Ostomy Post Quiz 1) Name some reasons why ostomy surgery may be needed.

a) colon cancer b) abdominal trauma c) diverticulitis d) congenital defect e) bladder cancer f) all of these 2) When a patient has a double barrel ostomy, one stoma is pouched to hold stool and the other stoma is a) for irrigation b) a mucous fistula c) covered with gauze d) both b & c 3) A loop ostomy can also be called a a) double barrel b) end ostomy c) temporary ostomy 4) If your patient has a purple, blue, or black stoma you should a) change to a different type of pouch b) report to MD c) recheck on next shift d) do nothing, this is normal 5) mechanical breakdown to be added later 6) Treatment for mechanical breakdown is a) make sure peristomal skin is dry b) change pouch 1 - 2 times per week c) to hire a mechanic d) both a & b 7) A rash could be caused by a) allergy to pouch adhesive b) allergy to tape border of pouch c) fungus d) all of these 8) Foods that thicken stool are

a) rice b) applesauce c) toast d) marshmellows e) all of these 9) foods that cause gas are a) corn b) beans c) cheese d) peas e) all of these 10) Foods that can cause blockage for those with an ileostomy are a) corn b) dried fruit c) celery d) popcorn e) nuts f) all of these 11) The United Ostomy Association is a) a support group b) both a & c c) an association whose members visit new ostomy patients 12) What are the parts of the small intestine a) duodenum b) jejunum c) ileum d) colon e) all f) all except d 13) What medications may be contraindicated for an ileostomate a) laxatives b) timed released medications c) antacids d) enteric coated e) all of these 14) What type of colostomy can be irrigated a) any b) sigmoid

c) ileostomy d) urostomy 15) what are some contraindications for irrigating a) young age b) diarrhea c) hernia d) transverse colostomy e) all of these 16) What devices can you use to help get rid of gas from a pouch besides opening the pouch up? A) osto eze b) filters 17) What are some products that help reduce or eliminate odor a) na scent b) spray deoderizers c) M9 d) all of these 18) who makes support belts for the ostomate in different widths and lengths a) Marlen b) Coloplast c) Nu Hope 19) The type of pouch used for a urostomy is a a) drainable pouch b) leg bag c) closed end 20) what can you use for a patient with a hernia a) a drainable pouch b) a hernia support belt c) an irrigation sleeve 21) What should a urostomy patient use when sleeping a) leg bag b) adapter c) night drainage d) b & c

22) Every time an ostomate leaves his or her home they should take a) biohazard bag b) everything they need to be able to change their pouch and a plastic bag 23) when should a pouch be emptied a) when full b) when full c) when full 24) The best time to change a pouch is a) when stoma is less active such as 2 hours after a meal b) right after a shower 25) Melt down or undermining is a) when seal or barrier is broken b) when it is hot and melts the pouch 26) The best way to tell if you have undermining is a) by looking at pouch seal to see if area is brown b) look where seal was after taking off pouch to see if there is stool there c) both a & b 27) A sign of impending leakage or undermining is a) itching b) burning c)odor d) all of these 28) What does the small intestine do a) absorbs water b) digests fats and carbohydrates c) absorbs some vitamins d) b & c True or Fal The Patient with an Ostomy Written by Administrator Friday, 01 April 2011 23:06

MULTIPLE CHOICE 1. The nurse explains that an artificial opening into a body cavity is a(n): 1. gastrostomy. 2. ostomy. 3. colonoscopy. 4. ureterostomy. ANS: 2 An ostomy is an artificial opening into a body cavity. PTS: 1 DIF: Cognitive Level: Knowledge REF: 396 OBJ: 3 TOP: Terminology KEY: Nursing Process Step: Implementation MSC: NCLEX: N/A 2. The colostomy patient is instructed to measure the width of the stomas for the first 6 weeks postoperatively before applying each new pouch because: 1. the stoma will shrink during this time. 2. a poor-fitting pouch will cause infection of the stoma. 3. the paste will not adhere. 4. prolapse will result. ANS: 1 During the first 6 weeks, the stoma normally shrinks. The pouch needs to fit as closely to the stoma as is comfortable and safe to prevent skin irritation. PTS: 1 DIF: Cognitive Level: Application REF: 406 OBJ: 4 TOP: Pouch Fit KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 3. A 47-year-old patient who is 3 days postsurgery with a permanent colostomy reports some abdominal discomfort and abdominal rigidity. The assessment that the nurse should report and record is: 1. vital signstemperature, 100; pulse, 92; blood pressure, 160/98. 2. stoma is swollen and red; small amount of blood at base. 3. pouch drainage of 110 mL green-brown liquid, oozing from pouch edges. 4. stoma is protruding. ANS: 1 Vital signs in conjunction with complaint of abdominal discomfort should be reported and recorded as possible signs of impending peritonitis. PTS: 1 DIF: Cognitive Level: Application REF: 403 OBJ: 4 TOP: Signs of Peritonitis in a Postoperative Colostomy Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse is aware that many ostomates have an altered self-image, which may cause: 1. self-care deficits.

2. sexual dysfunction. 3. nonadherence to diet. 4. irrational anger. ANS: 2 A damaged self-image or body image may cause ostomates to feel unattractive and embarrassed about possible sexual activity. Open-ended questions assist the patient to talk about their feelings. PTS: 1 DIF: Cognitive Level: Application REF: 400 and 410 OBJ: 4, 7 TOP: Self-Concept Issues in an Ostomate KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity 5. To ensure a good fit of the appliance to avoid leakage, which of the following should the nurse consider for pouch placement? 1. Place the pouch only when the patient is lying down. 2. The pouch placement should be checked for sitting comfort, standing comfort, and ambulation. 3. The pouch should fit very snugly to edges of stoma. 4. The pouch must cover the entire abdomen. ANS: 2 Placement of the pouch should be comfortable in all positions, but not too snug on the stoma for fear of laceration. The pouch need only cover enough of the abdomen to allow for a firm fit. PTS: 1 DIF: Cognitive Level: Application REF: 399 OBJ: 4 TOP: Placement of the Stoma KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 6. In assisting a colostomy patient choose an appropriate diet with little risk of excess gas or diarrhea, the nurse would encourage the patient to choose: 1. roast beef, mashed potatoes, peeled stewed tomatoes. 2. broiled pork chop, boiled potato, corn on the cob. 3. broiled trout, mashed potatoes, spinach. 4. BBQ on white bun, coleslaw, French fries. ANS: 1 Gas-forming or spicy foods and roughage, such as corn, fish, and cabbage, usually cause gas and diarrhea. PTS: 1 DIF: Cognitive Level: Analysis REF: 403-404 OBJ: 7 TOP: Ostomy Nutrition Teaching KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 7. A patient who has had a temporary colostomy to rest his ulcerated bowel says, I dont know how I will continue to work at my job with this thing stuck to my stomach. The nurses best response to stimulate communication would be:

1. This is only a temporary adjustment for you and the colostomy will be reanastomosed in less than 6 months. 2. A nurse with special training will be in to help you. 3. What is there about your job that you feel you cannot do? 4. Many people feel as you do, but they learn to dress and act and work just like they did before the surgery. ANS: 3 Open-ended questions without prejudgment or belittling encourage the patient to identify sources of anxiety and help the patient cope with, adapt to, or problemsolve stressful events. PTS: 1 DIF: Cognitive Level: Comprehension REF: 407, Nursing Care Plan OBJ: 2 TOP: Interpersonal Communication Skills KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 8. The nurse explains to a preoperative patient that a J-pouch anal anastomosis procedure has the primary advantage of: 1. no odor. 2. easier to irrigate. 3. near-normal bowel elimination. 4. less problem with diarrhea. ANS: 3 Preoperative teaching includes the expectation of near-normal bowel elimination. As with any bowel elimination, there will be odor and possibly occasional diarrhea. There is no need for an irrigation. PTS: 1 DIF: Cognitive Level: Comprehension REF: 401 OBJ: 2 TOP: Preoperative Teaching for J-pouch KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 9. In postoperative teaching to a ureterotomy patient, the nurse would include information pertaining to: 1. significance of ureteral catheter for the first week. 2. appropriate use of karaya gum products. 3. daily pouch change schedule. 4. changing pouch in the evening before bedtime. ANS: 1 Information about the ureteral catheter, which will be in place for the first week, is important. Karaya gum products are not used for urinary appliances because urine breaks down the karaya. Pouches are changed only every 4 to 6 days to prevent skin irritation. The pouch is best changed in the morning. PTS: 1 DIF: Cognitive Level: Application REF: 412 OBJ: 4 TOP: Postoperative Teaching to Ureterotomy Patient KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

10. An ostomate asks the nurse what limitations must be observed in the immediate postoperative period when at home. The most informative information that the nurse can share is: 1. avoidance of heavy lifting for at least 3 months. 2. limit fluid intake to no more than 1000 mL/day. 3. wear loose clothing, without belts or elastic. 4. cover your appliance with plastic sheeting while showering. ANS: 1 Avoidance of heavy lifting for 3 months is advised. Ostomates should take in at least 2000 mL of fluid every day. They may wear ordinary clothes that dont bind the stoma. Showering is allowed, because the appliance is waterproof. PTS: 1 DIF: Cognitive Level: Application REF: 401, Patient Teaching Plan OBJ: 7 TOP: Postoperative Limitations for Ostomates KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 11. The colostomy patient continues to worry about odor. The nurse can help allay those concerns by explaining that odor: 1. only occurs when changing the colostomy appliance. 2. is caused by certain foods that can be omitted from the diet. 3. is mainly caused by poor hygiene and can be remedied. 4. is far more noticeable to the patient than to others. ANS: 2 The problem of odor is a frequent cause of anxiety to the colostomy patient. Gas is the main cause of odor production. Omission of gas-causing foods can reduce gas and odor, mainly by the trial and error method. Odor is noticeable to both the patient and others. PTS: 1 DIF: Cognitive Level: Application REF: 403-404 OBJ: 7 TOP: Controlling Odor from a Colostomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 12. Common surgeries to divert urine may include cutaneous ureterostomy, ileal conduit, and ureteroileostomy. In developing a nursing care plan for any of these patients, the concept that is common to them all is that: 1. a ureterostomy is smaller and lighter in color than an intestinal stoma and urine drainage is expected to be expelled through the stoma continuously. 2. the drainage pouch is cleaned with sterile water and soap only, regardless of how foul the odor has become. 3. the patient should be encouraged to drink about 750 mL water daily. 4. the urine will leak through the pouch at night, so care must be taken to protect the bedclothes.

ANS: 1 To develop an effective plan of care, the nurse must be knowledgeable about surgical procedures and expected outcomes. PTS: 1 DIF: Cognitive Level: Comprehension REF: 409 OBJ: 6 TOP: Care Plan Development KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 13. The nurse caring for a 2-day postoperative colostomy patient should report immediately if a stoma is assessed as: 1. beefy and red. 2. having swelling. 3. having a small amount of bleeding around it. 4. blue-tinged. ANS: 4 A stoma should be beefy red. Blue or black coloration is an indication of poor circulation and should be reported immediately. Swelling and a small amount of blood around the stoma are normal in early postoperative days. PTS: 1 DIF: Cognitive Level: Application REF: 398 OBJ: 4 TOP: Stoma Assessment in Colostomy KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 14. A baby born without a urinary bladder has a cutaneous ureterostomy with one stoma and a cutaneous ureterostomy has been surgically created. There is one stoma. Discussion with the childs family regarding care should include which of the following? 1. This urinary diversion is permanent and urine will drain from it continuously. 2. In the future, there will be a second surgery to offer an exit for the urine from the other kidney. 3. This pouch needs to be changed only about once a week. 4. You should notify the surgeon if the stoma becomes paler in color. ANS: 1 The babys ureterostomy and drainage of urine are constant. This is a permanent solution because of the lack of a bladder. Both ureters are joined for urine release through the stoma. The pouch will be on continuously and needs to be changed as needed several times a day. PTS: 1 DIF: Cognitive Level: Application REF: 409 OBJ: 5 TOP: Congenital Indications and Outcomes for Cutaneous Ureterostomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 15. The initial assessment of a patient just returned from surgery for creation of an Indiana pouch would include: 1. drainage of urine from the Penrose drain at the operative site. 2. the condition and color of the stoma 3. the appearance of mucus in the urine.

4. copious and odorous urine drainage from the incision. ANS: 1 Indiana pouches initially have a Penrose drain to drain the small amount of urine; it will have mucus in it, but no odor. There is no stoma to observe. Irrigations may be necessary to remove clots and mucus. PTS: 1 DIF: Cognitive Level: Analysis REF: 413 OBJ: 3 TOP: Assessment of New Postoperative Patient KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment 16. The patient says, I hate this yucky paste under my appliance. I think I will just tape it on. The nurses most informative response to this remark would be which of the following? 1. Taping will not work! 2. Taping will not seal the wafer tight enough to prevent leakage or fill in creases. 3. Taping with waterproof tape is just as effective as the paste. 4. Taping is far more irritating to the skin than the paste would be. ANS: 2 Reminding that the paste both bonds and waterproofs is the best information. PTS: 1 DIF: Cognitive Level: Comprehension REF: 409 OBJ: 7 TOP: Function of Paste on Ostomy Appliance KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 17. The patient comes to the industrial nurse and is frantic because the stoma to the colostomy has prolapsed after 1 year postsurgery. The nurses best counsel would be which of the following? 1. If there are still feces coming from the stoma, it is not blocked. Contact your surgeon for an evaluation. 2. You must come in immediately, because the stoma may completely retract into your abdomen. 3. This is an emergency situation, because it has stenosed. 4. Dont worry about that. Coughing or sneezing might have caused the prolapse. It will come back out in a few hours. ANS: 1 The prolapse of a stoma is very disturbing to a client. The condition should be evaluated by the surgeon, but if the stoma is still patent, there is no need for emergency implementation. Prolapse can be caused by coughing or sneezing, but the stoma will still need evaluation. PTS: 1 DIF: Cognitive Level: Comprehension REF: 405 OBJ: 7 TOP: Stomal Prolapse KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 18. A patient is receiving discharge instructions. He shares with the nurse

that he intends to do a lot of traveling. Instructions for travel should include which of these points? 1. Pack plenty of extra colostomy supplies in your checked airline luggage. Some places you might visit do not always carry those supplies you will need. 2. Exercise caution with new foods, especially local fruits and vegetables, because they may cause diarrhea or gas. 3. If visiting somewhere where drinking local water is not advised, it is still all right to irrigate the colostomy with the local water. 4. Repeat back to me what we just talked about so that you will be sure and remember carefully everything you have been taught. ANS: 2 Warning about foods in a different country is appropriate. Supplies should be placed in a carry-on bag for quick access or in the case of lost luggage. Water that is not safe to drink is not appropriate as irrigation fluid. PTS: 1 DIF: Cognitive Level: Application REF: 412 OBJ: 7 TOP: Discharge Instructions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 19. The nurse caring for the immediate postoperative patient with an ileal conduit should report and/or intervene for: 1. lack of bowel sounds. 2. distended abdomen. 3. mucus present in the urine. 4. small amount of blood in the drainage. ANS: 2 The distended abdomen suggests that the GI suction is not effective to prevent bowel distention. The nurse must check the efficiency of the suction. Lack of bowel sounds, mucus in the urine, and a small amount of blood in the drainage is to be expected as normal postoperative assessments. PTS: 1 DIF: Cognitive Level: Application REF: 412 OBJ: 3 TOP: Postoperative Care of Ileal Conduit KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 20. The patient asks if rectal suppositories can be used to assist with constipation problems with his colostomy. The nurse clarifies that suppositories: 1. can be used in double-barreled colostomies. 2. cannot be used in a stoma. 3. should not ever be used in a colostomy. 4. will not penetrate well enough to relieve constipation. ANS: 2 Suppositories can be used effectively in double-barreled colostomies and in stomas of a single colostomy. PTS: 1 DIF: Cognitive Level: Application REF: 408

OBJ: 7 TOP: Use of Rectal Suppositories KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse identifies an electrolyte imbalance in a preoperative ileostomy patient based on the laboratory values of: 1. Na+, 144 mEq/L; K+, 5 mEq/L; HCO3, 26 mEq/L; poor tissue turgor. 2. Na+, 140 mEq/L; K+, 4.5 mEq/L; HCO3, 28 mEq/L; no nausea or vomiting, request for pain analgesic q5hr. 3. Na+, 160 mEq/L; K+, 2.5 mEq/L; HCO3, 18 mEq/L; confused, and weak. 4. Hct, 41 mL/dL; Hgb, 11 g/dL; WBC, 8000/mm3; shallow rapid respirations. ANS: 3 Normal values of electrolytes are Na+ = 140 mEq/L, K+ = 5 mEq/L, HCO3 = 27 mEq/L. PTS: 1 DIF: Cognitive Level: Analysis REF: 399 OBJ: 2 TOP: Signs of Electrolyte Imbalance KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 22. The best nursing strategy for encouraging ostomy patient self-care would be to: 1. plan to change the pouch when family members will be present, have the patient watch, and listen to the procedure. 2. frequently tell the patient that if he or she does not learn stoma self-care, no one is going to do it for them. 3. encourage the patient to watch the stoma care procedure, gradually encouraging participation. 4. shield the patient from sight of the stoma until the patient actually asks to see it. ANS: 3 The goal for teaching ostomates is to assist them to care for themselves without pressure or forcing. PTS: 1 DIF: Cognitive Level: Analysis REF: 407, Nursing Care Plan OBJ: 4 TOP: Implementing the Teaching Plan to Encourage Self-Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 23. The nurse clarifies that the condition that would necessitate an ostomy would be: 1. tumor obstructing the digestive tract lumen. 2. congenital absence of one ureter. 3. chronic diarrhea. 4. fracture of the pelvis and pubis. ANS: 1 Obstructions in the GI tract are common indications for a colostomy.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 396 OBJ: 1 TOP: Indications for Ostomy Surgery KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 24. The nurse cautions that some adhesive pouch material used to hold the appliance in place may cause: 1. melting of the pouch. 2. excoriation of the stoma. 3. an allergic reaction. 4. unpleasant odor. ANS: 3 Pouch adhesive can cause allergic reactions, but does not melt the pouch or cause odor. Because the paste is not in contact with the stoma, it does not affect the stoma. PTS: 1 DIF: Cognitive Level: Application REF: 399 OBJ: 3 TOP: Responses of Body, Stoma, to Pouch Materials KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 25. The most effective way for a nurse to help provide support to the ostomate patient who has ineffective regimen management is to: 1. ask a volunteer from the American Cancer Society or United Ostomy Association to visit. 2. ask a volunteer from the Reach for Recovery Society to visit. 3. send a close family member for psychiatric counseling. 4. obtain humor books pertaining to illness, such as Anatomy of an Illness, or watch several episodes of Three Stooges on TV. ANS: 1 Contact with persons who have coped with all the aspects of ostomies are excellent resources for the persons with new ostomies. Every effort is made to send a volunteer of the same age and gender. PTS: 1 DIF: Cognitive Level: Comprehension REF: 397 OBJ: 4, 6 TOP: Support for Ostomy Patients KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. The postoperative colostomy ostomate is at risk for loss of fluid volume and electrolyte imbalance. The assessments that indicate such loss are (select all that apply): 1. changing mental status. 2. twitching. 3. poor skin turgor. 4. dry mucous membranes. 5. edema. ANS: 1, 2, 3, 4, 5

All the options are indicators for fluid and electrolyte loss. The loss of base products from the bowel that allow for metabolic acidosis can be a very serious postoperative complication. PTS: 1 DIF: Cognitive Level: Analysis REF: 399 OBJ: 4 TOP: Assessments for Fluid and Electrolyte Loss KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 2. The nurse instructs the patient to be diligent in cleaning fecal matter from around the stoma because the fecal matter can cause (select all that apply): 1. fungal infection. 2. bacterial infection. 3. yeast infection. 4. deterioration of the stoma. 5. odor. ANS: 1, 2, 3, 5 Fecal matter left on the skin and trapped under the pouch can cause fungal, bacterial, and yeast infections as well as odor. PTS: 1 DIF: Cognitive Level: Analysis REF: 399 OBJ: 4 TOP: Cleaning Stoma of Fecal Matter KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. The 1-day postoperative ileostomy patient is concerned about the fact that there has been no drainage from the ileostomy. The nurse reminds the patient that (select all that apply): 1. the drainage does not start until about 24 to 48 hours postsurgery. 2. the first drainage will have blood in it. 3. mucus will be obvious in the early drainage. 4. the first drainage is expelled with a great deal of force. 5. a large amount of flatus will accompany the first drainage. ANS: 1, 2, 3 Drainage does not begin because of the empty bowel prior to surgery. The first drainage appears 24 to 48 hours postsurgery and is accompanied by small amounts of blood and mucus from the bowel. The first drainage is expelled with low pressure and very little, if any, gas. PTS: 1 DIF: Cognitive Level: Analysis REF: 398 OBJ: 1 TOP: Expected Drainage from an Ileostomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse counsels that complications of the continent pouches (Kock and Indiana) may be (select all that apply): 1. incontinence. 2. difficult catheterization. 3. pyelonephritis.

4. rupture of the pouch. 5. peritonitis. ANS: 1, 2, 3 The most frequent complications are incontinence, difficult catheterization, and reflux pyelonephritis. Rupture and peritonitis are not threats to the patient from this surgery. PTS: 1 DIF: Cognitive Level: Analysis REF: 413 OBJ: 7 TOP: Complication of Kock and Indiana Continent Pouches KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity A client suffering with ulcerative colitis has discussed the need for a temporary colostomy to rest the colon and help the healing process. The colostomy will be located in the descending colon. The type of stool that the client can expect from this stoma is:

Liquid that cannot be regulated Malodorous and mushy drainage Increasingly solid Liquid fecal drainage After having a transverse colostomy constructed for colon cancer, discharge planning for home care would include teaching about the ostomy appliance. Information appropriate for this intervention would include: Instructing the client to report redness, swelling, fever, or pain at the site to the physician for evaluation of infection Nothing can be done about the concerns of odor with the appliance. Ordering appliances through the client's health care provider The appliance will not be needed when traveling. The nurse has completed the administration of a cleaning enema for a client being prepared for intestinal surgery. Complete documentation by the nurse of this event includes all but which of the following assessments? (Select all that apply.) Type of solution

Length of time solution retained Relief of flatus and abdominal distention Amount of return Surgical Care Written by Administrator Friday, 01 April 2011 19:15 MULTIPLE CHOICE 1. A postoperative patient is complaining of incisional pain. An order has been given for morphine every 4 to 6 hours PRN. The first assessment by the nurse should be to: 1. assess for the presence of bowel sounds. 2. assess pupillary reaction. 3. ask the patients family if she is having pain. 4. see when the patient last received pain medication. ANS: 4 Verifying the time of the last dose decreases the risk of a dose of medication being given too soon. PTS: 1 DIF: Cognitive Level: Analysis REF: 264 OBJ: 9 TOP: Acute Pain KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment 2. The nurse is admitting a patient who is scheduled for a hysterectomy. Malignant hyperthermia is a potential postoperative complication. In gathering information on the patients medical history, the nurse should ask: 1. Do you think you might have a fever? 2. Do you currently have an infection? 3. Has anyone in your family ever had problems with general anesthesia? 4. Have you ever had any type of malignancy? ANS: 3 Malignant hyperthermia is a life-threatening complication that occurs in response to certain drugs. Susceptibility to this response is inherited. PTS: 1 DIF: Cognitive Level: Analysis REF: 260 OBJ: 7 TOP: General Anesthesia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. A patient who had a hysterectomy yesterday has been NPO. The physician has now ordered the patients diet to be clear liquids. Before administering the diet, the nurse should check for: 1. feelings of hunger. 2. bowel sounds. 3. positive Homans sign.

4. gag reflex. ANS: 2 Absence of bowel sounds would contraindicate a diet. PTS: 1 DIF: Cognitive Level: Application REF: 263 OBJ: 9 TOP: Postoperative Nursing Implementations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The technique the nurse should use to change a postoperative dressing is: 1. enteric isolation. 2. aseptic technique. 3. clean technique. 4. respiratory isolation. ANS: 2 Aseptic technique is important to reduce the risk of infection. PTS: 1 DIF: Cognitive Level: Comprehension REF: 272 OBJ: 9 TOP: Postoperative Risk for Infection KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 5. The nurse is caring for the postoperative patient who has had spinal anesthesia. The nurse would place highest priority on reporting which of these assessments? 1. Complaints of a headache 2. Pulse rate of 78 beats per minute 3. Voided 300 mL 4. Blood pressure of 126/78 ANS: 1 One complication of spinal anesthesia is postspinal headache. It is caused by the leaking of cerebrospinal fluid at the puncture site. PTS: 1 DIF: Cognitive Level: Analysis REF: 259 OBJ: 7 TOP: Regional Anesthesia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 6. The nurse is caring for a postoperative patient. To best prevent deep vein thrombosis (DVT) in this patient, the nurse plans to diligently ensure that the patient: 1. splints the incision. 2. coughs and deep-breathes every 2 hours. 3. regularly removes antiembolism stockings. 4. ambulates frequently. ANS: 4 DVT is best prevented by early and frequent ambulation of the patient. PTS: 1 DIF: Cognitive Level: Application REF: 263

OBJ: 7 TOP: Postoperative Complications KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 7. During the nurses preoperative assessment, the nurse notices that the patient is extremely anxious. The patients blood pressure is 142/92 mm Hg, heart rate is 104 per minute, and respirations are 34. The nurse should: 1. go ahead and give the preoperative medicine early to help calm the patient. 2. call the operating room and cancel the surgery. 3. notify the anesthesiologist or surgeon. 4. instruct the patient on possible postoperative complications. ANS: 3 Extreme fear is associated with surgical complications. Sometimes, surgery is postponed until anxiety is reduced. PTS: 1 DIF: Cognitive Level: Analysis REF: 250 OBJ: 3 TOP: Preoperative Anxiety KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 8. The nurse is performing a postoperative assessment on a patient who has just returned from a hernia repair. The patients blood pressure is 90/60 mm Hg and apical pulse is 102. The nurses first action would be to: 1. check the dressing for bleeding. 2. notify the RN. 3. document the vital signs. 4. increase the rate of infusion of IV fluids. ANS: 1 A decrease in blood pressure and tachycardia could indicate postoperative bleeding. The first action of the nurse should be to check the dressing and then report to the RN. PTS: 1 DIF: Cognitive Level: Application REF: 261-264, Table 17-2 OBJ: 8 TOP: Postoperative Complications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The postoperative patient who has no previous medical conditions is difficult to arouse when transferred to the surgical unit from the postanesthesia care unit. The nurse monitors the pulse oximeter and gets a reading of 85%. The nurses next action should be to: 1. assess the pulse oximeter reading again in 1 hour. 2. arouse the patient and have him cough and deep-breathe. 3. administer a dose of pain medication. 4. suction the patient. ANS: 2 If the pulse oximeter reading is less than 90%, the patient should be aroused and encouraged to take deep breaths. The patients respirations may not be adequate as a result of the effects of anesthesia.

PTS: 1 DIF: Cognitive Level: Application REF: 261 OBJ: 8 TOP: Hypoxia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 10. The nurse has completed giving discharge instructions to the patient after a hernia repair. The nurse would determine that the patient understands the instructions if he verbalizes that he will: 1. be going back to work tomorrow. 2. not change the dressing until he sees his physician in 2 weeks. 3. ignore changes in the size of his abdomen. 4. report fever, redness, swelling, or increased pain at the incision site. ANS: 4 The patient should report any signs and symptoms of infection (fever, redness, swelling, or pain). PTS: 1 DIF: Cognitive Level: Analysis REF: 271-272 OBJ: 10 TOP: Discharge Planning KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance 11. The nurse should include the proper use of an incentive spirometer in teaching for a preoperative patient. Postoperative monitoring of this patient would reveal that the incentive spirometry has been effective if the patient has: 1. adventitious breath sounds. 2. expiratory wheezing. 3. thick, green respiratory secretions. 4. clear breath sounds. ANS: 4 An incentive spirometer is used to promote lung expansion, which opens airways, reduces atelectasis, and stimulates coughing to clear secretions. PTS: 1 DIF: Cognitive Level: Comprehension REF: 261, Table 17-2 OBJ: 4 TOP: Impaired Gas Exchange KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 12. The suprapubic area of a postoperative patient is distended. The patient states that he has not voided since surgery about 9 hours ago. The nurses first action would be to: 1. notify the physician. 2. insert a catheter. 3. have the patient sit on the side of the bed and try to void. 4. prepare the patient to return to surgery. ANS: 3 The patient should be encouraged to try to void in a natural position before other measures are taken. PTS: 1 DIF: Cognitive Level: Application REF: 263, Table 17-2

OBJ: 8 TOP: Postoperative Urinary Retention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. Postoperative instructions must be modified for a patient with an intraocular lens implant. The nurse modifies postoperative care from that given most general surgery patients as follows: 1. Early ambulation is not necessary. 2. The dressing should be removed immediately on return to the surgical unit. 3. Do not have this patient cough. 4. The patient should not be allowed to have visitors. ANS: 3 There are a few instances in which coughing is contraindicated. They include surgeries for hernias, cataracts, and brain surgery. PTS: 1 DIF: Cognitive Level: Analysis REF: 273 OBJ: 7 TOP: Postoperative Complications KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 14. When obtaining the patients signature on the operative consent form, the patient seems confused about the procedure to be performed. The appropriate response by the nurse is to: 1. tell the patient to talk to the physician after he gets to the operating room. 2. ask the patient to go ahead and sign the consent. 3. ask the patient what the physician told him and then call the physician if necessary. 4. encourage the patient to ask his family what the physician told them. ANS: 3 The patient may not understand some of the medical terms used by the physician and the nurse may be able to explain them. If the patient still needs further information, notify the physician. It is the physicians responsibility to explain the procedure and risks to the patient. PTS: 1 DIF: Cognitive Level: Application REF: 251 OBJ: 3 TOP: Consent Form KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 15. The nurse is doing an assessment of a patient who has returned from a cardiac catheterization and had conscious sedation. The nurse should report which of the following findings? 1. Patient is difficult to arouse 2. Blood pressure of 124/72 3. Oxygen saturation of 96% 4. Patient complains of needing to void ANS: 1 Conscious sedation uses intravenous drugs to reduce pain intensity or

awareness without loss of reflexes. A complication may be excessive sedation approaching that of general anesthesia. The patient should be easily aroused. PTS: 1 DIF: Cognitive Level: Analysis REF: 260 OBJ: 6 TOP: Anesthesia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 16. A patient diagnosed with colon cancer is being prepared for palliative surgery to correct an intestinal obstruction. The nurse understands that palliative surgery is: 1. the removal and study of tissue to make a diagnosis. 2. done to relieve symptoms or improve function without correcting the basic problem. 3. done to remove diseased tissue or to correct defects. 4. done to correct serious defects that only affect appearance. ANS: 2 Palliative surgery is done only to relieve symptoms or improve function. It is not curative. PTS: 1 DIF: Cognitive Level: Knowledge REF: 247 OBJ: 1 TOP: Types of Surgery KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 17. During the preoperative assessment, it is most important that the nurse ask the patient for information about: 1. current address and telephone number. 2. food preferences. 3. allergies, medications, and past medical conditions. 4. bathing and sleep patterns. ANS: 3 If an emergency should arise, any allergies can be determined promptly. Knowledge of the patients medications can enable you to anticipate possible drug interactions. Past medical conditions may increase surgical risks or require special attention in the perioperative period. PTS: 1 DIF: Cognitive Level: Analysis REF: 248 OBJ: 2 TOP: Preoperative Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 18. The member of the surgical team who administers anesthetics and monitors the patients status throughout the procedure is the: 1. surgeon. 2. circulating nurse. 3. perfusionist. 4. anesthesiologist. ANS: 4 The anesthesiologist and nurse anesthetist have special training and are the

members of the surgical team that administers anesthesia and are responsible for close patient monitoring during surgery. PTS: 1 DIF: Cognitive Level: Knowledge REF: 258 OBJ: 5 TOP: Surgical Team KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 19. A nurse is assisting in the transfer of a postoperative patient from the postanesthesia care unit to the surgical nursing unit. To ensure the safety of the patient, the nurse would: 1. put the side rails up after moving the patient from the stretcher to the bed. 2. ask the patient to move from the stretcher to the bed. 3. move the patient rapidly from the stretcher to the bed. 4. uncover the patient before transferring from the stretcher to the bed. ANS: 1 The patient will probably still be experiencing residual effects of anesthesia; the side rails should be up to prevent the patient from falling out of bed. PTS: 1 DIF: Cognitive Level: Application REF: 261 OBJ: 9 TOP: Postoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 20. A patient who has just undergone a colon resection complains to the nurse that he felt something pop under his dressing while trying to get out of bed. The nurse removes the dressing and finds that dehiscence of the wound has occurred. The nurses first action should be to: 1. replace the dressing; dehiscence is normal. 2. call the physician. 3. pull the wound edges together and replace the dressing. 4. cover the wound with sterile dressings saturated with normal saline. ANS: 4 The first action of the nurse should be to prevent damage from drying of the exposed organs by covering the wound with saline-saturated dressings and then calling the physician. PTS: 1 DIF: Cognitive Level: Comprehension REF: 263 OBJ: 9 TOP: Wound Dehiscence KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. A patient has just returned to the surgical unit after varicose vein stripping and ligation. The best technique by the nurse to evaluate pain relief is: 1. checking the patients record for the last dose of pain medication administered. 2. asking the patient to rate the severity of the pain on a scale of 1 to 10. 3. asking the family if they think that the patient is having pain. 4. telling the patient to ask for pain medicine when it is needed.

ANS: 2 Having the patient rate the pain provides a system for evaluating response to the pain medication. Pain is controlled better if treated before it becomes severe, and the patient may not ask for pain medicine soon enough. PTS: 1 DIF: Cognitive Level: Application REF: 268 OBJ: 8 TOP: Postoperative Pain Relief KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 22. The patient scheduled for a liver biopsy has given the nurse a list of medications routinely taken at home. The nurse should be concerned about the: 1. aspirin. 2. multivitamin. 3. furosemide. 4. acetaminophen. ANS: 1 Aspirin is an anticoagulant, which can increase the risk of postoperative bleeding. Drugs taken long term may require dosage adjustments because of the effects of surgery or additional drugs. PTS: 1 DIF: Cognitive Level: Analysis REF: 263 OBJ: 2 TOP: Preoperative Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 23. The patient scheduled for a bronchoscopy is given nothing by mouth (NPO) after midnight, before the procedure. The patient is complaining of being thirsty and requests some water on the morning of the procedure. The nurse should explain to the patient that the reason for keeping him NPO is to prevent: 1. accumulation of fluid in the lungs. 2. pulmonary infections. 3. vomiting and aspiration during the procedure. 4. a full bladder during surgery. ANS: 3 Patients are given nothing by mouth from midnight before the scheduled procedure to reduce the risk of vomiting and aspiration during or after the procedure. PTS: 1 DIF: Cognitive Level: Analysis REF: 253 OBJ: 3 TOP: Preparation for Surgery KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment 24. To prevent the effects of postoperative immobility on the gastrointestinal system, the nurse suggests that the patient: 1. avoid taking antibiotics. 2. increase her fluid intake.

3. avoid high-fiber foods. 4. limit her activity for the first 3 to 4 days. ANS: 2 The intake of oral fluids and ingestion of a normal diet help stimulate peristalsis. PTS: 1 DIF: Cognitive Level: Comprehension REF: 274 OBJ: 9 TOP: Postoperative Complications KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 25. The postanesthesia care nurse is evaluating the patient for possible transfer to the surgical unit. The following assessment would prevent the patients transfer: 1. Blood pressure is 126/78 mm Hg. 2. Pulse rate is 82 beats per minute. 3. Pulse oximeter reading is 85%. 4. Respirations are 22 per minute. ANS: 3 The pulse oximeter reading should be 95% to 100%. The patient should not be transferred from the recovery room until the vital signs are stable, respiratory and circulatory functions are adequate, pain is minimal, he or she is easily wakened, no complications are experienced, and the gag reflex is present. PTS: 1 DIF: Cognitive Level: Analysis REF: 266 OBJ: 8 TOP: Postoperative Assessment KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Patients with preoperative disorders put them at risk during recovery. The nurse should be aware of disorders that may pose this hazard, which are (select all that apply): 1. diabetes. 2. warfarin therapy. 3. fungal skin infection. 4. hepatitis C. 5. COPD. ANS: 1, 4, 5 Diabetes, hepatitis C, and COPD all complicate recovery related to blood-clotting deficiencies, respiratory problems, or disturbance in the healing process. Warfarin therapy will have been discontinued well before surgery and fungal skin infections do not pose a threat. PTS: 1 DIF: Cognitive Level: Application REF: 247 OBJ: 8 TOP: Conditions That Complicate Recovery KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. The patient has an extensive bowel preparation of oral laxatives and

enemas for a colon resection. When asked about the rigorous prep, the nurse would list as the rationales (select all that apply): 1. Reduces possibility of fecal contamination of the operative site 2. Flattens the colon 3. Decreases postoperative distention 4. Avoids postoperative constipation 5. Decreases straining at stool ANS: 1, 3, 4, 5 Preoperative bowel prep reduces the risk for infection from bowel contents and decreases postoperative distention, constipation, and straining at stool. PTS: 1 DIF: Cognitive Level: Application REF: 252 OBJ: 4 TOP: Rationale for Bowel Prep KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. The nurse carefully monitors the obese hysterectomy patient for the peculiar postoperative complications associated with obesity (select all that apply): 1. Nausea 2. Vomiting 3. Hypertension 4. Hemorrhage 5. Respiratory difficulties ANS: 5 Obese patients are especially prone to postoperative respiratory complications of pneumonia and atelectasis. PTS: 1 DIF: Cognitive Level: Application REF: 247, 262 OBJ: 8 TOP: Postoperative Complications in the Obese Patient KEY: Nursing Process Step: Assessment MSC: NCLEX: Physical Integrity COMPLETION 1. The nurse discovers on the preoperative assessment that the patient has a condition that would require increased amounts of general anesthesia. The condition is ____________________. ANS: Alcoholism PTS: 1 DIF: Cognitive Level: Application REF: 248, 249, Drug Therapy table OBJ: 6 TOP: Conditions That Affect Anesthesia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 31. A nurse has administered approximately half of a high cleansing enema when the client complains of pain and cramping. Which nursing action is appropriate? a) reassuring the client and continuing the flow b) discontinuing the enema and notifying the physician

c) raising the enema bag so that the solution can be completed quickly d) clamping the tubing for 30 seconds and restarting the flow at a slower rate 32. Which client position does the nurse use to administer a cleansing enema? a) dorsal recumbent position b) supine position with the legs elevated c) left lateral position with flexed right knee d) right lateral position with flexed left knee

33. A nurse is preparing to administer an intermittent tube feeding through a nasogastric tube (NGT). The nurse assesses gastric residual volume before administering tube feeding to: a) confirm proper NGT placement b) determine the clients nutritional status c) assess clients fluid and electrolyte status d) evaluate the adequacy of gastric emptying

34. Before administering an intermittent tube feeding, the nurse aspirates 40 ml of undigested formula from the clients nasogastric tube. Which should the nurse implement as a result of this finding? a) discard the aspirate and record as client output b) mix with new formula to administer the feeding c) dilute with water and inject into the nasogastric tube d) reinstill the aspirate through the nasogastric tube via gravity using syringe

35. The nurse prepares to teach a client to ambulate with a cane. Before teaching cane-assisted ambulation, the priority nursing assessment is to determine that the client has: a) self-consciousness about using a cane b) full range of motion in lower extremities c) an adequate level of stamina and energy d) balance, muscle strength, and confidence

Fundamental NCLEX Questions Answers and Rationale

31) B - The enema fluid should be administered slowly. If the client complains of pain or cramping, the flow is stopped for 30 seconds and restarted at a slower rate. Slow enema administration and stopping the flow temporarily, if necessary, will decrease the likelihood of intestinal spasm and premature ejection of the solution. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum. There is no need to discontinue the enema and notify the physician at this time.

32) C - The sigmoid and descending colon are located on the left side. Therefore, the left lateral position uses gravity to facilitate the flow of solution into the sigmoid and descending colon. Acute flexion of the right leg allows for adequate exposure of the anus. Options A, B, and D are incorrect positions because they fail to adequately expose the anus or facilitate infusion of the enema solution.

33) D - All stomach contents are aspirated and measured before administering a tube feeding to determine the gastric residual volume. If the stomach fails to empty and propel its contents forward, the tube feeding accumulates in the stomach and increases the clients risk of aspiration. If the aspirated gastric contents exceed the predetermined limit, the nurse withholds the tube feeding and collaborates with the provider on a plan of care. Assessing residual does not confirm placement or assess fluid and electrolyte status. The nurse uses clinical indicators including serum albumin levels to determine the clients nutritional status.

34) D - After checking residual feeding contents, the nurse reinstills the gastric contents into the stomach by removing the syringe bulb or plunger and pouring the gastric contents via the syringe into the nasogastric tube. Gastric contents should be reinstilled (unless they exceed an amount of 100 mL or as defined by agency policy) in order to maintain the clients fluid and electrolyte balance. The nurse avoids mixing gastric aspirate with fresh formula to prevent contamination. Because the gastric aspirate is a small volume, it should be reinstilled; however, mixing the formula with water can, also, disrupt the clients fluid and electrolyte balance unless the nurse determines that the client is dehydrated.

35) D - Assessing the clients balance, strength, and confidence helps determine if the cane is a suitable assistive device for the client. Although body image (self-consciousness) is a

component of the assessment, it is not the priority. Full range of motion and a high level of stamina are not needed for walking with a cane. Question: What is the priority nursing action for the client who is complaining of nausea in the recovery room after gastric resection? 1. Evaluate the nasogastric tube for patency. 2. Call the physician for the antiemetic order. 3. Place client in semi-Fowler's position so that he will not aspirate. 4. Medicate the client with a narcotic analgesic. 1. Nurse Berlinda is assigned to a 41-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of: a. 45 units/L b. 100 units/L c. 300 units/L d. 500 units/L

2. A male client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been bored with the clear liquid diet. The nurse would offer which full liquid item to the client? a. Tea b. Gelatin c. Custard d. Popsicle

3. Nurse Juvy is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intension to increase the intake of: a. Pork b. Milk c. Chicken d. Broccoli

4. Nurse Oliver checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is appropriate action for the nurse to take?

a. Hold the feeding b. Reinstill the amount and continue with administering the feeding c. Elevate the clients head at least 45 degrees and administer the feeding d. Discard the residual amount and proceed with administering the feeding

5. A nurse is inserting a nasogastric tube in an adult male client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the appropriate nursing action? a. Quickly insert the tube b. Notify the physician immediately c. Remove the tube and reinsert when the respiratory distress subsides d. Pull back on the tube and wait until the respiratory distress subsides

6. Nurse Ryan is assessing for correct placement of a nosogartric tube. The nurse aspirates the stomach contents and check the contents for pH. The nurse verifies correct tube placement if which pH value is noted? a. 3.5 b. 7.0 c. 7.35 d. 7.5

7. A nurse is preparing to remove a nasogartric tube from a female client. The nurse should instruct the client to do which of the following just before the nurse removes the tube? a. Exhale b. Inhale and exhale quickly c. Take and hold a deep breath d. Perform a Valsalva maneuver

8. Nurse Joy is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse would: a. Position the client supine to assist in medication absorption b. Aspirate the nasogastric tube after medication administration to maintain patency c. Clamp the nasogastric tube for 30 minutes following administration of the medication d. Change the suction setting to low intermittent suction for 30 minutes after medication administration

9. A nurse is preparing to care for a female client with esophageal varices who has just has a Sengstaken-Blakemore tube inserted. The nurse gathers supplies, knowing that which of the following items must be kept at the bedside at all times? a. An obturator b. Kelly clamp

c. An irrigation set d. A pair of scissors

10. Dr. Smith has determined that the client with hepatitis has contracted the infection form contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? a. Hepatitis A b. Hepatitis B c. Hepatitis C d. Hepatitis D

11. A client is suspected of having hepatitis. Which diagnostic test result will assist in confirming this diagnosis? a. Elevated hemoglobin level b. Elevated serum bilirubin level c. Elevated blood urea nitrogen level d. Decreased erythrocycle sedimentation rate 12. The nurse is reviewing the physicians orders written for a male client admitted to the hospital with acute pancreatitis. Which physician order should the nurse question if noted on the clients chart? a. NPO status b. Nasogastric tube inserted c. Morphine sulfate for pain d. An anticholinergic medication 13. A female client being seen in a physicians office has just been scheduled for a barium swallow the next day. The nurse writes down which instruction for the client to follow before the test? a. Fast for 8 hours before the test b. Eat a regular supper and breakfast c. Continue to take all oral medications as scheduled d. Monitor own bowel movement pattern for constipation

14. The nurse is performing an abdominal assessment and inspects the skin of the abdomen. The nurse performs which assessment technique next? a. Palpates the abdomen for size b. Palpates the liver at the right rib margin c. Listens to bowel sounds in all for quadrants d. Percusses the right lower abdominal quadrant

15. Polyethylene glycol-electrlyte solution (GoLYTELY) is prescribed for the female client scheduled for a colonoscopy. The client begins to experience diarrhea following administration of the solution. What action by the nurse is appropriate? a. Start an IV infusion b. Administer an enema c. Cancel the diagnostic test d. Explain that diarrhea is expected

16. The nurse is caring for a male client with a diagnosis of chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency? a. Vitamin A b. Vitamin B12 c. Vitamin C d. Vitamin E

17. The nurse is reviewing the medication record of a female client with acute gastritis. Which medication, if noted on the clients record, would the nurse question? a. Digoxin (Lanoxin) b. Furosemide (Lasix) c. Indomethacin (Indocin) d. Propranolol hydrochloride (Inderal)

18. The nurse is assessing a male client 24 hours following a cholecystectomy. The nurse noted that the T tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is appropriate? a. Clamp the T tube b. Irrigate the T tube c. Notify the physician d. Document the findings

19. The nurse is monitoring a female client with a diagnosis of peptic ulcer. Which assessment findings would most likely indicate perforation of the ulcer? a. Bradycardia b. Numbness in the legs c. Nausea and vomiting d. A rigid, board-like abdomen

20. A male client with a peptic ulcer is scheduled for a vagotomy and the client asks the nurse about the purpose of this procedure. Which response by the nurse best describes the purpose

of a vagotomy? a. Halts stress reactions b. Heals the gastric mucosa c. Reduces the stimulus to acid secretions d. Decreases food absorption in the stomach

21. The nurse is caring for a female client following a Billroth II procedure. Which postoperative order should the nurse question and verify? a. Leg exercises b. Early ambulation c. Irrigating the nasogastric tube d. Coughing and deep-breathing exercises

22. The nurse is providing discharge instructions to a male client following gastrectomy and instructs the client to take which measure to assist in preventing dumping syndrome? a. Ambulate following a meal b. Eat high carbohydrate foods c. Limit the fluid taken with meal d. Sit in a high-Fowlers position during meals

23. The nurse is monitoring a female client for the early signs and symptoms of dumping syndrome. Which of the following indicate this occurrence? a. Sweating and pallor b. Bradycardia and indigestion c. Double vision and chest pain d. Abdominal cramping and pain

24. The nurse is preparing a discharge teaching plan for the male client who had umbilical hernia repair. What should the nurse include in the plan? a. Irrigating the drain b. Avoiding coughing c. Maintaining bed rest d. Restricting pain medication

25. The nurse is instructing the male client who has an inguinal hernia repair how to reduce postoperative swelling following the procedure. What should the nurse tell the client? a. Limit oral fluid b. Elevate the scrotum c. Apply heat to the abdomen d. Remain in a low-fiber diet

26. The nurse is caring for a hospitalized female client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician? a. Hypotension b. Bloody diarrhea c. Rebound tenderness d. A hemoglobin level of 12 mg/dL

27. The nurse is caring for a male client postoperatively following creation of a colostomy. Which nursing diagnosis should the nurse include in the plan of care? a. Sexual dysfunction b. Body image, disturbed c. Fear related to poor prognosis d. Nutrition: more than body requirements, imbalanced 28. The nurse is reviewing the record of a female client with Crohns disease. Which stool characteristics should the nurse expect to note documented in the clients record? a. Diarrhea b. Chronic constipation c. Constipation alternating with diarrhea d. Stools constantly oozing form the rectum

29. The nurse is performing a colostomy irrigation on a male client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action? a. Notify the physician b. Stop the irrigation temporarily c. Increase the height of the irrigation d. Medicate for pain and resume the irrigation

30. The nurse is teaching a female client how to perform a colostomy irrigation. To enhance the effectiveness of the irrigation and fecal returns, what measure should the nurse instruct the client to do? a. Increase fluid intake b. Place heat on the abdomen c. Perform the irrigation in the evening d. Reduce the amount of irrigation solution 1. Answer C. The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Options A and B are within normal limits. Option D is an extremely elevated level seen in acute pancreatitis.

2. Answer C. Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, and strained vegetable juices. A clear liquid diet consists of foods that are relatively transparent. The food items in options A, B, and D are clear liquids. 3. Answer A. The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Milk contains vitamins A, D, and B2. Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid 4. Answer A. Unless specifically indicated, residual amounts more than 100 mL require holding the feeding. Therefore options B, C, and D are incorrect. Additionally, the feeding is not discarded unless its contents are abnormal in color or characteristics. 5. Answer D. During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. Options B and C are unnecessary. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus. 6. Answer A. If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric aspirates have acidic pH values and should be 3.5 or lower. Option B indicates a slightly acidic pH. Option C indicates a neutral pH. Option D indicates an alkaline pH. 7. Answer C. When the nurse removes a nasogastric tube, the client is instructed to take and hold a deep breath. This will close the epiglottis. This allows for easy withdrawal through the esophagus into the nose. The nurse removes the tube with one smooth, continuous pull. 8. Answer C. If a client has a nasogastric tube connected to suction, the nurse should wait up to 30 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered. The client should not be placed in the supine position because of the risk for aspiration. 9. Answer C. When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the clients bedside at all times. The client needs to be observed for sudden respiratory distress, which occurs if the gastric balloon ruptures and the entire tube moves upward. If this occurs, the nurse immediately cuts all balloon lumens and removes the tube. An obturator and a Kelly clamp are kept at the bedside of a client with a tracheostomy. An irrigation set may be kept at the bedside, but it is not the priority item. 10. Answer A. Hepatitis A is transmitted by the fecal-oral route via contaminated food or

infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids. 11. Answer B. Laboratory indicators of hepatitis include elevated liver enzyme levels, elevated serum bilirubin levels, elevated erythrocyte sedimentation rates, and leukopenia. An elevated blood urea nitrogen level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis. 12. Answer C. Meperidine (Demerol) rather than morphine sulfate is the medication of choice to treat pain because morphine sulfate can cause spasms in the sphincter of Oddi. Options A, B, and D are appropriate interventions for the client with acute pancreatitis. 13. Answer A. A barium swallow is an x-ray study that uses a substance called barium for contrast to highlight abnormalities in the gastrointestinal tract. The client should fast for 8 to 12 hours before the test, depending on physician instructions. Most oral medications also are withheld before the test. After the procedure, the nurse must monitor for constipation, which can occur as a result of the presence of barium in the gastrointestinal tract. 14. Answer C. The appropriate sequence for abdominal examination is inspection, auscultation, percussion, and palpation. Auscultation is performed after inspection to ensure that the motility of the bowel and bowel sounds are not altered by percussion or palpation. Therefore, after inspecting the skin on the abdomen, the nurse should listen for bowel sounds. 15. Answer D. The solution GoLYTELY is a bowel evacuant used to prepare a client for a colonoscopy by cleansing the bowel. The solution is expected to cause a mild diarrhea and will clear the bowel in 4 to 5 hours. Options A, B, and C are inappropriate actions. 16. Answer B. Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of the function of the parietal cells. The source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia. The client is not at risk for vitamin A, C, or E deficiency. 17. Answer C. Indomethacin (Indocin) is a nonsteroidal anti-inflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Furosemide (Lasix) is a loop diuretic. Digoxin is a cardiac medication. Propranolol (Inderal) is a -adrenergic blocker. Furosemide, digoxin, and propranolol are not contraindicated in clients with gastric disorders. 18. Answer D. Following cholecystectomy, drainage from the T tube is initially bloody and then turns to a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output. 19. Answer D. Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over

the abdomen, which becomes rigid and board-like. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding. 20. Answer C. A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion. Options A, B, and D are incorrect descriptions of a vagotomy. 21. Answer C. In a Billroth II procedure, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically ordered by the physician. In this situation, the nurse should clarify the order. Options A, B, and D are appropriate postoperative interventions. 22. Answer C. Dumping syndrome is a term that refers to a constellation of vasomotor symptoms that occurs after eating, especially following a Billroth II procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the amount of fluid taken at meals and to avoid high-carbohydrate foods, including fluids such as fruit nectars; to assume a low-Fowlers position during meals; to lie down for 30 minutes after eating to delay gastric emptying; and to take antispasmodics as prescribed. 23. Answer A. Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. 24. Answer B. Coughing is avoided following umbilical hernia repair to prevent disruption of tissue integrity, which can occur because of the location of this surgical procedure. Bed rest is not required following this surgical procedure. The client should take analgesics as needed and as prescribed to control pain. A drain is not used in this surgical procedure, although the client may be instructed in simple dressing changes. 25. Answer B. Following inguinal hernia repair, the client should be instructed to elevate the scrotum and apply ice packs while in bed to decrease pain and swelling. The nurse also should instruct the client to apply a scrotal support when out of bed. Heat will increase swelling. Limiting oral fluids and a low-fiber diet can cause constipation. 26. Answer C. Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the physician. 27. Answer B. Body image, disturbed relates to loss of bowel control, the presence of a

stoma, the release of fecal material onto the abdomen, the passage of flatus, odor, and the need for an appliance (external pouch). No data in the question support options A and C. Nutrition: less than body requirements, imbalanced is the more likely nursing diagnosis. 28. Answer A. Crohns disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options B, C, and D are not characteristics of Crohns disease. 29. Answer B. If cramping occurs during a colostomy irrigation, the irrigation flow is stopped temporarily and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or is causing too much pressure. The physician does not need to be notified. Increasing the height of the irrigation will cause further discomfort. Medicating the client for pain is not the appropriate action in this situation. 30. Answer A. To enhance effectiveness of the irrigation and fecal returns, the client is instructed to increase fluid intake and to take other measures to prevent constipation. Options B, C and D will not enhance the effectiveness of this procedure.
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A blood pressure cuff thats too narrow can cause a falsely elevated blood pressure reading. When preparing a single injection for a patient who takes regular and neutral protein Hagedorn insulin, the nurse should draw the regular insulin into the syringe first so that it does not contaminate the regular insulin. Rhonchi are the rumbling sounds heard on lung auscultation. They are more pronounced during expiration than during inspiration. Gavage is forced feeding, usually through a gastric tube (a tube passed into the stomach through the mouth). According to Maslows hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have the highest priority. The safest and surest way to verify a patients identity is to check the identification band on his wrist. In the therapeutic environment, the patients safety is the primary concern. Fluid oscillation in the tubing of a chest drainage system indicates that the system is working properly. The nurse should place a patient who has a Sengstaken-Blakemore tube in semi-Fowler position. The nurse can elicit Trousseaus sign by occluding the brachial or radial artery. Hand and finger spasms that occur during occlusion indicate Trousseaus sign and suggest hypocalcemia. For blood transfusion in an adult, the appropriate needle size is 16 to 20G. Intractable pain is pain that incapacitates a patient and cant be relieved by drugs. In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic means. Decibel is the unit of measurement of sound. Informed consent is required for any invasive procedure. A patient who cant write his name to give consent for treatment must make an X in the presence of two witnesses, such as a nurse, priest, or physician. The Z-track I.M. injection technique seals the drug deep into the muscle, thereby minimizing skin irritation and staining. It requires a needle thats 1" (2.5 cm) or longer.

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In the event of fire, the acronym most often used is RACE. (R) Remove the patient. (A) Activate the alarm. (C) Attempt to contain the fire by closing the door. (E) Extinguish the fire if it can be done safely. A registered nurse should assign a licensed vocational nurse or licensed practical nurse to perform bedside care, such as suctioning and drug administration. If a patient cant void, the first nursing action should be bladder palpation to assess for bladder distention. The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity. To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2" (5 cm) to that measurement. Assessment begins with the nurses first encounter with the patient and continues throughout the patients stay. The nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies. The appropriate needle size for insulin injection is 25G and 5/8" long. Residual urine is urine that remains in the bladder after voiding. The amount of residual urine is normally 50 to 100 ml. The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation. Assessment is the stage of the nursing process in which the nurse continuously collects data to identify a patients actual and potential health needs. Nursing diagnosis is the stage of the nursing process in which the nurse makes a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Planning is the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan. Implementation is the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions. Evaluation is the stage of the nursing process in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan. Before administering any as needed pain medication, the nurse should ask the patient to indicate the location of the pain. Jehovahs Witnesses believe that they shouldnt receive blood components donated by other people. To test visual acuity, the nurse should ask the patient to cover each eye separately and to read the eye chart with glasses and without, as appropriate. When providing oral care for an unconscious patient, to minimize the risk of aspiration, the nurse should position the patient on the side. During assessment of distance vision, the patient should stand 20 (6.1 m) from the chart. For a geriatric patient or one who is extremely ill, the ideal room temperature is 66 to 76 F (18.8 to 24.4 C). Normal room humidity is 30% to 60%. Hand washing is the single best method of limiting the spread of microorganisms. Once gloves are removed after routine contact with a patient, hands should be washed for 10 to 15 seconds. To perform catheterization, the nurse should place a woman in the dorsal recumbent position. A positive Homans sign may indicate thrombophlebitis. Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A milliequivalent is the number of milligrams per 100 milliliters of a solution.

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Metabolism occurs in two phases: anabolism (the constructive phase) and catabolism (the destructive phase). The basal metabolic rate is the amount of energy needed to maintain essential body functions. Its measured when the patient is awake and resting, hasnt eaten for 14 to 18 hours, and is in a comfortable, warm environment. The basal metabolic rate is expressed in calories consumed per hour per kilogram of body weight. Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains intestinal motility, and helps to establish regular bowel habits. Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs. Petechiae are tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage. Purpura is a purple discoloration of the skin thats caused by blood extravasation. According to the standard precautions recommended by the Centers for Disease Control and Prevention, the nurse shouldnt recap needles after use. Most needle sticks result from missed needle recapping. The nurse administers a drug by I.V. push by using a needle and syringe to deliver the dose directly into a vein, I.V. tubing, or a catheter. When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are applied. A nurse should have assistance when changing the ties on a tracheostomy tube. A filter is always used for blood transfusions. A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide. A good way to begin a patient interview is to ask, What made you seek medical help? When caring for any patient, the nurse should follow standard precautions for handling blood and body fluids. Potassium (K+) is the most abundant cation in intracellular fluid. In the four-point, or alternating, gait, the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot. In the three-point gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg. In the two-point gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch simultaneously. The vitamin B complex, the water-soluble vitamins that are essential for metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12). When being weighed, an adult patient should be lightly dressed and shoeless. Before taking an adults temperature orally, the nurse should ensure that the patient hasnt smoked or consumed hot or cold substances in the previous 15 minutes. The nurse shouldnt take an adults temperature rectally if the patient has a cardiac disorder, anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery. In a patient who has a cardiac disorder, measuring temperature rectally may stimulate a vagal response and lead to vasodilation and decreased cardiac output. When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3, bounding pulse (readily palpable and forceful); +2, normal pulse (easily palpable); +1, thready or weak pulse (difficult to detect); and 0, absent pulse (not detectable). The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia care unit. On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasnt taken anything by mouth since midnight, has taken a shower

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with antimicrobial soap, has had mouth care (without swallowing the water), has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have been taken and recorded. Artificial limbs and other prostheses are usually removed. Comfort measures, such as positioning the patient, rubbing the patients back, and providing a restful environment, may decrease the patients need for analgesics or may enhance their effectiveness. A drug has three names: generic name, which is used in official publications; trade, or brand, name (such as Tylenol), which is selected by the drug company; and chemical name, which describes the drugs chemical composition. To avoid staining the teeth, the patient should take a liquid iron preparation through a straw. The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon). An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin. In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma. To turn a patient by logrolling, the nurse folds the patients arms across the chest; extends the patients legs and inserts a pillow between them, if needed; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet. The diaphragm of the stethoscope is used to hear high-pitched sounds, such as breath sounds. A slight difference in blood pressure (5 to 10 mm Hg) between the right and the left arms is normal. The nurse should place the blood pressure cuff 1" (2.5 cm) above the antecubital fossa. When instilling ophthalmic ointments, the nurse should waste the first bead of ointment and then apply the ointment from the inner canthus to the outer canthus. The nurse should use a leg cuff to measure blood pressure in an obese patient. If a blood pressure cuff is applied too loosely, the reading will be falsely elevated. Ptosis is drooping of the eyelid. A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position. To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessels lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle. To move a patient to the edge of the bed for transfer, the nurse should follow these steps: Move the patients head and shoulders toward the edge of the bed. Move the patients feet and legs to the edge of the bed (crescent position). Place both arms well under the patients hips, and straighten the back while moving the patient toward the edge of the bed. When being measured for crutches, a patient should wear shoes. The nurse should attach a restraint to the part of the bed frame that moves with the head, not to the mattress or side rails. The mist in a mist tent should never become so dense that it obscures clear visualization of the patients respiratory pattern. To administer heparin subcutaneously, the nurse should follow these steps: Clean, but dont rub, the site with alcohol. Stretch the skin taut or pick up a well-defined skin fold. Hold the shaft of the needle in a dart position. Insert the needle into the skin at a right (90-degree) angle. Firmly depress the plunger, but dont aspirate. Leave the needle in place for 10 seconds. Withdraw the needle gently at the angle of insertion. Apply pressure to the injection site with an alcohol pad.

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For a sigmoidoscopy, the nurse should place the patient in the knee-chest position or Sims position, depending on the physicians preference. Maslows hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, sex, rest, and comfort), safety and security, love and belonging, self-esteem and recognition, and self-actualization. When caring for a patient who has a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness. During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed through the tube. In documenting drainage on a surgical dressing, the nurse should include the size, color, and consistency of the drainage (for example, 10 mm of brown mucoid drainage noted on dressing). To elicit Babinskis reflex, the nurse strokes the sole of the patients foot with a moderately sharp object, such as a thumbnail. A positive Babinskis reflex is shown by dorsiflexion of the great toe and fanning out of the other toes. When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis. The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours. Antiembolism stockings decompress the superficial blood vessels, reducing the risk of thrombus formation. In adults, the most convenient veins for venipuncture are the basilic and median cubital veins in the antecubital space. Two to three hours before beginning a tube feeding, the nurse should aspirate the patients stomach contents to verify that gastric emptying is adequate. People with type O blood are considered universal donors. People with type AB blood are considered universal recipients. Hertz (Hz) is the unit of measurement of sound frequency. Hearing protection is required when the sound intensity exceeds 84 dB. Double hearing protection is required if it exceeds 104 dB. Prothrombin, a clotting factor, is produced in the liver. If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory request. During lumbar puncture, the nurse must note the initial intracranialpressure and the color of the cerebrospinal fluid. If a patient cant cough to provide a sputum sample for culture, a heated aerosol treatment can be used to help to obtain a sample. If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first. When leaving an isolation room, the nurse should remove her gloves before her mask because fewer pathogens are on the mask. Skeletal traction, which is applied to a bone with wire pins or tongs, is the most effective means of traction. The total parenteral nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before use. Delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction. Drugs arent routinely injected intramuscularly into edematous tissue because they may not be absorbed. When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice.

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Dentures should be cleaned in a sink thats lined with a washcloth. A patient should void within 8 hours after surgery. An EEG identifies normal and abnormal brain waves. Samples of feces for ova and parasite tests should be delivered to the laboratory without delay and without refrigeration. The autonomic nervous system regulates the cardiovascular and respiratory systems. When providing tracheostomy care, the nurse should insert the catheter gently into the tracheostomy tube. When withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 seconds and use a slight twisting motion. A low-residue diet includes such foods as roasted chicken, rice, and pasta. A rectal tube shouldnt be inserted for longer than 20 minutes because it can irritate the rectal mucosa and cause loss of sphincter control. A patients bed bath should proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum. To prevent injury when lifting and moving a patient, the nurse should primarily use the upper leg muscles. Patient preparation for cholecystography includes ingestion of a contrast medium and a lowfat evening meal. While an occupied bed is being changed, the patient should be covered with a bath blanket to promote warmth and prevent exposure. Anticipatory grief is mourning that occurs for an extended time when the patient realizes that death is inevitable. The following foods can alter the color of the feces: beets (red), cocoa (dark red or brown), licorice (black), spinach (green), and meat protein (dark brown). When preparing for a skull X-ray, the patient should remove all jewelry and dentures. The fight-or-flight response is a sympathetic nervous system response. Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia. Wheezing is an abnormal, high-pitched breath sound thats accentuated on expiration. Wax or a foreign body in the ear should be flushed out gently by irrigation with warm saline solution. If a patient complains that his hearing aid is not working, the nurse should check the switch first to see if its turned on and then check the batteries. The nurse should grade hyperactive biceps and triceps reflexes as +4. If two eye medications are prescribed for twice-daily instillation, they should be administered 5 minutes apart. In a postoperative patient, forcing fluids helps prevent constipation. A nurse must provide care in accordance with standards of care established by the American Nurses Association, state regulations, and facility policy. The kilocalorie (kcal) is a unit of energy measurement that represents the amount of heat needed to raise the temperature of 1 kilogram of water 1 C. As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and excretion. The body metabolizes alcohol at a fixed rate, regardless of serum concentration. In an alcoholic beverage, proof reflects the percentage of alcohol multiplied by 2. For example, a 100-proof beverage contains 50% alcohol. A living will is a witnessed document that states a patients desire for certain types of care and treatment. These decisions are based on the patients wishes and views on quality of life. The nurse should flush a peripheral heparin lock every 8 hours (if it wasnt used during the previous 8 hours) and as needed with normal saline solution to maintain patency.

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Quality assurance is a method of determining whether nursing actions and practices meet established standards. The five rights of medication administration are the right patient, right drug, right dose, right route of administration, and right time. The evaluation phase of the nursing process is to determine whether nursing interventions have enabled the patient to meet the desired goals. Outside of the hospital setting, only the sublingual and translingual forms of nitroglycerin should be used to relieve acute anginal attacks. The implementation phase of the nursing process involves recording the patients response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patients activities. The Patients Bill of Rights offers patients guidance and protection by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization. To minimize omission and distortion of facts, the nurse should record information as soon as its gathered. When assessing a patients health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present. When assessing a patients health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present. A nurse shouldnt give false assurance to a patient. After receiving preoperative medication, a patient isnt competent to sign an informed consent form. When lifting a patient, a nurse uses the weight of her body instead of the strength in her arms. A nurse may clarify a physicians explanation about an operation or a procedure to a patient, but must refer questions about informed consent to the physician. When obtaining a health history from an acutely ill or agitated patient, the nurse should limit questions to those that provide necessary information. If a chest drainage system line is broken or interrupted, the nurse should clamp the tube immediately. The nurse shouldnt use her thumb to take a patients pulse rate because the thumb has a pulse that may be confused with the patients pulse. An inspiration and an expiration count as one respiration. Eupnea is normal respiration. During blood pressure measurement, the patient should rest the arm against a surface. Using muscle strength to hold up the arm may raise the blood pressure. Major, unalterable risk factors for coronary artery disease include heredity, sex, race, and age. Inspection is the most frequently used assessment technique. Family members of an elderly person in a long-term care facility should transfer some personal items (such as photographs, a favorite chair, and knickknacks) to the persons room to provide a comfortable atmosphere. Pulsus alternans is a regular pulse rhythm with alternating weak and strong beats. It occurs in ventricular enlargement because the stroke volume varies with each heartbeat. The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication. Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidomastoid muscle use during respiration. When patients use axillary crutches, their palms should bear the brunt of the weight. Activities of daily living include eating, bathing, dressing, grooming, toileting, and interacting socially.

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Normal gait has two phases: the stance phase, in which the patients foot rests on the ground, and the swing phase, in which the patients foot moves forward. The phases of mitosis are prophase, metaphase, anaphase, and telophase. The nurse should follow standard precautions in the routine care of all patients. The nurse should use the bell of the stethoscope to listen for venous hums and cardiac murmurs. The nurse can assess a patients general knowledge by asking questions such as Who is the president of the United States? Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury. The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex centers). The autonomic nervous system controls the smooth muscles. A correctly written patient goal expresses the desired patient behavior, criteria for measurement, time frame for achievement, and conditions under which the behavior will occur. Its developed in collaboration with the patient. Percussion causes five basic notes: tympany (loud intensity, as heard over a gastric air bubble or puffed out cheek), hyperresonance (very loud, as heard over an emphysematous lung), resonance (loud, as heard over a normal lung), dullness (medium intensity, as heard over the liver or other solid organ), and flatness (soft, as heard over the thigh). The optic disk is yellowish pink and circular, with a distinct border. A primary disability is caused by a pathologic process. A secondary disability is caused by inactivity. Nurses are commonly held liable for failing to keep an accurate count of sponges and other devices during surgery. The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and wholegrain cereals. Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, green leafy vegetables, eggs, and whole grains, commonly have a low water content. Collaboration is joint communication and decision making betweennurses and physicians. Its designed to meet patients needs by integrating the care regimens of both professions into one comprehensive approach. Bradycardia is a heart rate of fewer than 60 beats/minute. A nursing diagnosis is a statement of a patients actual or potential health problem that can be resolved, diminished, or otherwise changed by nursing interventions. During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health history, physical examination, and laboratory and diagnostic test data. The patients health history consists primarily of subjective data, information thats supplied by the patient. The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation. When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign each entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines. Factors that affect body temperature include time of day, age, physical activity, phase of menstrual cycle, and pregnancy. The most accessible and commonly used artery for measuring a patients pulse rate is the radial artery. To take the pulse rate, the artery is compressed against the radius. In a resting adult, the normal pulse rate is 60 to 100 beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults.

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Laboratory test results are an objective form of assessment data. The measurement systems most commonly used in clinical practice are the metric system, apothecaries system, and household system. Before signing an informed consent form, the patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phases; the risks involved; and the possible complications. The patient should also have a general idea of the time required from surgery to recovery. In addition, he should have an opportunity to ask questions. A patient must sign a separate informed consent form for each procedure. During percussion, the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds. This procedure is done to determine the size, shape, position, and density of underlying organs and tissues; elicit tenderness; or assess reflexes. Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound. A foot cradle keeps bed linen off the patients feet to prevent skin irritation and breakdown, especially in a patient who has peripheral vascular disease or neuropathy. Gastric lavage is flushing of the stomach and removal of ingested substances through a nasogastric tube. Its used to treat poisoning or drug overdose. During the evaluation step of the nursing process, the nurse assesses the patients response to therapy. Bruits commonly indicate life- or limb-threatening vascular disease. O.U. means each eye. O.D. is the right eye, and O.S. is the left eye. To remove a patients artificial eye, the nurse depresses the lower lid. The nurse should use a warm saline solution to clean an artificial eye. A thready pulse is very fine and scarcely perceptible. Axillary temperature is usually 1 F lower than oral temperature. After suctioning a tracheostomy tube, the nurse must document the color, amount, consistency, and odor of secretions. On a drug prescription, the abbreviation p.c. means that the drug should be administered after meals. After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment. After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment. Laws regarding patient self-determination vary from state to state. Therefore, the nurse must be familiar with the laws of the state in which she works. Gauge is the inside diameter of a needle: the smaller the gauge, the larger the diameter. An adult normally has 32 permanent teeth. After turning a patient, the nurse should document the position used, the time that the patient was turned, and the findings of skin assessment. PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round, and reactive to light with accommodation. When percussing a patients chest for postural drainage, the nurses hands should be cupped. When measuring a patients pulse, the nurse should assess its rate, rhythm, quality, and strength. Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchairs footrests to the sides and lock its wheels. When assessing respirations, the nurse should document their rate, rhythm, depth, and quality. For a subcutaneous injection, the nurse should use a 5/8" 25G needle.

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The notation AA & O 3 indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows where he is), and time (knows the date and time). Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or feces, and perspiration. After administering an intradermal injection, the nurse shouldnt massage the area because massage can irritate the site and interfere with results. When administering an intradermal injection, the nurse should hold the syringe almost flat against the patients skin (at about a 15-degree angle), with the bevel up. To obtain an accurate blood pressure, the nurse should inflate the manometer to 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure. The nurse should count an irregular pulse for 1 full minute. A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus. Prophylaxis is disease prevention. Body alignment is achieved when body parts are in proper relation to their natural position. Trust is the foundation of a nurse-patient relationship. Blood pressure is the force exerted by the circulating volume of blood on the arterial walls. Malpractice is a professionals wrongful conduct, improper discharge of duties, or failure to meet standards of care that causes harm to another. As a general rule, nurses cant refuse a patient care assignment; however, in most states, they may refuse to participate in abortions. A nurse can be found negligent if a patient is injured because the nurse failed to perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldnt perform. States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from the assistance. These laws dont apply to care provided in a health care facility. A physician should sign verbal and telephone orders within the time established by facility policy, usually 24 hours. A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of his refusal. Although a patients health record, or chart, is the health care facilitys physical property, its contents belong to the patient. Before a patients health record can be released to a third party, the patient or the patients legal guardian must give written consent. Under the Controlled Substances Act, every dose of a controlled drug thats dispensed by the pharmacy must be accounted for, whether the dose was administered to a patient or discarded accidentally. A nurse cant perform duties that violate a rule or regulation established by a state licensing board, even if they are authorized by a health care facility or physician. To minimize interruptions during a patient interview, the nurse should select a private room, preferably one with a door that can be closed. In categorizing nursing diagnoses, the nurse addresses life-threatening problems first, followed by potentially life-threatening concerns. The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions. Standing orders, or protocols, establish guidelines for treating a specific disease or set of symptoms.

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In assessing a patients heart, the nurse normally finds the point of maximal impulse at the fifth intercostal space, near the apex. The S1 heard on auscultation is caused by closure of the mitral and tricuspid valves. To maintain package sterility, the nurse should open a wrappers top flap away from the body, open each side flap by touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward the body. The nurse shouldnt dry a patients ear canal or remove wax with acotton-tipped applicator because it may force cerumen against the tympanic membrane. A patients identification bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises. The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse potential. Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States. Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential, but currently have accepted medical uses. Their use may lead to physical or psychological dependence. Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both. Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs. Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances. Activities of daily living are actions that the patient must perform every day to provide selfcare and to interact with society. Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI. The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with the stethoscope slightly raised from the chest. The most important goal to include in a care plan is the patients goal. Fruits are high in fiber and low in protein, and should be omitted from a low-residue diet. The nurse should use an objective scale to assess and quantify pain. Postoperative pain varies greatly among individuals. Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings. The nurse should provide honest answers to the patients questions. Milk shouldnt be included in a clear liquid diet. When caring for an infant, a child, or a confused patient, consistency in nursing personnel is paramount. The hypothalamus secretes vasopressin and oxytocin, which are stored in the pituitary gland. The three membranes that enclose the brain and spinal cord are the dura mater, pia mater, and arachnoid. A nasogastric tube is used to remove fluid and gas from the small intestine preoperatively or postoperatively. Psychologists, physical therapists, and chiropractors arent authorized to write prescriptions for drugs. The area around a stoma is cleaned with mild soap and water. Vegetables have a high fiber content.

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The nurse should use a tuberculin syringe to administer a subcutaneous injection of less than 1 ml. For adults, subcutaneous injections require a 25G 1" needle; for infants, children, elderly, or very thin patients, they require a 25G to 27G " needle. Before administering a drug, the nurse should identify the patient by checking the identification band and asking the patient to state his name. To clean the skin before an injection, the nurse uses a sterile alcohol swab to wipe from the center of the site outward in a circular motion. The nurse should inject heparin deep into subcutaneous tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation. If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure. The nurse shouldnt cut the patients hair without written consent from the patient or an appropriate relative. If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops. If bruising occurs, the nurse should monitor the site for an enlarging hematoma. When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head. The frequency of patient hair care depends on the length and texture of the hair, the duration of hospitalization, and the patients condition. Proper function of a hearing aid requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries. The hearing aid thats marked with a blue dot is for the left ear; the one with a red dot is for the right ear. A hearing aid shouldnt be exposed to heat or humidity and shouldnt be immersed in water. The nurse should instruct the patient to avoid using hair spray while wearing a hearing aid. The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy. The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown. Heat is applied to promote vasodilation, which reduces pain caused by inflammation. A sutured surgical incision is an example of healing by first intention (healing directly, without granulation). Healing by secondary intention (healing by granulation) is closure of the wound when granulation tissue fills the defect and allows reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered. Keloid formation is an abnormality in healing thats characterized by overgrowth of scar tissue at the wound site. The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldnt massage the injection site. An ascending colostomy drains fluid feces. A descending colostomy drains solid fecal matter. A folded towel (scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis. When giving an injection to a patient who has a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection. Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation. To insert a nasogastric tube, the nurse instructs the patient to tilt the head back slightly and then inserts the tube. When the nurse feels the tube curving at the pharynx, the nurse should

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tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.) Families with loved ones in intensive care units report that their four most important needs are to have their questions answered honestly, to be assured that the best possible care is being provided, to know the patients prognosis, and to feel that there is hope of recovery. Double-bind communication occurs when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to. A nonjudgmental attitude displayed by a nurse shows that she neither approves nor disapproves of the patient. Target symptoms are those that the patient finds most distressing. A patient should be advised to take aspirin on an empty stomach, with a full glass of water, and should avoid acidic foods such as coffee, citrus fruits, and cola. For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for the problem, and selecting the intervention from the choices provided that will enable the patient to reach that goal. Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient. Administering an I.M. injection against the patients will and without legal authority is battery. An example of a third-party payer is an insurance company. The formula for calculating the drops per minute for an I.V. infusion is as follows: (volume to be infused drip factor) time in minutes = drops/minute On-call medication should be given within 5 minutes of the call. Usually, the best method to determine a patients cultural or spiritual needs is to ask him. An incident report or unusual occurrence report isnt part of a patients record, but is an inhouse document thats used for the purpose of correcting the problem. Critical pathways are a multidisciplinary guideline for patient care. When prioritizing nursing diagnoses, the following hierarchy should be used: Problems associated with the airway, those concerning breathing, and those related to circulation. The two nursing diagnoses that have the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern. A subjective sign that a sitz bath has been effective is the patients expression of decreased pain or discomfort. For the nursing diagnosis Deficient diversional activity to be valid, the patient must state that hes bored, that he has nothing to do, or words to that effect. The most appropriate nursing diagnosis for an individual who doesnt speak English is Impaired verbal communication related to inability to speak dominant language (English). The family of a patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him. Before instilling medication into the ear of a patient who is up to age 3, the nurse should pull the pinna down and back to straighten the eustachian tube. To prevent injury to the cornea when administering eyedrops, the nurse should waste the first drop and instill the drug in the lower conjunctival sac. After administering eye ointment, the nurse should twist the medication tube to detach the ointment. When the nurse removes gloves and a mask, she should remove the gloves first. They are soiled and are likely to contain pathogens. Crutches should be placed 6" (15.2 cm) in front of the patient and 6" to the side to form a tripod arrangement. Listening is the most effective communication technique.

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Before teaching any procedure to a patient, the nurse must assess the patients current knowledge and willingness to learn. Process recording is a method of evaluating ones communication effectiveness. When feeding an elderly patient, the nurse should limit high-carbohydrate foods because of the risk of glucose intolerance. When feeding an elderly patient, essential foods should be given first. Passive range of motion maintains joint mobility. Resistive exercises increase muscle mass. Isometric exercises are performed on an extremity thats in a cast. A back rub is an example of the gate-control theory of pain. Anything thats located below the waist is considered unsterile; a sterile field becomes unsterile when it comes in contact with any unsterile item; a sterile field must be monitored continuously; and a border of 1" (2.5 cm) around a sterile field is considered unsterile. A shift to the left is evident when the number of immature cells (bands) in the blood increases to fight an infection. A shift to the right is evident when the number of mature cells in the blood increases, as seen in advanced liver disease and pernicious anemia. Before administering preoperative medication, the nurse should ensure that an informed consent form has been signed and attached to the patients record. A nurse should spend no more than 30 minutes per 8-hour shift providing care to a patient who has a radiation implant. A nurse shouldnt be assigned to care for more than one patient who has a radiation implant. Long-handled forceps and a lead-lined container should be available in the room of a patient who has a radiation implant. Usually, patients who have the same infection and are in strict isolation can share a room. Diseases that require strict isolation include chickenpox, diphtheria, and viral hemorrhagic fevers such as Marburg disease. For the patient who abides by Jewish custom, milk and meat shouldnt be served at the same meal. Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps involved in the procedure (cognitive domain of learning). According to Erik Erikson, developmental stages are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to age 3), initiative versus guilt (ages 3 to 5), industry versus inferiority (ages 5 to 12), identity versus identity diffusion (ages 12 to 18), intimacy versus isolation (ages 18 to 25), generativity versus stagnation (ages 25 to 60), and ego integrity versus despair (older than age 60). When communicating with a hearing impaired patient, the nurse should face him. An appropriate nursing intervention for the spouse of a patient who has a serious incapacitating disease is to help him to mobilize a support system. Hyperpyrexia is extreme elevation in temperature above 106 F (41.1 C). Milk is high in sodium and low in iron. When a patient expresses concern about a health-related issue, before addressing the concern, the nurse should assess the patients level of knowledge. The most effective way to reduce a fever is to administer an antipyretic, which lowers the temperature set point. When a patient is ill, its essential for the members of his family to maintain communication about his health needs. Ethnocentrism is the universal belief that ones way of life is superior to others. When a nurse is communicating with a patient through an interpreter, the nurse should speak to the patient and the interpreter.

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In accordance with the hot-cold system used by some Mexicans, Puerto Ricans, and other Hispanic and Latino groups, most foods, beverages, herbs, and drugs are described as cold. Prejudice is a hostile attitude toward individuals of a particular group. Discrimination is preferential treatment of individuals of a particular group. Its usually discussed in a negative sense. Increased gastric motility interferes with the absorption of oral drugs. The three phases of the therapeutic relationship are orientation, working, and termination. Patients often exhibit resistive and challenging behaviors in the orientation phase of the therapeutic relationship. Abdominal assessment is performed in the following order: inspection, auscultation, palpation, and percussion. When measuring blood pressure in a neonate, the nurse should select a cuff thats no less than one-half and no more than two-thirds the length of the extremity thats used. When administering a drug by Z-track, the nurse shouldnt use the same needle that was used to draw the drug into the syringe because doing so could stain the skin. Sites for intradermal injection include the inner arm, the upper chest, and on the back, under the scapula. When evaluating whether an answer on an examination is correct, the nurse should consider whether the action thats described promotes autonomy (independence), safety, self-esteem, and a sense of belonging. When answering a question on the NCLEX examination, the student should consider the cue (the stimulus for a thought) and the inference (the thought) to determine whether the inference is correct. When in doubt, the nurse should select an answer that indicates the need for further information to eliminate ambiguity. For example, the patient complains of chest pain (the stimulus for the thought) and the nurse infers that the patient is having cardiac pain (the thought). In this case, the nurse hasnt confirmed whether the pain is cardiac. It would be more appropriate to make further assessments. Veracity is truth and is an essential component of a therapeutic relationship between a health care provider and his patient. Beneficence is the duty to do no harm and the duty to do good. Theres an obligation in patient care to do no harm and an equal obligation to assist the patient. Nonmaleficence is the duty to do no harm. Fryes ABCDE cascade provides a framework for prioritizing care by identifying the most important treatment concerns. A = Airway. This category includes everything that affects a patent airway, including a foreign object, fluid from an upper respiratory infection, and edema from trauma or an allergic reaction. B = Breathing. This category includes everything that affects the breathing pattern, including hyperventilation or hypoventilation and abnormal breathing patterns, such as Korsakoffs, Biots, or Cheyne-Stokes respiration. C = Circulation. This category includes everything that affects thecirculation, including fluid and electrolyte disturbances and disease processes that affect cardiac output. D = Disease processes. If the patient has no problem with the airway, breathing, or circulation, then the nurse should evaluate the disease processes, giving priority to the disease process that poses the greatest immediate risk. For example, if a patient has terminal cancer and hypoglycemia, hypoglycemia is a more immediate concern. E = Everything else. This category includes such issues as writing an incident report and completing the patient chart. When evaluating needs, this category is never the highest priority.

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When answering a question on an NCLEX examination, the basic rule is assess before action. The student should evaluate each possible answer carefully. Usually, several answers reflect the implementation phase of nursing and one or two reflect the assessment phase. In this case, the best choice is an assessment response unless a specific course of action is clearly indicated. Rule utilitarianism is known as the greatest good for the greatest number of people theory. Egalitarian theory emphasizes that equal access to goods and services must be provided to the less fortunate by an affluent society. Active euthanasia is actively helping a person to die. Brain death is irreversible cessation of all brain function. Passive euthanasia is stopping the therapy thats sustaining life. A third-party payer is an insurance company. Utilization review is performed to determine whether the care provided to a patient was appropriate and cost-effective. A value cohort is a group of people who experienced an out-of-the-ordinary event that shaped their values. Voluntary euthanasia is actively helping a patient to die at the patients request. Bananas, citrus fruits, and potatoes are good sources of potassium. Good sources of magnesium include fish, nuts, and grains. Beef, oysters, shrimp, scallops, spinach, beets, and greens are good sources of iron. Intrathecal injection is administering a drug through the spine. When a patient asks a question or makes a statement thats emotionally charged, the nurse should respond to the emotion behind the statement or question rather than to whats being said or asked. The steps of the trajectory-nursing model are as follows: Step 1: Identifying the trajectory phase Step 2: Identifying the problems and establishing goals Step 3: Establishing a plan to meet the goals Step 4: Identifying factors that facilitate or hinder attainment of the goals Step 5: Implementing interventions Step 6: Evaluating the effectiveness of the interventions A Hindu patient is likely to request a vegetarian diet. Pain threshold, or pain sensation, is the initial point at which a patient feels pain. The difference between acute pain and chronic pain is its duration. Referred pain is pain thats felt at a site other than its origin. Alleviating pain by performing a back massage is consistent with the gate control theory. Rombergs test is a test for balance or gait. Pain seems more intense at night because the patient isnt distracted by daily activities. Older patients commonly dont report pain because of fear of treatment, lifestyle changes, or dependency. No pork or pork products are allowed in a Muslim diet. Two goals of Healthy People 2010 are: Help individuals of all ages to increase the quality of life and the number of years of optimal health Eliminate health disparities among different segments of the population. A community nurse is serving as a patients advocate if she tells a malnourished patient to go to a meal program at a local park. If a patient isnt following his treatment plan, the nurse should first ask why. Falls are the leading cause of injury in elderly people. Primary prevention is true prevention. Examples are immunizations, weight control, and smoking cessation.

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Secondary prevention is early detection. Examples include purified protein derivative (PPD), breast self-examination, testicular self-examination, and chest X-ray. Tertiary prevention is treatment to prevent long-term complications. A patient indicates that hes coming to terms with having a chronic disease when he says, Im never going to get any better. On noticing religious artifacts and literature on a patients night stand, a culturally aware nurse would ask the patient the meaning of the items. A Mexican patient may request the intervention of a curandero, or faith healer, who involves the family in healing the patient. In an infant, the normal hemoglobin value is 12 g/dl. The nitrogen balance estimates the difference between the intake and use of protein. Most of the absorption of water occurs in the large intestine. Most nutrients are absorbed in the small intestine. When assessing a patients eating habits, the nurse should ask, What have you eaten in the last 24 hours? A vegan diet should include an abundant supply of fiber. A hypotonic enema softens the feces, distends the colon, and stimulates peristalsis. First-morning urine provides the best sample to measure glucose, ketone, pH, and specific gravity values. To induce sleep, the first step is to minimize environmental stimuli. Before moving a patient, the nurse should assess the patients physical abilities and ability to understand instructions as well as the amount of strength required to move the patient. To lose 1 lb (0.5 kg) in 1 week, the patient must decrease his weekly intake by 3,500 calories (approximately 500 calories daily). To lose 2 lb (1 kg) in 1 week, the patient must decrease his weekly caloric intake by 7,000 calories (approximately 1,000 calories daily). To avoid shearing force injury, a patient who is completely immobile is lifted on a sheet. To insert a catheter from the nose through the trachea for suction, the nurse should ask the patient to swallow. Vitamin C is needed for collagen production. Only the patient can describe his pain accurately. Cutaneous stimulation creates the release of endorphins that block the transmission of pain stimuli. Patient-controlled analgesia is a safe method to relieve acute pain caused by surgical incision, traumatic injury, labor and delivery, or cancer. An Asian American or European American typically places distance between himself and others when communicating. The patient who believes in a scientific, or biomedical, approach to health is likely to expect a drug, treatment, or surgery to cure illness. Chronic illnesses occur in very young as well as middle-aged and very old people. The trajectory framework for chronic illness states that preferences about daily life activities affect treatment decisions. Exacerbations of chronic disease usually cause the patient to seek treatment and may lead to hospitalization. School health programs provide cost-effective health care for low-income families and those who have no health insurance. Collegiality is the promotion of collaboration, development, and interdependence among members of a profession. A change agent is an individual who recognizes a need for change or is selected to make a change within an established entity, such as a hospital. The patients bill of rights was introduced by the American Hospital Association.

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Abandonment is premature termination of treatment without the patients permission and without appropriate relief of symptoms. Values clarification is a process that individuals use to prioritize their personal values. Distributive justice is a principle that promotes equal treatment for all. Milk and milk products, poultry, grains, and fish are good sources of phosphate. The best way to prevent falls at night in an oriented, but restless, elderly patient is to raise the side rails. By the end of the orientation phase, the patient should begin to trust the nurse. Falls in the elderly are likely to be caused by poor vision. Barriers to communication include language deficits, sensory deficits, cognitive impairments, structural deficits, and paralysis. The three elements that are necessary for a fire are heat, oxygen, and combustible material. Sebaceous glands lubricate the skin. To check for petechiae in a dark-skinned patient, the nurse should assess the oral mucosa. To put on a sterile glove, the nurse should pick up the first glove at the folded border and adjust the fingers when both gloves are on. To increase patient comfort, the nurse should let the alcohol dry before giving an intramuscular injection. Treatment for a stage 1 ulcer on the heels includes heel protectors. Seventh-Day Adventists are usually vegetarians. Endorphins are morphinelike substances that produce a feeling of well-being. Pain tolerance is the maximum amount and duration of pain that an individual is willing to endure. Subscribe to our newslet Surgical Care Written by Administrator Friday, 01 April 2011 19:15 MULTIPLE CHOICE 1. A postoperative patient is complaining of incisional pain. An order has been given for morphine every 4 to 6 hours PRN. The first assessment by the nurse should be to: 1. assess for the presence of bowel sounds. 2. assess pupillary reaction. 3. ask the patients family if she is having pain. 4. see when the patient last received pain medication. ANS: 4 Verifying the time of the last dose decreases the risk of a dose of medication being given too soon. PTS: 1 DIF: Cognitive Level: Analysis REF: 264 OBJ: 9 TOP: Acute Pain KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment 2. The nurse is admitting a patient who is scheduled for a hysterectomy. Malignant hyperthermia is a potential postoperative complication. In gathering information on the patients medical history, the nurse should ask: 1. Do you think you might have a fever?

2. Do you currently have an infection? 3. Has anyone in your family ever had problems with general anesthesia? 4. Have you ever had any type of malignancy? ANS: 3 Malignant hyperthermia is a life-threatening complication that occurs in response to certain drugs. Susceptibility to this response is inherited. PTS: 1 DIF: Cognitive Level: Analysis REF: 260 OBJ: 7 TOP: General Anesthesia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 3. A patient who had a hysterectomy yesterday has been NPO. The physician has now ordered the patients diet to be clear liquids. Before administering the diet, the nurse should check for: 1. feelings of hunger. 2. bowel sounds. 3. positive Homans sign. 4. gag reflex. ANS: 2 Absence of bowel sounds would contraindicate a diet. PTS: 1 DIF: Cognitive Level: Application REF: 263 OBJ: 9 TOP: Postoperative Nursing Implementations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. The technique the nurse should use to change a postoperative dressing is: 1. enteric isolation. 2. aseptic technique. 3. clean technique. 4. respiratory isolation. ANS: 2 Aseptic technique is important to reduce the risk of infection. PTS: 1 DIF: Cognitive Level: Comprehension REF: 272 OBJ: 9 TOP: Postoperative Risk for Infection KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment 5. The nurse is caring for the postoperative patient who has had spinal anesthesia. The nurse would place highest priority on reporting which of these assessments? 1. Complaints of a headache 2. Pulse rate of 78 beats per minute 3. Voided 300 mL 4. Blood pressure of 126/78 ANS: 1

One complication of spinal anesthesia is postspinal headache. It is caused by the leaking of cerebrospinal fluid at the puncture site. PTS: 1 DIF: Cognitive Level: Analysis REF: 259 OBJ: 7 TOP: Regional Anesthesia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 6. The nurse is caring for a postoperative patient. To best prevent deep vein thrombosis (DVT) in this patient, the nurse plans to diligently ensure that the patient: 1. splints the incision. 2. coughs and deep-breathes every 2 hours. 3. regularly removes antiembolism stockings. 4. ambulates frequently. ANS: 4 DVT is best prevented by early and frequent ambulation of the patient. PTS: 1 DIF: Cognitive Level: Application REF: 263 OBJ: 7 TOP: Postoperative Complications KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 7. During the nurses preoperative assessment, the nurse notices that the patient is extremely anxious. The patients blood pressure is 142/92 mm Hg, heart rate is 104 per minute, and respirations are 34. The nurse should: 1. go ahead and give the preoperative medicine early to help calm the patient. 2. call the operating room and cancel the surgery. 3. notify the anesthesiologist or surgeon. 4. instruct the patient on possible postoperative complications. ANS: 3 Extreme fear is associated with surgical complications. Sometimes, surgery is postponed until anxiety is reduced. PTS: 1 DIF: Cognitive Level: Analysis REF: 250 OBJ: 3 TOP: Preoperative Anxiety KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 8. The nurse is performing a postoperative assessment on a patient who has just returned from a hernia repair. The patients blood pressure is 90/60 mm Hg and apical pulse is 102. The nurses first action would be to: 1. check the dressing for bleeding. 2. notify the RN. 3. document the vital signs. 4. increase the rate of infusion of IV fluids. ANS: 1 A decrease in blood pressure and tachycardia could indicate postoperative bleeding. The first action of the nurse should be to check the dressing and then report to the RN. PTS: 1 DIF: Cognitive Level: Application

REF: 261-264, Table 17-2 OBJ: 8 TOP: Postoperative Complications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 9. The postoperative patient who has no previous medical conditions is difficult to arouse when transferred to the surgical unit from the postanesthesia care unit. The nurse monitors the pulse oximeter and gets a reading of 85%. The nurses next action should be to: 1. assess the pulse oximeter reading again in 1 hour. 2. arouse the patient and have him cough and deep-breathe. 3. administer a dose of pain medication. 4. suction the patient. ANS: 2 If the pulse oximeter reading is less than 90%, the patient should be aroused and encouraged to take deep breaths. The patients respirations may not be adequate as a result of the effects of anesthesia. PTS: 1 DIF: Cognitive Level: Application REF: 261 OBJ: 8 TOP: Hypoxia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 10. The nurse has completed giving discharge instructions to the patient after a hernia repair. The nurse would determine that the patient understands the instructions if he verbalizes that he will: 1. be going back to work tomorrow. 2. not change the dressing until he sees his physician in 2 weeks. 3. ignore changes in the size of his abdomen. 4. report fever, redness, swelling, or increased pain at the incision site. ANS: 4 The patient should report any signs and symptoms of infection (fever, redness, swelling, or pain). PTS: 1 DIF: Cognitive Level: Analysis REF: 271-272 OBJ: 10 TOP: Discharge Planning KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance 11. The nurse should include the proper use of an incentive spirometer in teaching for a preoperative patient. Postoperative monitoring of this patient would reveal that the incentive spirometry has been effective if the patient has: 1. adventitious breath sounds. 2. expiratory wheezing. 3. thick, green respiratory secretions. 4. clear breath sounds. ANS: 4 An incentive spirometer is used to promote lung expansion, which opens

airways, reduces atelectasis, and stimulates coughing to clear secretions. PTS: 1 DIF: Cognitive Level: Comprehension REF: 261, Table 17-2 OBJ: 4 TOP: Impaired Gas Exchange KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 12. The suprapubic area of a postoperative patient is distended. The patient states that he has not voided since surgery about 9 hours ago. The nurses first action would be to: 1. notify the physician. 2. insert a catheter. 3. have the patient sit on the side of the bed and try to void. 4. prepare the patient to return to surgery. ANS: 3 The patient should be encouraged to try to void in a natural position before other measures are taken. PTS: 1 DIF: Cognitive Level: Application REF: 263, Table 17-2 OBJ: 8 TOP: Postoperative Urinary Retention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 13. Postoperative instructions must be modified for a patient with an intraocular lens implant. The nurse modifies postoperative care from that given most general surgery patients as follows: 1. Early ambulation is not necessary. 2. The dressing should be removed immediately on return to the surgical unit. 3. Do not have this patient cough. 4. The patient should not be allowed to have visitors. ANS: 3 There are a few instances in which coughing is contraindicated. They include surgeries for hernias, cataracts, and brain surgery. PTS: 1 DIF: Cognitive Level: Analysis REF: 273 OBJ: 7 TOP: Postoperative Complications KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 14. When obtaining the patients signature on the operative consent form, the patient seems confused about the procedure to be performed. The appropriate response by the nurse is to: 1. tell the patient to talk to the physician after he gets to the operating room. 2. ask the patient to go ahead and sign the consent. 3. ask the patient what the physician told him and then call the physician if necessary. 4. encourage the patient to ask his family what the physician told them. ANS: 3 The patient may not understand some of the medical terms used by the physician and the nurse may be able to explain them. If the patient still needs

further information, notify the physician. It is the physicians responsibility to explain the procedure and risks to the patient. PTS: 1 DIF: Cognitive Level: Application REF: 251 OBJ: 3 TOP: Consent Form KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity 15. The nurse is doing an assessment of a patient who has returned from a cardiac catheterization and had conscious sedation. The nurse should report which of the following findings? 1. Patient is difficult to arouse 2. Blood pressure of 124/72 3. Oxygen saturation of 96% 4. Patient complains of needing to void ANS: 1 Conscious sedation uses intravenous drugs to reduce pain intensity or awareness without loss of reflexes. A complication may be excessive sedation approaching that of general anesthesia. The patient should be easily aroused. PTS: 1 DIF: Cognitive Level: Analysis REF: 260 OBJ: 6 TOP: Anesthesia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 16. A patient diagnosed with colon cancer is being prepared for palliative surgery to correct an intestinal obstruction. The nurse understands that palliative surgery is: 1. the removal and study of tissue to make a diagnosis. 2. done to relieve symptoms or improve function without correcting the basic problem. 3. done to remove diseased tissue or to correct defects. 4. done to correct serious defects that only affect appearance. ANS: 2 Palliative surgery is done only to relieve symptoms or improve function. It is not curative. PTS: 1 DIF: Cognitive Level: Knowledge REF: 247 OBJ: 1 TOP: Types of Surgery KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 17. During the preoperative assessment, it is most important that the nurse ask the patient for information about: 1. current address and telephone number. 2. food preferences. 3. allergies, medications, and past medical conditions. 4. bathing and sleep patterns. ANS: 3 If an emergency should arise, any allergies can be determined promptly.

Knowledge of the patients medications can enable you to anticipate possible drug interactions. Past medical conditions may increase surgical risks or require special attention in the perioperative period. PTS: 1 DIF: Cognitive Level: Analysis REF: 248 OBJ: 2 TOP: Preoperative Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 18. The member of the surgical team who administers anesthetics and monitors the patients status throughout the procedure is the: 1. surgeon. 2. circulating nurse. 3. perfusionist. 4. anesthesiologist. ANS: 4 The anesthesiologist and nurse anesthetist have special training and are the members of the surgical team that administers anesthesia and are responsible for close patient monitoring during surgery. PTS: 1 DIF: Cognitive Level: Knowledge REF: 258 OBJ: 5 TOP: Surgical Team KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 19. A nurse is assisting in the transfer of a postoperative patient from the postanesthesia care unit to the surgical nursing unit. To ensure the safety of the patient, the nurse would: 1. put the side rails up after moving the patient from the stretcher to the bed. 2. ask the patient to move from the stretcher to the bed. 3. move the patient rapidly from the stretcher to the bed. 4. uncover the patient before transferring from the stretcher to the bed. ANS: 1 The patient will probably still be experiencing residual effects of anesthesia; the side rails should be up to prevent the patient from falling out of bed. PTS: 1 DIF: Cognitive Level: Application REF: 261 OBJ: 9 TOP: Postoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment 20. A patient who has just undergone a colon resection complains to the nurse that he felt something pop under his dressing while trying to get out of bed. The nurse removes the dressing and finds that dehiscence of the wound has occurred. The nurses first action should be to: 1. replace the dressing; dehiscence is normal. 2. call the physician. 3. pull the wound edges together and replace the dressing. 4. cover the wound with sterile dressings saturated with normal saline.

ANS: 4 The first action of the nurse should be to prevent damage from drying of the exposed organs by covering the wound with saline-saturated dressings and then calling the physician. PTS: 1 DIF: Cognitive Level: Comprehension REF: 263 OBJ: 9 TOP: Wound Dehiscence KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 21. A patient has just returned to the surgical unit after varicose vein stripping and ligation. The best technique by the nurse to evaluate pain relief is: 1. checking the patients record for the last dose of pain medication administered. 2. asking the patient to rate the severity of the pain on a scale of 1 to 10. 3. asking the family if they think that the patient is having pain. 4. telling the patient to ask for pain medicine when it is needed. ANS: 2 Having the patient rate the pain provides a system for evaluating response to the pain medication. Pain is controlled better if treated before it becomes severe, and the patient may not ask for pain medicine soon enough. PTS: 1 DIF: Cognitive Level: Application REF: 268 OBJ: 8 TOP: Postoperative Pain Relief KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 22. The patient scheduled for a liver biopsy has given the nurse a list of medications routinely taken at home. The nurse should be concerned about the: 1. aspirin. 2. multivitamin. 3. furosemide. 4. acetaminophen. ANS: 1 Aspirin is an anticoagulant, which can increase the risk of postoperative bleeding. Drugs taken long term may require dosage adjustments because of the effects of surgery or additional drugs. PTS: 1 DIF: Cognitive Level: Analysis REF: 263 OBJ: 2 TOP: Preoperative Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment 23. The patient scheduled for a bronchoscopy is given nothing by mouth (NPO) after midnight, before the procedure. The patient is complaining of being thirsty and requests some water on the morning of the procedure. The nurse should explain to the patient that the reason for keeping him NPO is to prevent:

1. accumulation of fluid in the lungs. 2. pulmonary infections. 3. vomiting and aspiration during the procedure. 4. a full bladder during surgery. ANS: 3 Patients are given nothing by mouth from midnight before the scheduled procedure to reduce the risk of vomiting and aspiration during or after the procedure. PTS: 1 DIF: Cognitive Level: Analysis REF: 253 OBJ: 3 TOP: Preparation for Surgery KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment 24. To prevent the effects of postoperative immobility on the gastrointestinal system, the nurse suggests that the patient: 1. avoid taking antibiotics. 2. increase her fluid intake. 3. avoid high-fiber foods. 4. limit her activity for the first 3 to 4 days. ANS: 2 The intake of oral fluids and ingestion of a normal diet help stimulate peristalsis. PTS: 1 DIF: Cognitive Level: Comprehension REF: 274 OBJ: 9 TOP: Postoperative Complications KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 25. The postanesthesia care nurse is evaluating the patient for possible transfer to the surgical unit. The following assessment would prevent the patients transfer: 1. Blood pressure is 126/78 mm Hg. 2. Pulse rate is 82 beats per minute. 3. Pulse oximeter reading is 85%. 4. Respirations are 22 per minute. ANS: 3 The pulse oximeter reading should be 95% to 100%. The patient should not be transferred from the recovery room until the vital signs are stable, respiratory and circulatory functions are adequate, pain is minimal, he or she is easily wakened, no complications are experienced, and the gag reflex is present. PTS: 1 DIF: Cognitive Level: Analysis REF: 266 OBJ: 8 TOP: Postoperative Assessment KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity MULTIPLE RESPONSE 1. Patients with preoperative disorders put them at risk during recovery. The nurse should be aware of disorders that may pose this hazard, which are (select all that apply):

1. diabetes. 2. warfarin therapy. 3. fungal skin infection. 4. hepatitis C. 5. COPD. ANS: 1, 4, 5 Diabetes, hepatitis C, and COPD all complicate recovery related to blood-clotting deficiencies, respiratory problems, or disturbance in the healing process. Warfarin therapy will have been discontinued well before surgery and fungal skin infections do not pose a threat. PTS: 1 DIF: Cognitive Level: Application REF: 247 OBJ: 8 TOP: Conditions That Complicate Recovery KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. The patient has an extensive bowel preparation of oral laxatives and enemas for a colon resection. When asked about the rigorous prep, the nurse would list as the rationales (select all that apply): 1. Reduces possibility of fecal contamination of the operative site 2. Flattens the colon 3. Decreases postoperative distention 4. Avoids postoperative constipation 5. Decreases straining at stool ANS: 1, 3, 4, 5 Preoperative bowel prep reduces the risk for infection from bowel contents and decreases postoperative distention, constipation, and straining at stool. PTS: 1 DIF: Cognitive Level: Application REF: 252 OBJ: 4 TOP: Rationale for Bowel Prep KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 3. The nurse carefully monitors the obese hysterectomy patient for the peculiar postoperative complications associated with obesity (select all that apply): 1. Nausea 2. Vomiting 3. Hypertension 4. Hemorrhage 5. Respiratory difficulties ANS: 5 Obese patients are especially prone to postoperative respiratory complications of pneumonia and atelectasis. PTS: 1 DIF: Cognitive Level: Application REF: 247, 262 OBJ: 8 TOP: Postoperative Complications in the Obese Patient KEY: Nursing Process Step: Assessment MSC: NCLEX: Physical Integrity

COMPLETION 1. The nurse discovers on the preoperative assessment that the patient has a condition that would require increased amounts of general anesthesia. The condition is ____________________. ANS: Alcoholism PTS: 1 DIF: Cognitive Level: Application REF: 248, 249, Drug Therapy table OBJ: 6 TOP: Conditions That Affect Anesthesia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance