of
Moderate amount
Small amount of
Small amount of
serous drainage
of sanguineous drainage
serosanguineous drainage
purulent drainage

"Answer: A.
A small amount of serous drainage is normal postoperatively. A moderate amount o
f sanguineous drainage would indicate bleeding. Purulent drainage would indicate
infection."
"Which of the following are common sites for the development of pressure ulcers?
(Select all that apply.)
A.
B.
C.
D.
E.
F.
Sternum
Heels
Sacrum
Lateral malleoli
Trochanters
Ischial tuberosities

"Answers: B, C,
D, E, F.
Common sites for the development of pressure ulcers include the sacrum, heels, e
lbows, lateral malleoli, trochanters, and ischial tuberosities. (Helpful, I know
.)"
"Identify contributing factors to pressure ulcer formation. (Select all that app
ly.)
A.
B.
C.
D.
E.
F.
Malnutrition
Middle age
Decreased sensory perception/mobility
Anemia
Excessive sweating
Ethnic background

"Answers: A, C,
D, E.
Three pressure-related forces contribute to the development of a pressure ulcer:
intensity of pressure (how much pressure is applied), duration of pressure (how
long the pressure is applied), and tissue tolerance (the ability of the tissue
to redistribute the weight). Having decreased mobility or decreased ability to p
erceive the need to shift one's weight or change position places an individual a
t risk for pressure ulcer development. Three extrinsic factors, shear, friction,
and moisture, make the tissues less tolerant of pressure. Other factors importa
nt in pressure ulcer development include poor nutrition, advanced age, medical c

onditions that support poor tissue perfusion (low blood pressure, smoking, eleva
ted temperature, anemia), and psychosocial status, in particular stress-induced
cortisol secretion."
"Identify prevention strategies for pressure ulcers. (Select all that apply.)
A. Use a moisture barrier ointment, applied after each incontinent episode.
B. Reposition patient at least every 4 hours; use a written schedule.
C. When the patient is in the side-lying position in bed, use the 30-degree late
ral position.
D. Place patient on a pressure-reducing support surface.
E. Maintain the head of the bed at 45 degrees.
F. Massage reddened bony prominences.
G. Oral supplements should be instituted if the patient is found to be undernour
ished.
"Answers: A, C,
D, G.
Patients should be repositioned every 2 hours to reduce the duration and intensi
ty of pressure. The 30-degree lateral position avoids direct contact of the troc
hanter with the support surface. Placing the patient on a pressure-reducing supp
ort surface reduces the amount of pressure exerted against the tissues. The head
of the bed should be maintained at 30 degrees. If the head is elevated more tha
n this, it can increase the potential of the patient to slide toward the foot of
the bed and incur a shear injury. Massaging reddened areas increases breaks in
the capillaries in the underlying tissues and increases the risk of injury to un
derlying tissue, and therefore it should be avoided. A moisture barrier ointment
protects reddened intact skin from incontinence. There is a strong relationship
between poor nutrition and pressure ulcer development. Supplements may provide
lacking nutrients."
"The nurse is observing the patient's wife perform treatment of her husband's pr
essure ulcer. Which action, if made by the patient's wife, indicates that furthe
r instruction is needed?
A. She premedicates the patient for pain before beginning the dressing change.
B. She performs hand hygiene and removes the old dressing and begins to clean th
e ulcer with soap and water.
C. While wearing gloves, she rinses the ulcer with normal saline, gently wiping
around the wound base and surrounding skin with moistened gauze.
D. She applies solution to the gauze and wrings out any excess. She unfolds the
gauze and packs the wound with the moistened dressing. She covers the gently pac
ked wound with dry 4 x 4 gauze pads and applies tape to secure the dressing. She
removes her gloves and performs hand hygiene.
"Answer: B.
To avoid transfer of microorganisms, the caretaker should apply nonsterile glove
s to remove the old dressing and discard the gloves and old dressing materials i
n a plastic bag. She should perform hand hygiene and apply new gloves before beg
inning to cleanse the wound. She should use the ordered solution, most generally
normal saline, because soap can be very drying to tissues and may leave a resid
ue."
"A family member calls the nurse to ask for advice regarding their mother who ha
s developed a ""bedsore"" on her right heel. The family member describes the pre
ssure ulcer as ""a blister that has now popped and you can see redness."" Based
on this description, at what stage would the nurse classify this pressure ulcer?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
"Answer: B.
A stage II pressure ulcer can be described as an abrasion, a blister, or shallow
crater with skin loss involving the epidermis and/or dermis. A stage I pressure
ulcer appears as an area of color change (e.g., persistent redness) on intact s
kin. A stage III pressure ulcer presents clinically as a deep crater. A stage IV
pressure ulcer involves bone, muscle, or supporting structures."
"Which of the following is an example of healing by secondary intention? (Select
all that apply.)
A.
B.
C.
D.
A
A
A
A
full-thickness pressure ulcer

surgical incision
dog bite
burn

"Answers: A, C,
D.
Healing by secondary intention often accompanies traumatic open wounds with tiss
ue loss or wounds with a high microorganism count. Examples of wounds that heal
by secondary intention are pressure ulcers, a dog bite, a severe laceration, or
a burn. Healing by primary intention is expected when the edges of a clean surgi
cal incision are sutured or stapled together, tissue loss is minimal or absent,
and the wound is uncontaminated by microorganisms. Examples of healing by primar
y intention are a surgical incision, an abrasion, or a skin tear."
"It is suspected that a patient is developing a wound infection. Which assessmen
t data would support this conclusion? (Select all that apply.)
A.
B.
C.
D.
E.
F.
Yellow-tinged drainage
Temperature 100.3F (37.94C)
Increased complaints of pain at wound site
White blood cell count 13,000 mm3 (elevated)
Wound edges of pink to normal skin color
Foul odor noted from previous dressing

"Answers: A, B,
C, D, F.
The patient has a fever, tenderness, and pain at the wound site and an elevated
white blood cell count (normal 5,000 to 10,000 per mm3). Wound edges that appear
red and inflamed indicate infection. If drainage is present, it is odorous and
purulent, which causes a yellow, green, or brown color, depending on the causati
ve organism."
"Which of the following lab results or measurements indicate a risk for impaired
wound healing? (Select all that apply.)
A.
B.
C.
D.
E.
A BMI (body mass index) of 35 (elevated)

Fasting blood glucose of 215 mg/dl (elevated)
A serum albumin of 2.9 g/dl (decreased)
A hemoglobin of 10.0 g per dL (decreased)
A white blood cell count of 7000 per mm3 (normal)

"Answers: A, B,
C, D.
A BMI over 30 indicates obesity, which is a factor that may impair wound healing
because fatty tissue has a poor blood supply. Elevated blood glucose indicates
diabetes, which is a chronic disease that leads to poor tissue perfusion. A seru
m albumin below 3.5 indicates malnutrition. Adequate nutrition plays a significa
nt role in wound healing. Hemoglobin below 12 g per dL indicates anemia and a de
creased oxygen-carrying capacity necessary for tissue growth. The normal white b
lood cell count is 5,000 to 10,000 mm3. If the white blood cell count were eleva
ted, this would indicate infection, which also is a factor that impairs wound he
aling."
"Identify the functions of dressings. (Select all that apply.)
A.
B.
C.
D.
E.
F.
Maintaining a moist environment

Preventing shear
Control of bleeding and drainage
Removing surface bacteria
Protection from outside contaminants and further tissue injury
Increased patient comfort

"Answers: A, C,
E, F.
Dressings serve several functions, including maintaining a moist environment con
ducive to wound healing; protecting the wound from outside contaminants, further
tissue injury, and transfer of microorganisms; maintaining hemostasis by contro
lling bleeding with pressure dressings; managing drainage to prevent excoriation
of skin; and increased patient comfort. Cleaning the wound removes surface bact
eria."
"Which of the following regarding removal of the old dressing on a surgical inci
sion are accurate? (Select all that apply.)
A. Tape should be pulled parallel to the skin in a direction away from the incis
ion.
B. If dressing is over a hairy area, remove tape in the direction of hair growth
.
C. While wearing clean gloves, remove the dressing layers all at one time and di
scard.
D. Use caution to avoid tension on any drains that are present.
"Answers: B, D.
Tape should be pulled parallel to the skin, in a direction toward the dressing t
o avoid pulling on the suture line. If the dressing is over a hairy area, remove
in the direction of hair growth. With clean gloves, remove dressings one layer
at a time, observing appearance and drainage. Use caution to avoid tension on an
y drains that are present."
"Which of the following is a method of wound debridement?
A.
B.
C.
D.
Gauze dressing
Transparent dressing
Moist-to-dry dressing
Hemovac drain

"Answer: C.
Necrotic tissue may be loosened and possibly removed by the use of moist-to-dry
dressings. Transparent dressings are used for partial-thickness wounds with mini
mal wound exudate. Dry gauze dressings are used for wounds that will heal by pri
mary intention with little drainage such as a closed surgical incision. A Hemova
c drain is used to collect drainage, but not for wound debridement."
"The nurse is teaching the NAP in a nursing home about daily routine measures to
reduce the incidence of pressure ulcers within the facility. Which of the follo
wing should the nurse include in the teaching? (Select all that apply.)
A.
B.
C.
D.
E.
F.
Turning patients at least every 2 hours

Rubbing reddened bony prominences
Use of pillow bridging when needed
Positioning the patient in the 30-degree lateral position
Using a turn sheet to reposition patients
Decreasing patients' fluid intake to decrease the incidence of incontinence

"Answers: A, C,
D, E.
There are several strategies to prevent the development of pressure ulcers. Pati
ents should be repositioned at least every 2 hours to reduce the duration and in
tensity of pressure. The use of pillow bridging will prevent direct contact betw
een bony prominences. Using a turning sheet to reposition patients prevents drag
ging along the sheets (friction). Maintaining the head of the bed at 30 degrees
decreases the potential for the patient to slide toward the foot of the bed and
incur a shear injury. The 30-degree lateral position should prevent positioning
directly over the bony prominence. Avoid massaging reddened bony prominences bec
ause this may cause skin breakdown. Incontinence should be managed by methods ot
her than withholding fluids. Dehydration can also negatively affect tissue integ
rity."
"How is the vacuum re-established after emptying a drain such as a Jackson-Pratt
drain or Hemovac?
A.
B.
C.
D.
By
By
By
By
turning the
keeping the
compressing
""milking""
suction on
drain lower than the insertion site
the drain reservoir
the tubing

"Answer: C.
Compressing the surface of the Hemovac drain or the bulb of the Jackson-Pratt dr
ain and quickly reinserting the cap re-establishes the vacuum. Suction is never
used with a Jackson-Pratt drain."
"A nurse is explaining how to perform a dressing change. Which of the following
sequences for changing a surgical wound dressing (wound drain present) indicates
that the nurse requires further education regarding this procedure?
A. Dispose of gloves and soiled dressings in waterproof bag. Perform hand hygien
e. Create a sterile field with individually wrapped sterile supplies on the over
-bed table. Pour necessary prescribed solution into sterile basin. Apply sterile
gloves.
B. Cleanse wound. Use a separate swab for each cleansing stroke. Clean incision
from top to bottom. Cleanse around drain by using a circular stroke starting nea
r the drain and moving outward.
C. Cleanse wound. Use a separate swab for each cleansing stroke. Cleanse around
drain by using a circular stroke starting near the drain and moving outward. Cle
an incision in direction of bottom to top.
D. Use sterile dry gauze to blot dry. Apply prescribed antiseptic ointment by us
ing the same technique as for cleansing. Apply loose, woven gauze as contact lay
er. Place drain sponge (precut gauze) around drain. Apply additional layers of g
auze as needed. Apply thicker woven pad (e.g., ABD or Surgipad).
"Answer: C.
The nurse should clean from the least-contaminated area to the most-contaminated
because this avoids introducing microorganisms from surrounding skin into the i
ncision. The nurse should clean the incision first in a direction of top to bott
om and then clean the drain site."

"A patient is to have frequent dressing changes. What should the nurse use to se
cure the dressing?
A.
B.
C.
D.
Hypoallergenic tape
Paper tape
Adhesive tape
Montgomery ties

"Answer: D.
Frequent removal of tape for dressing changes is irritating to the skin. These d
ressings should be secured with Montgomery ties . Montgomery ties are wide tapes
with holes to use with ties that secure dressings and facilitate changes withou
t removing the tape each time."
"Why does a wound bed need to stay moist?
A.
B.
C.
D.
To
To
To
To
support healing by enabling granulation tissue to grow

prevent excessive fluid loss from the body
determine if the area has reactive hyperemia
decrease patient discomfort

"Answer: A.
Granulation tissue is the healthy, red, fleshy projection of moist tissue that i
ndicates healing. If the wound bed were dry, this process would be impaired. Ope
n wounds frequently have fluid loss as drainage. Replacing this loss is relevant
to the patient's overall hydration."
"A nurse is applying a wound V.A.C. dressing independently for the first time. W
hat action, if made by the nurse, indicates that further instruction is needed i
n performing this procedure?
A. The nurse turns the V.A.C. unit off, applies clean gloves, disconnects the tu
bes to drain fluids into the canister, and tightens the clamp on the canister tu
be.
B. With dressing tube unclamped, the nurse instills 10 to 30 mL of normal saline
into the tubing to soak the foam underneath. The nurse gently pulls the transpa
rent film horizontally and removes the old V.A.C. dressing, noting drainage. The
nurse discards the dressing, removes gloves, and performs hand hygiene.
C. The nurse applies new gloves, irrigates the wound with normal saline, and the
n gently blots it dry. The nurse measures the wound, removes and discards gloves
, and applies a new pair of gloves. The nurse cuts the foam approximately one-ha
lf inch smaller than the size of the wound and gently places the foam in the wou
nd, avoiding any tunneled and undermined areas.
D. The nurse applies the tubing to the foam in the wound, applies a skin protect
ant to skin around the wound, and applies the transparent dressing, covering 3 t
o 5 cm (1.2 to 2 inches) of surrounding healthy tissue. The nurse secures the tu
bing to the transparent dressing and connects the tubing from the dressing to th
e tubing from the canister and V.A.C. unit. The nurse makes sure the tubing clam
ps are open, turns the wound V.A.C. unit on, and sets the pressure at 125 mm Hg.

"Answer: C.
The nurse should use sterile scissors to cut the foam to fit the size and shape
of the wound, including tunnels and undermined areas. The nurse should place the
foam in the wound, being sure that the foam is in contact with the entire wound
base and margins and tunneled and undermined areas. This maintains negative pre
ssure to the entire wound. The edges of the foam dressing must be in direct cont
act with the patient's skin."
"The nurse may use clean gloves for changing the dressing on which of the follow
ing?
A. Chronic pressure ulcer
B. Surgical wound
C. Sterile gloves should always be used for dressing changes performed by nurses
.
D. Sterile gloves should always be used for dressing changes performed in the ho
spital setting.
"Answer: A.
Clean gloves and clean technique are acceptable only for the care of chronic wou
nds. Sterile technique or a no-touch technique with sterile forceps may be used
when changing the dressing of a new surgical wound. Sterile gloves or nonsterile
gloves may be worn with chronic wounds. Research has noted an absence of differ
ence in wound infection rates when using sterile gloves or clean gloves, and the
re is a lowered cost for dressing supplies. Gloves should be changed, however, t
o avoid cross-contamination of microorganisms. The type of wound should determin
e whether clean or sterile technique is used, not who performs the dressing chan
ge or the setting."
"The nurse is reading electronic documentation from the emergency room on a pati
ent who is to be admitted to the unit. The documentation states the patient has
a hematoma on the right knee. The nurse knows to expect to see:
A. A shallow wound with loss of the epidermis and partial loss of the dermis.
B. A localized collection of blood underneath the tissues that often takes on a
bluish discoloration.
C. A deep wound extending into the dermis.
D. An area of skin that has been scraped away.
"Answer: B.
A hematoma is a localized collection of blood underneath the tissues that often
takes on a bluish discoloration. A shallow wound with loss of the epidermis and
partial loss of the dermis is a partial thickness wound. A deep wound extending
into the dermis is a full-thickness wound.
An area of skin that has been scraped is an abrasion."
"When is a surgical wound at greatest risk for hemorrhage?
A.
B.
C.
D.
During the first 24 to 48 hours after surgery.

Two to three days after surgery.
Four to five days after surgery.
Five to seven days after surgery.

"Answer: A.
The greatest risk of hemorrhage is during the first 24 to 48 hours after surgery
or injury, indicating inadequate hemostasis. The nurse should monitor for decre
ased blood pressure and increased pulse rate and observe dressing and underneath
the patient for any bloody drainage."
"The nurse inspects all wounds for signs of infection. A contaminated or traumat
ic wound may show signs of infection:
A.
B.
C.
D.
during the first 24 to 48 hours after injury.

two to three days after injury.
Up to five days after injury.
five to seven days after injury.

"Answer: B.
A contaminated or traumatic wound may show signs of infection early, within 2 to
3 days. A surgical wound infection usually develops postoperatively within 4 to
5 days."
"A patient with lung cancer received radiation therapy to reduce the size of the
tumor prior to a lobectomy (surgical removal of part of the lung). The patient
is now being seen on home health services for packing of an abnormal passage bet
ween the patient's chest cavity and an opening on the patient's back. The nurse
is aware the patient is at increased risk for:
A.
B.
C.
D.
edema
hemorrhage
nerve damage with decreased sensation
fluid and electrolyte imbalance

"Answer: D.
The patient has a fistula, an abnormal passage between two organs or between an
organ and the outside of the body. Most fistulas form as a result of poor wound
healing or as a complication of disease, such as in this case cancer and radiati
on exposure in this case. The patient is at an increased risk for fluid and elec
trolyte imbalances from fluid loss through the fistula. Chronic drainage of flui
ds through a fistula can also predispose a person to skin breakdown."
"The nurse is instructing a patient on how to change a transparent dressing. Whi
ch statement, if made by the nurse, requires correction?
A. ""The old dressing may be removed while wearing clean gloves. Remove in direc
tion of hair growth and toward the center. Remove disposable gloves pulling them
inside out over the soiled dressing and dispose of properly.""
B. ""You will need to apply new gloves after you open your supplies and before y
ou clean the wound. Make sure the area around the wound is dry before applying a
new transparent dressing.""
C. ""You will want to remove your gloves to prevent the transparent dressing fro
m sticking to them. Remove the paper backing of the transparent dressing and fir
mly stretch it over the wound to prevent wrinkling.""
D. ""When the dressing change is completed, be sure to wash your hands. A transp
arent dressing is beneficial because it maintains a moist environment aiding wou
nd healing, allows you to examine the wound without having to remove the dressin
g, and conforms well to body contours.""
"Answer: C.
Gloves are not discarded until the new dressing has been applied. The transparen
t film should be placed smoothly over the wound without stretching because wrink
les can provide a tunnel for drainage."
"The nurse is performing a dressing change on a patient who is postoperative fro
m a laparotomy. The patient coughs and the nurse sees a few loops of intestine u
ncoiling from the wound. What is the nurse's best action at this time?
A.
B.
C.
D.
Apply sterile gloves and push the intestines back into the wound.
Instruct the patient to avoid looking at the wound.
Apply sterile saline-soaked towels to the area.
Assess the wound to determine the extent of evisceration.

"Answer: C.
When evisceration occurs, the nurse places sterile towels soaked in sterile sali
ne over the extruding tissues. The patient should be allowed nothing by mouth (N
PO), observed for signs and symptoms of shock, and prepared for emergency surger
y."
"Which of the following may indicate an increased risk for wound dehiscence?
A.
B.
C.
D.
It is within the first 24 to 48 hours after surgery.

The patient holds a pillow over the abdomen whenever coughing.
There is a small amount of serous drainage noted on the dressing.
There is an increase in serosanguineous drainage from the wound.

"Answer: D.
When there is an increase in serosanguineous drainage from a wound, the nurse sh
ould be alert for the potential for dehiscence. Dehiscence most commonly occurs
before collagen formation (3 to 11 days after injury or surgery). Risk for hemor
rhage is greatest during the first 24 to 48 hours following surgery. Placing a p
illow or folded thin blanket over the abdomen provides a splint to the area, sup
porting the healing tissue when coughing increases the intra-abdominal pressure.
This is done to prevent wound dehiscence."
"Which of the following patients is at greatest risk for developing a wound infe
ction?
A.
B.
C.
D.
A diabetic obese patient who smokes.

An adolescent who takes steroids for asthma.
An alcoholic.
An elderly patient.

"Answer: A.
The diabetic patient has the most risk factors for developing a wound infection.
Other risk factors include: having a chronic disease, being obese, and smoking.
Although taking steroids is one risk factor, this patient has fewer risk factor
s than the patient who has a chronic disease, is obese, and smokes. The same is
true of the other patients."
"The nurse is caring for a patient with a Jackson-Pratt drain. Which of the foll
owing indicates correct understanding? (Select all that apply.)
A. The nurse instructs the NAP to empty the drain every 8-12 hours or when it is
2/3 full and document the amount as output on the intake and output record.
B. The nurse expects the Jackson-Pratt drain to be used when there is a large am
ount of drainage (500 mL).
C. The nurse ensures the drainage device appears deflated after it is emptied.
D. The nurse pins the Jackson-Pratt drain above the wound.
E. The nurse instructs the NAP to determine and report what type of drainage is
present in the JP drain.
"Answers: A, C.
The drainage device should be emptied every 8-12 hours or sooner if one-half to
two-thirds full. To function properly the drainage device should be compressed.
Determining the type of drainage present is the responsibility of the nurse."
"The nurse is completing an admission assessment of a new patient to the unit. T
he nurse notes a long, thin, fading scar on the patient's abdomen in the right l
ower quadrant. The nurse knows that scar tissue results from
A.
B.
C.
D.
Optimal functioning of the inflammatory process after an injury.

Fibrous tissue replacing damaged tissue when injury is extensive.
The development of chronic inflammation.
A surgical incision.
(Giddens: Concepts for Nursing Practice, 1st Edition, Chapter 21)"

B.
"Answer:
Scar tissue, or fibrous repair of damaged tissue, occurs when an area is damaged
too extensively for the body to replace damaged tissue with identically functio
ning tissue after removal of injurious agents and pathogens. Optimal functioning
of the inflammatory process will result in regeneration of tissue that function
s identically to the damaged and replaced tissue. Chronic inflammation can resul
t in fibrous, or scar, tissue, but that scar tissue production is continuous as
the inflammation continues. Fibrous tissue production can result from many diffe
rent kinds of injuries, not just surgical wounds."
"Which of the following patients is at higher risk for inflammatory reactions?
A.
B.
C.
D.
2-year-old girl with a healthy diet.

38-year-old man who is obese.
54-year-old woman in menopause.
79-year-old man with diabetes.

"Answer:
D.
The 79-year-old man is at highest risk for inflammatory reactions among these pa
tients for two reasons, his age and having diabetes. The risk would be high duri
ng the first year of life, but this 2-year-old girl has gotten beyond this risk
period and she also has the positive factor of a healthy diet. The 38-year-old m
an is not in a high-risk category because of age but is because of obesity. Alth
ough a 54-year-old woman is getting older, being in menopause does not increase
the risk for inflammatory reactions."
"A patient admitted to an acute care floor has rubor of an area of injury on the
left lower extremity. The nurse understands that this redness is caused by
A.
B.
C.
D.
Vasodilation.
Extravasation.
Neutrophils.
Exudate.

"Answer:
A.
The inflammatory process results in rubor, or redness, of an area of insult. The
body responds to injury by increasing the blood flow to an area through vasodil
ation. This allows increased oxygen and more nutrients and appropriate white blo
od cells to reach the area, isolating the area and beginning the immune response
. Extravasation is the movement of fluid from its confined space into the surrou
nding tissue. Neutrophils are one of the most common types of white blood cells.
Exudate is the fluid filled with proteins and white blood cells that moves out
of the vascular spaces through extravasation."
"A patient comes to a clinic with a chief complaint of, ""My left arm is red and
swollen. It hurts badly enough that I couldn't go to work today."" The physicia
n orders computer-assisted tomography (CT) scanning of the left upper extremity.
The nurse knows the patient understands the reason for the procedure when he st
ates
A. ""I need to have this done because my arm is broken.""
B. ""The doctor wants me to have this so that the pain will stop.""
C. ""This will tell you what I did to my elbow because I really don't know what
happened.""
D. ""This test will help to better determine where the injury actually is and ho
w severe it is.""
"Answer:
D.
Radiographic imaging studies such as CT scans help to determine the location and
extent of inflammation within the body. The CT scan will help with diagnosis. T
he diagnosis is not predetermined. CT scanning does not alleviate pain. Radiogra
phy does not necessarily determine a cause of an injury."

"The nurse is reviewing the erythrocyte sedimentation rate (ESR) for one of her
patients. An elevated ESR
A.
B.
C.
D.
Determines specific causes of inflammation.

Identifies the location of inflammation within the body.
Confirms the nonspecific presence of inflammation.
Indicates a diagnosis of systemic lupus.

"Answer:
C.
An elevated ESR is indicative of the presence of inflammation in the body. Prote
ins produced during the inflammatory process adhere to red blood cells, causing
them to be heavier and settle out of blood samples at a faster rate than normal.
The ESR does not identify specific causes of inflammation and does not determin
e a specific location of inflammation. The ESR is a nonspecific indicator of inf
lammation."
"The nurse in the skilled nursing facility is very busy and unable to answer the
call bell lights. Which tasks related to skin care can the nurse delegate to th
e nursing assistant? (Select all that apply):
A.
B.
C.
D.
E.
Applying over-the-counter lotions to skin that is not broken.

Assisting the client with frequent turning to prevent pressure ulcers.
Covering the client who complains of being cold with more blankets.
Placing a sterile gauze pad over broken skin to contain drainage.
Assessing a patient complaining of an itching rash.

"Answers
: A, B, C, D.
All the above options can be delegated to an unlicensed assistive personnel empl
oyee except for assessing a patient complaining of an itching rash. Assessment o
f a rash should be done by the nurse so the appropriate referrals can be made if
necessary. The nurse needs to investigate a new rash for the possibility of an
allergic reaction."
"The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressin
g for a patient who has a stage III pressure ulcer on the sacral area. The patie
nt's daughter will be dressing the wound at home. Which of the following steps s
hould the nurse include in the teaching plan? (Select all that apply):
A.
B.
C.
D.
Cleansing the wound.

Managing pain.
Applying a dry sterile dressing.
Using cold water in the bath.

"Answers
: A, B.
Administering pain medications will ensure that the patient is comfortable prior
to a dressing change. The nurse should cleanse the wound and then apply the ste
rile dressing. The order calls for a wet-to-dry normal saline dressing. A cold w
ater bath would be contraindicated for pressure ulcer treatment."
"The nurse would explain to a patient that effective treatments for atopic pruri
tus include (Select all that apply):
A.
B.
C.
D.
E.
Oral steroids.
Topical steroids.
Oral antihistamines.
Topical antihistamines.
Topical petroleum ointment.
"Answers
: A, B.
Oral and topical steroids may be given for acute cases of atopic pruritus. Oral
and topical antihistamines are not usually given, because they are ineffective a
nd may cause further irritation. Petroleum is also ineffective."
"To help decrease the threat of melanoma in a blonde-haired, fair-skinned patien
t at risk, the nurse would advise the patient to (Select all that apply):
A.
B.
C.
D.
Wear sunglasses.
Drink plenty of water.
Eat plenty of foods high in vitamin K.
Apply sunscreen 30 minutes prior to exposure.

"Answers
: A, D.
Wearing sunglasses and using sunscreen are recommended by the National Cancer In
stitute. Drinking water will help with heat exhaustion but will not prevent mela
noma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful
in minimizing the risk of developing melanoma; however, vitamin K can cause the
blood to clot and has not been indicated."
"A nurse is instructing a nursing assistant in how to prevent pressure ulcers in
a frail elderly client. The nursing assistant indicates that she understands th
e instruction when she agrees to (Select all that apply):
A.
B.
C.
D.
Bathe and dry the skin vigorously

Keep the head of the bed elevated
Offer nutritional supplements and
Turn the patient at least every 2
to stimulate circulation.
30 degrees.
frequent snacks.
hours.

"Answers
: C, D.
The patient should be turned at least every 2 hours because permanent damage can
occur in 2 hours or less. If skin assessment reveals a stage I ulcer while the
patient is on a 2-hour turning schedule, the patient must be turned more frequen
tly. Protein-calorie malnutrition is another major risk factor for developing pr
essure ulcers. Additional supplements boost nutritional status, which is essenti
al to healthy skin. Use of donut pads, elevation of the head of the bed, and ove
rstimulation of the skin may all stimulate, if not actually encourage, dermal de
cline."
"The nurse is developing a teaching a plan for a client diagnosed with methicill
in-resistant Staphylococcus aureus (MRSA) infection. The nurse plans to include
which instruction in the client's teaching plan?
A.
B.
C.
D.
Take daily tub baths using a mild soap.

The infected area should be covered with a clean, dry bandage.
Wash the infected areas first, then wash the uninfected areas.
Use bath sponges or puffs when bathing.
(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)" "Answer:
B.
The infected area should be covered with a clean, dry bandage to prevent the spr
ead of infection. Uninfected areas should be washed first, then the infected are
as should be washed, to prevent the spread of infection."
"The nursing instructor reviews instructions with the nursing student on caring
for the older adult client with a pressure ulcer. What action by the nursing stu
dent indicates a need for further instruction about proper skin care for this cl
ient?
A. Massages bony prominences
B. Avoids reddened areas
C. Repositions the client every 1 to 2 hours
D. Uses a moisturizing lotion

A.
Massaging bony prominences should be avoided in older adult clients."
"The nurse is teaching the client with loss of sensation and movement in the low
er extremities secondary to spinal cord injury about protecting skin integrity.
Which daily prevention strategy will the nurse include in the client's teaching
plan?
A.
B.
C.
D.
Lift hips off the chair at least every 30 minutes.

Eat a low-fat diet.
Massage reddened areas.
Complete a pressure map.
A.
Lifting hips off the chair at least every 30 minutes relieves pressure and can p
revent pressure ulcers."
"During morning rounds, the nurse discovers that the older adult client has been
incontinent during the night. To protect the skin, what will the nurse do first
?
A.
B.
C.
D.
Apply a barrier cream.

Assess the area for skin breakdown.
Clean the client.
Place the client in a side-lying position.
C.
Cleaning and drying the client is the first priority for skin protection."
"The older adult client who is bedridden has a documented history of protein def
iciency. What will the nurse plan to monitor for?
A.
B.
C.
D.
Anemia
Decreased wound healing
Pressure ulcer development
Weight gain
(Ignatavicius: Concepts for Nursing Practice, 7th Edition, Chapter 27)" Answer:
C. This client is at risk for pressure ulcer if he or she remains bedridden. B i
s incorrect because there is no indicated wound.
"The client has had a melanoma lesion removed. For secondary prevention, what is
important for the nurse to teach the client?
A.
B.
C.
D.
Ensure that all lesions are reviewed by a dermatologist or a surgeon.

Avoid sun exposure.
Perform a total skin self-examination monthly.
Perform a total skin self-examination monthly with a partner.
D.
Performing a monthly total skin self-examination with another person is the best
secondary preventive measure. B is incorrect because avoiding sun exposure is a
primary prevention."
"In teaching the client about skin cancer prevention, which instruction will the
nurse include?
A. ""Avoid sun exposure between 11 AM and 3 PM.""
B. ""Examine skin quarterly for possible cancerous or precancerous lesions.""
C. ""Wear transparent clothing to protect the skin from the sun.""

D. ""It is safe to use a tanning bed.""
A.
The sun's rays are strongest between 11 AM and 3 PM and can cause more damage du
ring this time."
"The young client has been diagnosed with ringworm, but the mother would like th
e child to return to school. To avoid spreading the infection, what will the nur
se suggest to the mother?
A. ""Wash
B. ""Your
lass.""
C. ""Keep
D. ""Keep
your hands frequently.""

child may return to school but must be isolated from the rest of the c
the site covered with a bandage.""
your child out of school until the infection has cleared.""
C.
Keeping the site covered prevents spread of the infection. D is incorrect becaus
e keeping the child out of school is not necessary."
"The discharged obese client will require frequent dressing changes for a skin c
ondition on the left foot. How will the nurse assess whether the client is able
to perform this task at home?
A.
B.
C.
D.
Asks the client if he is squeamish

Demonstrates how to change the dressing
Determines whether the client can reach the affected area
Provides all the necessary dressing materials
C.
Whether the obese client can access the dressing site is the most important thin
g to assess. If the dressing site cannot be accessed by the client, it will be d
ifficult for the client to perform frequent dressing changes at home. If you cho
se B, it's incorrect because demonstration is a good start, but it does not asse
ss the client's ability to perform the task himself."
"The nurse prepares to administer vancomycin (Lyphocin, Vancocin) to a client di
agnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. How w
ill the nurse administer this medication?
A.
B.
C.
D.
Administer by bolus.
Give IV push.
Infuse over 60 minutes.
Mix vancomycin with primary intravenous (IV) bag.
C.
Vancomycin (Lyphocin, Vancocin) is irritating to the veins and can trigger throm
bophlebitis; it should be given over at least 60 minutes."
"The client has an odorous purulent wound. How does the nurse best support this
client?
A.
B.
C.
D.
Changes the dressing frequently

Encourages a diet high in protein
Suggests whirlpool therapy
Places room deodorizers in the room
A.
Frequent dressing changes help the client feel clean."

"The client with a foot ulcer says, ""I feel helpless."" What is the nurse's bes
t response?
A.
B.
C.
D.
Encourages participation in care of the wound

Encourages visitors
Says, ""I know how you feel""
Assures the client that it will be all right
A.
Encouraging participation in wound care gives the client a sense of autonomy. If
you chose D, it is incorrect because assuring the client that everything will b
e all right not only fails to address the underlying issue but also may be untru
e."
"The nurse understands that deep tissue wounds, such as chronic pressure ulcers,
take longer to heal because they heal by which intention?
A.
B.
C.
D.
First
Second
Third
Mixed
B.
Second intention healing is characterized by a cavity-like defect. This requires
gradual filling in of the dead space with connective tissue in deeper tissue in
juries or wounds with tissue loss."
"The nurse anticipates that the client with a deep necrotizing wound caused by a
brown recluse spider bite may require which type of healing therapy?
A.
B.
C.
D.
Hyperbaric oxygen
Nutrition therapy
Topical growth factors
Vacuum-assisted wound closure
A.
Hyperbaric oxygen therapy is usually reserved for life- or limb-threatening woun
ds such as burns, necrotizing soft tissue infections, brown recluse spider bites
, osteomyelitis, and diabetic ulcers."
"What is the best way for the nurse to prevent the client's stage I pressure ulc
er from advancing to stage II?
A.
B.
C.
D.
Massage
Pad the
Promote
Suggest
the reddened areas.

ulcer.
mobility and/or frequent repositioning.
an egg crate mattress.
C.
Frequent repositioning and/or promoting mobility is the best way to prevent furt
her deterioration of this client's pressure ulcer."
"The nurse is evaluating the effectiveness of interventions for pressure ulcer m
anagement. Which diagnostic test result with an increased level indicates client
progress and effective health care team collaboration?
A. Calcium
B. Hematocrit
C. Numbers of immature white blood cells (WBCs)
D. Serum albumin
D.
Albumin measures protein, which is necessary for healing. Increased serum albumi
n indicates successful collaboration with the dietitian."
"Which statement by the client with psoriasis indicates to the nurse that additi
onal teaching about his condition is required?
A.
B.
C.
D.
""A tanning bed will supply the ultraviolet light I need.""

""Medicine can prevent the growth of new skin cells.""
""I can never be cured.""
""Stress can cause my flare-ups.""
A.
Ultraviolet (UV) radiation is commonly used in the treatment of psoriasis, but t
he use of commercial tanning beds is specifically not recommended for these clie
nts. This statement indicates that the client requires further teaching."
"Which statement by the client with psoriasis indicates that teaching about the
condition has been effective?
A.
B.
C.
D.
""I know that I need to avoid warm climates.""

""I need to cover up the affected areas to prevent spread to my family.""
""I should practice good handwashing technique.""
""Psoriasis can be cured with steroids.""
C.
Infections such as strep throat can exacerbate psoriatic flare-ups. Handwashing
can help prevent infection."
"The nurse is teaching the client about decreasing the risk for melanomas and ot
her skin cancers. Which primary prevention technique is most important for the n
urse to include?
A.
B.
C.
D.
Avoiding or reducing skin exposure to sunlight

Avoiding tanning beds
Being aware of skin markings and performing skin self-examination
Wearing SPF 40 sunscreen
A.
Avoiding or reducing one's exposure to the sun is the most important prevention
technique. This includes avoiding direct sunlight, using sunscreen, and wearing
protective clothing (including hats)."
"The nurse admits a client to the clinic who is reporting severe itching to the
arms and legs caused by exposure to poison ivy. The nurse anticipates that the h
ealth care provider will prescribe which medication?
A.
B.
C.
D.
Anthralin (Anthaforte, Drithocreme, Lasan)

Benzyl benzoate (Ascabiol)
Calcipotriene (Dovonex)
Diphenhydramine (Benadryl)
D.
Treatment is aimed at removal of the triggering substance and relief of symptoms
. Because the skin reaction is caused by histamine release, antihistamines such
as diphenhydramine (Benadryl) are helpful."
"The nurse is caring for a client prescribed linezolid (Zyvox) for treatment of
methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse plans to

monitor the client for which adverse effect of linezolid?
A.
B.
C.
D.
Depression
Hyperglycemia
Hypertension
Incontinence
C.
Linezolid (Zyvox) constricts blood vessels and may trigger hypertensive crisis."
"Which nursing interventions can the nurse working in a long-term care facility
delegate to a nursing assistant?
A. Use the Braden scale to determine pressure ulcer risk for a newly admitted cl
ient.
B. Complete daily sterile dressing changes for a client with a venous leg ulcer.
C. Reposition every 2 hours a client who has had a stroke and is incontinent.
D. Admit a newly transferred client who had pedicle flap surgery 1 week ago.
C.
The nursing assistant has the education and scope of practice to reposition a cl
ient."
"The nurse working in the same-day surgery unit has just received report and pla
ns to assess which client first?
A. Adult with a basal cell carcinoma excised who needs discharge teaching about
wound care
B. Young adult who has had rhinoplasty and is swallowing frequently
C. Middle-aged adult who reports 7/10 pain after removal of a cyst
D. Older adult ready to be transferred to the long-term care facility after dbride
ment of a pressure ulcer
B.
Frequent swallowing after rhinoplasty may indicate bleeding, which requires imme
diate action by the nurse."
"A client with bacteremia associated with a bacterial skin infection is receivin
g clindamycin (Cleocin) intravenously (IV). Which assessment finding indicates t
he need for immediate action by the nurse?
A.
B.
C.
D.
Blood pressure is 88/40 mm Hg.

White blood cell count is 15,000/mm3.
Oral temperature is 101 F (38.3 C).
Heart rate is 102 beats/min.
A.
Too-rapid administration of clindamycin (Cleocin) can cause shock and cardiac ar
rest; the client's low blood pressure indicates a need to slow the rate and reas
sess the client."
"A female business professional has extremely dry skin on her legs. In addition
to using lotions after bathing, she asks the nurse about other measures to help
reduce the dryness. What is the nurse's best response?
A. ""Wear long-legged pajamas to sleep in rather than nightgowns.""
B. ""Avoid wearing pantyhose or nylon stockings for more than 2 hours at a time.
""
C. ""Leave the fat-containing soap on your skin when bathing rather than rinsing
it off.""
D. ""Bathe in water that is as warm as you can stand to stimulate the release of
body oils from your sebaceous glands.""
B.
Clothing that fits tightly and rubs can dry the skin. Prolonged contact with nyl
on stockings or pantyhose causes or exacerbates dry skin on the legs. Avoiding t
hese clothing items can reduce this dryness.
Reference: p. 472, Health Promotion and Maintenance"
"The newly admitted client has all of the following laboratory test values. Whic
h value suggests to the nurse that the client may be at an increased risk for pr
essure ulcer formation?
A.
B.
C.
D.
International normalized ratio (INR) of 1.5

White blood cell (WBC) count of 5200/mm3
Serum sodium concentration of 134 mEq/L
Serum prealbumin concentration of 15.2 mg/dL
C.
Adequate nutrition, especially protein intake, helps promote healthy skin and pr
event tissue breakdown. A serum prealbumin concentration less than 19.5 mg/dL in
dicates inadequate nutrition and a severe protein deficiency. With so little pro
tein, the skin cannot repair itself and is at great risk for injury even with mi
nor trauma.
Reference: p. 477, Safe and Effective Care Environment"
"Which intervention does the nurse use to promote ""take"" of a graft placed on
the client's right heel?
A. Elevate the client's right foot by placing pillows under the leg from the kne
e to the ankles.
B. Position the client on the abdomen with the right foot hyperextended for at l
east 4 hours daily.
C. Ensure that the grafted area is pressed tightly to the bed to promote adheren
ce to the wound bed.
D. Assess the circulation distal to the graft every hour and compare the finding
s with those from the left foot.
A.
No pressure should be placed on the graft, and care must be taken to ensure it d
oes not move over the wound so the blood vessels can connect the graft with the
wound bed. Elevating the area allows better circulation and no pressure.
Reference: p. 488, Physiological Integrity"
"Which precaution is most important for the nurse to teach a client prescribed a
dalimumab (Humira)?
A.
B.
C.
D.
Drinking a full glass of water when taking each drug dose

Reducing the drug dosage when psoriasis symptoms decrease
Reporting symptoms of infection to the prescriber immediately
Avoiding sunlight and tanning beds for the duration of drug therapy
D.
Humira suppresses inflammatory and immune responses to some degree. This makes t
he client more susceptible to infection and may suppress some of the usual manif
estations of infection. Together, these actions can allow a minor infection to b
ecome more severe very quickly. Any potential infection, no matter how minor, sh
ould receive immediate medical attention.
Reference: p. 501, Health Promotion and Maintenance"

"In which position does the nurse place the client immediately after a rhytidect
omy to promote venous return and prevent swelling?
A.
B.
C.
D.
Fowler's
Lithotomy
Lateral Sims'
Trendelenburg
A.
Only Fowler's position would make the face less dependent, thus promoting venous
return and decreasing swelling.
Reference: p. 507, Safe and Effective Care Environment"
"A student nurse is caring for a 78-year-old patient with multiple sclerosis. Th
e patient has had an indwelling Foley catheter in for 3 days. Eight hours ago th
e patient's temperature was 37.1 C (98.8 F). The student reports her recent assessme
nt to the registered nurse (RN): the patient's temperature is 37.2 C (99 F); the Fol
ey catheter is still in place, draining dark urine; and the patient is uncertain
what time of day it is. From what the RN knows about presentation of symptoms i
n older adults, what should he recommend?
A. Tell the
entation
B. Tell the
ncentrated
C. Tell the
D. Tell the
student that temporary confusion is normal and simply requires reori

student to increase the patient's fluid intake since the urine is co
student that her assessment findings are normal for an older adult
student that he will notify the physician of the findings

"Answer: D.
The patient may have subtle symptoms of a urinary tract infection, as evidenced
by a slight increase in body temperature, development of confusion, and the dark
-colored urine. Temporary confusion is not a normal condition in older adults. I
ncreasing the fluid intake is acceptable but not a recommendation for the set of
symptoms the patient presents. The presenting set of symptoms is not normal."
"A patient's family member is considering having her mother placed in a nursing
center. You have talked with the family before and know that this is a difficult
decision. Which of the following criteria would you recommend in choosing a nur
sing center? (Select all that apply.)
A.The center should be clean, and rooms should look like a hospital room.
B.There should be adequate staffing on all shifts.
C.Social activities should be available for all residents.
D.Three meals should be served daily with a set menu and serving schedule.
E.Family involvement in care planning and assisting with physical care is necess
ary.
"Answers: B, C,
E.
Adequate staffing, provision of social activities, and active family involvement
are essential. Meals should be high quality with options for what to eat and wh
en it is served. A nursing center should be clean, but it should look like a per
son's home."
"A nurse has conducted an assessment of a new patient who has come to the medica
l clinic. The patient is 82 years old and has had osteoarthritis for 10 years an
d diabetes mellitus for 20 years. He is alert but becomes easily distracted duri
ng the nursing history. He recently moved to a new apartment, and his pet beagle
died just 2 months ago. He is most likely experiencing:
A. Dementia.
B. Depression.
C. Delirium.
D. Disengagement.
"Answer: B.
Factors that often lead to depression include presence of a chronic disease or a
recent change or life event (such as loss). Patients are alert but easily distr
acted in conversation."
"A major life event such as the death of a loved one, a move to a nursing home,
or a cancer diagnosis could precipitate:
A.
B.
C.
D.
Dementia.
Delirium.
Depression.
Stroke.

"Answer: C.
The onset of depression could be abrupt or gradual, but the usual cause is a maj
or life-altering event in the life of the person experiencing the depression."
"Sexuality is maintained throughout our lives. Which answer below best explains
sexuality in an older adult?
A. When the sexual partner passes away, the survivor no longer feels sexual.
B. A decrease in an older adult's libido occurs.
C. Any outward expression of sexuality suggests that the older adult is having a
developmental problem.
D. All older adults, whether healthy or frail, need to express sexual feelings.
"Answer: D.
Sexuality is normal throughout the life span, and older adults need to be able t
o express their sexual feelings.
Ew."
"Older adults experience a change in sexual activity. Which best explains this c
hange?
A.
B.
C.
D.
The need to touch and be touched is decreased.

The sexual preferences of older adults are not as diverse.
Physical changes usually do not affect sexual functioning.
Frequency and opportunities for sexual activity may decline.

"Answer: D.
As a result of loss of a loved one or a chronic illness in themselves or their p
artner, opportunities for sexual activity may decline."
"You see a 76-year-old woman in the outpatient clinic. Her chief complaint is vi
sion. She states she has really noticed glare in the lights at home. Her vision
is blurred; and she is unable to play cards with her friends, read, or do her ne
edlework. You suspect that she may have:
A.
B.
C.
D.
Presbyopia.
Disengagement.
Cataract(s).
Depression.

"Answer: C.
Cataracts normally result in blurred vision, sensitivity to glare, and gradual l
oss of vision. Presbyopia is a common eye condition resulting in a person having
difficulty adjusting to near and far vision. The symptoms are not reflective of
depression since her vision affects her ability to interact. She has not chosen
to avoid her friends. Disengagement is a term referring to aging theory."
"A nurse is caring for a patient preparing for discharge from the hospital the n
ext day. The patient does not read and has a hearing loss. His family caregiver
will be visiting before discharge. What can you do to facilitate the patient's u
nderstanding of his discharge instructions? (Select all that apply.)
A.Speak loudly so the patient can hear you.
B.Sit facing the patient so he is able to watch your lip movements and facial ex
pressions.
C.Present one idea or concept at a time.
D.Send a written copy of the instructions home with him and tell him to have the
family review them.
E.Include the family caregiver in the teaching session.
"Answers: B, C,
E.
Teaching and communication are more effective with older adults when you sit and
face the patient and present one idea or concept at a time. This requires plann
ing. Speaking loudly can distort sound. Speak in a normal tone. Sending instruct
ions is helpful but will not directly facilitate the patient's own understanding
. Sharing information with a caregiver provides someone to clarify instructions.
"
"Taste buds atrophy and lose sensitivity, and appetite may decrease. As a result
, the older adult is less able to discern:
A.
B.
C.
D.
Spicy and bland foods.

Salty, sour, and bitter tastes.
Hot and cold food temperatures.
Moist and dry food preparations.

"Answer: B.
Often an older adult uses ""heavy"" spices because of his or her inability to ta
ste the food."
"Kyphosis, a change in the musculoskeletal system, leads to:
A. Decreased bone density in the vertebrae and hips.
B. Increased risk for pathological stress fractures in the hips.
C. Changes in the configuration of the spine that affect the lungs and thorax.
D. Calcification of the bony tissues of the long bones such as in the legs and a
rm.
"Answer: C.
This can also affect the ability of the patient to deep breath and cough effecti
vely."
"A 63-year-old patient is retiring from his job at an accounting firm where he w
as in a management role for the past 20 years. He has been with the same company
for 42 years and was a dedicated employee. His wife is a homemaker. She raised
their five children, babysits for her grandchildren as needed, and belongs to nu
merous church committees. What are your major concerns for this patient? (Select
all that apply.)
A.The loss of his work role
B.The risk of social isolation
C.A determination if the wife will need to start working
D.How the wife expects household tasks to be divided in the home in retirement
E.The age the patient chose to retire
"Answers: A, D.
The psychosocial stresses of retirement are usually related to role changes with
a spouse or within the family and to loss of the work role. Often there are new
expectations of the retired person. This patient is not likely to become social
ly isolated because of the size of the family. Whether the wife will have to wor
k is not a major concern at this time, nor is the age of the patient."
"During a home health visit a nurse talks with a patient and his family caregive
r about the patient's medications. The patient has hypertension and renal diseas
e. Which of the following findings places him at risk for an adverse drug event?
(Select all that apply.)
A.Taking two medications for hypertension
B.Taking a total of eight different medications during the day.
C.Having one physician who reviews all medications
D.Patient's health history
E.Involvement of the caregiver in assisting with medication administration"
"Answers: B, D.
The patient is at risk for an adverse drug event (ADE) because of polypharmacy a
nd his history of renal disease, which affects drug excretion. Taking two medica
tions for hypertension is common. Having one physician review all medications an
d involving a family caregiver are desirable and are safety factors for preventi
ng ADEs."
"You are caring for an 80-year-old man who recently lost his wife. He shares wit
h you that he has been drinking more than he ever did in the past and feels hope
less without his wife. He reports that he rarely sees his children and feels iso
lated and alone. This patient is at risk for:
A.
B.
C.
D.
Dementia.
Liver failure.
Dehydration.
Suicide.

"Answer: D.
The patient is sharing that he is depressed. Key concepts include recent loss of
his wife, excessive drinking, hopelessness, and isolation, making him at risk f
or suicide."
"You are working with an older adult after an acute hospitalization. Your goal i
s to help this person be more in touch with time, place, and person. What might
you try?
A.
B.
C.
D.
Reminiscence
Validation therapy
Reality orientation
Body image interventions

"Answer: C.
Reality orientation is a communication technique that can help restore a sense o
f reality, improve level of awareness, promote socialization, elevate independen
t functioning, and minimize confusion."
"A 71-year-old patient enters the emergency department after falling down stairs
in the home. The nurse is conducting a fall history with the patient and his wi
fe. They live in a one-level ranch home. He has had diabetes for over 15 years a
nd experiences some numbness in his feet. He wears bifocal glasses. His blood pr
essure is stable around 130/70. The patient does not exercise regularly and comp
lains of weakness in his legs when climbing stairs. He is alert, oriented, and a
ble to answer questions clearly. What are the fall risk factors for this patient
? (Select all that apply.)
A.Presence of a chronic disease
B.Impaired vision
C.Residence design
D.Blood pressure
E.Leg weakness
F.Exercise history
"Answers: B, E,
F.
Risk factors for falling include sensory changes such as visual loss, musculoske
letal conditions affecting mobility (in this case weakness), and deconditioning
(from lack of exercise). The mere presence of a chronic disease is not a risk fa
ctor unless it is a condition such as a neurological disorder that alters mobili
ty or cognitive function. The patient's blood pressure is stable, and there is n
o report of orthostatic hypotension. A one-floor residence should not pose risks
."
"Instruments such as the Functional Activities Questionnaire (FAQ) for postopera
tive patients who are at home, the Minimum Data Set for Nursing Facility Residen
t Assessment and Care Screening (MDS) for nursing home patients, the Functional
Status Scale (FSS) for children, and the Edmonton Functional Assessment Tool for
cancer patients are used to assess activities of daily living (ADLs). The nurse
needs to remember that a disadvantage of these instruments includes
A. The efficacy and reliability of the instruments.
B. The variations in assessments and responses may be subjective because of self
-reporting of functional activities.
C. The instruments do not show a true measure of ability because of a lack of in
teractivity during the assessments.
D. The information contained in the instruments is insufficient to make a determ
ination about functional status in these populations.
(Giddens: Concepts for Nursing Practice, 1st Edition, Concept 2 - Functional Abi
lity)" "Answer: B.
A disadvantage of many of the ADLs and instrumental activities of daily living (
IADLs) scales is the self-reporting of functional activities. Efficacy and relia
bility are not measured when assessing ADLs and IADLs. Interaction with the pati
ent is necessary to complete the ADL and IADL assessments. The FAQ and FSS are c
omprehensive tools that can help the nurse determine functional status."
"The nurse is assessing a patient's ability to perform instrumental activities o
f daily living (IADLs). Which of the following activities are considered in the
IADLs assessment? (Select all that apply):
A.
B.
C.
D.
E.
F.
Feeding oneself.
Preparing a meal.
Balancing a checkbook.
Walking.
Toileting.
Grocery shopping.
lity)" "Answers: B, C, F.
IADLs include shopping, meal preparation, housekeeping, doing laundry, managing
finances, taking medications, and using transportation. The other activities lis
ted are activities of daily living (ADLs) related to self-care."
"The nurse is assessing a patient's ability to perform basic activities of daily
living (BADLs). Which of the following activities are considered in the BADLs a
ssessment? (Select all that apply):
A.
B.
C.
D.
Feeding oneself.
Preparing a meal.
Balancing a checkbook.
Walking.
E. Toileting.
F. Grocery shopping.
lity)" "Answers: A, D, E.
BADLs include feeding oneself, ambulation, and toileting. Instrumental activitie
s of daily living (IADLs) include shopping, meal preparation, housekeeping, doin
g laundry, managing finances, taking medications, and using transportation."
"Which of the following interventions should be included in a plan of care for a
patient who had a stroke 30 days ago and is now in home care rehabilitation? (S
elect all that apply).
A. Promoting independence and encouraging patient participation in activities of
daily living (ADLs).
B. Promoting rest and sleep.
C. Promoting a diet rich in protein.
D. Promoting exercise and ambulation.
E. Assisting the patient with ADLs.
F. Limiting visitors and social contacts.
lity)" "Answers: A, B, D.
It is important to promote independence in ADLs early in the plan of care to inc
rease independence in general. Promoting rest and sleep will promote well-being.
Ambulation and exercise promote well-being and increase healing by circulating
oxygen to the brain. Protein promotes healing in postsurgical patients but is no
t a main focus in stroke patients. Assisting the patient does not promote indepe
ndence. Limiting visitors will isolate the patient, which can lead to depression
."
"The nurse is caring for an 85-year-old woman 6 weeks following a hysterectomy s
econdary to ovarian cancer. The patient will need chemotherapy and irradiation o
n an outpatient basis. Which of the following priorities would be seen as a barr
ier to healing and need to be considered when planning care for this patient? (S
elect all that apply):
A.
B.
C.
D.
E.
F.
Can feed herself and prepare meals but cannot drive to the store.
Lives on a fixed income and can balance her checkbook.
Has stress incontinence.
Was active at the senior center and now cannot participate in activities.
Lives alone and has no nearby relatives.
Has no transportation to the oncology clinic.
lity)" "Answers: C, E, F.
The patient will not be able to get treatment if she has no transportation or no
relatives that live nearby who can help her with recovery. Stress incontinence
increases the risk of falls because of urgency and rushing to get to the bathroo
m. Income and social abilities are lower priorities during this phase of recover
y."
"The nurse is having difficulty reading a physician's order for a medication. He
or she knows that the physician is very busy and does not like to be called. Wh
at is the most appropriate next step for the nurse to take?
A.
B.
C.
D.
Call a pharmacist to interpret the order

Call the physician to have the order clarified
Consult the unit manager to help interpret the order
Ask the unit secretary to interpret the physician's handwriting
"Answer: B.
You must have the right documentation and clarify all orders with the prescriber
before administering medications."
"The patient has an order for 2 tablespoons of Milk of Magnesia. How much medica
tion does the nurse give him or her?
A.
B.
C.
D.
2 mL
5 mL
16 mL
30 mL

"Answer: D.
1 tablespoon = 15 mL; 2 tablespoons = 30 mL."
"A nurse is administering eardrops to an 8-year-old patient with an ear infectio
n. How does the nurse pull the patient's ear when administering the medication?
A.
B.
C.
D.
Outward
Back
Upward and back
Upward and outward

"Answer: D.
Eardrops are administered with the ear positioned upward and outward for patient
s greater than 3 years of age."
"A patient is to receive cephalexin (Kefl ex) 500 mg PO. The pharmacy has sent 2
50-mg tablets. How many tablets does the nurse administer?
A.
B.
C.
D.
tablet
1 tablet
1 tablets
2 tablets

"Answer: D.
Using dimensional analysis:
Tablets = 1tablet/250 mg 500 mg = 500/250 = 2 tablets."
"A nurse is administering medications to a 4-year-old patient. After he or she e
xplains which medications are being given, the mother states, ""I don't remember
my child having that medication before."" What is the nurse's next action?
A. Give the medications
B. Identify the patient using two patient identifiers
C. Withhold the medications and verify the medication orders
D. Provide medication education to the mother to help her better understand her
child's medications
"Answer: C.
Do not ignore patient or caregiver concerns; always verify orders whenever a med
ication is questioned before administering it."
"A patient is transitioning from the hospital to the home environment. A home ca
re referral is obtained. What is a priority in relation to safe medication admin
istration for the discharge nurse?
A. Set up the follow-up appointments with the physician for the patient.
B. Ensure that someone will provide housekeeping for the patient at home.
C. Ensure that the home care agency is aware of medication and health teaching n
eeds.
D. Make sure that the patient's family knows how to safely bathe him or her and
provide mouth care.
"Answer: C.
A nursing responsibility is to collaborate with community resources when patient
s have home care needs or difficulty understanding their medications."

"A nursing student takes a patient's antibiotic to his room. The patient asks th
e nursing student what it is and why he should take it. Which information does t
he nursing student include when replying to the patient?
A. Only the patient's physician can give this information.
B. The student provides the name of the medication and a description of its desi
red effect.
C. Information about medications is confidential and cannot be shared.
D. He has to speak with his assigned nurse about this.
"Answer: B.
Patients need to know information about their medications so they can take them
correctly and safely."
"The nurse is administering a sustained-release capsule to a new patient. The pa
tient insists that he cannot swallow pills. What is the nurse's next best course
of action?
A.
B.
C.
D.
Ask the prescriber to change the order

Crush the pill with a mortar and pestle
Hide the capsule in a piece of solid food (lol!)
Open the capsule and sprinkle it over pudding

"Answer: A.
Enteric-coated or sustained-release capsules should not be crushed; the nurse ne
eds to contact the prescriber to change the medication to a form that is liquid
or can be crushed."
"The nurse takes a medication to a patient, and the patient tells him or her to
take it away because she is not going to take it. What is the nurse's next actio
n?
A.
B.
C.
D.
Ask the patient's reason for refusal

Explain that she must take the medication
Take the medication away and chart the patient's refusal
Tell the patient that her physician knows what is best for her

"Answer: A.
When patients refuse a medication, first ask why they are refusing it."
"The nurse receives an order to start giving a loop diuretic to a patient to hel
p lower his or her blood pressure. The nurse determines the appropriate route fo
r administering the diuretic according to:
A.
B.
C.
D.
Hospital policy.
The prescriber's orders.
The type of medication ordered.
The patient's size and muscle mass.

"Answer: B.
The order from the prescriber needs to indicate the route of administration."
"A patient is receiving an intravenous (IV) push medication. If the drug infiltr
ates into the outer tissues, the nurse:
A.
B.
C.
D.
Continues to let the IV run.

Applies a warm compress to the infiltrated site.
Stops the administration of the medication and follows agency policy.
Should not worry about this because vesicant filtration is not a problem.

"Answer: C.
When an IV medication infiltrates, stop giving the medication and follow agency
policy."
"If a patient who is receiving intravenous (IV) fluids develops tenderness, warm
th, erythema, and pain at the site, the nurse suspects:
A.
B.
C.
D.
Sepsis.
Phlebitis.
Infiltration.
Fluid overload.

"Answer: B.
Redness, warmth, and tenderness at the IV site are signs of phlebitis."
"After seeing a patient, the physician gives a nursing student a verbal order fo
r a new medication. The nursing student first needs to:
A. Follow ISMP guidelines for safe medication abbreviations.
B. Explain to the physician that the order needs to be given to a registered nur
se.
C. Write down the order on the patient's order sheet and read it back to the phy
sician.
D. Ensure that the six rights of medication administration are followed when giv
ing the medication.
"Answer: B.
Nursing students cannot take orders."
"A nurse accidently gives a patient a medication at the wrong time. The nurse's
first priority is to:
A.
B.
C.
D.
Complete an occurrence report.

Notify the health care provider.
Inform the charge nurse of the error.
Assess the patient for adverse effects.

"Answer: D.
Patient safety and assessing the patient are priorities when a medication error
occurs."
"A patient is taking albuterol through a pressurized metered dose inhaler (pMDI)
that contains a total of 200 puffs. The patient takes 2 puffs every 4 hours. Ho
w many days will the
pMDI last?
__________ days
"Correct Respons
es: ""16, Two puffs 6 times a day = 12 puffs per day; 200 puffs/12 puffs per day
= 16.67 days, or about 16 days. This cannot be rounded up since the inhaler will
not last a total of 17 days., 16, Two puffs 6 times a day = 12 puffs per day; 20
0 puffs/12 puffs per day = 16.67 days, or about 16 days. This cannot be rounded
up since the inhaler will not last a total of 17 days."""
"Which components of pharmacokinetics does the nurse need to understand before a
dministering a drug? (Select all that apply.)
a.Drugs with a smaller volume of drug distribution have a longer half-life.
b.Oral drugs are dissolved through the process of pinocytosis.
c.Patients with kidney disease may have fewer protein-binding sites and are at r
isk for drug toxicity.
d.Rapid absorption decreases the bioavailability of the drug.
e.When the drug metabolism rate is decreased, excess drug accumulation can occur
, which can cause toxicity.
(Kee: Pharmacology, A Patient-Centered Nursing Process Approach, 8th Edition, Ch
apter 1)"
Answer: C, E.
"The nurse will question the health care provider if a drug with a half-life (t1
/2) of more than 24 hours is ordered to be given more than how often?
a.Once daily
b.Every other day
c.Twice weekly
d.Once weekly
apter 1)"
Answer: A.
"The nurse is explaining drug action to a nursing student. Which statement made
by the nurse is correct?
a.""Water-soluble and ionized drugs are quickly absorbed.""
b.""A drug not bound to protein is an active drug.""
c.""Most receptors are found under the cell membrane.""
d.""Toxic effects can result if the trough level is low.""
apter 1)"
Answer: B.
"The nurse is caring for a patient with congestive heart failure who is receivin
g digoxin (Digitek, Lanoxicaps, Lanoxin). The nurse plans to take which action w
hen administering digoxin?
a.
b.
c.
d.
Check the peak levels of digoxin.

Check the trough levels digoxin.
Monitor for tachyphylaxis.
Monitor the therapeutic range of digoxin.

apter 1)"
Answer: D.
"The nurse anticipates that the health care provider will order which laboratory
test for an older adult with renal dysfunction?
a.Creatinine clearance
b.Glomerular filtration rate
c.Urine specific gravity
d.Urine pH
apter 1)"
Answer: A.
"When reviewing the patient's medication regimen, the nurse understands that the
interval of drug dosage is related to what?
a.Half-life
b.Stimulation of receptors
c.Therapeutic index
d.Trough level
apter 1)"
Answer: A.
"Which nursing assessment(s) will the nurse include when developing a patient me
dication plan? (Select all that apply.)
a. Check peak and trough levels of drugs.
b. Check the drug literature for the protein-binding percentage of a drug.
c. Identify side effects of drugs that are nonspecific.
d. Evaluate the patient's reaction to a drug.
e. To enhance absorption, advise the patient to crush an enteric-coated tablet b
efore taking.
apter 1)"
Answers: A, B, C.
"A student nurse is studying the phases of drug action. Which statement by the s
tudent indicates to the nursing instructor that the student understands the phar
maceutic phase?
a.""To achieve drug action, drugs are moved by four processes.""
b.""For the drug to cross the biologic membrane, the drug becomes a solution.""
c.""In this phase, drugs are concentrated and a biologic or physiologic response
occurs.""
d.""The pharmaceutic phase is the process by which the drug becomes available to
body fluids and tissue.""
apter 1)"
Answer: B.
"The nurse plans to advise the patient to avoid which food(s) before ingesting a
n enteric-coated medication? (Select all that apply.)
a.Bananas
b.Baked lamb chops
c.Broiled fish
d.Ice cream
e.Fried chicken
(Kee: Pharmacology, A Patient-Centered Nursing
apter 1)"
Answers: D, E.
"The nurse is having a health teaching session
ions about the history of drug labels. What is
rence for drug labels and increased control on
Process Approach, 8th Edition, Ch

with a patient who has many quest
the nurse's best legislation refe
drug safety?
a.Kefauver-Harris Amendment to the 1938 Act

b.Controlled Substances Act
c.Food, Drug, and Cosmetic Act
d.Durham-Humphrey Amendment to the 1938 Act
apter 2)"
Answer: A.
"The nurse is reviewing a patient's list of medications and notes that several h
ave the highest abuse potential. According to U.S. standards, the highest potent
ial for abuse of drugs with accepted medical use is found in drugs included in w
hich schedule?
a.
b.
c.
d.
II
III
IV
V

apter 2)"
Answer: A.
"The nurse is reviewing the drug-approval process in the United States and learn
s that the Food and Drug Administration Modernization Act of 1997 contains which
provisions? (Select all that apply.)
a.Review of new drugs is accelerated.
b.Drug companies must provide information on ""off-label"" drugs.
c.Privacy of individually identifiable health information must be protected.
d.Drug companies must offer advanced notice of plans to discontinue drugs.
e.Drug labels must describe side effects and adverse effects.
apter 2)"
Answers: A, B, D.
"The patient has questions about counterfeit drugs. Which factors alert the pati
ent or nurse that a drug is counterfeit or adulterated? (Select all that apply.)
a.Variations in packaging
b.Unexpected side effects
c.Different taste
d.Different chemical components
e.Different odor
apter 2)"
Answers: A, B, C.
"The nurse must be knowledgeable about the Nurse Practice Act. In the event the
nurse gives the correct drug via the wrong route, resulting in the death of the
patient, what may the nurse be charged with in a civil court?
a.
b.
c.
d.
Misfeasance
Nonfeasance
Malfeasance
Negligence

apter 2)"
Answer: C.
"The nurse knows the importance of administering the right medication to the pat
ient and that drugs have many names. It is therefore most important that drugs b
e ordered by which name?
a.Generic
b.Brand
c.Trade
d.Chemical
apter 2)"
Answer: A.
"A drug label has ""t/c"" on it. The nurse knows that which statement is true ab
out this designation? (Select all that apply.)
a.It
b.It
c.It
d.It
e.It
is
is
is
is
is
on all schedule F prescription drugs.

on targeted substances, such as benzodiazepines.
a designation of the Canadian Controlled Drugs and Substances Act.
on all narcotics.
on over-the-counter drugs.

apter 2)"
Answers: B, C.
"What provisions from the Controlled Substances Act of 1970 were designed to rem
edy drug abuse?
a.
b.
c.
d.
The
The
The
The
act
act
act
act
established treatment and rehabilitation facilities.

tightened controls on experimental drugs.
required clinical trial data on drugs.
required drug companies to give information on off-label drugs.

apter 2)"
Answer: A.
"The nurse is performing a health assessment on a newly admitted patient of Asia
n descent. The patient looks at the floor whenever the nurse asks a question. Co
mmunication is enhanced when the nurse does which action?
a. Frequently touches the patient
b. Asks questions that require only ""yes"" or ""no"" for answers
c. Discontinues the health assessment

d. Uses eye contact sparingly
apter 3)"
Answer: D.
"The nurse has been measuring the blood pressure of an African-American patient
every 4 hours for the past 3 days in a hospital setting. The blood pressure is c
onsistently above 140/90. The patient has been compliant with the antihypertensi
ve drug therapy while hospitalized. The nurse will initially perform which actio
n?
a.Question the patient about the types of food consumed in the last 3 to 4 days.
b.Inform the prescriber that the antihypertensive drug therapy is not working.
c.Increase blood pressure measurements to every 2 hours.
d.Place the patient on a restricted fluid intake.
apter 3)"
Answer: B.
"A nurse who is male is caring for a young, married woman who is an observant Mu
slim. It is important that the nurse perform which action?
a.Touch no part of the patient's body.
b.Identify the patient's preference regarding touch.
c.Touch the patient only when her spouse is present.
d.Tell the nurse manager he cannot care for female patients who practice Islam.
apter 3)"
Answer: B.
"A nurse is teaching a 16-year-old female patient about a newly prescribed medic
ation. The patient is bilingual in Spanish and English. Which behavior best indi
cates the patient's understanding of the instructions?
a. The
ons.
b. The
c. The
d. The
patient frequently nods her head while listening to the nurse's instructi
patient states that she understands the instructions.
patient repeats the nurse's instructions to her parents.
patient does not ask the nurse for clarification of the instructions.

apter 3)"
Answer: C.
"A Native American patient is newly diagnosed with diabetes mellitus type 2 and
is prescribed the antidiabetic drug metformin (Glucophage) 500 mg PO with mornin
g and evening meals. Which statement best indicates to the nurse that the patien
t will adhere to the pharmacotherapy?
a.""I will no longer put sugar on my cereal because that will help me be healthi
er.""
b.""If I take this medicine, I will feel better soon and won't have to take it a
nymore.""
c.""To reduce the possibility of damage to my body, I must take the medicine as
scheduled.""
d.""I have diabetes because of my ancestry, so there's not much I can do about i
t.""
apter 3)"
Answer: C.
"The rate of absorption of drugs can change when two drugs are taken at the same
time. The nurse is aware that the rate of absorption can be changed by which ac
tions? (Select all that apply.)
a.Modifying gastric emptying time

b.Changing gastric pH
c.Decreasing inflammation
d.Forming drug complexes
e.Eating too slowly
apter 4)"
Answers: A, B, D.
"The nurse is reviewing a patient's medications as part of patient teaching. The
nurse is aware that which drug is least likely to cause photosensitivity?
a.
b.
c.
d.
Penicillins
Sulfonamides
Sulfonylureas
Thiazides

apter 4)"
Answer: A.
"A patient asks the nurse about the drug qualities that determine the category i
n which a drug is placed. What is the nurse's best response? (Select all that ap
ply.)
a.""Drugs that are in clinical trials""
b.""Drugs judged to be both safe and effective""
c.""Drugs judged to be either unsafe or ineffective""
d.""Drugs with insufficient data to judge safety or efficacy""
e.""Herbal products""
apter 4)"
Answers: B, C, D.
"The nurse is meeting with a community group about medication safety. The nurse
must emphasize that patients at high risk for drug interactions include which gr
oups? (Select all that apply.)
a.Older patients
b.Patients with chronic health conditions
c.Patients taking three or more drugs
d.Patients dealing with only one pharmacy
e.Patients covered by Medicare or Medicaid
apter 4)"
Answer: A, B, C.
"The nurse recognizes that when a patient takes a hepatic enzyme inducer, the do
se of the warfarin (Coumadin) is usually modified in which way?
a.
b.
c.
d.
It
It
It
It
is increased.
is decreased.
remains the same.
is unpredictable.

apter 4)"
Answer: A.
"The nurse is conducting a patient assessment and notes that the patient has alk
aline urine, which promotes excretion of drugs that are weak acids. Which drug i
s a weak acid?
a.phenytoin (Dilantin)
b.acetylsalicylic acid (aspirin)
c.quinidine (Apo-Quinidine)
d.warfarin (Coumadin)

apter 4)"
Answer: B.
"The nurse is describing to a patient the synergistic effects of two of his medi
cations. Which statement by the nurse is correct about synergistic drug effects?
a.""Two drugs have antagonistic effects on each other.""
b.""The action of a drug is nullified by another drug.""
c.""One drug acts as an antidote to the side effects of another drug.""
d.""A greater effect is achieved when two drugs are combined.""
apter 4)"
Answer: D.
"A patient asks the nurse about cautions related to use of OTC medications. What
is the nurse's best response? (Select all that apply.)
a.
b.
c.
d.
e.
""Over-the-counter drugs may delay professional diagnosis.""

""They may mask symptoms.""
""They may make diagnosis easier.""
""Their inactive ingredients may cause adverse reactions.""
""They may be more expensive.""

apter 4)"
Answers: A, B, D.
"Patients on long-term digoxin (Lanoxin) therapy need regular digoxin-level moni
toring to detect early toxicity manifested by which symptoms? (Select all that a
pply.)
a.Visual problems
b.Nausea and vomiting
c.Skin eruptions
d.Urinary retention
e.Dizziness
apter 4)"
Answers: A, B, D.
"The nurse is reviewing a teaching plan with a patient who was recently diagnose
d with asthma. What cautions about the use of aspirin are important for the nurs
e to advise the patient? (Select all that apply.)
a.It may trigger an acute asthma attack.
b.It may trigger a heart attack.
c.There is an increased risk for bleeding if also taking an anticoagulant.
d.It may decrease renal function.
e.It may decrease hepatic function.
apter 4)"
Answers: A, C, D.
"A patient asks the nurse about drug interactions with OTC preparations. What is
the nurse's best response?
a.
b.
c.
d.
""Discuss this with the health care provider.""

""There are not many interactions, so don't worry about it.""
""Read the labels carefully, and check with your health care provider.""
""Avoid over-the-counter preparations.""

apter 4)"
Answer: C.
"When caring for a patient recovering from an episode of opioid toxicity, the nu
rse determines that the patient has an addiction to the drug based on which find
ing?
a.Physical withdrawal signs
b.A history of daily use
c.Craving that results in drug-seeking behaviors
d.Intravenous rather than oral use of the drug
apter 5)"
Answer: C.
"While teaching the parents of an adolescent who has been using marijuana, the n
urse explains that the euphoria that results from the use of abused psychoactive
substances is believed to be caused by which factor?
a.Blockade of opioid receptors in the mesolimbic system of the brain
b.Stimulation of the dopamine pathways in the pleasure areas of the brain
c.Increased release of serotonin in all areas of the brain
d.Reduction in the responsiveness of brain receptors
apter 5)"
Answer: B.
"A patient hospitalized with a fractured femur following an automobile accident
develops diarrhea and vomiting with abdominal cramps, chills with goose bumps, a
nd dilated pupils. The nurse suspects that the patient is experiencing which rea
ction?
a.
b.
c.
d.
Opioid withdrawal
Alcohol toxicity
Flashbacks from psychedelic abuse
Barbiturate withdrawal

apter 5)"
Answer: A.
"Which agent(s) will the nurse anticipate administering to a patient who has bee
n admitted with acute alcohol intoxication? (Select all that apply.)
a.naloxone (Narcan)
b.thiamine
c.lorazepam (Ativan)
d.naltrexone (ReVia)
e.intravenous glucose solution
f.flumazenil (Romazicon)
apter 5)"
Answers: B, C, E.
"A patient is admitted to the emergency department with acute cocaine toxicity.
Which is the most important intervention by the nurse?
a.Institute cardiac monitoring, and obtain frequent blood pressures.
b.Monitor the patient for decreasing respiratory function and level of conscious
ness.
c.Provide reality orientation with a calm, quiet approach.
d.Administer oral fluids with caffeine to prevent withdrawal symptoms.
apter 5)"
Answer: A.
"A nurse observes another nurse taking oral opioids from the medication room at
the hospital. Which is the best action by the nurse?
a. Report the finding to the nursing supervisor to enable the nurse's participat
ion in a diversion program.
b. Ignore the situation to protect the nurse from dismissal and possible loss of
licensure.
c. Confront the nurse and demand that the drugs be returned before someone notic
es their absence.
d. Ask the nurse to request pain medications from a physician rather than steali
ng them from the hospital.
apter 5)"
Answer: A.
"A patient is to start disulfiram (Antabuse) to help with alcohol abuse. The nur
se providing medication education about the drug will include which topics in th
e education plan? (Select all that apply.)
a.Importance of taking this medication every day
b.That better results are experienced when a support group helps with adhering t
o treatment
c.Common food and hygiene products containing alcohol
d.That disulfiram treatment should be stopped 1 day before alcohol consumption
e.That disulfiram works by disrupting the metabolism of alcohol
f.That use of alcohol with disulfiram may cause nausea and vomiting and may even
be fatal
apter 5)"
Answers: A, B, C, E, F.
"A patient in the hospital is experiencing methamphetamine withdrawal. What does
the nurse expect the symptoms and treatment to be?
a. Hypertension, tachycardia, and autonomic overactivity; treated by benzodiazep
ines
b. Hypersomnia, irritability; treated by supportive care including pushing food
and fluids
c. Minimal notable symptoms; no treatment needed
d. Anxiety, insomnia, hyperactivity, and rapid, pressured speech; treated by sym
ptom management
apter 5)"
Answer: B.
"What provisions of the Dietary Supplement Health and Education Act of 1994 are
most important for the nurse to know related to patient health teaching? (Select
all that apply.)
a.
b.
c.
d.
e.
Clarified marketing regulations

Reclassified herbs as dietary supplements
Stated that herbal products can be marketed with suggested dosages
Required that package labels give quality and strength of all contents
Stated that herbs can be used as drug

apter 6)"
Answer: A, B, C.
"The nurse discovers that a patient has recently decided to take four herbal pre
parations. Which action will the nurse take first?
a.Discuss the cost of herbal products.
b.Instruct the patient to inform the health care provider of all products taken.
c.Instruct the patient to stop taking all herbal products immediately.
d.Suggest that the patient taper off use of herbal products over the next 2 week
s.
apter 6)"
Answer: B.
"Labeling of herbal products is important. Which is an appropriate claim for an

herbal product?
a.""Prevents diabetes""
b.""Helps increase blood flow to the extremities""
c.""Cures Alzheimer's disease""
d.""Is safe for all""
apter 6)"
Answer: B.
"The nurse is reviewing a patient's current medications. Which herbal products i
nterfere with the action of anticoagulants? (Select all that apply.)
a.
b.
c.
d.
e.
aloe
feverfew
ginger
licorice
cranberry

apter 6)"
Answers: B, C, D.
"A patient has multiple prescription medications and is not able to recall which
herbal product he uses for relief of migraine headaches. He notes that it is a
serum antagonist and asks the nurse to assist him. What is the best response by
the nurse?
a.""Valerian""
b.""Feverfew""
c.""Milk thistle""
d.""Ginkgo""
apter 6)"
Answer: B.
"A patient is being followed by a cardiovascular clinic and takes garlic, which
is reported to decrease cholesterol, triglycerides, blood pressure, and blood-cl
otting capability. Which patient statement indicates a need for further teaching
? (Select all that apply.)
a.""I can just take garlic for my heart problems.""
b.""Garlic may provide some decrease in blood pressure.""
c.""Garlic is very effective in preventing depression.""
d.""Garlic may promote healing of my incision.""
e.""Garlic will not cure impotence.""
apter 6)"
Answers: A, C.
"The nurse notes that many patients are taking herbal remedies for relief of dep
ression and anxiety. Which herbal preparation has at least 10 pharmacologically
active components for relief of depression and anxiety?
a.
b.
c.
d.
St. John's wort

licorice
saw palmetto
goldenseal

apter 6)"
Answer: A.
"A patient who is pregnant asks the nurse, ""What herbal products can I take?""
What is the best response by the nurse?
a.""What are you taking now?""

b.""Taking a product at bedtime is usually not a problem.""
c.""How long have you been taking herbal products?""
d.""Discuss this with your health care provider.""
apter 6)"
Answer: D.
"A patient reports taking aloe, ginkgo, and licorice on a regular basis. Which p
atient statement indicates a need for health teaching about potential drug inter
actions?
a.""Aloe decreases the effect of my digoxin.""
b.""Ginkgo decreases the effects of my antiepileptics.""
c.""Licorice increases the effect of my digoxin.""
d.""Licorice decreases the effect of my antihypertensives.""
apter 6)"
Answer: A.
"A patient has nine medications prescribed to take daily. Which are common reaso
ns for nonadherence to the drug regimen in the older adult? (Select all that app
ly.)
a.Taking multiple drugs at one time
b.Impaired memory
c.Decreased dexterity
d.Increased mobility
e.Increased visual acuity
apter 8)"
Answers: A, B, C.
"The nurse is reviewing a patient's list of medications with the patient. The nu
rse understands that the older adult's slower absorption of oral medications is
primarily because of which phenomenon?
a.
b.
c.
d.
Decreased
Increased
Decreased
Increased
cardiac output
blood flow
enzyme function
pH of gastric secretions

apter 8)"
Answer: D.
"The older adult patient has questions about oral drug metabolism. What is the m
ost important information to include in this patient's teaching plan?
a.First-pass effect
b.Enzyme function
c.Glomerular filtration rate
d.Motility
apter 8)"
Answer: A.
"A 97-year-old patient asks why a protein supplement has been prescribed. What i
s the nurse's best response?
a.""You
b.""You
c.""You
d.""You
have
have
have
have
increased
decreased
decreased
increased
circulation of free drug.""

hepatic size.""
calcium absorption.""
motility.""
apter 8)"
Answer: A.
"An 80-year-old patient complains of recent onset of insomnia, saying, ""If only
I could get to sleep!"" If a drug is prescribed, which drug characteristics wou
ld be best for this situation? (Select all that apply.)
a.
b.
c.
d.
e.
Short-intermediate acting
Rapidly eliminated
Slowly eliminated
Multiple metabolites
Few metabolites

apter 8)"
Answers: A, B, E.
"An older patient has just started on hydrochlorothiazide (HydroDiuril) and is a
dvised by the health care provider to eat foods rich in potassium. What is the n
urse's best recommendation of foods?
a.Cabbage and corn
b.Pineapple and orange juice
c.Bran cereal and raisins
d.Brown rice and fish
apter 8)"
Answer: C.
"Insomnia is a frequent complaint voiced by the patient. What are the most impor
tant elements for the nurse to include in the teaching plan? (Select all that ap
ply.)
a.There are a limited number of FDA-approved medications to treat insomnia.
b.Benzodiazepines with long half-lives are preferred.
c.17% of the older adult population take hypnotics.
d.Temazepam is to be taken 1 to 2 hours before bedtime.
e.Triazolam should be tapered rather than abruptly stopped.
apter 8)"
Answer: A, D, E.
"1. The nurse in the clinical research setting is knowledgeable about ethical pr
inciples and protection of human subjects. What principle is demonstrated when e
nsuring the patient's right to self-determination?
a.Beneficence
b.Autonomy
c.Justice
d.Informed consent
apter 10)"
Answer: B.
"2. The research nurse is meeting with a patient and, based on the assessment, d
etermines that the patient meets the criteria. The patient agrees to participate
in the clinical trial. The nurse advises the patient that which member of the h
ealth care team has the responsibility to explain the study and respond to quest
ions?
a.Registered nurse
b.Pharmacist
c.Research associate
d.Health care provider
apter 10)"
Answer: D.
"3. The clinical research nurse knows that only a small proportion of drugs surv
ives the research and development process. An appreciation of the process and as
sociated costs grows when the nurse is aware that approximately one in how many
potential drugs is actually used in clinical situations?
a.100
b.1000
c.10,000
d.100,000
apter 10)"
Answer: C.
"4. The nurse is interviewing a patient in a Phase I clinical trial. Which patie
nt statement indicates an understanding of this trial phase?
a.
b.
c.
d.
""I
""I
""I
""I
am doing this to be sure this drug is safe.""

am doing this to be sure this drug is efficacious.""
hope this drug has no side effects.""
can be part of demonstrating a cure.""

apter 10)"
Answer: A.
"5. The nurse is reviewing the protocols associated with a triple-blind study. T
he nurse understands that this technique is preferred in clinical trials because
it removes which factor?
a.Knowledge
b.Conflicts
c.Prejudice
d.Bias
apter 10)"
Answer: D.
"6. The foundation of clinical trials, Good Clinical Practice (GCP) is a helpful
resource for nurses. The nurse is correct in choosing GPC as a reference for st
andards in which areas? (Select all that apply.)
a.Design and performance
b.Monitoring and auditing
c.Analyses
d.Reporting
e.Outcomes evaluation
(Kee: Pharmacology, A Patient-Centered Nursing
apter 10)"
Answers: A, B, C, D.
"7. The nurse has an important role in working
that require informed consent. The patient and
mensions of informed consent. Which dimensions
ply.)
a.
b.
c.
d.
e.
Process Approach, 8th Edition, Ch

with patients on aspects of care
the nurse must be aware of the di
are included? (Select all that ap
Protection of subjects from harm

Promotion of finding cure of disease
Protection of patient's self-determination
Promotion of patient's educated decision making
Promotion of individual autonomy

apter 10)"
Answers: A, C, D, E.
"8. The nurse researcher reviews the proposed informed consent form for a future
clinical trial. The nurse expects to find which in the document? (Select all th
at apply.)
a.Description of benefits and risks
b.Identification of related drugs, treatments, and techniques
c.Description of outcomes
d.Statement of compensation for participants, if any
e.Description of serious risks
apter 10)"
Answers: A, B, D, E.
"9. The nurse knows that the patient should be informed about available alternat
ives and consequences. What ethical principle does this describe?
a.Respect for persons
b.Veracity
c.Justice
d.Beneficence
apter 10)"
Answer: A.
"A patient needs to learn to use a walker. Which domain is required for learning
this skill?
A.
B.
C.
D.
Affective domain
Cognitive domain
Attentional domain
Psychomotor domain

"Answer: D.
Using a walker requires the integration of mental and muscular activity."
"The nurse is planning to teach a patient about the importance of exercise. When
is the best time for teaching to occur? (Select all that apply.)
A.
B.
C.
D.
When
When
Just
When
there are visitors in the room

the patient's pain medications are working
before lunch, when the patient is most awake and alert
the patient is talking about current stressors in his or her life

"Answer: B, C.
Plan teaching when the patient is most attentive, receptive, alert, and comforta
ble."
"A patient newly diagnosed with cervical cancer is going home. The patient is av
oiding discussion of her illness and postoperative orders. What is the nurse's b
est plan in teaching this patient?
A.
B.
C.
D.
Teach the patient's spouse

Focus on knowledge the patient will need in a few weeks
Provide only the information that the patient needs to go home
Convince the patient that learning about her health is necessary

"Answer: C.
This patient is in denial; thus it is appropriate to only give her information t
hat is needed immediately."
"The school nurse is about to teach a freshman-level high school health class ab
out nutrition. What is the best instructional approach to ensure that the studen
ts meet the learning outcomes?
A. Provide information using a lecture
B. Use simple words to promote understanding
C. Develop topics for discussion that require problem solving
D. Complete an extensive literature search focusing on eating disorders

"Answer: C.
Adolescents learn best when they are able to use problem solving to help them ma
ke choices."
"A nurse is going to teach a patient how to perform breast self-examination. Whi
ch behavioral objective does the nurse set to best measure the patient's ability
to perform the examination?
A. The patient will verbalize the steps involved in breast self-examination with
in 1 week.
B. The nurse will explain the importance of performing breast self-examination o
nce a month.
C. The patient will perform breast self-examination correctly on herself before
the end of the teaching session.
D. The nurse will demonstrate breast self-examination on a breast model provided
by the American Cancer Society.
"Answer: C.
Return demonstration provides an excellent source of feedback and reinforcement
to evaluate learning."
"A patient with chest pain is having an emergency cardiac catheterization. Which
teaching approach does the nurse use in this situation?
A.
B.
C.
D.
Telling approach
Selling approach
Entrusting approach
Participating approach

"Answer: A.
The telling approach is most appropriate when preparing a patient for an emergen
cy procedure."
"The nurse is teaching a parenting class to a group of pregnant adolescents. The
nurse pretends to be the baby's father, and the adolescent mother is asked to s
how how she would respond to the father if he gave her a can of beer. Which teac
hing approach did the nurse use?
A. Role play
B. Discovery
C. An analogy
D. A demonstration
"Answer: A.
In role play people are asked to play themselves or someone else in a situation
to enhance their confidence in handling that situation in the future."
"An older adult is being started on a new antihypertensive medication. In teachi
ng the patient about the medication, the nurse:
A. Speaks loudly.
B. Presents the information once.
C. Expects the patient to understand the information quickly.
D. Allows the patient time to express himself or herself and ask questions.
"Answer: D.
When teaching older adults, it is important to establish rapport, involve them i
n their care, and allow them to progress at their own pace."
"A patient needs to learn how to administer a subcutaneous injection. Which of t
he following reflects that the patient is ready to learn?
A. Describing difficulties a family member has had in taking insulin
B. Expressing the importance of learning the skill correctly
C. Being able to see and understand the markings on the syringe
D. Having the dexterity needed to prepare and inject the medication

"Answer: B.
Patients are ready to learn when they understand the importance of learning and
are motivated to learn."
"A patient who is hospitalized has just been diagnosed with diabetes. He is goin
g to need to learn how to give himself injections. Which teaching method does th
e nurse use?
A. Simulation
B. Demonstration
C. Group instruction
D. One-on-one discussion
"Answer: B.
Demonstration is used to help patients learn psychomotor skills."
"When a nurse is teaching a patient about how to administer an epinephrine injec
tion in case of a severe allergic reaction, he or she tells the patient to hold
the injection like a dart. Which of the following instructional methods did the
nurse use?
A. Telling
B. Analogy
C. Demonstration
D. Simulation
"Answer: B.
Analogies use familiar images when teaching to help explain complex information.
"
"A nurse needs to teach a young woman newly diagnosed with asthma how to manage
her disease. Which of the following topics does the nurse teach first?
A. How to use an inhaler during an asthma attack
B. The need to avoid people who smoke to prevent asthma attacks
C. Where to purchase a medical alert bracelet that says she has asthma
D. The importance of maintaining a healthy diet and exercising regularly
"Answer: A.
It is important to start with essential life-saving information when teaching pe
ople because they usually remember what you tell them first."
"A nurse is teaching a group of young college-age women the importance of using
sunscreen when going out in the sun. What type of content is the nurse providing
?
A. Simulation
B. Restoring health
C. Coping with impaired function
D. Health promotion and illness prevention
"Answer: D.
Health promotion and illness prevention are the focus when nurses provide inform
ation to help patients improve their health and avoid illness."
"A nurse is planning a teaching session about healthy nutrition with a group of
children who are in first grade. The nurse determines that after the teaching se
ssion the children will be able to name three examples of foods that are fruits.
This is an example of:
A. A teaching plan.
B. A learning objective.
C. Reinforcement of content.
D. Enhancing the children's self-efficacy.
"Answer: B.
A learning objective describes what the learner will do after the teaching sessi
on."
"A nurse is teaching a 27-year-old gentleman how to adjust his insulin dosages b
ased on his blood sugar results. What type of learning is this?

A. Cognitive
B. Affective
C. Adaptation
D. Psychomotor
"Answer: A.
Cognitive learning requires thinking; learning how to adjust insulin requires an
alysis, synthesis, and evaluation, which are all types of cognitive learning."

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(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

A seaweed derivative that is highly absorptive

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

Collection of wound drainage

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

Skin integrity at bony prominences, including any wounds

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

A surgical wound infection usually develops postoperatively within 14 days.

Distention or swelling of the affected body part

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

An 80-year-old man who has a burn

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

and partial-thickness wounds heal more efficiently in a moist, protected enviro

These are expected findings for this postoperative time period.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

be alert for an increase in serosanguineous drainage from th

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

""I should empty the drain when it is one-half to two-thirds full.""

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

When there is a change in color, amount, or odor of drainage

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

e for the nurse's inspection and changing of the drainage sponges."

Emptying a closed drainage container

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

and infected wound from a spider bite

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

Switch to the white polyvinyl alcohol (PVA) soft foam.

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

doctor will give you a referral to a home care facility.""

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

nt in pressure ulcer development include poor nutrition, advanced age, medical c

full-thickness pressure ulcer

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

A BMI (body mass index) of 35 (elevated)

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

Maintaining a moist environment

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

Turning patients at least every 2 hours

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

om and then clean the drain site."

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

support healing by enabling granulation tissue to grow

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

(Potter: Fundamentals of Nursing, 8th Edition, Chapter 48)"

During the first 24 to 48 hours after surgery.