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Ch 49 Terms Definitions
What is the basic functional and
structural unit of the kidneys?
nephron
The process of emptying thebladder is known as ________.
micturation
What is urinary incontinance? any involuntary loss of urine
What is autonomic bladder? voiding by reflex only because the person does
not have voluntarily control either due to brain
injury or disease or the higher nerve centers have
not yet developed such as in infancy.
T/F The first urine of the day is
usually more concentrated than
what is voided throughout the
day.
True: Because the first urine of the day is not
fresh, but rather an accumulation of a number of
hours of kidney output during sleep, this urine
may or may not be used as a specimen for certain
tests.
T/F People who habitually
urinate infrequently develop
more urinary tract infections
and kidney disorders than those
who urinate at least every 3 to 4
hours.
True: The reason for this is believed to be
stagnation of urine in the bladder, which serves
as a good medium for bacterial growth
A change in a persons normal
voiding pattern may indicate
_____.
illness or disease
Intentional or involuntary
urination into bed or clothes that
occurs after an age when
continence should be present is
termed _______.
enuresis
( is not seen as a medical problem until the child
reaches 6 years of age)
What types of food or fluid
would increase urine
production?
Caffeine, alcohol, and foods high in water
What in the diet would decrease
urine production?
high amounts of sodium
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What is hematuria? blood in the urine
What is polyuria excessive urine output
T/F a sterile urine specimen is
required for routine urinalysis.
False
If a sterile urine specimen is
required which collection
method would be used?
clean catch or mid-stream
In a 24 hour urine specimen, is
the first urine eliminated
counted or thrown out?
Thrown out; all urine output for the next 24
hours is collected.
What are the variables inhelping pts maintain normal
voiding habits?
schedule, privacy, position, & hygiene
How many mL should a healthy
adult drink per day?
2,000-2,400 mL
What is the main cause of
nosocomial infections?
catherization
Which type of catheter is
preferred for long term urinarydrainage?
suprapubic catheter
What is the Valsalva
Maneuver?
The technique of bearing down to deficate.
Why might the Valsalva
maneuver be contraindicated in
people with cardiovascular
problems and other illnesses?
Bearing down decreases blood flow to the atria
and ventricles, thus temporarily lowering cardiac
output. Once bearing down ceases, the pressure is
lessened, and a larger than normal amount of
blood returns to the heart. This act maydangerously elevate the blood pressure in an
already hypertensive individual.
Megan, why should you switch
to bottle feeding?
Less diapers to change! - breastfed infants can
pass from two to ten stools daily, whereas bottle-
fed infants typically pass one or two stools daily.
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What could be suspected when
a patient reports that his or her
stool has become narrower or
ribbon-like?
There may be an obstruction of the normal
passage of stool through the colon such as a
tumor.
The frequency of bowel sounds
may range from ___-___ per
minute depending on the rate of
peristalsis.
5-34
How many minutes must you
listen for before declaring
absent bowel sounds?
5 min.
A combination of which three
things has been shown to be aseffective as medications in
controlling constipation?
high-fiber foods, 8 to 10 glasses of water daily,
and exercise
What is the most common cause
of chronic constipation?
habitual laxative use
Ch 35
1. A client is nauseated, has been vomiting
for several hours, and needs to receive an
antiemetic (anti-nausea) medication. The
nurse recognizes that which of the
following is accurate?
A parenteral route is the route of choice.
contraindicated if there is rectal bleeding or if
the client had rectal surgery. Stool in the rectum
can impair absorption.
2. The client receiving an intravenous
infusion of morphine sulfate begins to
experience respiratory depression and
decreased urine output. This effect is
described as:
Toxic
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3. The client is to receive a medication via
the buccal route. The nurse plans to
implement which of the following actions?
Place the medication inside the cheek.
4. The physician orders a grain and a half
of Seconal to help a client sleep. The label
on the medication bottle reads Seconal 100
mg. How many capsules should the nurse
give the client?
1
Because 1 grain = 60 mg, the nurse may
multiply 1 by 60 to equal 90 mg. The nurse may
then use the following formula for calculating a
drug dosage:
90 mg
100 mg x 1 capsule = 0.9 capsules
Because 0.9 of a capsule cannot be
administered, it is rounded to 1 capsule. Thenurse will administer 1 capsule.
5. The physician has ordered 6 mg of
morphine sulfate every 3 to 4 hours prn for
a client's postoperative pain. The unit dose
in the medication dispenser has 15 mg in 1
mL. How much solution should the nurse
give?
2/5 mL
The nurse should use the following formula to
calculate a drug dosage:
6 mg
15 mg x 1 mL = 2/5 mL
6. To determine proper drug dosages for
children, calculations are most precisely
made on the basis of the child's:
Body surface area
7. The nurse is documenting
administration of a medication that is
given at 10:00 AM, 2:00 PM, and 6:00
PM. The medication that the nurse is
documenting is:
Diazepam 5 mg PO tid
8. The nurse is working on the pediatric
unit. In preparing to give medications to a
preschool-age child, an appropriate
interaction by the nurse is:
"Would you like the medication with water or
juice?"
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9. In preparing two different medications
from two vials, the nurse must:
Discard the medication from vial number 2 if
medication from vial number 1 is pushed into it
10. The nurse is teaching the client how toprepare 10 units of regular insulin and 5
units of NPH insulin for injection. The
nurse instructs the client to:
Inject air into both vials and withdraw theregular insulin first
11. A client has a prescription for a
medication that is administered via an
inhaler. To determine if the client requires
a spacer for the inhaler, the nurse will
determine the:
Coordination of the client
12. The student nurse reads the order to
give a 1-year-old client an intramuscular
injection. The appropriate and preferred
muscle to select for a child is the:
Ventrogluteal
13. The nurse administers the
intramuscular medication of iron by the Z-
track method. The medication was
administered by this method to:
Prevent the drug from irritating sensitive tissue
14. The client is ordered to have eye drops
administered daily to both eyes. Eye drops
should be instilled on the:
Lower conjunctival sac
15. Following the administration of ear
drops to the left ear, the client should be
positioned:
Right lateral
16. The order is for eye medication, ii gtt
OD. The nurse administers:
2 drops to the right eye
ii = 2;
OD = right eye.
OS = left eye.
OU = both eyes.
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17. The most effective way in the acute
care environment to determine the client's
identity before administering medications
is to:
Check the client's name band
18. An order is written for Demerol 500
mg IM q3-4h prn for pain. The nurse
recognizes that this is significantly more
than the usual therapeutic dose. The nurse
should:
Call the prescriber to clarify the order
19. An order is written for 80 mg of a
medication in elixir form. The medication
is available in 80 mg/tsp strength. Thenurse prepares to administer:
5 mL
20. The client is to receive a Mantoux test
for tuberculosis. This test is administered
via an intradermal injection. The nurse
recognizes that the angle of injection that
is used for an intradermal injection is:
15 degrees
21. The nurse prepares to administer an
intradermal injection for the administration
of medication for:
Allergy sensitivity
22. The nurse is evaluating the integrity of
the ventrogluteal injection site. The nurse
finds the site by locating the:
Greater trochanter, anterior iliac spine, and iliac
crest
23. The client is to receive heparin by
injection. The nurse prepares to inject this
medication in the client's:
Abdomen
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24. A medication is prescribed for the
client and is to be administered by IV
bolus injection. A priority for the nurse
before the administration of medication via
this route is to:
Confirm placement of the IV line
25. A client on the medical unit receives
regular insulin at 7:00 AM. The nurse is
alert to a possible hypoglycemic reaction
by:
10:00 AM
Regular insulin reaches its peak in 2 to 4 hours
after administration. Regular insulin has an
onset in 30 minutes. Intermediate-acting insulin
(i.e., NPH insulin) would peak in 6 to 12 hours,
not regular insulin.
26. A priority for the nurse in theadministration of oral medications and
prevention of aspiration is:
Checking for a gag reflex
27. The nurse is to administer several
medications to the client via the N/G tube.
The nurse's first action is to:
Check for placement of the nasogastric tube
28. The nurse is administering an injection
at the ventrogluteal site. On aspiration, the
nurse notices that there is blood in the
syringe. The nurse should:
Discontinue the injection and prepare the
medication again
29. A 3-year-old child is to receive an iron
preparation orally. The nurse should:
Use a straw
30. The client has an order for 30 units of
U-500 insulin. The nurse is using a U-100
syringe and will draw up and administer:
6 units
31. The nurse is preparing to administer 8
mg of a 10 mg dose of an intravenous
narcotic. Which of the following
statements made by the nurse best reflects
an understanding of the appropriate
"I need to get another RN to witness the waste
and sign the narcotic sheet."
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manner to handle this situation?
32. The nurse is caring for a client who is
experiencing severe pain and is insistent
about "getting some relief quickly." Whichof the following prescriptions is most
likely to produce the quickest pain relief?
Morphine sulfate intravenously
33. A 78-year-old client with congestive
heart failure (CHF) is reporting vascular
pain in his lower legs and requests his oral
narcotic analgesic. The nurse recognizes
that the client's pain relief will be
negatively affected primarily because of
The systemic effects of CHF
34. The nurse is aware that which of the
following clients is at greatest risk for
developing medication toxicity?
The 73-year-old diagnosed with hepatitis B
35. A 20 year old diagnosed with Crohn's
disease is experiencing severe pain and is
requesting the prescribed morphine as
often as it can be administered. The nurse
is particularly concerned about opioid
toxicity because of:
The client's compromised bowel absorption
36. The nurse recognizes which of the
following clients as being at greatest risk
for anaphylactic shock?
A 69-year-old client receiving an antibiotic for a
respiratory tract infection
37. During the admission interview a client
shares with the nurse that she is allergic to
latex. The nurse's immediate response isto:
Place an identification bracelet on the client that
identifies the latex allergy
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38. A client is observed swallowing a
chewable form of aspirin. Which of the
following statements made by the nurse
shows the best understanding of the
educational reinforcement needed by this
client?
"I realize that you usually swallow aspirin, but
this form only works if it's chewed."
39. To minimize the risk for injury to the
oral mucosa, a client ordered a buccally
administered medication is instructed to:
Alternate cheeks with each subsequent dose
40. To best prevent a systemic effect from
a topically applied medication patch, thenurse must:
Avoid applying the medication to broken skin
41. The nurse assigns ancillary personnel
the task of giving a client a pre-procedure
enema. Which of the following statements
made by the personnel requires immediate
follow-up by the nurse?
"The soapy water just came right back out."
42. Research has shown that the primary
reason nurses make medication errors is
related to:
Events that distract the nurse during the
administration process
43. The nurse has taken a verbal order for a
narcotic medication to be given to a client
experiencing severe pain related to
metastatic cancer of the bone. The nurse's
initial action regarding the order is to:
Write and then sign the complete order in the
appropriate location in the client's chart
44. During the admission interview theclient reports to the nurse that she is "a
little allergic to penicillin." Which of the
following questions asked by the nurse is
most likely to provide the most relevant
information regarding the client's possible
"Can you describe what happens when you takepenicillin?"
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allergy to penicillin?
45. Policies for the proper storage and
distribution of narcotics within a health
care organization are written by:
Health care organization
46. The nurse is administering
morphine sulfate to a client for
pain. The order has been written so
that the nurse can chose from
several routes of administration.
The nurse knows that the morphine
sulfate be most rapidly absorbed by
which of the following routes?
IV
47. On beginning the administration of 500
mg of aztreonam IV to a client with a
urinary tract infection, the client complains
of difficulty breathing. The nurse quickly
identifies this as a symptom of a(n):
Anaphylactic reaction
48. In the event of a medication error, the
nurse's first responsibility is to:
Ensure the client's safety
49. The nurse prepares to administer a
table to a client who has difficulty
swallowing pills. The nurse decides to
crush the tablet and mix it with food. The
nurse should mix the crushed medication:
In a very small amount of food
50. The nurse prepares to
administer a prn pain medicationby IM injection. The client refuses
the injection stating that "I don't
like shots." The best reaction by the
nurse is to:
Contact the physician for pain medication to be
given by a different route
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51. When teaching a pediatric client's
parents about administering his medication
at home, the nurse states that the mostaccurate device for measuring the liquid
medication is:
Oral plastic disposable syringe
52. The nurse is preparing to administer a
nasal instillation of medication to a client.
The best position for accessing the
posterior pharynx is to place the client in a
supine position and tilt the client's head:
Backward
53. The nurse has an order for 325 mg
acetaminophen p.r. q4h prn for pain for a
7-year-old client who has had surgery. In
preparing the client for insertion of the
suppository, the client states that she feels
the need to have a bowel movement. The
nurse's best response is to:
Allow the client to defecate first to clear the
rectum of stool
1. The nurse plays a major role in which of
the following aspects of medication
therapy? (Select all that apply.)
3. Preparation of the client's prescribed dose of
medication
4. Monitoring the pharmacological effects of the
prescribed medication
5. Delivering the medication in accordance with
the prescriber's directions
6. Instructing the client regarding the
pharmacological effects of the medication
The nurse plays an essential role in medication
preparation and administration, medication
teaching, and evaluating clients' responses to
medications. The remaining options are not in
the nursing scope of the RN.
2. The home health nurse is preparing to
educate a client on his or her newly
1. "This medication is designed to lower your
blood pressure."
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prescribed medications. Which of the
following nursing statements are
appropriate to be included in this
discussion? (Select all that apply.)
3. "The medication can make you dizzy
especially if you stand up quickly."
4. "What do you think will be the most difficult
thing about taking this medication?"
5. "You will need to take this medication once a
day; with breakfast seems to work best for most
people."
6. "It is important that you don't miss taking the
medication, If you do, take it when you
remember but never take two at a time."
Teaching clients about their medications and
their side effects, ensuring adherence with the
medication regimen, and evaluating the client's
ability to self-administer medications arenursing responsibilities. The remaining option
does not relate to the actually medication
regimen.
3. A nurse is accused of illegally abusing
narcotic medications originally prescribed
to clients. If found guilty this nurse is
subject to: (Select all that apply.)
1. Years of imprisonment in a federal prison
3. Inclusion on the State Board of Nursing
Suspended license list
4. Forfeiture of the professional license needed
to practice nursing5. Monetary fines that can be in the hundreds of
thousands of dollars
6. Termination of employment from the
institution where the abuse occurred
Violations of the Controlled Substances Act are
punishable by fines, imprisonment, and loss of
nurse licensure.
4. Which of the following clients is likely
to experience altered medication excretion
with resulting possible toxicity? (Select all
that apply.)
1. A 16 year old with asthma
2. A 34 year old with hepatitis B
4. A 20 year old with Crohn's disease
5. A 54 year old in end-stage renal failure
After medications are metabolized, they exit the
body through the kidneys, liver, bowel, lungs,
and exocrine glands.
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5. The pharmacist providescollaboration to the acute care
nursing staff in the form of: (Select
all that apply.)
1. Accurate dispersal of prescribed
medications
2. Information regarding
medication side effects
3. Appropriate labeling of
prescribed medications
4. Clarification regarding proper
medication dosage
5. Education of clients regarding
the therapeutic value of drugs6. Answering questions related to
potential drug incompatibilities
1. Accurate dispersal of prescribed
medications
2. Information regarding medication side
effects
3. Appropriate labeling of prescribed
medications
4. Clarification regarding proper
medication dosage
6. Answering questions related to
potential drug incompatibilities
Most medication companies deliver
medications in a form ready for use.
Dispensing the correct medication in the
proper dosage and amount and with anaccurate label is the pharmacist's main
task. The pharmacist also provides
information about medication side
effects, toxicity, interactions, and
incompatibilities. Client education is not
a collaborative action provided by the
pharmacist; client education is a nursing
responsibility.
6. The nursing role regarding a medication
error includes: (Select all that apply.)
1. Immediate assessment of the client
2. Notification of the health care provider
3. Report the error to the appropriate
institutional administrator
4. Notify the client's family or medical
power of attorney of the error
5. Attach a written incident report to theclient's chart within 24 hours
6. Monitoring of the client as indicated by
the potential effects of the medication
1. Immediate assessment of the client
2. Notification of the health care provider
3. Report the error to the appropriate
institutional administrator
6. Monitoring of the client as indicated by the
potential effects of the medication
When an error occurs, the client's safety and
well-being become the top priority. The nurse
assesses and monitors the client's condition andnotifies the physician or prescriber of the
incident as soon as possible. Once the client is
stable, the nurse reports the incident to the
appropriate person in the institution. The nurse
is responsible for preparing a written occurrence
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or incident report that usually needs to be filed
within 24 hours of the error. The occurrence
report is not a permanent part of the medical
record and is not referred to anywhere in the
record. Notification of the client's family is not
required unless the client's condition warrants it
Ch 38
Terms Definitions
1. The nurse has investigated safety hazards and recognizes
that which one of the following statements is accurate
regarding safety needs?
1. Bacterial contamination of foods is uncontrollable.
2. Fire is the greatest cause of unintentional death.
3. Carbon dioxide levels should be monitored in home
settings.
4. Temperature extremes seldom affect the safety of clients
in acute care facilities.
Carbon dioxide levels should
be monitored in home settings.
2. An ambulatory client is admitted to the extended care
facility with a diagnosis of Alzheimer's disease. In using a
falls assessment tool, the nurse knows that the greatest
indicator of risk is:
History of falls
3. An inservice program is being offered in the hospital on
bioterrorism and the response of the health care agency.
During the program, the mitigation phase is described. The
nurse is informed that this phase includes:
Determination of hazard
vulnerability and the impact of
the emergency situation
4. An inservice program is being offered in the hospital onbioterrorism and the response of the health care agency. An
important aspect of the program is the recognition of the
signs and symptoms of bacterial and viral infections. A
practice drill is held and the nurse recognizes that the clients
admitted with possible anthrax will demonstrate:
Flulike symptoms,gastrointestinal distress, and
papular lesions
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5. A 1-year-old child is scheduled to receive an IV line. The
most appropriate type of restraint to use for this client to
prevent removal of the IV line would be a(n):
Mummy restraint
6. A 79-year-old resident in a long-term care facility isknown to "wander at night" and has fallen in the past. Which
of the following is the most appropriate nursing
intervention?
The client should be checkedfrequently during the night.
7. The workmen cause an electrical fire when installing a
new piece of equipment in the intensive care unit. A client is
on a ventilator in the next room. The first action the nurse
should take is to:
Use an Ambu-bag and remove
the client from the area
8. In a nursing home an elderly client drops his burning
cigarette in a trash can and starts a fire. The most appropriate
type of fire extinguisher for the nurse to use is the:
Type A
9. A visiting nurse completes an assessment of the
ambulatory client in the home and determines the nursing
diagnosis of risk for injury related to decreased vision.
Based on this assessment, the client will benefit the most
from:
Becoming oriented to the
position of the furniture and
stairways
10. Which one of the following statements by the parent of a
child indicates that further teaching by the nurse is required?
"Now that my child is 2 years
old, I can let her sit in the
front seat of the car with me."
11. The nurse assesses that the client may need a restraint
and recognizes that:
Restraints are to be
periodically removed to have
the client reevaluated
12. On entering the client's room, the nurse sees a fireburning in the trash can next to the bed. The nurse removes
the client and calls in the fire. The next action of the nurse is
to:
Close all the doors of clientrooms
13. A mother of a young child enters the kitchen and finds Check the child's airway and
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the child on the floor. There is a bottle of cleanser next to the
child and particles of the substance around the child's mouth.
The parent's first action should be to:
breathing
14. Which of the following nursing assessment data are mostreflective of hypothermia?
Rectal temperature of 35 C(95 F)
15. Which of the following clients who is experiencing the
heat of mid-August is at greatest risk for heatstroke or heat
exhaustion?
A 65-year-old diagnosed with
COPD
16. The nurse should recognize which of the following
clients as being at greatest risk for an unintentional death?
A 72-year-old identified as at
high risk for falls
17. Which of the following nursing interventions has the
greatest likelihood of minimizing the risk of injury for a
client who frequently gets out of bed at night to go into the
bathroom?
Illuminating the pathway to
the bathroom
18. When discussing the prevention of fire-related injuries
and deaths, the nurse should place the greatest emphasis on
the:
Dangers of careless smoking
habits
19. The nurse recognizes that the leading cause of death for
the otherwise healthy 1 year old is:
Accidental injury
20. The nurse is preparing a safety-related program for a
group of parents of 5 to 14 year olds. Which of the following
topics is most likely to positively impact the leading cause of
injury for this age-group?
"Bicycle riding with safety in
mind"
21. The nurse recognizes which of the following clients is at
greatest risk for an accidental death?
A 50-year-old who recently
lost his job because of a work-related injury
22. A client who is experiencing a generalized clonic-tonic
seizure is at greatest risk for injury caused by:
The physical collapse that
occurs at the onset of the
seizure
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23. Which of the following clients is at greatest risk for
injury related to medical diagnoses and conditions?
A history of heart failure and
urinary urgency
24. The nurse is conducting an admission interview and
assessment on a cognitively impaired, uncooperative clientfor the risk for injury. Which of the following options will
most likely provide the information to confirm the
diagnosis?
Interview the client's family,
friends, and/or caregiversregarding pre-hospitalization
risk factors.
25. A nurse working in an acute care facility's emergency
department should recognize which of the following client
reports as being most suspicious of a terrorist attack?
15 cases of nausea and
vomiting reported over a 2-
day period when 4 cases
would be within normal for
the facility
26. The nurse is discussing safety issues with the mother of
three children. Which of the following statements has the
greatest possibility for decreasing the potential for injury
among the children?
Where do you see a need for
safety improvements in your
home?"
27. The nurse recognizes that the greatest benefit of
engaging the mother of two small children into a discussion
about child-proofing her home is that:
She is likely to monitor the
house for safety issues in the
future
28. The nurse and a mother of two small children are
discussing child safety issues. Which of the following
nursing interventions has the greatest potential for using
collaboration to help ensure the children's safety?
Helping the mother create a
list of emergency telephone
numbers to be posted next to
the home's telephone
29. When preparing a safety workshop for early teens (13 to
15 years old), the nurse recognizes that which of the
following active strategy topics has the greatest potential for
decreasing injuries in this population by affecting lifestylechanges?
Wearing a seat belt when
riding in an automobile
30. The nurse is discussing measures to minimize the risk of
injury from an automobile accident with an 83-year-old
adult client who lives alone and claims to drive only to
Plan driving for short trips and
only during the daylight hours.
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church, the doctor's office, and for groceries. Which of the
following suggestions has the greatest potential for affecting
this client's safety?
31. Which of the following assessment findings is mostcritical in a client who is currently being restrained with
mechanical wrist restraints?
Hands are cool to the touch
32. The nurse is discussing a newly ordered diuretic with an
older adult client who is home-bound. Which of the
following suggestions has the greatest potential for
minimizing the client's risk for injury related to urinary
urgency or incontinence?
Encourage the client to take
the medication early in the
morning.
33. A nurse caring for an elderly client who has had surgery
and is in the hospital knows that the client is at high risk for
developing a nosocomial infection. One of the most
important things that the nurse can do to prevent this client
from obtaining a nosocomial infection is to:
Request prophylactic
antibiotics for the client
34. The nurse caring for an elderly client in the hospital
notes on assessment that the client has a scald burn on her
foot. On questioning the client, the nurse learns that the
client scalded her foot when adding hot water from the tap to
her bath while she was in the tub. The nurse should do
which of the following?
Suggest that the temperature
of the hot water heater be
lowered.
35. A nurse in the emergency department (ED) of a
community hospital notes that an unusually high number of
clients have presented in the ED with flulike symptoms,
abdominal pain, nausea, vomiting, bloody diarrhea,
hematemesis and itching of the hands, forearms, and head.
The nurse is concerned with bioterrorism, reports this to the
supervisor, and suspects an outbreak of:
Anthrax
36. When discussing the new mother's pending discharge
from the hospital, the nurse determines that additional client
teaching needs to take place because of which of the
I can't wait to put my baby in
her new crib with the
ensemble that my mom made-
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following comments? sheets, blankets, and bumper
to match.
37. A confused client on a ventilator was restrained to
prevent him from pulling out his endotracheal tube. Whichof the following could be a possible alternative measure that
the nurse could use to avoid the use of the restraints?
Provide a trained sitter to
continuously supervise theclient.
38. A confused client needs to have restraints to prevent him
from pulling out his Foley catheter. Which of the following
can the nurse delegate to the nursing assistive personnel?
Applying restraints
39. A nurse finds that an electrical cord has shorted out in a
client's room, causing a fire. The nurse should do which ofthe following actions first?
Remove the client from the
room.
40. Which of the following statements indicates that the
client is at risk for an electrical shock at home?
My bread got stuck in my
toaster this morning, and I
unplugged it before trying to
remove it."
41. The nurse is caring for a client with a history of epileptic
seizures. The nursing assistive personnel notifies the nurse
that the client is having a seizure. The first thing that the
nurse should do when arriving in the room is to:
Position the client safely
42. A client with a history of epilepsy arrives in the
emergency department experiencing status epilepticus. The
nurse should never do which of the following?
Open client's mouth by
placing fingers on jaw and
inserting thumb on bottom
teeth to place oral airway
between seizures.
CH 45
Terms Definitions
Which one of the following nursing interventions for a
client in pain is based on the gate-control theory?
1. Giving the client a back
massage
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A priority nursing intervention when caring for a client
who is receiving an epidural infusion for pain relief is to:
3. Monitor vital signs every 15
minutes
The nurse should describe pain that is causing the client a
"burning sensation in the epigastric region" as:
3. Deep or visceral
Which of the following is most appropriate when the
nurse assesses the intensity of the client's pain?
3. Offer the client a pain scale to
objectify the information
The nurse on a postoperative care unit is assessing the
quality of the client's pain. In order to obtain this specific
information about the pain experience from the client, the
nurse should ask:
1. "What does your discomfort
feel like?"
When a client's husband questions how a patient-
controlled analgesia (PCA) pump works, the nurse
explains that the client:
1. Has control over the frequency
of the intravenous (IV) analgesia
An older client with mild musculoskeletal pain is being
seen by the primary care provider. The nurse anticipates
that treatment of this client's level of discomfort will
include:
3. Acetaminophen
Before inserting a Foley catheter, the nurse explains that
the client may feel some discomfort. This is an example
of:
3. Anticipatory response
The nurse knows that a PCA pump would be most
appropriate for the client who:
2. Is recovering after a total hip
replacement
A client with chronic back pain has an order for atranscutaneous electrical nerve stimulation (TENS) unit
for pain control. The nurse should instruct the client to:
2. Use the unit when pain isperceived
The nurse caring for a terminally ill client with liver
cancer understands which of the following goals would be
most appropriate?
3. Adapt the analgesics as the
nursing assessment reveals the
need for specific medications.
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A client is having severe, continuous discomfort from
kidney stones. Based on the client's experience, the nurse
anticipates which of the following findings in the client's
assessment?
4. Nausea and vomiting
Nurses working with clients in pain need to recognize and
avoid common misconceptions and myths about pain. In
regard to the pain experience, which of the following is
correct?
1. The client is the best authority
on the pain experience
A nonpharmacological approach that the nurse may
implement for clients experiencing pain that focuses on
promoting pleasurable and meaningful stimuli is:
2. Distraction
Which of the following is the most appropriate nursing
intervention for a client who is receiving epidural
analgesia?
3. Secure the catheter to the
outside skin
The client is experiencing breakthrough pain while
receiving opioids. An order is written for the client to
receive a transmucosal fentanyl "unit." In teaching about
this medication, the nurse should instruct the client to:
2. Do not chew the unit after
administration
When caring for a client who is experiencing continuous
severe pain, the nurse should expect that the pain
management plan would include:
3. Administering opioids with
nonopioid analgesics for severe
pain experiences
Which of the following symptoms would the nurse expect
with a client who is experiencing acute pain?
3. Diaphoresis
Which of the following statements made by a nurse
shows the greatest understanding of the personal nature ofthe pain experience?
4. " I can only accept what the
client reports concerning the painbeing felt and attempt to
intervene successfully in its
management."
Which of the following statements made by a nurse 2. "My postsurgical clients get
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requires follow-up with additional instruction regarding
the personal nature of pain?
the prescribed pain medications
on schedule with no diversion
from the schedule."
Which of the following statements made by a clientreporting severe pain expresses the most insight into how
pain impacts a client's energy reserves?
3. "I'm exhausted physically andemotionally trying to live with
this pain."
Which of the following statements made by a nurse
caring for a client reporting severe pain expresses the
most insight into how pain impacts a client's energy
reserves?
4. " Trying to cope with pain is
using up the energy so he can get
some rest."
Which of the following statements made by the nurseregarding the client's self-assessment of pain requires
immediate follow-up regarding the personal nature of
pain?
4. "She says she's in pain, but shedoesn't act like she is in pain."
The nurse recognizes that the most likely reason a runner
who has injured his ankle during a race is not aware of it
until after he crosses the finish line is that:
2. His endorphin levels were
high as a result of the physical
stressors of the race
Which of the following statements by the nurse reflects a
need for immediate follow-up regarding the physical
effects of chronic pain on body function?
1. "His pulse and blood pressure
are within his normal baseline
limits, so i'm sure the pain
medication is working"
A client with a history of chronic back pain is questioning
the need to "keep asking for pain medication," fearing
that he will be viewed as being weak by his family. The
most therapeutic nursing response to this client would be:
3."Taking the medication as
prescribed will help you to be
more active; your family will be
happy you can do things with
them again."
A client who is scheduled for the second in a series of
painful dressing changes asks for "my pain medication
now so it's working when the dressing is changed" is most
likely expressing:
3. An understanding that it is
easier to prevent the pain than to
stop the pain
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The nurse inquires of a postoperative client as to the need
for pain medication. The client denies the need then but
30 minutes later reports, "I am really in a lot of pain. Can
you bring me my pain pill now?" The nurse recognizes
that the most immediate need for client education is
related to explaining that:
4. His pain will be more
effectively managed if he reports
a need for pain medication while
the pain is still tolerable
The nurse is caring for a cognitively impaired client who
has experienced a painful procedure. The nurse is most
effective in determining the client's pain medication needs
when using which of the following assessment methods?
4. observing the client's body
movements and facial
expressions for typical pain
behavior
The nurse is attempting to ambulate a postoperative client
who continues to rate his pain as a 7 on a scale of 0 to 10,with 10 being the most severe. The client is reluctant to
walk and consents to move only to the chair, reporting
that "it hurts too much to walk." The nurse's primary
concern regarding the client's recovery related to his pain
experience is that:
4. He is not ready to participate
in the activities needed to recoverquickly
The nurse is attempting to ambulate an older adult client
who recently experienced a fall at the assisted living
facility where he resides. The client is reluctant to walk
and consents to move only to the chair, reporting that "it
hurts too much to walk." Which of the following nursing
interventions is most therapeutic regarding this client?
4. Assess the client for other
factors that may be affecting his
ability and motivation to
ambulate
A client with chronic pain states, "I just want to be pain-
free. Do something to make that happen." The most
therapeutic response is:
1. "Together we will all work at
making your pain tolerable."
The greatest barrier to a 3-year-old client's ability to self-
assess her pain is:
1.A limited vocabulary
The nurse is discussing the effects of pain with an older
adult client diagnosed with osteoarthritis. The most
therapeutic response to the client's comment of, "I wonder
whether it would hurt if I took a nap in the afternoon?"
4. " I think a nap is a good idea
because we seem to feel pain
more when we are tired."
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would be:
Which of the following statements is the most appropriate
response to a client's statement, "I thought you could tell I
was in pain"?
4. " I will make a point of asking
you to rate your pain at least
every 2 hours, so thismiscommunication won't happen
again."
A 44-year-old client shares with the admitting nurse that
the client is having epigastric pain that the client
identifies as a 7 on a 0 to 10 scale. In order to plan for the
pain management of this client, which is the most
appropriate response from the nurse?
1."What would be a satisfactory
level of pain control for us to
achieve?"
The home care nurse notes that a 67-year-old female
diabetic client's blood glucose level has been elevated
since she strained her back the previous week. The client
states that she cannot understand why her blood glucose
level is elevated. The nurse suspects the most likely cause
for the elevated blood sugar is:
2.Parasympathetic stimulation
from the body's normal response
to pain
A client with chronic pain presents in the emergency
department of the local hospital stating "I just can't take
this anymore." On questioning the client, the nurse
discovers that the client have experienced chronic pain
since being involved in an accident 2 years previously.
The client states that he has been labeled a "drug seeker"
because he is looking for relief for the pain and feels
hopeless, angry, and powerless to do anything about the
situation. The nurse understands that this client is at risk
for:
3.Suicide
A client who had knee replacement surgery the previous
day refuses to take any pain medication, even though he
rates his pain as an 8 on a 0 to 10 scale. Upon questioning
the client the nurse learns that the reason for refusing pain
medication is because he is concerned about injuring the
knee and not feeling it. The best information that the
1.The pain medication will help
speed his recovery time
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nurse can provide this client is to explain that:
A 38-year-old client presents to the pain clinic with
complaints of phantom pain. The client was involved in a
farming accident 3 years previously that resulted in abelow-the-elbow amputation of his right arm. The nurse
knows that phantom pain is categorized as:
4.Deafferentation pain
The daughter of an 88-year-old female client tells the
nurse that her mother has recently quit going on walks in
the neighborhood because of pain in her legs. Which of
the following is the best response from the nurse?
1. " I would like to speak with
your mother to get information."
The nursery nurse is explaining postcircumcision care to anew mother. Which of the following statements by the
new mother indicates that additional teaching needs to
occur?
1. "Babies don't experience pain,so i don't need to worry about
hurting him when i touch the
penis."
Taking into consideration the hospice client's chronic
pain from bone cancer, the most appropriate person to
collaborate with regarding management of pain is:
4. An oncology nurse
in creating the plan of care for a newly diagnosed breast
cancer client, the nurse is concerned about pain control.
The client has expressed an interest in relaxation therapy
as a complementary pain therapy. The nurse knows that
the best time to teach the client is:
4. When the client is comfortable
A client who ruptured his spleen in a motor vehicle
accident rates his postoperative pain as a level 8 on a 0 to
10 pain scale. After administering pain medication, the
nurse discusses the use of complementary therapies with
the client to explore ways to reduce the pain. The clientwould like to try a massage. The nurse delegates this task
to the assistive personnel (AP). Which of the following
instructions is most important for the nurse to share with
the AP?
3. "do not massage the client's
legs."
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CH 48
When repositioning an immobile client, the nurse notices
redness over a bony prominence. When the area is assessed,the red spot blanches with fingertip touch, indication?
Reactive hyperemia, a
reaction that causes the bloodvessels to dilate in the injured
area
This type of pressure ulcer has an observable pressure
related alteration of intact skin whose indicators, compared
with an adjacent or opposite area on the body, may include
changes in one or more of the following: skin temperature
(warmth or coolness), tissue consistency (firm or beefy feel),
and/or sensation (pain, itching).
Stage 1
When obtaining a wound culture to determine the presence
of a wound infection, the specimen should be taken from
the:
Wound after it has first been
cleansed with normal saline
Postoperatively the client with a closed abdominal wound
reports a sudden "pop" after coughing. When the nurse
examines the surgical wound site, the sutures are open and
pieces of small bowel are noted at the bottom of the now
opened wound. The correct intervention would be to:
Cover the areas with sterile
saline-soaked towels and
immediately notify the
surgical team; this is likely to
indicate a wound evisceration
Serous drainage from a wound is defined as: Clear, watery plasma
For a client who has a muscle sprain, localized hemorhage,
or hematoma, what wound care product helps prevent edema
formation, control bleeding, and anesthetize the body part?
Ice bag
Interventions to manage a client who is experiencing fecal
and urinary incontinence include:
Utilization of an incontinence
cleanser, followed by
application of a moisture
barrier ointment
The best description of a hydrocolloid dressing is: Addressing that forms a gel
that interacts with the wound
surface
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A binder placed around a surgical client with a new
abdominal wound is indicated for:
Reduction of stress on the
abdominal incision
Application of a warm compress is indicated: To improve blood flow to an
injured part
Ch 43
Terms Definitions
1. When evaluating a patient's pain, the nurse
knows that an example of acute pain would be:
kidney stones.
2. Which statement indicates that the nurseunderstands the pain experience in the elderly?
"Pain indicatespathology or injury and
is not a normal process
of aging."
3. A 4-year-old boy is brought to the
emergency department by his mother. She says
he points to his stomach and says, "It hurts so
bad." Which pain assessment tool would be the
best choice when assessing this child's pain?
The Wong-Baker Scale
4. A patient states that the pain medication is
"not working" and rates his postoperative pain
at a 10 on a 1 to 10 scale. Which of the
following assessment findings indicates an
acute pain response to poorly controlled pain?
Increased blood pressure
and pulse
5. A 60-year-old woman has developed
reflexive sympathetic dystrophy after
arthroscopic repair of her shoulder. A keyfeature of this condition is that:
the slightest touch, such
as a sleeve brushing
against her arm, causessevere, intense pain.
6. The nurse is assessing a patient's pain. The
nurse knows that which of the following is
The subjective report
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considered the most reliable indicator of pain?
7. A patient has had arthritic pain in her hips
for several years since a hip fracture. She is
able to move around in her room and has notoffered any complaints so far this morning.
However, when asked, she states that her pain
is "bad this morning" and rates it at an 8 on a 1
to 10 scale. What does the nurse suspect?
She has experienced
chronic pain for years
and has adapted to it.
8. Which type of pain is due to an abnormal
processing of the pain impulse through the
peripheral or central nervous system?
Neuropathic pain
9. When assessing the quality of a patient's
pain, the nurse should ask which question?
"What does your pain
feel like?"
10. When assessing a patient's pain, the nurse
knows that an example of visceral pain would
be:
cholecystitis.
11. Nociception is the term used to describe
how noxious stimuli are typically perceived as
pain. During which phase of nociception does
the conscious awareness of a painful sensation
occur?
Perception
2. When assessing the intensity of a patient's
pain, which question by the nurse is
appropriate?
"How much pain do you
have now?"
13. A patient is complaining of severe kneepain after twisting it during a basketball game
and is requesting pain medication. Which
action by the nurse is appropriate?
Administer painmedication and then
proceed with the
assessment.
14. The nurse knows that which statement is A procedure that
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true regarding the pain experienced by infants? induces pain in adults
will also induce pain in
the infant.