Chapter 6: Genetic Concepts for Medical-Surgical Nursing
Test Bank
MULTIPLE CHOICE
- Which statement by the nurse indicates correct understanding of the purpose of a pedigree?
| a. | “It is used for genetic counseling of the client by the geneticist.” |
| b. | “It is used to show family history of a trait over at least three generations.” |
| c. | “It is used to show a specific pattern of inheritance of a trait.” |
| d. | “It is used to identify penetrance of a gene in a family.” |
ANS: B
A pedigree is a graph of a family history for a specific trait or health problem over several generations. The other statements are inaccurate descriptions of the purpose of a pedigree.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 72
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
- The client exhibits a trait that has appeared in every generation of his or her family. This is an example of which type of inheritance?
| a. | Autosomal recessive |
| b. | Sex-linked recessive |
| c. | Autosomal dominant |
| d. | Sex-linked dominant |
ANS: C
Autosomal dominant (AD) single-gene traits require that the gene alleles controlling the trait be located on an autosomal chromosome. A dominant gene allele is expressed even when only one allele of the pair is dominant. Other criteria for AD patterns of inheritance include that the trait appears in every generation with no skipping. Autosomal recessive, sex-linked recessive, and sex-linked dominant types of inheritance do not require that the trait appear in every generation of a family. Rather, in the case of sex-linked traits, the gender of family members determines whether a trait will appear in a family.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 73
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
- The client has a family history of breast cancer. The physician has recommended that she undergo genetic testing. What action is most important for the nurse to take before scheduling the client for the procedure?
| a. | Making certain the client is prepared for the risk of psychological side effects |
| b. | Obtaining informed consent from the client and placing it on the chart |
| c. | Simultaneously scheduling genetic counseling with an advanced practice nurse |
| d. | Carefully explaining the procedure to the client and assuring her confidentiality |
ANS: B
Informed consent is required before genetic testing is undertaken. The person tested is the one who gives consent, even though genetic testing always gives information about a family and family members, not just the client. Although the procedure must be explained to the client and she must be prepared for the psychological effect of undergoing testing, the procedure cannot occur without an informed consent.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Informed Consent)
MSC: Integrated Process: Communication and Documentation
- The client undergoes genetic testing but chooses not to be told the results of the testing once it is completed. Which action is most important for the nurse to implement?
| a. | Encourage the client to ask for the results of the genetic testing. |
| b. | Share the results of the testing with the client’s family members. |
| c. | Explain to the client how this choice may affect other family members. |
| d. | Respect the client’s right to not know the results of the testing. |
ANS: D
The right to know genetic risk versus the right to not know is the individual client’s choice. The nurse should respect the client’s rights. It would not be appropriate for the nurse to encourage the client to ask for the results because this is a personal issue. The nurse would never share results with others because this is a violation of the Health Insurance Portability and Accountability Act (HIPAA). The client probably realizes that this choice affects other family members. The nurse would not have to explain this.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Client Rights) MSC: Integrated Process: Caring
- The nurse has been working with a client who has asked to receive the results of genetic testing. What will the nurse do before discussing the results with the client?
| a. | Obtain a signed and witnessed informed consent form and place it on the client’s chart. |
| b. | Assess the client’s ability to communicate clearly with the nurse and other personnel. |
| c. | Reassure the client that it is not necessary to inform other family members of the test results. |
| d. | Encourage the client to agree to undergo several sessions of further counseling. |
ANS: B
The nurse has to assess the client’s ability to receive and process information before giving results. Informed consent forms are obtained before blood is obtained for testing. The nurse would not reassure the client that it was not necessary to tell family members. This is something the client will need to decide. The nurse can suggest counseling, if necessary, but does not have to encourage the client to have counseling before giving him or her the results of testing.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
- Which client needs to undergo carrier genetic testing?
| a. | A middle-aged man whose father died at age 48 of colorectal cancer |
| b. | A young woman who has all the symptoms of rheumatoid arthritis |
| c. | A middle-aged woman whose mother died at age 52 of breast cancer |
| d. | A young woman of Eastern European Jewish ancestry |
ANS: D
The client who is of Eastern European Jewish ancestry would be given the highest priority to undergo carrier genetic testing. It is known that Ashkenazi Jews carry several genetic disorders. The client with a family history of breast cancer and colorectal cancer would undergo predisposition testing. The client with symptoms of rheumatoid arthritis would undergo symptomatic diagnostic testing.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
- The client has just completed the first session of genetic counseling. Which intervention will the nurse perform next?
| a. | Assessing the phase of the grieving process most applicable to the client at this time |
| b. | Asking the client to explain the various terms used in the discussion |
| c. | Determining whether the client has adequate coping methods to deal with the counseling process |
| d. | Asking the client to explain expectations and how they may have changed after the session |
ANS: D
After any discussion about genetic risk or genetic testing, the nurse would assess the client’s understanding of what was said and how the information may affect decisions in the future. The client may not be in the grieving process at this time. The nurse does not have to ask the client to explain each term after the session. However, the nurse should have encouraged the client to ask questions throughout the session. Although it is important to assess coping in the client, this is usually done after understanding is assessed. Support can then be offered to the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
- The client has just completed genetic testing and received a negative result. The client tells the nurse that he feels guilty because so many of his family members are carriers of a genetic disease but he is not. What is the nurse’s best response?
| a. | Make certain that the client recognizes that although he is not a carrier of the disease, he could still be symptomatic. |
| b. | Encourage the client to undergo a second round of testing to verify that the result was accurate. |
| c. | Arrange for the client to undergo counseling and offer support to him during this time. |
| d. | Emphasize to the client the importance of revealing his test results to other family members. |
ANS: C
Clients who have negative genetic test results need counseling and support. Some clients may have an unrealistic view of what a negative result means for their general health. Others may feel guilty that they were “spared” when some family members were not. The client will not be symptomatic if he is not a carrier of the disease. A second round of testing is not recommended, because false-negatives are rare with this type of testing. It is the client’s choice to reveal test results to family members; the nurse should not encourage him to do this.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Support Systems)
MSC: Integrated Process: Caring
- A client is not certain whether she and her family should participate in a genetic screening plan. She asks the nurse why the X-linked recessive disorder that has been noted in some of her family members is expressed in males more frequently than in females. What is the nurse’s best response?
| a. | “The disease tends to show up in males because they don’t have a second X chromosome to balance expression of the gene.” |
| b. | “One X chromosome of a pair is always inactive in females. This inactivity effectively negates the effects of the gene.” |
| c. | “Females are known to have more effective DNA repair mechanisms than males, thus negating the damage caused by the recessive gene.” |
| d. | “Expression of genes from the male’s Y chromosome does not occur in females, so they are essentially immune to the effects of the gene.” |
ANS: A
Because the number of X chromosomes in males and females is not the same (1:2), the number of X-linked chromosome genes in the two genders is also unequal. Males have only one X chromosome, a condition called hemizygosity, for any gene on the X chromosome. As a result, X-linked recessive genes have a dominant expressive pattern of inheritance in males and a recessive expressive pattern of inheritance in females. This difference in expression occurs because males do not have a second X chromosome to balance the expression of any recessive gene on the first X chromosome. It is incorrect to say that one X chromosome of a pair is always inactive in females, or that females have more effective DNA repair mechanisms than males. Also, it is not true that females can be immune to the effects of a gene because genes from the male’s Y chromosome are not expressed in females.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 74
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
- The client has been found to have a genetic mutation that increases the risk for colon cancer. The client does not want any family to know about this result. What is the nurse’s best response?
| a. | “It is required by law that you inform your siblings and your children about this result so that they also can be tested and monitored for colon cancer.” |
| b. | “It is not necessary to tell your siblings because they are adults, but you should tell your children so that they can be tested before they decide to have children of their own.” |
| c. | “It is not required that you tell anyone about this result. However, because your siblings and children may also be at risk for colon cancer, you should think about how this information might help them.” |
| d. | “It is your decision to determine with whom, if anyone, you discuss this test result. However, if you do not tell any of your family members and they get colon cancer, you could be held liable.” |
ANS: C
This situation represents an ethical dilemma. It is the client’s decision whether to disclose the information. However, the information can affect others in the client’s family. The law does not require the client to tell family members about the results, nor can the client be held liable for not telling them. The nurse may consider it ethically correct for the client to tell family members so that they can take action to prevent the development of cancer, but the nurse must respect the client’s decision.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Communication and Documentation
- Which response is accurate regarding a client who has type O blood? The client has:
| a. | A genotype of AO |
| b. | A genotype of OO |
| c. | Heterozygous alleles |
| d. | A different genotype and phenotype |
ANS: B
The blood type O allele is recessive, and both alleles must be type O (homozygous) for the person to express type O blood. In type O blood, the genotype and the phenotype are the same. If only one allele is a type O allele and the other allele is type A or type B, the dominant allele will be expressed and the O allele, although present, will not be expressed. When a person has heterozygous alleles for a trait, the phenotype and the genotype are not always the same as with type AB blood.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 70
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
- Which statement regarding genotype and phenotype is accurate?
| a. | For autosomal recessive traits, the phenotype is the same as the genotype. |
| b. | The only trait in which phenotype always follows genotype is physiologic gender. |
| c. | When a phenotype is fully penetrant, the trait is expressed in the heterozygous person. |
| d. | Genotype changes as a person ages, whereas phenotype is not affected by the aging process. |
ANS: A
Genotype refers to the exact alleles of a single gene trait. Phenotype refers to the observable characteristics present when a gene is expressed. For recessive traits, because both alleles must be the same (homozygous) for the gene to be expressed, the phenotype and the genotype are the same. Dominant traits are expressed in the phenotype, even when the person’s genotype is heterozygous for the alleles. Physiologic gender is not the only trait in which phenotype always follows genotype, nor is a trait necessarily expressed in the heterozygous person because a phenotype is fully penetrant. Also, both phenotype and genotype, as with other aspects of the genetic makeup of the individual, are affected by the aging process. The other statements are inaccurate descriptions of genotype and phenotype.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 70
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
- Which statement best describes the concept of multifactorial inheritance?
| a. | A mutation in a single gene results in the expression of problems in a variety of tissues and organs. |
| b. | Susceptibility to a problem is inherited as a single gene trait, but development of the problem is enhanced by environmental conditions. |
| c. | A mutated gene is inherited, but the results of expression of that gene are not evident until middle or late adulthood. |
| d. | Several genes are responsible for the mechanism of hearing, and a mutation in any one of them results in hearing impairment. |
ANS: B
Multifactorial inheritance indicates an interaction between a genetic predisposition and the environment. Although the predisposition to developing a health problem may be inherited, whether the problem is ever expressed is determined by environmental influences, including lifestyle. Some common adult health problems that are multifactorial include hypertension, obesity, diabetes mellitus, and some types of cancer. Multifactorial inheritance does not refer to mutations in one gene that result in problems in many tissues and organs. Although it is true that a gene mutation may not become evident until later in life, this is not the definition of multifactorial inheritance. It does not refer to mutations in several genes or to conditions in which several genes are involved.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 74
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
- A client’s father has hemochromatosis. Which type of genetic testing would be the primary type that is most appropriate for the client to have?
| a. | Presymptomatic |
| b. | Predisposition |
| c. | Diagnostic |
| d. | Carrier |
ANS: D
Hereditary hemochromatosis is an autosomal recessive disorder. The purpose of genetic testing for this client would be to determine whether he or she has one mutated gene allele (is a carrier) and could transmit this disorder to his or her children. All genetic testing is diagnostic in nature. Presymptomatic genetic testing is used with Huntington disease. Predisposition testing is used with colorectal cancer and breast cancer.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 6-4, p. 75
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Nursing Process (Assessment)
- Which disorder qualifies a client for presymptomatic diagnostic genetic testing?
| a. | Colorectal cancer |
| b. | Huntington disease |
| c. | Hemophilia |
| d. | Tay Sachs disease |
ANS: B
Of the disease processes listed, the only one that would make a client a candidate for presymptomatic diagnostic genetic testing is Huntington disease.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 6-4, p. 75
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Nursing Process (Assessment)
- Which disorder presents a need for predisposition genetic testing?
| a. | Huntington disease |
| b. | Sickle cell disease |
| c. | Hemophilia |
| d. | Breast cancer |
ANS: D
Of the disease processes listed, the only one that would make a client a candidate for predisposition diagnostic genetic testing is breast cancer.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 6-4, p. 75
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Nursing Process (Assessment)
- The client, whose mother has Huntington disease, is considering genetic testing but is not sure whether she really wants to know the results. She asks what the nurse would do in her situation. What is the nurse’s best response?
| a. | “I would have the test so I could decide whether to have children or to adopt children.” |
| b. | “I can only tell you the benefits and the risks of testing. You must make this decision yourself.” |
| c. | “Because there is no cure for this disease and testing would not be beneficial, I would not have the test.” |
| d. | “You need to check with your brothers and sisters to determine whether testing for this disease would be appropriate for you.” |
ANS: B
Any level of genetic counseling requires the counselor to be nondirective. The counselor must ensure that the client has adequate and accurate information on which to base the decision but cannot suggest or direct the client to test or not to test. The client may wish to discuss the issue with her family, but ultimately the decision about testing can be made only by the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Communication and Documentation
- The client, who has been found to have a mutation in the BRCA1 gene allele and to be at increased risk for breast and ovarian cancer, has asked the nurse to be present when she discloses this information to her adult daughter. What is the nurse’s role in this situation?
| a. | To act as the primary health care provider |
| b. | To function as a genetic counselor |
| c. | To serve as a client advocate |
| d. | To provide client support |
ANS: D
The nurse should be supporting the client emotionally while the client tells her daughter the information she has learned about the test results. The nurse should not interpret the results nor counsel the client or her daughter. The nurse should refer the client for counseling or support, if necessary.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Support Systems)
MSC: Integrated Process: Nursing Process (Implementation)
- After genetic testing, a client is found to have a specific mutation in the a1AT gene (alpha1-antitrypsin). What is the best action for the nurse to take to guide the client?
| a. | Advise scheduling an annual mammogram and ovarian ultrasound. |
| b. | Assess whether close family members have other identified genetic problems. |
| c. | Suggest limiting exposure to secondhand smoke and other respiratory irritants. |
| d. | Advise that cancer may be a risk but not a certainty for this mutation. |
ANS: C
The a1AT gene mutation increases risk for developing early-onset emphysema. By limiting exposure to smoke and other respiratory irritants, there is less environmental influence that may aggravate an early onset of emphysema. This gene mutation does not promote cancer, nor does it occur with other identified genetic problems. The BRCA1 gene mutation gives the client a higher risk for developing breast cancer. Because of the higher risk of this type of cancer, mammogram and ovarian ultrasound are advised to be performed yearly.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Teaching/Learning
- Which client response best indicates that the client has concerns about a genetic link to a specific condition?
| a. | “Heart disease in women seems to be a growing concern in the United States.” |
| b. | “Obesity is prevalent in the elementary school age population.” |
| c. | “My grandmother died of both breast and bone cancer at age 50.” |
| d. | “Both my aunt and my second cousin have osteoarthritis.” |
ANS: C
The first two responses are general statements about health problems in the United States. Osteoarthritis is not necessarily a genetically linked problem. Breast cancer with metastasis is considered an autosomal dominant inherited condition that may prompt a client to inquire about genetic testing and counseling. The nurse may be the first person to verify information that has genetic implications for the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Promotion/Disease Prevention) MSC: Integrated Process: Teaching/Learning
MULTIPLE RESPONSE
- What client diagnosis indicates a need for carrier genetic testing? (Select all that apply.)
| a. | Colorectal cancer |
| b. | Huntington disease |
| c. | Sickle cell disease |
| d. | Hemophilia |
| e. | Breast cancer |
| f. | Cystic fibrosis |
| g. | Tay Sachs disease |
ANS: C, D, F, G
Of the disease processes listed, the ones that would make the client a candidate for carrier genetic testing would be sickle cell disease, hemophilia, cystic fibrosis, and Tay Sachs disease. Although colorectal cancer, Huntington disease, and breast cancer all have genetic components, there is no evidence that carrier genetic testing would be beneficial in diseases such as these.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 6-4, p. 75
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Diagnostic Tests) MSC: Integrated Process: Nursing Process (Assessment)
- The client has just been typed and crossmatched for a unit of blood. Which statements by the nurse indicate a need for further genetic education? (Select all that apply.)
| a. | “The client can receive any unit of blood because all blood types are basically the same.” |
| b. | “Blood type is formed from three possible gene alleles: A, B, and O.” |
| c. | “Each blood type allele is inherited from the mother or the father.” |
| d. | “If the client’s blood type is AB, then the client is homozygous for that trait.” |
| e. | “If the client has a dominant and a recessive blood type allele, only the dominant will be expressed.” |
ANS: A, D
All blood types are not the same. There are three possible gene alleles: A, B, and O. The blood type OO is homozygous in contrast to the blood type AB, which is heterozygous. In the blood type AO, the gene allele A is dominant and will be expressed as blood type A. It is true that each blood type allele is inherited from the mother or the father.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 68
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Implementation)
- In the hospital, the nurse is caring for a client of Asian descent who was just started on warfarin (Coumadin). What would be the best plan of care for the client? (Select all that apply.)
| a. | Start warfarin at a high dose to decrease the chance for further clotting problems. |
| b. | Monitor international normalized ratio (INR) once a day in the hospital. |
| c. | Teach the client to frequently check for any bruising. |
| d. | Initiate fall precautions and strict activity limitations. |
| e. | Start warfarin at a lower-than-normal dose owing to slower metabolism of the drug. |
ANS: B, C, E
Most individuals of Asian heritage have a single nucleotide polymorphism in the CYP2C19 gene that results in low activity of the enzyme produced. This mutation greatly reduces the metabolism of warfarin, leading to increased bleeding risks and other serious side effects. Any person of Asian heritage who needs anticoagulation therapy should be started on very low dosages of warfarin and should have his or her international normalized ratio (INR) monitored more frequently. The nurse can always teach about the risk of bleeding and can monitor for any bruising. It is not necessary to initiate fall precautions and to limit activity based on the administration of warfarin.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Medication Administration) MSC: Integrated Process: Nursing Process (Planning)
- A client recently underwent genetic testing that revealed that she has a BRCA1 gene mutation for breast cancer. What are the best actions of the nurse? (Select all that apply.)
| a. | Encourage genetic counseling for self and family. |
| b. | Disclose the information to the medical insurance company. |
| c. | Recommend self–breast examination every week. |
| d. | Assess the client’s response to the test results. |
| e. | Aid in making a plan for prevention and risk reduction. |
ANS: A, D, E
The medical-surgical nurse can assess the client’s response to the test results and encourage genetic counseling for self and family. For some positive genetic test results, such as having a BRCA1 gene mutation, the risk for developing breast cancer is high but is not a certainty. Because the risk is high, the client should have a plan for prevention and risk reduction. One form of prevention is early detection. Self–breast examinations are helpful when performed monthly, but those performed every week may not be useful, especially around the time of menses. A client who tests positive for a BRCA1 mutation should have at least yearly mammograms and ovarian ultrasounds to detect cancer at an early stage, when it is more easily cured. Owing to confidentiality, the nurse would never reveal any information about a client to an insurance company without the client’s permission.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening)
MSC: Integrated Process: Nursing Process (Planning)
Chapter 9: End-of-Life Care
Test Bank
MULTIPLE CHOICE
- The client tells the nurse that even though it has been 4 months since her sister’s death, she frequently finds herself crying uncontrollably. The client is afraid that she is “losing her mind.” What is the nurse’s best response?
| a. | “Most people move on within a few months. You should see a grief counselor.” |
| b. | “Whenever you start to cry, distract yourself from thoughts of your sister.” |
| c. | “You should try not to cry. I’m sure your sister is in a better place now.” |
| d. | “Your feelings are completely normal and may continue for a long time.” |
ANS: D
Frequent crying is not an abnormal response. The nurse should let the client know that this is normal and okay. Although the client may benefit from talking with a grief counselor, it is not unusual for her to still be grieving after a few months. The other responses are not as therapeutic because they justify or minimize the client’s response.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Caring
- The nurse is discussing advance directives with a client. Which statement by the client indicates good understanding of the purpose of an advance directive?
| a. | “An advance directive will keep my children from selling my home when I’m old.” |
| b. | “An advance directive will be completed as soon as I’m incapacitated and can’t think for myself.” |
| c. | “An advance directive will specify what I want done when I can no longer make decisions about health care.” |
| d. | “An advance directive will allow me to keep my money out of the reach of my family.” |
ANS: C
An advance directive is a written document prepared by a competent individual that specifies what, if any, extraordinary actions a person would want taken when he or she can no longer make decisions about personal health care. It does not address issues such as the client’s residence in his or her own home.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 108
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Advance Directives) MSC: Integrated Process: Nursing Process (Assessment)
- The nurse is caring for a client who is considering being admitted to hospice. What is the nurse’s best response?
| a. | “Hospice admission has specific criteria. You may not be a viable candidate, so we will look at alternative plans for your discharge.” |
| b. | “Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms.” |
| c. | “Hospice care will not help with your symptoms of depression. I will refer you to the facility’s counseling services instead.” |
| d. | “You seem to be experiencing some difficulty with this stage of the grieving process. Let’s talk about your feelings.” |
ANS: B
As both a philosophy and a system of care, hospice care uses an interdisciplinary approach to assess and address the holistic needs of clients and families to facilitate quality of life and a peaceful death. This holistic approach neither hastens nor postpones death but provides relief of symptoms experienced by the dying client.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 108
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
- A hospitalized American Indian client is approaching death. Family members who are standing vigil in the client’s room begin to divide up his possessions among themselves as his symptoms progress. What is the nurse’s most important intervention?
| a. | Ask the family members to step outside the room so the client cannot hear them. |
| b. | Tell the family that they are being insensitive and their behavior is inappropriate. |
| c. | Recognize that this is a culturally appropriate activity and document it in the chart. |
| d. | Report these activities to the client’s physician and the nursing supervisor. |
ANS: C
American Indians often disperse material possessions before or after death to friends and family members. Recognizing this culturally appropriate activity would not be consistent with removing the family, stopping the activity, or reporting the client’s family’s behaviors.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Cultural Diversity)
MSC: Integrated Process: Caring
- The spouse of a dying client states that she is concerned that her husband is choking to death. What is the nurse’s best response?
| a. | “Do not worry. The choking sound is normal during the dying process.” |
| b. | “I will administer more morphine to keep your husband comfortable.” |
| c. | “I can ask the respiratory therapist to suction secretions out through his nose.” |
| d. | “I will have another nurse assist me to turn your husband on his side.” |
ANS: D
The choking sound or “death rattle” is common in dying clients. The nurse should acknowledge the spouse’s concerns and provide interventions that will reduce the choking sounds. Repositioning the client onto one side with a towel under the mouth to collect secretions is the best intervention. Morphine will assist with comfort but will not decrease the choking sounds. Nasal tracheal suctioning is not appropriate in a dying client. The nurse should not minimize the spouse’s concerns.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
- The terminally ill client is prescribed morphine to help cope with increasing discomfort. A family member expresses concern that the client is on “too much morphine.” What is the nurse’s best response?
| a. | “What has the physician told you about your family member’s illness?” |
| b. | “Don’t worry about that. We’re following the physician’s plan of care.” |
| c. | “Tell me more about what you mean by too much morphine.” |
| d. | “You should talk with your physician about this when he makes rounds.” |
ANS: C
Asking family members to explain what they mean by “too much morphine” serves to gain more information for the nurse. The other questions will not help the nurse obtain more information about the client’s care or the family’s concerns.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Caring and Communication
- The nurse is teaching a family member about various types of complementary therapies that might be effective for relieving the dying client’s anxiety and restlessness. Which statement by the family member indicates understanding of the nurse’s teaching?
| a. | “Maybe we should just hire a round-the-clock sitter to stay with Grandmother.” |
| b. | “I have some of her favorite hymns on a CD that I could bring for music therapy.” |
| c. | “I don’t think that she’ll need pain medication along with her herbal treatments.” |
| d. | “I will burn therapeutic incense in the room so we can stop the anxiety pills.” |
ANS: B
Music therapy is a complementary therapy that may produce relaxation by quieting the mind and removing a client’s inner restlessness. Complementary therapies are used in conjunction with traditional therapy. The complementary therapy would not replace pain or anxiety medication but may help decrease the need for these medications. Hiring an around-the-clock sitter does not demonstrate that the client’s family understands complementary therapies.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort Interventions) MSC: Integrated Process: Caring
- A terminally ill client has just died in a hospital setting with family members at the bedside. The health care provider is also present. What should be the nurse’s priority intervention as postmortem care begins?
| a. | Call for emergency assistance so that resuscitation procedures can begin. |
| b. | Ask the family members if they would like to spend time alone with the client. |
| c. | Ensure that a death certificate has been completed by the physician. |
| d. | Request family members to prepare the client’s body for the funeral home. |
ANS: B
Before moving the client’s body to the funeral home, the nurse should ask family members if they would like to be alone with the client. Emergency assistance will not be necessary. Although it is important to ensure that a death certificate has been completed before the client is moved to the mortuary, the nurse first should ask family members if they would like to be alone with the client. The client’s family should not be expected to prepare the body for the funeral home.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
- The nurse is providing care for a hospice client who is in the last stages of the dying process. The client develops a pressure ulcer on her sacrum, and family members tell the nurse that they would like a specialist consulted to treat the ulcer. When the nurse discusses this with the client, the client states that the ulcer does not bother her, that it is not causing her pain, and that she’d rather not have additional caregivers at this time. What should the hospice nurse do next?
| a. | Tell the family the wound care specialist will be consulted and treatment will begin. |
| b. | Ask the social worker and the chaplain to talk with family members about the dying process. |
| c. | Explain the client’s desires to the family, emphasizing that the client will be made as comfortable as possible. |
| d. | Ask the agency mental health nurse to speak with the client about refusing treatment. |
ANS: C
When palliative care is provided to the dying client, symptoms will be actively treated only if they are causing the client distress. In this case, the client has stated that the pressure ulcer is not causing her distress, and she does not want further intervention.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
- The nurse is being trained in hospice care. Which intervention by the nurse is most compatible with the goals of end-of-life care for the client?
| a. | Administer influenza and pneumococcal vaccinations. |
| b. | Prevent the client with chronic obstructive pulmonary disease from smoking. |
| c. | Perform passive range-of-motion exercises to prevent contractures. |
| d. | Permit the client with diabetes mellitus to have a serving of ice cream. |
ANS: D
When a client is near the end of life, nursing interventions should be focused toward facilitating peaceful death by granting the client’s wishes and identifying his or her needs. Allowing a client who wishes to have something that is not permitted in the diet can be comforting if he or she has a craving or a desire for that food. There is no reason to withhold it at this time.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
- The nurse is assessing the dying client. Which manifestations of a dying client should the nurse assess to determine whether the client is near death?
| a. | Level of consciousness |
| b. | Respiratory rate |
| c. | Bowel sounds |
| d. | Pain level on a 0 to 10 scale |
ANS: B
All of these assessments should be performed during the dying process. As the peripheral circulation decreases, the client’s level of consciousness and bowel sounds decrease. The client is unable to provide a numeric number on a pain scale. The nurse should continue to assess respiratory rate throughout the dying process. As the rate drops significantly and breathing becomes agonal, death is near.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
- The wife is concerned because her terminally ill husband does not want to eat. What is the nurse’s best response?
| a. | “Let him know that food is available if he wants it, but do not insist that he eat.” |
| b. | “A feeding tube can be placed in the nose to provide important nutrients.” |
| c. | “Force him to eat even if he does not feel hungry, or he will die sooner.” |
| d. | “He is getting all the nutrients he needs through his intravenous catheter.” |
ANS: A
When family members understand that the client is not suffering from hunger and is not “starving to death,” they may allow the client to determine when, what, or if to eat. Often, as death approaches, metabolic needs decrease and clients do not feel the sensation of hunger. Forcing them to eat frustrates the client and the family.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
- The family members of a client with a terminal illness tell a nurse that the client keeps asking if she is dying. What is the nurse’s best response?
| a. | “Whenever she asks about dying, change the subject.” |
| b. | “Tell her the truth in as gentle a way as possible.” |
| c. | “Tell her that she will get better eventually.” |
| d. | “Ask her if she is afraid to die.” |
ANS: B
Being honest and truthful at such a time is important. It helps the client develop trust in those caring for her. Changing the subject will frustrate the client and may make her distrustful. Providing false hope is not a realistic intervention. Asking a pointed question often will not elicit the information that you want from the client. It is better to ask open-ended questions.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
- The client’s family members are concerned that the client should have a urinary catheter placed because of her decreasing urinary output. What is the hospice nurse’s best response?
| a. | “A Foley catheter is inserted only if she is taking medications that affect output.” |
| b. | “I will insert a Foley catheter if her urinary output drops below 500 mL/day.” |
| c. | “A Foley catheter will be inserted if her bladder becomes distended.” |
| d. | “I will insert a Foley catheter if she becomes incontinent of urine.” |
ANS: C
Insertion of an indwelling catheter is acceptable if the client is unable to void, has a distended bladder, and would be more comfortable not moving. The other statements are not appropriate uses for an indwelling catheter in a hospice setting.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
- The health care provider suggests inpatient hospice for a client. The family members are concerned that their loved one will receive only custodial care. What is the nurse’s best response?
| a. | “The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left.” |
| b. | “Palliative care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop.” |
| c. | “A palliative care facility is like a nursing home and costs less than a hospital because only pain medications are given.” |
| d. | “Your relative is unaware of her surroundings and will not notice the difference between her home and a palliative care facility.” |
ANS: A
Palliative care provides an increased level of personal care designed to manage symptom distress. The focus is on pain control and helping the relative die with dignity.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 110
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
- A dying client’s family members are spending time with the client. What instruction is best to give to family members regarding noise in the client’s room?
| a. | “Remember that she cannot hear you.” |
| b. | “Try to get her to talk or respond to you.” |
| c. | “Avoid making any noise when you are with her.” |
| d. | “Talk in your normal speaking voice.” |
ANS: D
The sense of hearing may remain intact, even when it appears that the client is totally unresponsive to any sort of stimuli. The family member should speak to the client as if she were fully aware.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
- A client who is near death appears to be having difficulty breathing. What is the nurse’s highest-priority intervention?
| a. | Teach the family how to perform nasotracheal suctioning. |
| b. | Request that the physician order morphine sulfate. |
| c. | Document the finding in the client’s chart. |
| d. | Call a respiratory therapist to intubate the client. |
ANS: B
Morphine sulfate is the standard treatment for dyspnea near death; it relieves the psychological and physiologic distress that accompanies breathlessness. Suctioning or intubation may cause the client discomfort. Documentation is important, but it is not the priority intervention because it does nothing to relieve the client’s distress.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
- The nurse is caring for a dying client who becomes very agitated. What is the nurse’s best response?
| a. | Use music therapy to promote relaxation. |
| b. | Increase the dose of intravenous opioids. |
| c. | Provide a second antipsychotic medication. |
| d. | Assess the client for urinary retention. |
ANS: D
Dying clients become agitated when they are in pain or have some discomfort. Before administering medications or other therapies to decrease discomfort, the nurse should assess for potential causes of discomfort including urinary retention.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
- An experienced hospice nurse is training a new nurse in the practices of palliative care. What statement by the new nurse indicates understanding about drug therapy for end-of-life care?
| a. | “I can administer as much pain medication as I want because the client is dying.” |
| b. | “The administration of these medications will hasten the client’s death.” |
| c. | “I can administer medication per the protocol to relieve the client’s symptoms.” |
| d. | “The purpose of palliative sedation is to relieve family members’ distress.” |
ANS: C
Palliative care nurses follow protocols when administering medications. These protocols are standing prescriptions from the provider that identify the appropriate medication, dose, and situation for administration. The nurse cannot administer more than is prescribed. The medications are given to promote comfort and if administered per protocol will not hasten death.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Nursing Process (Evaluation)
- An older client was admitted to hospice owing to impending death in approximately 6 weeks. After 2 months, the family remains at the bedside but is becoming increasingly impatient and irritable. What is the best nursing intervention?
| a. | Ask the family to leave and not return until they are calmer. |
| b. | Sit with the family and listen to their concerns and fears. |
| c. | Tell the family members not to worry, the client will die soon. |
| d. | Consult the chaplain to come and pray with the client’s family. |
ANS: B
Death cannot be accurately predicted. The nurse should sit with the family and listen to their concerns. The nurse should not provide false hope or reassurance. Family members should remain with the client as long as they would like. The chaplain should be consulted if the family requests.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Caring
- An intensive care nurse is discussing withdrawal of care with a client’s family. The family expresses concerns related to discontinuation of therapy. What is the nurse’s best response?
| a. | “I understand your concerns, but in this state, discontinuation of care is not a form of active euthanasia.” |
| b. | “You will need to talk to the provider because I am not legally allowed to participate in the withdrawal of life support.” |
| c. | “I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death.” |
| d. | “There is no need to worry. Most religious organizations support the client’s decision to stop medical treatment.” |
ANS: C
The nurse should validate the family’s concerns and provide accurate information about the discontinuation of therapy. The other statements address specific issues related to the withdrawal of care but do not provide appropriate information about its purpose. If the client’s family asks for specific information about euthanasia, legal, or religious issues, the nurse should provide unbiased information about these topics.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
MULTIPLE RESPONSE
- The hospice nurse is caring for a dying client and her family members. What nursing interventions are appropriate to use? (Select all that apply.)
| a. | Teach family members about physical signs of impending death. |
| b. | Encourage the management of adverse symptoms. |
| c. | Assist family members by offering an explanation for their loss. |
| d. | Encourage reminiscence by both client and family members. |
| e. | Avoid spirituality because the client’s and the nurse’s beliefs may not be congruent. |
| f. | Do not encourage hope for the terminally ill client. |
ANS: A, B, D
The nurse should teach family members about the physical signs of death, because family members often become upset when they see physiologic changes in their loved one. Palliative care includes management of symptoms so that the peaceful death of the client is facilitated. Reminiscence will help both the client and family members cope with the dying process. The nurse is not expected to explain why this is happening to the family’s loved one. The nurse can encourage spirituality if the client is agreeable, regardless of whether her religion is the same.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
- The nurse is providing care for a dying client. The nurse would place highest priority on treating which symptoms? (Select all that apply.)
| a. | Anorexia |
| b. | Weight loss |
| c. | Pain |
| d. | Agitation |
| e. | Nausea |
| f. | Hair loss |
| g. | Dyspnea |
ANS: C, D, E, G
Only symptoms that cause distress for a dying client should be treated. Such symptoms include pain, nausea and vomiting, dyspnea, and agitation. These problems interfere with the client’s comfort. Even when symptoms, such as anorexia or weight loss, disturb the family, they should be treated only if the client is distressed by their presence. The nurse should provide education to the family and the client related to normal symptoms of dying.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (End-of-Life Care)
MSC: Integrated Process: Caring
- The nurse is admitting a new client to the hospital and needs to determine the plan of care. What criterion is required for the client to make his own medical decisions? (Select all that apply.)
| a. | Can communicate his treatment preferences |
| b. | Is able to read and write at an 8th grade level |
| c. | Is oriented enough to received information |
| d. | Can evaluate and deliberate information |
| e. | Has completed an advance directive |
ANS: A, C, D
To have decision-making ability, a person must be able to perform three tasks: receive information (but not necessarily oriented ´4); evaluate, deliberate, and mentally manipulate information; and communicate a treatment preference. The client does not have to read or write at a specific level. Education can be provided at the client’s level, so that he can make the necessary decisions. The client does not need to complete an advance directive to make his own medical decisions. An advance directive will be necessary if he wants to designate someone to make medical decisions when he is unable to.
DIF: Cognitive Level: Knowledge/Remembering REF: p. 107
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Advance Directives) MSC: Integrated Process: Nursing Process (Assessment)
Chapter 13: Assessment and Care of Patients with Fluid and Electrolyte Imbalances
Test Bank
MULTIPLE CHOICE
- The nurse observes skin tenting on the back of the older adult client’s hand. Which action by the nurse is most appropriate?
| a. | Notify the physician. |
| b. | Examine dependent body areas. |
| c. | Assess turgor on the client’s forehead. |
| d. | Document the finding and continue to monitor. |
ANS: C
Skin turgor cannot be accurately assessed on an older adult client’s hands because of age-related loss of tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely examining dependent body areas. Further assessment is needed rather than only documenting, monitoring, and notifying the physician.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC: Integrated Process: Nursing Process (Assessment)
- The client is taking a medication that inhibits aldosterone secretion and release. The nurse assesses for what potential complication?
| a. | Fluid retention |
| b. | Hyperkalemia |
| c. | Hyponatremia |
| d. | Hypervolemia |
ANS: B
Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client’s risk for excessive water loss and increased potassium reabsorption. The client would not be at risk for overhydration or sodium imbalance.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Assessment)
- Which assessment does the nurse use to determine the adequacy of circulation in a client whose blood osmolarity is 250 mOsm/L?
| a. | Measuring urine output |
| b. | Measuring abdominal girth |
| c. | Monitoring fluid intake |
| d. | Comparing radial versus apical pulses |
ANS: A
The blood osmolarity is low. The client could be dehydrated (hypo-osmolar dehydration) or overhydrated with dilution of blood solute. The most sensitive noninvasive indicator of circulation adequacy is urine output. Measuring abdominal girth, comparing pulses, and monitoring fluid intake would not be accurate assessment techniques for this client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
- Which statement made by the older adult client alerts the nurse to assess specifically for fluid and electrolyte imbalances?
| a. | “My skin is always so dry, especially here in the Southwest.” |
| b. | “I often use a glycerin suppository for constipation.” |
| c. | “I don’t drink liquids after 5 PM so I don’t have to get up at night.” |
| d. | “In addition to coffee, I drink at least one glass of water with each meal.” |
ANS: C
Restricting fluids without a medical reason can lead to dehydration. Many older clients believe that restricting fluids will prevent incontinence and reduce the number of times that they wake up during the night. The increased osmolarity of the urine in response to reducing fluid intake increases irritation of the bladder and sphincter, increasing the sensation of needing to urinate. The other statements do not indicate practices that could potentially lead to dehydration.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
- A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been effective?
| a. | Chinese take-out, including steamed rice |
| b. | A grilled cheese sandwich with tomato soup |
| c. | Slices of ham and cheese on whole grain crackers |
| d. | A chicken leg, one slice of bread with butter, and steamed carrots |
ANS: D
Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The Chinese food likely would have soy sauce, the tomato soup is processed, and the crackers are a snack food—a category of foods often high in sodium.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
- A client is on a potassium-restricted diet. Which protein choice by the client indicates a good understanding of the dietary regimen?
| a. | 1% or 2% milk |
| b. | Grilled salmon |
| c. | Poached eggs |
| d. | Baked chicken |
ANS: C
Eggs contain few cells and have one of the lowest potassium contents among high-protein foods. Meat and fish have cells that contain large amounts of potassium. Dairy products are also high in potassium.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
- Which assessment finding obtained while taking the history of an older adult client alerts the nurse that the client needs further assessment for fluid or electrolyte imbalance?
| a. | “I am often cold and need to wear a sweater.” |
| b. | “I seem to urinate more when I drink coffee.” |
| c. | “In the summer, I feel thirsty more often.” |
| d. | “My rings seem to be tighter this week.” |
ANS: D
A change in ring size over a relatively short period of time may indicate a change in body fluid amount or distribution rather than a change in body fat. The other statements are not indicators of a fluid or electrolyte imbalance.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC: Integrated Process: Nursing Process (Assessment)
- Which client is at greatest risk for dehydration?
| a. | Younger adult client on bedrest |
| b. | Older adult client receiving hypotonic IV fluid |
| c. | Younger adult client receiving hypertonic IV fluid |
| d. | Older adult client with cognitive impairment |
ANS: D
Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 174
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration) MSC: Integrated Process: Nursing Process (Assessment)
- Which question does the nurse ask the client who has isotonic dehydration to determine a possible cause?
| a. | “Do you take diuretics, or ‘water pills’?” |
| b. | “What do you normally eat over a day’s time?” |
| c. | “How many bowel movements do you have daily?” |
| d. | “Have you been diagnosed with diabetes mellitus?” |
ANS: A
Misuse or overuse of diuretics is a common cause of isotonic dehydration. The other statements are not indicative of causes of isotonic dehydration.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Assessment)
- Which intervention in a client with dehydration-induced confusion is most likely to relieve the confusion?
| a. | Measuring intake and output every four hours |
| b. | Applying oxygen by mask or nasal cannula |
| c. | Increasing the IV flow rate to 250 mL/hr |
| d. | Placing the client in a high Fowler’s position |
ANS: B
Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)
- A client is being treated for dehydration. Which statement made by the client indicates understanding of this condition?
| a. | “I must drink a quart of water or other liquid each day.” |
| b. | “I will weigh myself each morning before I eat or drink.” |
| c. | “I will use a salt substitute when making and eating my meals.” |
| d. | “I will not drink liquids after 6 PM so I won’t have to get up at night.” |
ANS: B
Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
- What intervention is most important to teach the client about identifying the onset of dehydration?
| a. | Measuring abdominal girth |
| b. | Converting ounces to milliliters |
| c. | Obtaining and charting daily weight |
| d. | Selecting food items with high water content |
ANS: C
Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. Obtaining and charting accurate daily weights is the most sensitive and cost-effective way of monitoring fluid balance in the home. The other options would not be useful for early detection of dehydration.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Implementation)
- A nurse is caring for several clients with dehydration. The nurse assesses the client with which finding as needing oxygen therapy?
| a. | Tenting of skin on the back of the hand |
| b. | Increased urine osmolarity |
| c. | Weight loss of 10 pounds |
| d. | Pulse rate of 115 beats/min |
ANS: D
Severe dehydration can decrease circulating volume and decrease cardiac output, placing vital organs at risk for hypoxia, anoxia, and ischemia. Whenever cardiac output is decreased with dehydration, oxygen therapy is indicated.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Assessment)
- Which action does the nurse teach a client to reduce the risk for dehydration?
| a. | Restricting sodium intake to no greater than 4 g/day |
| b. | Maintaining an oral intake of at least 1500 mL/day |
| c. | Maintaining a daily oral intake approximately equal to daily fluid loss |
| d. | Avoiding the use of glycerin suppositories to manage constipation |
ANS: C
Although a fixed oral intake of 1500 mL daily is good, the key to prevention of dehydration is to match all fluid losses with the same volume for fluid intake. This is especially true in warm or dry environments, or when conditions result in greater than usual fluid loss through perspiration or ventilation.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 174
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
- Which item of assessment data obtained by the home care nurse suggests that an older adult client may be dehydrated?
| a. | The client has dry, scaly skin on bilateral upper and lower extremities. |
| b. | The client states that he gets up three or more times during the night to urinate. |
| c. | The client states that he feels lightheaded when he gets out of bed or stands up. |
| d. | The nurse observes tenting on the back of the hand when testing skin turgor. |
ANS: C
Orthostatic or postural hypotension can be caused by or worsened by dehydration. The other statements are not as indicative of the severe degree of dehydration as dizziness on standing.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 175
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
- A client is being discharged with mild dehydration. Which statement by the client indicates an understanding of measures to prevent mild dehydration from becoming more severe?
| a. | “I will weigh myself at the same time daily wearing the same clothes.” |
| b. | “When I feel lightheaded, I will drink a full glass of water.” |
| c. | “I will decrease my fluid intake if my urine output increases.” |
| d. | “If I forget to take my diuretic, I will take twice the dose next time.” |
ANS: B
Feeling lightheaded or dizzy is an indication of low blood pressure and poor perfusion. Mild dehydration can cause these problems, and increasing fluid intake at the first sign of dehydration may prevent it from becoming worse. The other options would not prevent mild dehydration from progressing.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
- During assessment of hydration status, the client tells the nurse that she usually drinks 3 quarts of liquids each day. Which question by the nurse is best?
| a. | “Do you usually drink liquids that are hot or cold?” |
| b. | “How much salt do you add to your food?” |
| c. | “What kinds of liquids do you usually drink?” |
| d. | “Do you drink fluids with meals or between meals?” |
ANS: C
It is just as important to determine the types of fluids ingested as the amount, because fluids vary widely in their osmolarity. In addition, some liquids, such as those that contain alcohol or caffeine, can contribute to fluid and electrolyte imbalances.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
- A nurse is caring for several clients at risk for overhydration. The nurse assesses the older client with which finding first?
| a. | Has had diabetes mellitus for 12 years |
| b. | Uses sodium-containing antacids frequently |
| c. | Just received 3 units of packed red blood cells |
| d. | Had abdominal surgery and has a nasogastric tube |
ANS: C
Blood replacement therapy involves intravenous fluid administration, which inherently increases the risk for overhydration. The fact that the fluid consists of packed red blood cells greatly increases the risk, because this fluid increases the colloidal oncotic pressure of the blood, causing fluid to move from interstitial and intracellular spaces into the plasma volume. An older adult may not have sufficient cardiac or renal reserve to manage this extra fluid.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures)
MSC: Integrated Process: Nursing Process (Assessment)
- A client has been diagnosed with overhydration and is confused. Which intervention does the nurse include in the client’s plan of care to relieve the confusion?
| a. | Measuring intake and output every shift |
| b. | Slowing the IV flow rate to 50 mL/hr |
| c. | Administering diuretic agents as prescribed |
| d. | Placing the client in Trendelenburg position |
ANS: C
Overhydration most frequently leads to poor neuronal function, causing confusion as a result of electrolyte imbalances (usually sodium dilution). Eliminating fluid excess is the best way to reduce confusion. The other interventions would not relieve the client’s confusion.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—Expected Actions/Outcomes)
MSC: Integrated Process: Nursing Process (Implementation)
- The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse’s priority?
| a. | Document the observation in the chart. |
| b. | Measure urine specific gravity and volume. |
| c. | Assess the pulse and blood pressure. |
| d. | Assess the client’s deep tendon reflexes. |
ANS: C
Neck veins in the normovolemic person are full in the supine position and flat in the sitting position. Full neck veins in the sitting position are an indicator of overhydration. Checking the pulse and blood pressure can help determine whether overhydration is present. Urine specific gravity is not as important a measure of volume status and deep tendon reflexes and does not give information on volume status at all. The nurse needs to document the finding, but interventions should not end there.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
- A client in the emergency department has potassium of 2.9 mEq/L. For which disease process or condition does the nurse assess the client?
| a. | Diabetes mellitus |
| b. | Addison’s disease |
| c. | Hyperaldosteronism |
| d. | Diabetes insipidus |
ANS: C
Hyperaldosteronism results in increased reabsorption of sodium and water while enhancing excretion of potassium. Therefore, any client with this condition is at high risk for the development of hypokalemia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
- A client is taking furosemide (Lasix) and becomes confused. Which potassium level does the nurse correlate with this condition?
| a. | 2.9 mEq/L |
| b. | 3.8 mEq/L |
| c. | 5.0 mEq/L |
| d. | 6.0 mEq/L |
ANS: A
Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to perform problem-solving tasks, disorientation, and coma. Normal potassium levels are 3.5 to 5.0 mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to neurologic manifestations.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Analysis)
- A client has hypokalemia. Which question by the nurse obtains the most information on a possible cause?
| a. | “Do you use sugar substitutes?” |
| b. | “Do you use diuretics or laxatives?” |
| c. | “Do you have any kidney disease?” |
| d. | “Have your bowel habits changed recently?” |
ANS: B
Misuse and overuse of diuretics, especially high-ceiling (loop) and thiazide diuretics, and laxatives are common causes of hypokalemia in older adults and in clients with eating disorders. Sugar substitutes and bowel habits are not related to hypokalemia. The client with kidney disease would be more likely to have hyperkalemia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Assessment)
- A client has been treated for hypokalemia. Which clinical manifestation or condition indicates that treatment has been effective?
| a. | Having a bowel movement daily |
| b. | Gaining 2 lb during the past week |
| c. | Electrocardiogram (ECG) showing inverted T-waves |
| d. | Fasting blood glucose level of 106 mg/dL |
ANS: A
Hypokalemia depresses all excitable tissues, including gastrointestinal smooth muscle. Clients who have hypokalemia have reduced or absent bowel sounds and are constipated. The other answer options are not applicable to hypokalemia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Evaluation)
- The nurse notes that the handgrip of the client with hypokalemia has diminished since the previous assessment one hour ago. Which intervention by the nurse is the priority?
| a. | Assess the client’s respiratory rate, rhythm, and depth. |
| b. | Measure the client’s pulse and blood pressure. |
| c. | Document findings and monitor the client. |
| d. | Call the health care provider. |
ANS: A
In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Next, the nurse would call the health care provider to obtain orders for potassium replacement.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
- The client is receiving an intravenous infusion of 60 mEq of potassium chloride in a 1000 mL solution of dextrose 5% in 0.45% saline. The client states that the area around the IV site burns. What intervention does the nurse perform first?
| a. | Notify the physician. |
| b. | Assess for a blood return. |
| c. | Document the finding. |
| d. | Stop the IV infusion. |
ANS: D
Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the potassium and discontinue the IV altogether, in which case the client would need another site started. Assessing for a blood return may or may not be successful. The solution could be diluted (less potassium) and the rate could be slowed once it is determined that the needle is in the vein.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Implementation)
- A client has been taught to increase potassium in the diet. What dietary meal selection indicates to the nurse that teaching has been effective?
| a. | Toasted English muffin with butter and blueberry jam, and tea with sugar |
| b. | Two scrambled eggs, a slice of white toast, and a cup of strawberries |
| c. | Sausage, one slice of whole wheat toast, cup of raisins, and a glass of milk |
| d. | Bowl of oatmeal with brown sugar, cup of sliced peaches, and coffee |
ANS: C
Meat, dairy products, and dried fruit have high concentrations of potassium. Eggs, breads, cereals, sugar, and some fruits (berries, peaches) are low in potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of items with higher potassium content.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
- Which client statement indicates the need for more teaching regarding identification of the early manifestations of hypokalemia?
| a. | “I have been weighing myself every day.” |
| b. | “When I am constipated, I drink more fluids.” |
| c. | “When my muscles feel weak, I eat a banana.” |
| d. | “I check my pulse each morning and each night.” |
ANS: B
The intestinal tract is relatively sensitive to decreasing potassium levels. Common manifestations of hypokalemia are decreased peristalsis and constipation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Nursing Process (Evaluation)
- A nurse is caring for several clients. Which client does the nurse assess most carefully for hyperkalemia?
| a. | Client with heart failure using a salt substitute |
| b. | Client taking a thiazide diuretic for hypertension |
| c. | Client taking nonsteroidal anti-inflammatory drugs daily |
| d. | Client with type 2 diabetes taking an oral antidiabetic agent |
ANS: A
Many salt substitutes are composed of potassium chloride. Heavy use can contribute to the development of hyperkalemia. The client should be taught to read labels and to choose a salt substitute that does not contain potassium. NSAIDs promote the retention of sodium but not potassium.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
- A client at risk for continuing hyperkalemia states that she is upset because she cannot eat fruit every day. Which response by the nurse is best?
| a. | “You are correct. Fruit is usually very high in potassium.” |
| b. | “If you cook the fruit first, that lowers the potassium.” |
| c. | “Berries, cherries, apples, and peaches are low in potassium.” |
| d. | “Fresh fruit is higher in potassium than dried fruit.” |
ANS: C
Not all fruit is potassium rich. Fruits that are relatively low in potassium and can be included in the diet include apples, apricots, berries, cherries, grapefruit, peaches, and pineapples. Fruits high in potassium include bananas, kiwi, cantaloupe, oranges, and dried fruit. Cooking fruit does not alter its potassium content.
DIF: Cognitive Level: Comprehension/Understanding REF: Chart 13-8, p. 188
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
- A client is being discharged and needs to self-monitor for the development of hyperkalemia. Which intervention is most important for the nurse to teach the client?
| a. | Weighing self daily at the same time of day |
| b. | Assessing radial pulse for a full minute twice a day |
| c. | Ensuring an oral intake of a least 3 L of fluids per day |
| d. | Restricting sodium as well as potassium intake |
ANS: B
As potassium levels rise, dysrhythmias can develop. By being vigilant for changes in pulse rate, rhythm, and quality, the client can seek medical attention before hyperkalemia becomes severe. Taking a daily weight will help determine fluid retention, but this is not an accurate indicator of potassium increase or decrease. Fluid intake should be based on body weight. Sodium restriction may not be necessary.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
- A client is admitted with hyponatremia. Four hours after the initial assessment, the nurse notes that the client has new hyperactive bowel sounds in all four quadrants. What analysis about the client’s condition is correct?
| a. | The hyponatremia is worse. |
| b. | The hyponatremia is the same. |
| c. | The hyponatremia is better. |
| d. | The client now has hypernatremia. |
ANS: A
Clinical manifestations of hyponatremia are most evident in excitable tissues and include lethargy, decreased blood pressure, increased gastric motility, and diminished deep tendon reflexes. Bowel sounds that are more hyperactive than on a previous assessment indicate that the condition is worsening.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
- A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at greatest risk for developing hyponatremia?
| a. | Client who is NPO receiving intravenous D5W |
| b. | Client taking a sulfonamide antibiotic |
| c. | Client taking ibuprofen (Motrin) |
| d. | Client taking digoxin (Lanoxin) |
ANS: A
D5W contains no electrolytes. Because the client is not taking any food or fluids by mouth, normal sodium excretion can lead to hyponatremia. The antibiotic, Motrin, and digoxin will not put a client at risk for hyponatremia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Parenteral/Intravenous Therapies)
MSC: Integrated Process: Nursing Process (Assessment)
- The nurse is providing discharge teaching for a client who is at risk for mild hypernatremia. What action is most important for the nurse to teach the client?
| a. | “Weigh yourself every morning and every night.” |
| b. | “Check your radial pulse twice a day.” |
| c. | “Read food labels to determine sodium content.” |
| d. | “Bake or grill the meat rather than frying it.” |
ANS: C
Most prepackaged foods have high sodium content. Teaching the client how to read labels and calculate the sodium content of food can help him or her adhere to the prescribed sodium restriction and can prevent hypernatremia. Daily self-weighing and checking the pulse are methods of identifying manifestations of hypernatremia, but they do not prevent it. The addition of substances during cooking increases the sodium content of a meal, not the method of cooking.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 183
TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)
MSC: Integrated Process: Teaching/Learning
- A client has a history of hypothyroidism. Which laboratory value is the nurse most concerned about?
| a. | Na+ 146 mEq/L |
| b. | K+ 3.6 mEq/L |
| c. | Ca2+ 8.2 mg/dL |
| d. | Mg2+ 1.1 mEq/L |
ANS: C
A common cause of hypocalcemia is hypothyroidism. The calcium value is low, correlating with this condition. The sodium level is only slightly high, and hypothyroidism is not related to sodium imbalances. The potassium level is normal. The magnesium level is low, but hypothyroidism can cause hypermagnesemia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Analysis)
- When taking the blood pressure of a very ill client, the nurse observes that the client’s hand undergoes flexion contractions. Which intervention is most appropriate?
| a. | Administer isotonic intravenous fluids. |
| b. | Remove the blood pressure cuff and give oxygen. |
| c. | Ensure the client has a patent intravenous line. |
| d. | Document the finding in the client’s chart. |
ANS: C
Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. Flexion contractions that occur during blood pressure measurement are indicative of hypocalcemia and are referred to as a positive Trousseau’s sign. Client safety is a priority, and the nurse must ensure that the client has a working intravenous line. Seizure precautions and decreasing environmental stimuli are also important.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)
- A client has the following laboratory values: Ca2+ 8.7 mg/dL; K+ 4.2 mEq/L; Na+ 142 mEq/L. Which intervention by the nurse is most appropriate?
| a. | Prepare to administer IV potassium chloride. |
| b. | Ask the lab to redraw and rerun the tests. |
| c. | Document findings and continue to assess. |
| d. | Prepare to administer aluminum hydroxide. |
ANS: D
The client’s calcium is low. Treatment for hypocalcemia includes calcium replacement, administering drugs that increase calcium absorption, and giving medications to control bothersome neuromuscular effects. Aluminum hydroxide helps the body absorb calcium. The client’s potassium is normal, so giving potassium is not warranted. Asking the laboratory to rerun the tests will not help the client’s problem, although if this seems contradictory to the client’s condition, it might be an option. Documenting findings and performing ongoing assessments will not help the client’s problem.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation)
- A client has a history of hypocalcemia. What intervention is most important for the nurse to add to this client’s care plan?
| a. | Push fluids to 2 L/day. |
| b. | Strain all urine output. |
| c. | Use nonslip footwear to get out of bed. |
| d. | Position the client supine twice a day. |
ANS: C
Clients with long-standing hypocalcemia have brittle bones that may fracture easily. Safety needs are a priority. Having the client wear nonslip footwear to get out of bed can help prevent falls. The other interventions would not provide safety for this client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Assessment)
- Which client is at greatest risk for developing hypercalcemia?
| a. | Client taking furosemide (Lasix) for heart failure |
| b. | Client with long-standing osteoarthritis |
| c. | Woman who is pregnant with twins |
| d. | Client with hyperparathyroidism |
ANS: D
The parathyroid glands secrete parathyroid hormone. The actions of parathyroid hormone include increasing intestinal absorption of calcium, decreasing renal excretion of calcium, and increasing calcium resorption from the bones. All these actions increase the serum calcium level.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 13-10, p. 190
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
- A client has a calcium level of 14 mg/dL. Which intervention is the priority?
| a. | Forcing fluids to 2 L/day |
| b. | Placing the client on a cardiac monitor |
| c. | Assessing for Chvostek’s sign every 2 hours |
| d. | Administering IV calcium chloride |
ANS: B
This client has hypercalcemia. Both forcing fluids and providing cardiac monitoring are appropriate, but because calcium has significant cardiac effects, placing the client on a cardiac monitor takes priority. Assessing for Chvostek’s sign and administering calcium would be appropriate for the client with hypocalcemia.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities)
MSC: Integrated Process: Nursing Process (Implementation)
- A client is admitted with multiple fractures from a motor vehicle crash (MVC). Which of the client’s previous or concurrent health problems is most likely to increase the client’s risk for hypophosphatemia?
| a. | Chronic alcoholic pancreatitis |
| b. | 50–pack-year smoking history |
| c. | Prostate cancer history |
| d. | Heart surgery 8 years ago |
ANS: A
Chronic alcoholism leads to malnutrition. Malnutrition is a major contributing factor to the development of hypophosphatemia. None of the other conditions contribute to hypophosphatemia.
DIF: Cognitive Level: Knowledge/Remembering REF: Table 13-11, p. 192
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
- A client with hypophosphatemia is being discharged. Which activity demonstrated by the client indicates that discharge teaching has been effective?
| a. | Assessing radial pulse rate and rhythm |
| b. | Interspersing daily activities with periods of rest |
| c. | Selecting foods high in phosphorus and low in calcium |
| d. | Weighing himself or herself correctly at the same time each day |
ANS: C
Chronic hypophosphatemia can be managed with nutrition therapy. The client needs to increase his or her ingestion of phosphorus and to decrease ingestion of calcium because phosphorus and calcium exist in the blood in a balanced inverse relationship.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Maintenance and Promotion (Self-Care)
MSC: Integrated Process: Nursing Process (Implementation)
- The nurse observes that the handgrip of the client with hypophosphatemia has diminished in strength since the last assessment 2 hours ago. What is the nurse’s primary intervention?
| a. | Document the finding and continue to assess. |
| b. | Assess respiratory status immediately. |
| c. | Request an order for a serum calcium level. |
| d. | Administer a rapid bolus of intravenous phosphorus. |
ANS: B
Decreased handgrip strength indicates worsening of hypophosphatemia and general muscle weakness. Muscle weakness can impair respiratory effort and reduce gas exchange to the point that the client becomes hypoxemic. IV phosphorus is given slowly to avoid rebound hyperphosphatemia. Phosphorus and calcium exist in an inverse relationship, and the nurse might want to know the calcium level, but this is less important than ensuring that the client has adequate respiratory function. Simply documenting the finding without intervening would not help the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Evaluation)
MULTIPLE RESPONSE
- Which ethnic groups should the nurse screen specifically for hypocalcemia? (Select all that apply.)
| a. | Whites |
| b. | Blacks |
| c. | Asians |
| d. | Hispanics |
| e. | American Indians |
ANS: B, C, E
Lactose intolerance can lead to hypocalcemia because people avoid milk and dairy products to control their symptoms. Although anyone can have lactose intolerance, the incidence is between 75% and 90% among Asians, blacks, and American Indians.
DIF: Cognitive Level: Comprehension/Understanding
REF: Cultural Awareness Box, p. 188
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment)
Chapter 17: Ignatavicius/Workman: Medical-Surgical Nursing Patient-Centered Collaborative Care 7th edition – $30 [publisher mislabeled chapter 17]
Chapter 17 is mislabeled/mispublished as the same as chapter 16 unfortunately the publisher company has not made/provided a new revised chapter 17 for this test bank on the instructor cd.
Chapter 16: Care of Preoperative Patients (NO CHAPTER 17)
Test Bank
MULTIPLE CHOICE
- A client voluntarily signed the operative consent form. What is the nurse’s next action?
| a. | Teach the client about the surgery. |
| b. | Have family members witness the signature. |
| c. | Sign under the client’s name as a witness. |
| d. | Call for the physician to sign the form. |
ANS: C
The nurse’s signature as a witness indicates that the consent form was signed by the client voluntarily. None of the other steps are necessary.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Informed Consent)
MSC: Integrated Process: Communication and Documentation
- The nurse is caring for an older adult client with a history of chronic lung disease who will be undergoing surgery the following day. When postoperative care is planned, which potential problem is the highest priority for this client?
| a. | Maintaining oxygenation |
| b. | Tolerating activity |
| c. | Anxiety and fear |
| d. | Hypovolemia |
ANS: A
Breathing problems take priority over the other problems listed. This would be compounded in a client with any chronic lung disorder.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Analysis)
- The nurse is completing preoperative teaching for a client, and it becomes apparent that the client does not understand the surgery that will be performed. What is the priority action for the nurse?
| a. | Obtain informed consent from the client. |
| b. | Continue teaching the client about the surgery. |
| c. | Revise the teaching plan for the client. |
| d. | Notify the surgeon and document the finding. |
ANS: D
The surgeon should be notified right away so that the client can be instructed about the surgery to be performed. The client cannot give informed consent unless he or she understands the procedure.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Informed Consent) MSC: Integrated Process: Teaching/Learning
- During the preoperative assessment, the client tells the nurse that he smokes three packs of cigarettes daily. Which action by the nurse is best?
| a. | Call the surgeon to cancel the surgery. |
| b. | Have baseline laboratory studies drawn. |
| c. | Perform a respiratory assessment. |
| d. | Give a nebulizer treatment. |
ANS: C
Smoking increases the client’s risk for atelectasis and hypoxia. The nurse should assess the client for signs of respiratory disease. The physician will need to know this information but will not necessarily cancel the operation. Baseline laboratory studies need to be ordered by the physician. There is no indication for giving a nebulizer to this client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Intervention)
- When the nurse brings a client’s preoperative medications, the client responds, “I don’t need that. I had a good night’s sleep last night.” What is the nurse’s best response?
| a. | “The doctor ordered this medication so you should take it.” |
| b. | “I will make a note that you refused to take the medication.” |
| c. | “I will ask your surgeon if you have to take the medication.” |
| d. | “Let me teach you about your medications for surgery.” |
ANS: D
Preoperative medications can include sedatives but are often given to prevent laryngospasm and to help reduce pharyngeal and gastric secretions. The client must be fully aware of the rationale for all medications and the risks of not taking them.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)
MSC: Integrated Process: Communication and Documentation
- A client receiving preoperative medication tells the nurse that she took all the following vitamins and herbs last night before going to bed. Which one does the nurse report to the surgical team as a priority?
| a. | Valerian root |
| b. | St. John’s wort |
| c. | Garlic |
| d. | Chamomile |
ANS: C
Garlic interferes with coagulation, increasing the client’s risk for bleeding during and after the surgical procedure. This would be a critical piece of information for the surgical team to know.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions)
MSC: Integrated Process: Nursing Process (Intervention)
- The nurse reviews a client’s laboratory results before surgery and notes a fasting blood glucose of 120 mg/dL, a prothrombin time (PT) of 25 seconds, and potassium (K+) of 3.8 mEq/L. Which action by the nurse is best?
| a. | Ask the surgeon for additional laboratory studies. |
| b. | Administer a potassium supplement of 20 mEq. |
| c. | Increase the IV infusion of D5W to 100 mL/hr. |
| d. | Record laboratory results on the preoperative assessment. |
ANS: A
The prothrombin time is elevated, which could lead to bleeding during or after surgery. The surgeon and the anesthesiologist should be notified of this laboratory test result right away, and additional coagulation studies will be needed. The potassium is within normal limits. The blood glucose level is elevated but not critically so. The surgeon should be notified of all laboratory work, and the client may need an IV solution without glucose. The results should be recorded, but the surgery will likely be cancelled owing to the coagulation problem, which is the priority concern with this client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Analysis)
- A client is brought to the emergency department (ED) after a motorcycle accident. The client has suffered a ruptured spleen. What is the immediate priority?
| a. | Emergent surgery to control bleeding |
| b. | Aggressive pain control |
| c. | Calling the family members |
| d. | Assessment of neurologic status |
ANS: A
Emergent surgery is indicated when the client may die without immediate intervention. Other interventions are appropriate but do not have the priority because controlling hemorrhage via surgery is the priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Medical Emergencies) MSC: Integrated Process: Nursing Process (Implementation)
- The nurse has just completed preoperative teaching with a client who will be having surgery the following day. Which statement by the client indicates that additional teaching is needed?
| a. | “When I brush my teeth before surgery, I will be sure to spit out the water.” |
| b. | “I will go to the bathroom as soon as I receive all my preoperative medications.” |
| c. | “I will remember to wear my glasses tomorrow instead of my contact lenses.” |
| d. | “I won’t have to worry about putting my makeup on tomorrow morning.” |
ANS: B
The client should void before receiving any preoperative medication. The medication could make the client sleepy and at risk for falling. The other statements are correct.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention) MSC: Integrated Process: Teaching/Learning
- The nurse is performing preoperative teaching with an older adult client who will be having colon resection surgery the following day. The surgeon has ordered bowel preparation the night before. Which action is a priority?
| a. | Administer antibiotics with a sip of water. |
| b. | Encourage the client to drink plenty of juice. |
| c. | Teach the client to eat only low-fat foods the night before surgery. |
| d. | Tell the client not to get up and go to the bathroom alone. |
ANS: D
Safety is the priority, and the older adult client can become exhausted and may fall. Antibiotics, if ordered, would be administered with a sip of water, but this is not the priority. The client would not be encouraged to drink juice, because this is not a clear liquid.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
- When examining an adult client’s preoperative laboratory results, the nurse notes that the potassium level is 2.9 mEq/mL. What is the nurse’s priority action?
| a. | Document the finding. |
| b. | Alter the client’s diet to include fruit. |
| c. | Increase the IV flow rate. |
| d. | Notify the surgeon. |
ANS: D
The normal range for serum potassium is 3.5 to 5.0 mEq/L or mmol/L. A value of 2.9 represents hypokalemia, which must be corrected before surgery. The surgeon should be notified of this finding. The finding should be documented; however, notifying the surgeon is the priority.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Implementation)
- What recently learned information about a client who is scheduled to have surgery within the next 2 hours is the nurse certain to communicate to the surgical team?
| a. | An allergy to cats |
| b. | Hearing problem |
| c. | Consumption of a glass of wine 12 hours ago |
| d. | Taking 2000 mg of vitamin C each day |
ANS: B
The team will need to communicate with the client in the surgical holding area, in the operating room, and in the postanesthesia recovery unit. Any problem with communication, such as a hearing impairment, should be stressed, so that team members can use alternative means to ensure accurate communication with the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
- A client will be undergoing palliative surgery. The client’s daughter asks what this means. What is the nurse’s best response?
| a. | “The surgery will relieve the symptoms but will not cure your father.” |
| b. | “There are fewer risks with this type of surgery.” |
| c. | “There is no guarantee of the outcome of the surgery.” |
| d. | “The surgery must be performed immediately to save your father’s life.” |
ANS: A
The purpose of palliative surgery is to improve the client’s quality of life by reducing or eliminating distressing symptoms. It does not cure a health problem and often does not prolong life.
DIF: Cognitive Level: Comprehension/Understanding REF: Table 16-1, p. 242
TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Non-Pharmacological Comfort Measures)
MSC: Integrated Process: Communication and Documentation
- Twenty minutes after a client has received a preoperative injection of atropine and midazolam (Versed), the client tells the nurse that he must be allergic to the medication because his mouth is dry and his heart seems to be beating faster than normal. What is the nurse’s priority action?
| a. | Document the findings. |
| b. | Assess the client’s pulse and blood pressure. |
| c. | Administer diphenhydramine (Benadryl). |
| d. | Explain to the client that these symptoms are expected. |
ANS: B
Although these are expected physiologic responses to the preoperative medication, whenever the client states that he or she can feel a change in normal cardiac function, he should be assessed.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes)
MSC: Integrated Process: Nursing Process (Implementation)
- A client undergoing preoperative assessment informs the nurse that he takes medication for high blood pressure and for asthma. What is the nurse’s best action?
| a. | Tell the client not to take the medication on the day of surgery. |
| b. | Notify the surgeon and the anesthesiologist. |
| c. | Document the information in the client’s record. |
| d. | Tell the client to take medications preoperatively with a sip of water. |
ANS: B
Medications for cardiac and respiratory problems usually are given with sips of water before surgery. However, the nurse should notify the surgeon and the anesthesiologist before giving the client any advice. While some medications can be given with a sip of water, other medications must be held for a specified time before surgery. Documentation should occur, but only after the nurse has consulted with the physician and anesthesiologist and has spoken to the client.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
- Which action is most appropriate during a preoperative chart review?
| a. | Ensure that the consent form is signed, dated, and witnessed. |
| b. | Call the surgeon if the client has any food allergies. |
| c. | Make sure all marks are washed off the surgical site. |
| d. | Make sure the client understands the procedure. |
ANS: A
During the preoperative chart review, the nurse should make sure that the consent form is signed, dated, and witnessed. The nurse does not have to call the surgeon for food allergies, nor should the marks be washed off the surgical site. The client should be taught about the procedure before the preoperative chart review.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 259
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
- The nurse is caring for a client who will be undergoing emergency surgery as soon as possible. Which information is most important for the nurse to teach the client at this time?
| a. | How the surgery will be performed |
| b. | Importance of early ambulation after surgery |
| c. | What to expect in the operating and recovery rooms |
| d. | Complications that may occur after surgery |
ANS: C
With only a few minutes before surgery, the nurse should tell the client what to expect in the operating room and in the recovery room to minimize his or her anxiety. Although the other information is important, the nurse needs to start with what is vital for the client to know right now.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Psychosocial Integrity (Therapeutic Communication)
MSC: Integrated Process: Teaching/Learning
- A client tells the nurse that he has an advance directive with durable power of attorney for health care. The client asks how the advance directive will affect the surgery. What is the nurse’s best response?
| a. | “You will not be intubated during general anesthesia for the surgery.” |
| b. | “There will be no effect on your surgery.” |
| c. | “The surgical staff will resuscitate only if your heart stops during the operation.” |
| d. | “If you are unable to make a decision, your designee will be asked.” |
ANS: D
The advance directive with durable power of attorney indicates whom the client wishes to designate for medical decisions if he is unable to make decisions for himself. An advance directive with power of attorney does not eliminate the need for intubation during surgery. Although the document does not affect the procedure, simply acknowledging that fact does not help the client understand. If the client’s heart stops during the operation and the client has not made his or her wishes known about that situation, the power of attorney would be consulted.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 252
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Advance Directives MSC: Integrated Process: Communication and Documentation
- A client is brought to the hospital unconscious and needs emergency surgery. The client’s only family member cannot come to the hospital before the surgery. Which is the best option for obtaining informed consent for the client’s emergent surgery?
| a. | Proceed with surgery and have the family member sign the consent as soon as possible. |
| b. | Contact the family member by phone and obtain verbal consent with two witnesses. |
| c. | Obtain written consultation with two surgeons that the surgery is needed. |
| d. | Have the hospital administrator appoint a temporary legal guardian. |
ANS: B
In the event that a family member cannot come to the hospital before the surgery needs to begin, verbal consent should be obtained over the phone with two witnesses.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Informed Consent)
MSC: Integrated Process: Communication and Documentation
- Four clients are scheduled for surgery. Which client does the nurse determine is at highest risk for postsurgical complications?
| a. | 89-year-old scheduled for a knee replacement |
| b. | 40-year-old requiring gallbladder surgery |
| c. | 19-year-old requiring a laparoscopy |
| d. | 10-year-old admitted for a tonsillectomy |
ANS: A
The older client is at highest risk for postoperative complications. Older adults often have multiple medical conditions, take several medications, are slightly dehydrated, and may have cognitive or physical impairments that potentially could hinder their recovery from an operation.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
- The nurse is conducting preoperative assessments. Which client does the nurse teach about the possibility of developing a venous thromboembolism (VTE)?
| a. | Client with a latex allergy |
| b. | Client with body mass index (BMI) of 19 |
| c. | Client with an international normalized ratio (INR) of 2.2 |
| d. | Client undergoing hip replacement surgery |
ANS: D
The client will have limited mobility following hip replacement surgery, increasing the risk of postoperative venous thromboembolism (VTE). The other conditions will not increase the risk of VTE.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Assessment)
- The nurse applies antiembolism stockings to a client preoperatively. When the client says that they are uncomfortably tight, what is the nurse’s best action?
| a. | Remove the stockings for an hour to relieve the pressure. |
| b. | Pull the stockings down so that they are not constricting. |
| c. | Measure the client’s calf to ensure that they are the correct size. |
| d. | Teach the client the purpose of wearing the stockings. |
ANS: D
Thromboembolic disease (TED) stockings should feel slightly tight on the legs to promote venous return and prevent the client from developing venous thromboembolism (VTE). The nurse should not remove the stockings nor pull them down. The calf would have been measured before the stockings were obtained.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
MULTIPLE RESPONSE
- The nurse is assessing a client before surgery. Which assessments contraindicate the client having surgery as scheduled? (Select all that apply.)
| a. | Potassium level of 2.8 mEq/L |
| b. | International normalized ratio (INR) of 4 |
| c. | Prothrombin time (PTT) of 30 seconds |
| d. | Calcium level of 8.8 mEq/dL |
| e. | Positive pregnancy test |
| f. | Platelet count of 150,000 |
ANS: A, B, E
Hypokalemia, elevated bleeding times, and a positive pregnancy test could all contradict the client having surgery as scheduled and could lead to complications. Normal PTT, normal calcium, and normal platelet count would not contradict surgery.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Assessment)
- Which medications does the nurse correctly administer preoperatively? (Select all that apply.)
| a. | Hydroxyzine (Atarax, Vistaril) for sedation |
| b. | Lorazepam (Ativan) for anxiety |
| c. | Hydromorphone (Dilaudid) to decrease postoperative secretions |
| d. | Metoclopramide (Reglan) to increase stomach emptying |
| e. | Aspirin to decrease blood clotting postoperatively |
| f. | Cimetidine (Tagamet) to prevent infection |
ANS: A, B, D
The nurse will administer hydroxyzine (Atarax) for sedation, lorazepam (Ativan) for anxiety, and metoclopramide (Reglan) to increase stomach emptying. Hydromorphone is given for pain, and cimetidine (Tagamet) decreases histamine. Aspirin would not be administered preoperatively because it can increase bleeding.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Assessment)
- The nurse is conducting preoperative teaching with a client who will be undergoing pelvic surgery. What teaching is essential for this client? (Select all that apply.)
| a. | “Wearing elastic stockings and using pneumatic compression devices are essential after surgery.” |
| b. | “Extended bedrest will help you heal after this type of surgery.” |
| c. | “Coughing and deep breathing will help to decrease postoperative complications.” |
| d. | “Turning and moving your legs after surgery will help prevent clots from forming.” |
| e. | “You will need to have your abdomen shaved before surgery.” |
| f. | “You cannot wear your hearing aid into the surgical suite.” |
ANS: A, C, D
A pneumatic compression device and elastic stockings will help prevent clots after pelvic surgery. Coughing and deep breathing will help to decrease postoperative respiratory complications. Turning and moving legs after surgery will also help prevent clots. Hearing aids can be worn into the surgical suite because this will help communication before surgery. Extended bedrest is not helpful, and shaving would not be necessary.
DIF: Cognitive Level: Application/Applying or higher REF: N/A
TOP: Client Needs Category: Health Promotion and Maintenance (Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
- What data are essential for the nurse to assess on a client who is scheduled for surgery? (Select all that apply.)
| a. | Use of tobacco |
| b. | Current medications |
| c. | Use of herbal or over-the-counter therapy |
| d. | Mental status examination |
| e. | Power of attorney |
| f. | Allergies |
| g. | Date of last tetanus shot |
ANS: A, B, C, D, F
The client should be screened for things that may increase the risk of complications during surgery. Smoking, certain medications and herbs, and allergies may increase a client’s risk. Mental status examination is essential to determine competency and ability to teach. The date of the client’s last tetanus shot is not required information from a preoperative chart review.
DIF: Cognitive Level: Comprehension/Understanding REF: p. 242
TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations)
MSC: Integrated Process: Communication and Documentation
OTHER
- The nurse is preparing to transfer a client to the operating room for surgery. Put the interventions in order for the nurse to perform. (List in order of priority.)
- Take a full set of vital signs.
- Have the client go to the bathroom to void.
- Ask the client to state his or her name and check the ID band.
- Administer ordered preoperative sedation.
ANS:
c, b, a, d
First, the nurse should identify the client using two identifiers to ensure that the correct client is being prepped for surgery. Next, the nurse should assist the client to the bathroom, then take vital signs, then finally administer preoperative sedation once the client is in bed.
DIF: Cognitive Level: Application/Applying or higher
TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
