Results for Lesson 7: Reduction of Risk Potential

Questions are numbered by the order in which they appeared in the test.
Represents the correct answer.
Question 1
A 60 year-old male client had a hernia repair in an Answers Correct C
outpatient surgery clinic. He is awake and alert, but has not Student's C
been able to void since he returned from surgery 6 hours
ago. He received 1000 mL of IV fluid. Which action would
be most likely to help him void?
A) Have him drink several glasses of water
Perform Credé's method on the bladder from the
B)
bottom to the top
C) Assist him to stand by the side of the bed to void
D) Wait 2 hours and have him try to void again
Review Information: The correct answer is C: Assist him to stand by the side of the
bed to void
When a male is not able to use a urinal unassisted, the client should stand by the side
of the bed to void. This is the most desirable position for normal voiding for male
clients. Also, given his age, he most likely has some degree of prostate enlargement
which may interfere with voiding.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Question 2
A nurse checks a client who is on a volume-cycled Answers Correct D
ventilator. Which finding indicates that the client may need Student's D
suctioning?
A) Drowsiness
B) Complaint of nausea
C) Pulse rate of 82
D) Restlessness
Review Information: The correct answer is D: Restlessness
Restlessness, increased heart and respiratory rates, and noisy expiration suggest
hypoxia and are indications for suctioning.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA:

Thompson Delmar Learning.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Question 3
A nurse is to collect a sputum specimen for acid-fast Answers Correct D
bacillus (AFB) from a client. Which action should the Student's B
nurse take first?
A) Ask client to cough sputum into container
B) Have the client take several deep breaths
C) Provide a appropriate specimen container
D) Assist with oral hygiene
Review Information: The correct answer is D: Assist with oral hygiene
Obtain a specimen early in the morning after mouth care. The other responses follow
this first action: the client should take several deep breaths then cough into the
appropriate sterile container to obtain the AFB specimen of the sputum.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA:

Thompson Delmar Learning.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Question 4
A client is diagnosed with a spontaneous pneumothorax Answers Correct B
necessitating the insertion of a chest tube. What is the best Student's B
explanation for the nurse to provide this client?
A) "The tube will drain fluid from your chest."
B) "The tube will remove excess air from your chest."
"The tube controls the amount of air that enters your
C)
chest."
D) "The tube will seal the hole in your lung."
Review Information: The correct answer is B: "The tube will remove excess air from
your chest."
The purpose of the chest tube is to create negative pressure and remove the air that has
accumulated in the pleural space.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.
Question 5
The nurse is preparing a client who will undergo a Answers Correct B
myelogram. Which of the following statements by the Student's B
client indicates a contraindication for this test?
"I can't lie in one position for more than thirty
A)
minutes."
B) "I am allergic to shrimp."
C) "I suffer from claustrophobia."
D) "I developed a severe headache after a spinal tap."
Review Information: The correct answer is B: "I am allergic to shrimp."
A client undergoing myelography should be questioned carefully about allergies to
iodine and iodine-containing substances such as seafood. An allergy to iodine or
seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An
allergic reaction could even include seizures.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Question 6
The nurse is performing a physical assessment on a client Answers Correct C
who just had an endotracheal tube (ET) inserted. Which Student's C
finding would call for immediate action by the nurse?
A) Breath sounds can be heard bilaterally
B) Mist is visible in the T-Piece
C) Pulse oximetry of 88 BPM
D) Client is unable to speak
Review Information: The correct answer is C: Pulse oximetry of 88 BPM
Pulse oximetry should not be lower than 90. Placement of the ET will need to be
checked, along with the ventilator settings.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Question 7
A 4 year-old has been hospitalized for 24 hours with Answers Correct A
skeletal traction for treatment of a fracture of the right Student's A
femur. The nurse finds that the child is now crying and the
right foot is pale with the absence of a pulse. What should
the nurse do first?
A) Notify the health care provider
B) Readjust the traction
C) Administer the ordered prn medication
D) Reassess the foot in fifteen minutes
Review Information: The correct answer is A: Notify the health care provider
The findings are indicative of circulatory impairment. The health care provider (or
practitioner) must be notified immediately.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s
Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their
families. USA: Thompson, Delmar, Learning.

Question 8
The nurse is reviewing laboratory results on a client with Answers Correct D
acute renal failure. Which one of the following should be Student's D
reported immediately?
A) Blood urea nitrogen 50 mg/dl
B) Hemoglobin of 10.3 mg/dl
C) Venous blood pH 7.30
D) Serum potassium 6 mEq/L
Review Information: The correct answer is D: Serum potassium 6 mEq/L
Although all of these findings are abnormal, the elevated potassium level is a life
threatening finding and must be reported immediately.

Daniels, R. (2003). Delmar’s manual of laboratory and diagnostic tests. USA:

Thompson Delmar Learning.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Question 9
The nurse is caring for a client who requires a mechanical Answers Correct B
ventilator for breathing. The high pressure alarm goes off Student's B
on the ventilator. What is the first action the nurse should
perform?
Disconnect the client from the ventilator and use a
A)
manual resuscitation bag
B) Perform a quick assessment of the client's condition
C) Call the respiratory therapist for help
D) Press the alarm re-set button on the ventilator
Review Information: The correct answer is B: Perform a quick assessment of the
client''s condition
A number of situations can cause the high pressure alarm to sound. It can be as simple
as the client coughing. A quick assessment of the client will alert the nurse to whether
it is a more serious or complex situation that might then require using a manual
resuscitation bag and calling the respiratory therapist.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Question 10
To prevent unnecessary hypoxia during suctioning of a Answers Correct A
tracheostomy, the nurse must Student's A
A) apply suction for no more than 10 seconds
B) maintain sterile technique
C) lubricate 3 to 4 inches of the catheter tip
D) withdraw catheter in a circular motion
Review Information: The correct answer is A: apply suction for no more than 10
seconds
Applying suction for more than 10 seconds may result in hypoxia. Although options
B, C, and D are important in during suctioning a tracheostomy, hypoxia results from
actions that decrease the oxygen supply.

Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Question 11
A client has a history of chronic obstructive pulmonary Answers Correct C
disease (COPD). As the nurse enters the client's room, his Student's C
oxygen is running at 6 liters per minute, his color is
flushed and his respirations are 8 per minute. What should
the nurse do first?
A) Obtain a 12-lead EKG
B) Place client in high Fowler's position
C) Lower the oxygen rate
D) Take baseline vital signs
Review Information: The correct answer is C: Lower the oxygen rate
A low oxygen level acts as a stimulus for respiration. A high concentration of
supplemental oxygen removes the hypoxic drive to breathe, leading to increased
hypoventilation, respiratory decompensation, and the development of or worsening of
respiratory acidosis. Unless corrected, it can lead to the client''s death.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Question 12
A client is receiving external beam radiation to the Answers Correct B
mediastinum for treatment of bronchial cancer. Addressing Student's B
which of the following should take priority in planning
care?
A) Esophagitis
B) Leukopenia
C) Fatigue
D) Skin irritation
Review Information: The correct answer is B: Leukopenia
Clients develop leukopenia due to the depressant effect of radiation therapy on bone
marrow function. Infection is the most frequent cause of morbidity and death in clients
with cancer.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Question 13
The nurse is caring for a child immediately after surgical Answers Correct B
correction of a ventricular septal defect. Which of the Student's B
following nursing assessments should be a priority?
A) Blanch nail beds for color and refill
B) Assess for post-operative arrhythmias
C) Auscultate for pulmonary congestion
D) Monitor equality of peripheral pulses
Review Information: The correct answer is B: Assess for post-operative arrhythmias
The atrioventricular bundle (bundle of His), a part of the electrical conduction system
of the heart, extends from the atrioventricular node along each side of the
interventricular septum and then divides into right and left bundle branches. Surgical
repair of a ventricular septal defect consists of a purse-string approach or a patch sewn
over the opening.

Hockenberry, M.J., Wilson, D., Winklestein, M.L., & Kline, N.E. (2003). Wong’s
Nursing Care of Infants and Children, (7th ed). St. Louis: Mosby.

Potts, N.L. and Mandleco, B.L. (2002). Pediatric nursing, caring for children and their
families. USA: Thompson, Delmar, Learning.

Question 14
A client has returned from a cardiac catheterization. Which Answers Correct C
one of the following findings would indicate the client is Student's C
experiencing a complication from the procedure?
A) Increased blood pressure
B) Increased heart rate
C) Loss of pulse in the extremity
D) Decreased urine output
Review Information: The correct answer is C: Loss of pulse in the extremity
Loss of the pulse in the extremity would indicate impaired circulation.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Question 15
The nurse is caring for a client undergoing the placement Answers Correct C
of a central venous catheter line. Which of the following Student's C
would require the nurse’s immediate attention?
A) Pallor
B) Increased temperature
C) Dyspnea
D) Involuntary muscle spasms
Review Information: The correct answer is C: Dyspnea
Client’s having the insertion of a central venous catheter are at risk for tension
pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this
complication.

Kidd, P.S. & Wagner, R.D. (2001). High Acuity Nursing, (3rd ed). Upper Saddle
River, NJ: Prentice-Hall.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Question 16
The nurse is assessing a client 2 hours postoperatively after Answers Correct C
a femoral popliteal bypass. The upper leg dressing Student's C
becomes saturated with blood. The nurse's first action
should be to
A) wrap the leg with elastic bandages
B) apply pressure at the bleeding site
C) reinforce the dressing and elevate the leg
D) remove the dressings and re-dress the incision
Review Information: The correct answer is C: reinforce the dressing and elevate the
leg
The interventions that must be taken are: reinforce the dressing, elevate the extremity
to decrease blood flow into the extremity and thus decrease bleeding, and call the
provider immediately. This is an emergency post surgical situation.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Question 17
The provider order reads "Aspirate nasogastric (NG) Answers Correct A
feeding tube every 4 hours and check pH of aspirate." The Student's A
pH of the aspirate is 10. Which action should the nurse
take?
A) Hold the tube feeding and notify the provider
B) Administer the tube feeding as scheduled
C) Irrigate the tube with diet cola soda
D) Apply intermittent suction to the feeding tube
Review Information: The correct answer is A: Hold the tube feeding and notify the
provider
A pH of less than 4 indicates that the tube is appropriately placed in the stomach, a
highly acidic environment. A pH higher than 4 (alkaline pH) indicates intestinal
placement.
Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Cavanaugh, B. M. (2003). Nurse’s manual of laboratory and diagnostic tests, 4th ed.
Philadelphia: Davis.

Question 18
A client has a chest tube inserted following a left lower Answers Correct D
lobectomy required by a stab wound to the chest. While Student's D
repositioning the client, the nurse notices 200 cc of dark,
red fluid flows into the collection chamber of the chest
drain. What is the most appropriate nursing action?
A) Clamp the chest tube
B) Call the surgeon immediately
C) Prepare for blood transfusion
D) Continue to monitor the rate of drainage
Review Information: The correct answer is D: Continue to monitor the rate of
drainage
It is not unusual for blood to collect in the chest and be released into the chest drain
when the client changes position. The dark color of the blood indicates it is not fresh
bleeding inside the chest.

Altman, G. (2004). Delmar’s Fundamental and Advanced Nursing Skills, 2nd ed.
Albany, NY: Delmar.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Question 19
The most effective nursing intervention to prevent Answers Correct B
atelectasis from developing in a post-operative client is to Student's B
A) maintain adequate hydration
B) assist client to turn, deep breathe, and cough
C) ambulate client within 12 hours
D) splint incision
Review Information: The correct answer is B: assist client to turn, deep breathe, and
cough
Deep air excursion by turning, deep breathing, and coughing will expand the lungs
and stimulate surfactant production. The nurse should instruct the client on how to
splint the chest when coughing. Humidification, hydration and nutrition all play a part
in preventing atelectasis following surgery.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.
Potter P. and Perry, A. (2005). Fundamental of Nursing. (6th Edition). St. Louis,
Missouri: Mosby.

Question 20
When caring for a client with a post-right thoracotomy Answers Correct B
who has undergone an upper lobectomy, the nurse focuses Student's B
on pain management to promote
A) relaxation and sleep
B) deep breathing and coughing
C) incisional healing
D) range of motion exercises
Review Information: The correct answer is B: deep breathing and coughing
The priority is preventing postoperative respiratory complications. This client will
quickly develop profound atelectasis and eventually pneumonia without adequate gas
exchange. Client compliance with recommended deep breathing and coughing
exercises will only be achieved with the appropriate pain management.

Lewis, S.M., Heitkemper, M.M., & Dirksen, S. R. (2004). Medical-Surgical Nursing:

Assessment & management of clinical problems. St. Louis: Mosby.

Smeltzer, S.C. and Bare, B.G. (2004). Medical surgical nursing. (10th edition).
Philadelphia, PA. Lippincott Williams & Wilkins.