Medical Surgical Nursing Patient Centered Collaborative Care 8th Edition by Donna D. Ignatavicius – Test Bank A+

$35.00
Medical Surgical Nursing Patient Centered Collaborative Care 8th Edition by Donna D. Ignatavicius – Test Bank A+

Medical Surgical Nursing Patient Centered Collaborative Care 8th Edition by Donna D. Ignatavicius – Test Bank A+

$35.00
Medical Surgical Nursing Patient Centered Collaborative Care 8th Edition by Donna D. Ignatavicius – Test Bank A+

Chapter 6: Rehabilitation Concepts for Chronic and Disabling Health Problems
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. A nurse assesses a client recovering from coronary artery bypass graft surgery. Which assessment should the nurse complete to evaluate the client’s activity tolerance?
a.
Vital signs before, during, and after activity
b.
Body image and self-care abilities
c.
Ability to use assistive or adaptive devices
d.
Client’s electrocardiography readings
ANS: A
To see whether a client is tolerating activity, vital signs are measured before, during, and after the activity. If the client is not tolerating activity, heart rate may increase more than 20 beats/min, blood pressure may increase over 20 mm Hg, and vital signs will not return to baseline within 5 minutes after the activity. A body image assessment is not necessary before basic activities are performed. Self-care abilities and ability to use assistive or adaptive devices is an important assessment when planning rehabilitation activities, but will not provide essential information about the client’s activity tolerance. Electrocardiography is not used to monitor clients in a rehabilitation setting.
DIF: Applying/Application REF: 77
KEY: Rehabilitation care| functional ability
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse teaches a client with a past history of angina who has had a total knee replacement. Which statement should the nurse include in this client’s teaching prior to beginning rehabilitation activities?
a.
“Use analgesics before and after activity, even if you are not experiencing pain.”
b.
“Let me know if you start to experience shortness of breath, chest pain, or fatigue.”
c.
“Do not take your prescribed beta blocker until after you exercise with physical therapy.”
d.
“If you experience knee pain, ask the physical therapist to reschedule your therapy.”
ANS: B
Participation in exercise may increase myocardial oxygen demand beyond the ability of the coronary circulation to deliver enough oxygen to meet the increased need. The nurse must determine the client’s ability to tolerate different activity levels. Asking the client to notify the nurse if symptoms of shortness of breath, chest pain, or fatigue occur will assist the nurse in developing an appropriate cardiac rehabilitation plan.
DIF: Applying/Application REF: 78
KEY: Rehabilitation care| nitroglycerin/nitrates| pain
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
3. A rehabilitation nurse prepares to move a client who has new bilateral leg amputations.
Which is the best approach?
a. Use the bear-hug method to transfer the client safely.
b. Ask several members of the health care team to carry the client.
c. Utilize the facility’s mechanical lift to move the client.
d. Consult physical therapy before performing all transfers.
ANS: C
Use mechanical lifts to minimize staff work-related musculoskeletal injuries. The bear-hug
method and the use of several members of the team to carry the client do not eliminate staff
injuries. Physical therapy should be consulted but cannot be depended upon for all transfers.
Nursing staff must be capable of transferring a client safely.
DIF: Applying/Application REF: 81
KEY: Rehabilitation care| patient safety| staff safety
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection
Control
4. A nurse performs passive range-of-motion exercises on a semiconscious client and meets
resistance while attempting to extend the right elbow more than 45 degrees. Which action
should the nurse take next?
a. Splint the joint and continue passive range of motion to the shoulder only.
b. Progressively increase joint motion 5 degrees beyond resistance each day.
c. Apply weights to the right distal extremity before initiating any joint exercise.
d. Continue to move the joint only to the point at which resistance is met.
ANS: D
Moving a joint beyond the point at which the client feels pain or resistance can damage the
joint. The nurse should move the joint only to the point of resistance. Splinting the joint will
not assist the client’s range of motion. The client’s joint should not be forced. Applying
weights to the extremity will not increase range of motion of the joint but most likely will
cause damage.
DIF: Applying/Application REF: 84
KEY: Rehabilitation care| exercise
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
5. A nurse cares for a client with decreased mobility. Which intervention should the nurse
implement to decrease this client’s risk of fracture?
a. Apply shoes to improve foot support.
b. Perform weight-bearing activities.
c. Increase calcium-rich foods in the diet.
d. Use pressure-relieving devices.
ANS: B
Weight-bearing activity reduces bone mineral loss and promotes bone uptake of calcium, contributing to maintenance of bone density and reducing the risk for bone fracture. Although increasing calcium in the diet is a good intervention, this alone will not reduce the client’s susceptibility to bone fracture. A foot support and pressure-relieving devices will not help prevent fracture, but may help with mobility and skin integrity.
DIF: Applying/Application REF: 83
KEY: Rehabilitation care| exercise
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A rehabilitation nurse cares for a client who has generalized weakness and needs assistance with activities of daily living. Which exercise should the nurse implement?
a.
Passive range of motion
b.
Active range of motion
c.
Resistive range of motion
d.
Aerobic exercise
ANS: B
Active range of motion is a part of a restorative nursing program. Active range of motion will promote strength, range of motion, and independence with activities of daily living.
DIF: Applying/Application REF: 84
KEY: Rehabilitation care| exercise
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. A nurse plans care for a client who is bedridden. Which assessment should the nurse complete to ensure to prevent pressure ulcer formation?
a.
Nutritional intake and serum albumin levels
b.
Pressure ulcer diameter and depth
c.
Wound drainage, including color, odor, and consistency
d.
Dressing site and antibiotic ointment application
ANS: A
Assessing serum albumin levels helps determine the client’s nutritional status and allows care providers to alter the diet, as needed, to prevent pressure ulcers. All other options are treatment oriented rather than prevention oriented.
DIF: Applying/Application REF: 85
KEY: Rehabilitation care| skin breakdown
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
8. A nurse teaches a client about performing intermittent self-catheterization. The client states, “I am not sure if I will be able to afford these catheters.” How should the nurse respond?
a.
“I will try to find out whether you qualify for money to purchase these necessary supplies.”
b.
“Even though it is expensive, the cost of taking care of urinary tract infections would be even higher.”
c.
“Instead of purchasing new catheters, you can boil the catheters and reuse them up to 10 times each.”
d.
“You can reuse the catheters at home. Clean technique, rather than sterile technique, is acceptable.”
ANS: D
At home, clean technique for intermittent self-catheterization is sufficient to prevent cystitis and other urinary tract infections. The nurse would refer the client to the social worker to explore financial concerns. The nurse should not threaten the client, nor should the client be instructed to boil the catheters.
DIF: Applying/Application REF: 86
KEY: Rehabilitation care| elimination MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
9. A nurse delegates the ambulation of an older adult client to an unlicensed nursing assistant (UAP). Which statement should the nurse include when delegating this task?
a.
“The client has skid-proof socks, so there is no need to use your gait belt.”
b.
“Teach the client how to use the walker while you are ambulating up the hall.”
c.
“Sit the client on the edge of the bed with legs dangling before ambulating.”
d.
“Ask the client if pain medication is needed before you walk the client in the hall.”
ANS: C
Before the client gets out of bed, have the client sit on the bed with legs dangling on the side. This will enhance safety for the client. A gait belt should be used for all clients. The UAP cannot teach the client to use a walker or assess the client’s pain.
DIF: Applying/Application REF: 81
KEY: Rehabilitation care| exercise| delegation
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
10. A nurse assesses a client who is admitted with hip problems. The client asks, “Why are you asking about my bowels and bladder?” How should the nurse respond?
a.
“To plan your care based on your normal elimination routine.”
b.
“So we can help prevent side effects of your medications.”
c.
“We need to evaluate your ability to function independently.”
d.
“To schedule your activities around your elimination pattern.”
ANS: A
Bowel elimination varies from client to client and must be evaluated on the basis of the client’s normal routine. The nurse asks about bowel and bladder habits to develop a client-centered plan of care. The other answers are correct but are not the best responses. Oral analgesics may cause constipation, but they do not interfere with bladder control. The client is in rehabilitation to assist his or her ability to function independently. Elimination usually is scheduled around rehabilitation activities but should be taken into consideration when a plan of care is developed.
DIF: Applying/Application REF: 78
KEY: Rehabilitation care| elimination
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Psychosocial Integrity
11. A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should the nurse implement to assist with bladder dysfunction?
a.
Insert an indwelling urinary catheter.
b.
Stroke the medial aspect of the thigh.
c.
Use the Credé maneuver every 3 hours.
d.
Apply a Texas catheter with a leg bag.
ANS: C
Two techniques are used to facilitate voiding in a client with a flaccid bladder: the Valsalva maneuver and the Credé maneuver. Indwelling urinary catheters generally are not used because of the increased incidence of urinary tract infection. Stroking the medial aspect of the thigh facilitates voiding in clients with upper motor neuron problems. If the spinal cord injury is above T12, the client is unaware of a full bladder and does not void or is incontinent. Therefore, the client would not benefit from a Texas catheter with a leg bag.
DIF: Applying/Application REF: 86
KEY: Rehabilitation care| elimination
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs: Physiological Integrity: Physiological Adaptation
12. A nurse teaches a client who has a flaccid bladder. Which bladder training technique should the nurse teach?
a.
Stroking the medial aspect of the thigh
b.
Valsalva maneuver
c.
Self-catheterization
d.
Frequent toileting
ANS: B
With a flaccid bladder, the voiding reflex arc is not intact and additional stimulation may be needed to initiate voiding, such as with the Valsalva and Credé maneuvers. Intermittent catheterization may be used after the previous maneuvers are attempted. In reflex bladder, the voiding arc is intact and voiding can be initiated by any stimulus, such as stroking the medial aspect of the thigh. A consistent toileting routine is used to re-establish voiding continence with an uninhibited bladder.
DIF: Applying/Application REF: 86
KEY: Rehabilitation care| elimination
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
13. A rehabilitation nurse cares for a client who is wheelchair bound. Which intervention should the nurse implement to prevent skin breakdown?
a.
Place pillows under the client’s heels.
b.
Have the client do wheelchair push-ups.
c.
Perform wound care as prescribed.
d.
Massage the client’s calves and feet with lotion.
ANS: B
Clients who sit for prolonged periods in a wheelchair should perform wheelchair push-ups for at least 10 seconds every hour. Chair-bound clients also need to be re-positioned at least every 1 to 2 hours. The lower legs, where the wheelchair could rub against the legs, also need to be assessed. Pillows under the heels could exert pressure on the heels; it is better to place the pillow under the ankle. Performing wound care as prescribed is important to improve the healing of pressure ulcers, but this intervention will not prevent skin breakdown. The calves of a client with no or decreased lower extremity mobility should not be massaged because of the risk of embolization or thrombus.
DIF: Applying/Application REF: 85
KEY: Rehabilitation care| exercise| skin breakdown
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Health Promotion and Maintenance
14. A nurse assists a client with left-sided weakness to walk with a cane. What is the correct order of steps for gait training with a cane?
1. Apply a transfer belt around the client’s waist.
2. Move the cane and left leg forward at the same time.
3. Guide the client to a standing position.
4. Move the right leg one step forward.
5. Place the cane in the client’s right hand.
6. Check balance and repeat the sequence.
a.
3, 1, 5, 4, 2, 6
b.
1, 3, 5, 2, 4, 6
c.
5, 3, 1, 2, 4, 6
d.
3, 5, 1, 4, 2, 6
ANS: B
To ambulate a client with a cane, the nurse should first apply a transfer belt around the client’s waist, then guide the client to a standing position and place the cane in the client’s strong hand. Next the nurse should assist the client to move the cane and weaker leg forward together. Then move the stronger leg forward and check balance before repeating the sequence.
DIF: Remembering/Knowledge REF: 83
KEY: Rehabilitation care| exercise
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. A nurse collaborates with an occupational therapist when providing care for a rehabilitation client. With which activities should the occupational therapist assist the client? (Select all that apply.)
a.
Achieving mobility
b.
Attaining independence with dressing
c.
Using a walker in public
d.
Learning techniques for transferring
e.
Performing activities of daily living (ADLs)
f.
Completing job training
ANS: B, E
The role of the occupational therapist is to assist the client with ADLs, dressing, and activities needed for job training. The physical therapist assists with muscle strength development and ambulation. Vocational counselors assist with job placement, training, and further education.
DIF: Understanding/Comprehension REF: 76
KEY: Rehabilitation care| interdisciplinary team
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
2. An interdisciplinary team is caring for a client on a rehabilitation unit. Which team members are paired with the correct roles and responsibilities? (Select all that apply.)
a.
Speech-language pathologist – Evaluates and retrains clients with swallowing problems
b.
Physical therapist – Assists clients with ambulation and walker training
c.
Recreational therapist – Assists physical therapists to complete rehabilitation therapy
d.
Vocational counselor – Works with clients who have experienced head injuries
e.
Registered dietitian – Develops client-specific diets to ensure client needs are met
ANS: A, B, E
Speech-language pathologists evaluate and retrain clients with speech, language, or swallowing problems. Physical therapists help clients to achieve self-management by focusing on gross mobility. Registered dietitians develop client-specific diets to ensure that clients meet their needs for nutrition. Recreational therapists work to help clients continue or develop hobbies or interests. Vocational counselors assist with job placement, training, or further education.
DIF: Remembering/Knowledge REF: 77
KEY: Rehabilitation care| interdisciplinary team
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A rehabilitation nurse is caring for an older adult client who states, “I tire easily.” How should the nurse respond? (Select all that apply.)
a.
“Schedule all of your tasks for the morning when you have the most energy.”
b.
“Use a cart to push your belongings instead of carrying them.”
c.
“Your family should hire someone who can assist you with daily chores.”
d.
“Plan to gather all of the supplies needed for a chore prior to starting the activity.”
e.
“Try to break large activities into smaller parts to allow rest periods between activities.”
ANS: B, D, E
A cart is useful because it takes less energy to push items than to carry them. Gathering equipment before performing a chore decreases unneeded steps. Breaking larger chores into smaller ones allows rest periods between activities and still gives the client a sense of completion even if the client is unable to complete the whole task. Major tasks should be performed in the morning, when energy levels are high, while lesser tasks should be done throughout the day after frequent rest periods. Someone should be hired to do the chores only if the client cannot do them. The outcome should be achieving independence as close to the pre-disability level as possible.
DIF: Applying/Application REF: 84
KEY: Rehabilitation care
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Health Promotion and Maintenance
4. A nurse is caring for clients as a member of the rehabilitation team. Which activities should the nurse complete as part of the nurse’s role? (Select all that apply.)
a.
Maintain the safety of adaptive devices by monitoring their function and making repairs.
b.
Coordinate rehabilitation team activities to ensure implementation of the plan of care.
c.
Assist clients to identify support services and resources for the coordination of services.
d.
Counsel clients and family members on strategies to cope with disability.
e.
Support the client’s choices by acting as an advocate for the client and family.
ANS: B, E
The rehabilitation nurse’s role includes coordination of rehabilitation activities to ensure the client’s plan of care is effectively implemented and advocating for the client and family. The biomedical technician monitors and repairs adaptive and electronic devices. The social worker assists clients with support services and resources. The clinical psychologist counsels clients and families on their psychological problems and on strategies to cope with disability.
DIF: Understanding/Comprehension REF: 76
KEY: Rehabilitation care| interdisciplinary team
MSC: Integrated Process: Nursing Process: Implementation

Chapter 7: End-of-Life Care
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. A nurse cares for a dying client. Which manifestation of dying should the nurse treat first?
a.
Anorexia
b.
Pain
c.
Nausea
d.
Hair loss
ANS: B
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 hair loss, disturb the family, they should be treated only if the client is distressed by their presence. The nurse should treat the client’s pain first.
DIF: Applying/Application REF: 97
KEY: End-of-life care| advance directives
MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity
2. A nurse plans care for a client who is nearing end of life. Which question should the nurse ask when developing this client’s plan of care?
a.
“Is your advance directive up to date and notarized?”
b.
“Do you want to be at home at the end of your life?”
c.
“Would you like a physical therapist to assist you with range-of-motion activities?”
d.
“Have your children discussed resuscitation with your health care provider?”
ANS: B
When developing a plan of care for a dying client, consideration should be given for where the client wants to die. Advance directives do not need to be notarized. A physical therapist would not be involved in end-of-life care. The client should discuss resuscitation with the health care provider and children; do-not-resuscitate status should be the client’s decision, not the family’s decision.
DIF: Applying/Application REF: 94
KEY: End-of-life care| advance directives
MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity
3. A nurse is caring for a client who has lung cancer and is dying. Which prescription should the nurse question?
a.
Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5
b.
Albuterol (Proventil) metered dose inhaler every 4 hours PRN for wheezes
c.
Atropine solution 1% sublingual every 4 hours PRN for excessive oral secretions
d.
Sodium biphosphate (Fleet) enema once a day PRN for impacted stool
ANS: A
Pain medications should be scheduled around the clock to maintain comfort and prevent reoccurrence of pain. The other medications are appropriate for this client.
DIF: Applying/Application REF: 96
KEY: End-of-life care| pharmacologic pain management
MSC: Integrated Process: Nursing Process: Planning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A client tells the nurse that, even though it has been 4 months since her sister’s death, she frequently finds herself crying uncontrollably. How should the nurse respond?
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: Applying/Application REF: 101
KEY: End-of-life care| coping MSC: Integrated Process: Caring
5. After teaching a client about advance directives, a nurse assesses the client’s understanding. Which statement indicates the client correctly understands the teaching?
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 or financial matters.
DIF: Understanding/Comprehension REF: 92
KEY: End-of-life care| advance directives
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
6. A nurse teaches a client who is considering being admitted to hospice. Which statement should the nurse include in this client’s teaching?
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: Applying/Application REF: 94
KEY: End-of-life care| palliative/hospice care
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Psychosocial Integrity
7. A nurse is caring for a dying client. The client’s spouse states, “I think he is choking to death.” How should the nurse respond?
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. The nurse should not minimize the spouse’s concerns. Morphine will assist with comfort but will not decrease the choking sounds. Nasotracheal suctioning is not appropriate in a dying client.
DIF: Applying/Application REF: 99 KEY: End-of-life care
MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity
8. 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 made by the family member indicates understanding of the nurse’s teaching?
a.
“Maybe we should just hire an around-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. Hiring an around-the-clock sitter does not demonstrate that the client’s family understands complementary therapies. Complementary therapies are used in conjunction with traditional therapy. Complementary therapy would not replace pain or anxiety medication but may help decrease the need for these medications.
DIF: Applying/Application REF: 100
KEY: End-of-life care| nonpharmacologic pain management
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
9. A nurse is caring for a terminally ill client who has just died in a hospital setting with family members at the bedside. Which action should the nurse take first?
a.
Call for emergency assistance so that resuscitation procedures can begin.
b.
Ask 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: Applying/Application REF: 102
KEY: End-of-life care| postmortem care MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity
10. A nurse assesses a client who is dying. Which manifestation 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
Although all of these assessments should be performed during the dying process, periods of apnea and Cheyne-Strokes respirations indicate death is near. As peripheral circulation decreases, the client’s level of consciousness and bowel sounds decrease, and the client would be unable to provide a numeric number on a pain scale. Even with these other symptoms, 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: Applying/Application REF: 95 KEY: End-of-life care
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
11. A nurse is caring for a client who is terminally ill. The client’s spouse states, “I am concerned because he does not want to eat.” How should the nurse respond?
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: Applying/Application REF: 96
KEY: End-of-life care| nutrition MSC: Integrated Process: Caring
12. A nurse discusses inpatient hospice with a client and the client’s family. A family member expresses concern that her loved one will receive only custodial care. How should the nurse respond?
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: Understanding/Comprehension REF: 94
KEY: End-of-life care| palliative/hospice care
MSC: Integrated Process: Caring NOT: Client Needs: Psychosocial Integrity
13. An intensive care nurse discusses withdrawal of care with a client’s family. The family expresses concerns related to discontinuation of therapy. How should the nurse respond?
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 their 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: Applying/Application REF: 103
KEY: End-of-life care| withdrawal of care
MSC: Integrated Process: Caring NOT: Client Needs: Psychosocial Integrity
14. A hospice nurse is caring for a variety of clients who are dying. Which end-of-life and death ritual is paired with the correct religion?
a.
Roman Catholic – Autopsies are not allowed except under special circumstances.
b.
Christian – Upon death, a religious leader should perform rituals of bathing and wrapping the body in cloth.
c.
Judaism – A person who is extremely ill and dying should not be left alone.
d.
Islam – An ill or dying person should receive the Sacrament of the Sick.
ANS: C
According to Jewish law, a person who is extremely ill or dying should not be left alone. Orthodox Jews do not allow autopsies except under special circumstances. The Islamic faith requires a religious leader to perform rituals of bathing and wrapping the body in cloth upon death. A Catholic priest performs the Sacrament of the Sick for ill or dying people.
DIF: Remembering/Knowledge REF: 100
KEY: End-of-life care| religion/spirituality
MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity
MULTIPLE RESPONSE
1. A hospice nurse is caring for a dying client and her family members. Which interventions should the nurse implement? (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.
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 the client’s religion is the same.
DIF: Applying/Application REF: 96 KEY: End-of-life care
MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity
2. A nurse admits an older adult client to the hospital. Which criterion should the nurse use to determine if the client can make his own medical decisions? (Select all that apply.)
a.
Can communicate his treatment preferences
b.
Is able to read and write at an eighth-grade level
c.
Is oriented enough to understand information provided
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: Remembering/Knowledge REF: 92
KEY: Advance directives
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A hospice nurse plans care for a client who is experiencing pain. Which complementary therapies should the nurse incorporate in this client’s pain management plan? (Select all that apply.)
a.
Play music that the client enjoys.
b.
Massage tissue that is tender from radiation therapy.
c.
Rub lavender lotion on the client’s feet.
d.
Ambulate the client in the hall twice a day.
e.
Administer intravenous morphine.
ANS: A, C
Complementary therapies for pain management include massage therapy, music therapy, Therapeutic Touch, and aromatherapy. Nurses should not massage over sites of tissue damage from radiation therapy. Ambulation and intravenous morphine are not complementary therapies for pain management.
DIF: Understanding/Comprehension REF: 97
KEY: Advance directives
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs: Physiological Integrity: Basic Care and Comfort
4. A nurse teaches a client’s family members about signs and symptoms of approaching death. Which manifestations should the nurse include in this teaching? (Select all that apply.)
a.
Warm and flushed extremities
b.
Long periods of insomnia
c.
Increased respiratory rate
d.
Decreased appetite
e.
Congestion and gurgling
ANS: D, E
Common physical signs and symptoms of approaching death including coolness of extremities, increased sleeping, irregular and slowed breathing rate, a decrease in fluid and food intake, congestion and gurgling, incontinence, disorientation, and restlessness.
DIF: Remembering/Knowledge REF: 96 KEY: End-of-life care
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological AdaptationChapter 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration?
a.
A 36-year-old who is prescribed long-term steroid therapy
b.
A 55-year-old receiving hypertonic intravenous fluids
c.
A 76-year-old who is cognitively impaired
d.
An 83-year-old with congestive heart failure
ANS: C
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: Understanding/Comprehension REF: 156 KEY: Hydration
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
2. A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?
a.
Measure intake and output every 4 hours.
b.
Apply oxygen by mask or nasal cannula.
c.
Increase the IV flow rate to 250 mL/hr.
d.
Place 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 optimal. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the client too rapidly with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client in a high-Fowler’s position will not address the client’s problem.
DIF: Applying/Application REF: 156 KEY: Hydration
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. After teaching a client who is being treated for dehydration, a nurse assesses the client’s understanding. Which statement indicates the client correctly understood the teaching?
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
One liter of water weighs 1 kg; therefore, a 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: Analyzing/Analysis REF: 156 KEY: Hydration
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
4. A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess?
a.
Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
b.
Daily weight increase from 55 kg to 57 kg
c.
Heart rate decrease from 100 beats/min to 82 beats/min
d.
Respiratory rate increase from 12 breaths/min to 15 breaths/min
ANS: A
ACE inhibitors will disrupt the renin–angiotensin II pathway and prevent the kidneys from reabsorbing water and sodium. The kidneys will excrete more water and sodium, decreasing the client’s blood pressure.
DIF: Applying/Application REF: 166
KEY: Hydration| angiotensin-converting enzyme (ACE) inhibitor
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
5. A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss?
a.
Client taking furosemide (Lasix)
b.
Anxious client who has tachypnea
c.
Client who is on fluid restrictions
d.
Client who is constipated with abdominal pain
ANS: B
Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for fluid loss.
DIF: Applying/Application REF: 153 KEY: Hydration
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan?
a.
Increased respiratory rate from 12 breaths/min to 22 breaths/min
b.
Decreased skin turgor on the client’s posterior hand and forehead
c.
Increased urine specific gravity from 1.012 to 1.030 g/mL
d.
Decreased orthostatic light-headedness and dizziness
ANS: D
The focus of management for clients with dehydration is to increase fluid volumes to normal. When fluid volumes return to normal, clients should perfuse the brain more effectively, therefore improving confusion and decreasing orthostatic light-headedness or dizziness. Increased respiratory rate, decreased skin turgor, and increased specific gravity are all manifestations of dehydration.
DIF: Applying/Application REF: 156 KEY: Hydration
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client’s understanding. Which food choice for lunch indicates the client correctly understood the teaching?
a.
Slices of smoked ham with potato salad
b.
Bowl of tomato soup with a grilled cheese sandwich
c.
Salami and cheese on whole wheat crackers
d.
Grilled chicken breast with glazed 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 ham, tomato soup, salami, and crackers are often high in sodium.
DIF: Applying/Application REF: 157
KEY: Electrolyte imbalance MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
8. A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?
a.
A 34-year-old on NPO status who is receiving intravenous D5W
b.
A 50-year-old with an infection who is prescribed a sulfonamide antibiotic
c.
A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin)
d.
A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)
ANS: A
Dextrose 5% in water (D5W) contains no electrolytes. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.
DIF: Applying/Application REF: 161
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral
Therapies
9. A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this client’s teaching?
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 a high sodium content. Teaching clients how to read labels and calculate the sodium content of food can help them adhere to prescribed sodium restrictions and can prevent hypernatremia. Daily self-weighing and pulse checking are methods of identifying manifestations of hypernatremia, but they do not prevent it. The addition of substances during cooking, not the method of cooking, increases the sodium content of a meal.
DIF: Applying/Application REF: 160
KEY: Electrolyte imbalance MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
10. A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
a.
Depth of respirations
b.
Bowel sounds
c.
Grip strength
d.
Electrocardiography
ANS: A
A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse should assess the client’s respiratory status first to ensure respirations are sufficient. The respiratory assessment should include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the client’s respiratory status.
DIF: Analyzing/Analysis REF: 164
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
11. A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first?
a.
Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth.
b.
Provide a heart healthy, low-potassium diet.
c.
Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
d.
Prepare the client for hemodialysis treatment.
ANS: C
A client with a high serum potassium level and cardiac changes should be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore should be administered with dextrose to prevent hypoglycemia. Kayexalate may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first prescription the nurse should implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client’s current potassium level.
DIF: Applying/Application REF: 166
KEY: Electrolyte imbalance| insulin
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
12. A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia?
a.
Client with pancreatitis who has continuous nasogastric suctioning
b.
Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor
c.
Client in a motor vehicle crash who is receiving 6 units of packed red blood cells
d.
Client with uncontrolled diabetes and a serum pH level of 7.33
ANS: A
A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia. The other clients are at risk for potassium excess or hyperkalemia.
DIF: Understanding/Comprehension REF: 164
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
13. A nurse is assessing a client with hypokalemia, and notes that the client’s handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?
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. Cardiac dysrhythmias are also associated with hypokalemia. The client’s pulse and blood pressure should be assessed after assessing respiratory status. Next, the nurse would call the health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client should occur during and after potassium replacement therapy.
DIF: Applying/Application REF: 163
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
14. After teaching a client to increase dietary potassium intake, a nurse assesses the client’s understanding. Which dietary meal selection indicates the client correctly understands the teaching?
a.
Toasted English muffin with butter and blueberry jam, and tea with sugar
b.
Two scrambled eggs, a slice of white toast, and a half cup of strawberries
c.
Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk
d.
Bowl of oatmeal with brown sugar, a half 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: Applying/Application REF: 163
KEY: Electrolyte imbalance MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
15. A client at risk for developing hyperkalemia states, “I love fruit and usually eat it every day, but now I can’t because of my high potassium level.” How should the nurse respond?
a.
“Potatoes and avocados can be substituted for fruit.”
b.
“If you cook the fruit, the amount of potassium will be lower.”
c.
“Berries, cherries, apples, and peaches are low in potassium.”
d.
“You are correct. Fruit is very high in potassium.”
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: Applying/Application REF: 163
KEY: Electrolyte imbalance
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Psychosocial Integrity
16. A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?
a.
Encourage oral fluid intake.
b.
Connect the client to a cardiac monitor.
c.
Assess urinary output.
d.
Administer oral calcitonin (Calcimar).
ANS: B
This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.
DIF: Applying/Application REF: 169
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
17. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?
a.
Ask family members to speak quietly to keep the client calm.
b.
Assess urine color, amount, and specific gravity each day.
c.
Encourage the client to drink at least 1 liter of fluids each shift.
d.
Dangle the client on the bedside before ambulating.
ANS: D
An older adult with moderate dehydration may experience orthostatic hypotension. The client should dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the client’s urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 liter of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency.
DIF: Applying/Application REF: 157
KEY: Electrolyte imbalance| safety| mobility/immobility
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
MULTIPLE RESPONSE
1. A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.)
a.
Increased pulse rate
b.
Distended neck veins
c.
Decreased blood pressure
d.
Warm and pink skin
e.
Skeletal muscle weakness
ANS: A, B, E
Manifestations of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, and skeletal muscle weakness.
DIF: Remembering/Knowledge REF: 159 KEY: Hydration
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that apply.)
a.
A 36-year-old who is malnourished
b.
A 42-year-old with uncontrolled diabetes
c.
A 50-year-old with hyperparathyroidism
d.
A 58-year-old with chronic renal failure
e.
A 76-year-old who is prescribed antacids
ANS: A, B, E
Clients at risk for hypophosphatemia include those who are malnourished, those with uncontrolled diabetes mellitus, and those who use aluminum hydroxide–based or magnesium-based antacids. Hyperparathyroidism and chronic renal failure are common causes of hyperphosphatemia.
DIF: Remembering/Knowledge REF: 170
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.)
a.
Urine output of 25 mL/hr
b.
Serum potassium level of 5.4 mEq/L
c.
Urine specific gravity of 1.02 g/mL
d.
Serum sodium level of 128 mEq/L
e.
Blood osmolality of 250 mOsm/L
ANS: B, E
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 (increased urine output), increased potassium reabsorption, decreased blood osmolality, and increased urine specific gravity. The client would not be at risk for sodium imbalance.
DIF: Applying/Application REF: 161 KEY: Hydration
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.)
a.
Electrocardiogram changes
b.
Slow, shallow respirations
c.
Orthostatic hypotension
d.
Paralytic ileus
e.
Skeletal muscle weakness
ANS: A, D, E
Electrolyte imbalances associated with acute renal failure include hyperkalemia and hyperphosphatemia. The nurse should assess for electrocardiogram changes, paralytic ileus caused by decrease bowel mobility, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia.
DIF: Applying/Application REF: 152
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.)
a.
Hypokalemia – Flaccid paralysis with respiratory depression
b.
Hyperphosphatemia – Paresthesia with sensations of tingling and numbness
c.
Hyponatremia – Decreased level of consciousness
d.
Hypercalcemia – Positive Trousseau’s and Chvostek’s signs
e.
Hypomagnesemia – Bradycardia, peripheral vasodilation, and hypotension
ANS: A, C
Flaccid paralysis with respiratory depression is associated with hypokalemia. Decreased level of consciousness is associated with hyponatremia. Paresthesia with sensations of tingling and numbness is associated with hypophosphatemia or hypercalcemia. Positive Trousseau’s and Chvostek’s signs are associated with hypocalcemia or hyperphosphatemia. Bradycardia, peripheral vasodilation, and hypotension are associated with hypermagnesemia.
DIF: Analyzing/Analysis REF: 164
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. After administering 40 mEq of potassium chloride, a nurse evaluates the client’s response. Which manifestations indicate that treatment is improving the client’s hypokalemia? (Select all that apply.)
a.
Respiratory rate of 8 breaths/min
b.
Absent deep tendon reflexes
c.
Strong productive cough
d.
Active bowel sounds
e.
U waves present on the electrocardiogram (ECG)
ANS: C, D
A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all manifestations of hypokalemia and do not demonstrate that treatment is working.
DIF: Understanding/Comprehension REF: 165
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
7. A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this client’s care plan? (Select all that apply.)
a.
Encourage oral fluid intake of at least 2 L/day.
b.
Use a draw sheet to reposition the client in bed.
c.
Strain all urine output and assess for urinary stones.
d.
Provide nonslip footwear for the client to use when out of bed.
e.
Rotate the client from side to side every 2 hours.
ANS: B, D
Clients with long-standing hypocalcemia have brittle bones that may fracture easily. Safety needs are a priority. Nursing staff should use a draw sheet when repositioning the client in bed and have the client wear nonslip footwear when out of bed to prevent fractures and falls. The other interventions would not provide safety for this client.
DIF: Applying/Application REF: 169
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection ControlChapter 15: Care of Intraoperative Patients
Ignatavicius: Medical-Surgical Nursing, 8th Edition
MULTIPLE CHOICE
1. The circulating nurse is plugging in a piece of equipment and notes that the cord is frayed. What action by the nurse is best?
a.
Call maintenance for repair.
b.
Check the machine before using.
c.
Get another piece of equipment.
d.
Notify the charge nurse.
ANS: C
The circulating nurse is responsible for client safety. If an electrical cord is frayed, the risk of fire or sparking increases. The nurse should obtain a replacement. The nurse should also tag the original equipment for repair as per agency policy. Checking the equipment is not important as the nurse should not even attempt to use it. Calling maintenance or requesting maintenance per facility protocol is important, but first ensure client safety by having a properly working piece of equipment for the procedure about to take place. The charge nurse probably does need to know of the need for equipment repair, but ensuring client safety is the priority.
DIF: Applying/Application REF: 239
KEY: Intraoperative nursing| circulating nurse| safety
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
2. The circulating nurse and preoperative nurse are reviewing the chart of a client scheduled for minimally invasive surgery (MIS). What information on the chart needs to be reported to the surgeon as a priority?
a.
Allergies noted and allergy band on
b.
Consent for MIS procedure only
c.
No prior anesthesia exposure
d.
NPO status for the last 8 hours
ANS: B
All MIS procedures have the potential for becoming open procedures depending on findings and complications. The client’s consent should include this possibility. The nurse should report this finding to the surgeon prior to surgery taking place. Having allergies noted and an allergy band applied is standard procedure. Not having any prior surgical or anesthesia exposure is not the priority. Maintaining NPO status as prescribed is standard procedure.
DIF: Applying/Application REF: 250
KEY: Intraoperative care| informed consent| circulating nurse
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to “break scrub” when going to the console and sitting down. What action by the nurse is best?
a.
Call a “time-out” to discuss sterile procedure and scrub technique.
b.
Document the time the robotic portion of the procedure begins.
c.
Inform the surgeon that the scrub preparation has been compromised.
d.
Report the surgeon’s actions to the charge nurse and unit manager.
ANS: B
During a robotic operative procedure, the surgeon inserts the articulating arms into the client, then “breaks scrub” to sit at the viewing console to perform the operation. The nurse should document the time the robotic portion of the procedure began. There is no need for the other interventions.
DIF: Applying/Application REF: 242
KEY: Intraoperative care| circulating nurse| robotic technology| sterile procedure
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
4. The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate?
a.
Ask the surgeon to change the sterile gown.
b.
Do nothing; this is acceptable sterile procedure.
c.
Inform the surgeon that the sterile field has been broken.
d.
Obtain a new pair of sterile gloves for the surgeon to put on.
ANS: C
The surgical gown is considered sterile from the chest to the level of the surgical field. By placing the hands down by the hips, the surgeon has broken sterile field. The circulating nurse informs the surgeon of this breach. Changing only the gloves or only the gown does not “restore” the sterile sections of the gown. Doing nothing is unacceptable.
DIF: Applying/Application REF: 244
KEY: Intraoperative nursing| sterile field| surgical scrub| surgical gowning
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5. A client is in stage 2 of general anesthesia. What action by the nurse is most important?
a.
Keeping the room quiet and calm
b.
Being prepared to suction the airway
c.
Positioning the client correctly
d.
Warming the client with blankets
ANS: B
During stage 2 of general anesthesia (excitement, delirium), the client can vomit and aspirate. The nurse must be ready to react to this potential occurrence by being prepared to suction the client’s airway. Keeping the room quiet and calm does help the client enter the anesthetic state, but is not the priority. Positioning the client usually occurs during stage 3 (operative anesthesia). Keeping the client warm is important throughout to prevent hypothermia.
DIF: Applying/Application REF: 246
KEY: Intraoperative nursing| stages of anesthesia| airway
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
6. A client is having surgery. The circulating nurse notes the client’s oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best?
a.
Assess the client’s end-tidal carbon dioxide level.
b.
Document the findings in the client’s chart.
c.
Inform the anesthesia provider of these values.
d.
Prepare to administer dantrolene sodium (Dantrium).
ANS: A
Malignant hyperthermia is a rare but serious reaction to anesthesia. The triad of early signs include decreased oxygen saturation, tachycardia, and elevated end-tidal carbon dioxide (CO2) level. The nurse should quickly check the end-tidal CO2 and then report findings to the anesthesia provider and surgeon. Documentation is vital, but not the most important action at this stage. Dantrolene sodium is the drug of choice if the client does have malignant hyperthermia.
DIF: Applying/Application REF: 246
KEY: Intraoperative nursing| malignant hyperthermia| dantrolene sodium
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. A nurse is monitoring a client after moderate sedation. The nurse documents the client’s Ramsay Sedation Scale (RSS) score at 3. What action by the nurse is best?
a.
Assess the client’s gag reflex.
b.
Begin providing discharge instructions.
c.
Document findings and continue to monitor.
d.
Increase oxygen and notify the provider.
ANS: C
An RSS score of 3 means the client is able to respond quickly, but only to commands. The client has not had enough time to fully arouse. The nurse should document the findings and continue to monitor per agency policy. If the client had an oral endoscopy or was intubated, checking the gag reflex would be appropriate prior to permitting eating or drinking. The client is not yet awake enough for teaching. There is no need to increase oxygen and notify the provider.
DIF: Applying/Application REF: 250
KEY: Intraoperative nursing| Ramsay Sedation Scale| moderate sedation
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
8. A client is scheduled for a below-the-knee amputation. The circulating nurse ensures the proper side is marked prior to the start of surgery. What action by the nurse is most appropriate?
a.
Facilitate marking the site with the client and surgeon.
b.
Have the client mark the operative site.
c.
Mark the operative site with a waterproof marker.
d.
Tell the surgeon it is time to mark the surgical site.
ANS: A
The Joint Commission now recommends that both the client and the surgeon mark the operative site together in order to prevent wrong-site surgery. The nurse should facilitate this process.
DIF: Applying/Application REF: 250
KEY: Intraoperative nursing| wrong-site surgery| The Joint Commission National Patient Safety Goals MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
9. A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important?
a.
Assist with administering muscle relaxants to the client.
b.
Place the client on a cardiac monitor and pulse oximeter.
c.
Prepare to administer intravenous antiemetics to the client.
d.
Prevent the client from experiencing postoperative shivering.
ANS: B
Intravenous anesthetic agents have the potential to cause respiratory and circulatory depression. The nurse should ensure the client is on a cardiac monitor and pulse oximeter. Muscle relaxants are not indicated for this client at this time. Intravenous anesthetics have a lower rate of postoperative nausea and vomiting than other types. Shivering can occur in any client, but is more common after inhalation agents.
DIF: Applying/Application REF: 246
KEY: Intraoperative nursing| anesthetic agents| inhalation agents
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
10. A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client?
a.
Allow the client to keep hearing aids in until anesthesia begins.
b.
Pad the table as appropriate for the surgical procedure.
c.
Position the client for maximum visualization of the site.
d.
Stay with the client, providing emotional comfort and support.
ANS: A
Many older clients have sensory loss. To help prevent disorientation, facilities often allow older clients to keep their eyeglasses on and hearing aids in until the start of anesthesia. The other actions are appropriate for all operative clients.
DIF: Remembering/Knowledge REF: 251
KEY: Intraoperative nursing| older adult
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Health Promotion and Maintenance
11. A circulating nurse wishes to provide emotional support to a client who was just transferred to the operating room. What action by the nurse would be best?
a.
Administer anxiolytics.
b.
Give the client warm blankets.
c.
Introduce the surgical staff.
d.
Remain with the client.
ANS: D
The nurse can provide emotional support by remaining with the client until anesthesia has been provided. An extremely anxious client may need anxiolytics, but not all clients require this for emotional support. Physical comfort and introductions can also help decrease anxiety.
DIF: Applying/Application REF: 251
KEY: Intraoperative nursing| anxiety| comfort
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Psychosocial Integrity
12. A client in the operating room has developed malignant hyperthermia. The client’s potassium is 6.5 mEq/L. What action by the nurse takes priority?
a.
Administer 10 units of regular insulin.
b.
Administer nifedipine (Procardia).
c.
Assess urine for myoglobin or blood.
d.
Monitor the client for dysrhythmias.
ANS: A
For hyperkalemia in a client with malignant hyperthermia, the nurse administers 10 units of regular insulin in 50 mL of 50% dextrose. This will force potassium back into the cells rapidly. Nifedipine is a calcium channel blocker used to treat hypertension and dysrhythmias, and should not be used in a client with malignant hyperthermia. Assessing the urine for blood or myoglobin is important, but does not take priority. Monitoring the client for dysrhythmias is also important due to the potassium imbalance, but again does not take priority over treating the potassium imbalance.
DIF: Applying/Application REF: 247
KEY: Intraoperative nursing| malignant hyperthermia| hyperkalemia
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. A student nurse observing in the operating room notes that the functions of the Certified Registered Nurse First Assistant (CRNFA) include which activities? (Select all that apply.)
a.
Dressing the surgical wound
b.
Grafting new or synthetic skin
c.
Reattaching severed nerves
d.
Suctioning the surgical site
e.
Suturing the surgical wound
ANS: A, D, E
The CRNFA can perform tasks under the direction of the surgeon such as suturing and dressing surgical wounds, cutting away tissue, suctioning the wound to improve visibility, and holding retractors. Reattaching severed nerves and performing grafts would be the responsibility of the surgeon.
DIF: Remembering/Knowledge REF: 239
KEY: Surgery| Certified Registered Nurse First Assistant (CRNFA)
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. The nursing student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles? (Select all that apply.)
a.
Ensuring the client’s safety
b.
Accounting for all sharps
c.
Documenting all care given
d.
Maintaining the sterile field
e.
Monitoring traffic in the room
ANS: A, E
The circulating nurse has several functions, including maintaining client safety and privacy, monitoring traffic in and out of the operating room, assessing fluid losses, reporting findings to the surgeon and anesthesia provider, anticipating needs of the team, and communicating to the family. The circulating nurse and scrub person work together to ensure accurate counts of sharps, sponges, and instruments. The circulating nurse also documents care, but in the perioperative area, the preoperative or holding room nurse would also document care received there. Maintaining the sterile field is a joint responsibility among all members of the surgical team.
DIF: Remembering/Knowledge REF: 239
KEY: Perioperative| circulating nurse MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. The circulating nurse reviews the day’s schedule and notes clients who are at higher risk of anesthetic overdose and other anesthesia-related complications. Which clients does this include? (Select all that apply.)
a.
A 75-year-old client scheduled for an elective procedure
b.
Client who drinks a 6-pack of beer each day
c.
Client with a serum creatinine of 3.8 mg/dL
d.
Client who is taking birth control pills
e.
Young male client with a RYR1 gene mutation
ANS: A, B, C, E
People at higher risk for anesthetic overdose or other anesthesia-related complications include people with a slowed metabolism (older adults generally have slower metabolism than younger adults), those with kidney or liver impairments, and those with mutations of the RYR1 gene. Drinking a 6-pack of beer per day possibly indicates some liver disease; a creatinine of 3.8 is high, indicating renal disease; and the genetic mutation increases the chance of malignant hyperthermia. Taking birth control pills is not a risk factor.
DIF: Analyzing/Analysis REF: 247
KEY: Intraoperative nursing| anesthesia
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
4. A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.)
a.
Assessing distal circulation to the operative arm after positioning
b.
Keeping the client warm during the operative procedure
c.
Padding the client’s shoulder and arm on the operating table
d.
Preparing to suction the client’s airway if the client vomits
e.
Speaking in a low, quiet voice as anesthesia is administered
ANS: A, C
After regional anesthesia is administered, the client loses all sensation distally. The nurse ensures client safety by assessing distal circulation and padding the shoulder and arm appropriately. Although awake, the client will not be able to report potential injury. Keeping the client warm is not related to this anesthesia, nor is suctioning or speaking quietly.
DIF: Applying/Application REF: 248
KEY: Intraoperative nursing| regional anesthesia
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5. What actions by the circulating nurse are important to promote client comfort? (Select all that apply.)
a.
Correct positioning
b.
Introducing one’s self
c.
Providing warmth
d.
Remaining present
e.
Removing hearing aids
ANS: A, B, C, D
The circulating nurse can do many things to promote client comfort, including positioning the client correctly and comfortably, introducing herself or himself to the client, keeping the client warm, and remaining present with the client. Removing hearing aids does not promote comfort and, if the client is still awake when they are removed, may contribute to disorientation and anxiety.
DIF: Remembering/Knowledge REF: 239
KEY: Intraoperative nursing| comfort
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
SHORT ANSWER
1. A client has developed malignant hyperthermia. The client weighs 136 pounds. What is the safe dose range for one dose of dantrolene sodium (Dantrium)? (Enter your answer using whole numbers, separated by a hyphen with no spaces.) _____ mg
ANS:
124-186 mg
The dose of dantrolene is 2 to 3 mg/kg. The client weighs 62 kg, so the safe dose range is 124 to 186 mg.
DIF: Applying/Application REF: 247
KEY: Intraoperative nursing| dantrolene sodium| malignant hyperthermia
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral T

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