Integumentary/Isolation
A nurse assesses patients on a medical-surgical unit. Which patient is at greatest risk for pressure ulcer development?
a. A 44-year-old prescribed IV antibiotics for pneumonia
b. A 26-year-old who is bedridden with a fractured leg
c. A 65-year-old with hemi-paralysis and incontinence
d. A 78-year-old requiring assistance to ambulate with a walker
ANS: C
Being immobile and being incontinent are two significant risk factors for the development of pressure ulcers. The patient with pneumonia does not have specific risk factors. The young patient who has a fractured leg and the patient who needs assistance with ambulation might be at moderate risk if they do not move about much, but having two risk factors makes the 65-year-old the person at highest risk.
PTS: 1 DIF: Cognitive Level: Applying KEY: Skin breakdown | Braden Scale
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse assesses a patient with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the patient reports constant abdominal pain. Which action would the nurse take next?
a. Administer intravenous opioid medications.
b. Position the patient with knees to chest.
c. Insert a nasogastric tube for decompression.
d. Assess the patient’s bowel sounds.
ANS: D
A change in the nature and timing of abdominal pain in a patient with a bowel obstruction can signal peritonitis or perforation. The nurse would immediately check for rebound tenderness and the absence of bowel sounds. The nurse would not medicate the patient until the provider has been notified of the change in his or her condition. The nurse may help the patient to the knee-chest position for comfort, but this is not the priority action. The nurse need not insert a nasogastric tube for decompression.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Intestinal obstruction | pain management
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
After teaching a patient with diverticular disease, a nurse assesses the patient’s understanding. Which menu selection made by the patient indicates the patient correctly understood the teaching?
a. Roasted chicken with rice pilaf and a cup (236 mL) of coffee with cream
b. Spaghetti with meat sauce, a fresh fruit cup (175 g), and hot tea
c. Garden salad with a cup (240 mL) of bean soup and a glass of low-fat milk
d. Baked fish with steamed carrots and a glass of apple juice
ANS: D
Patients who have diverticular disease are prescribed a low-residue diet. Whole grains (rice pilaf), uncooked fruits and vegetables (salad, fresh fruit cup), and high-fiber foods (cup [240 mL] of bean soup) would be avoided with a low-residue diet. Canned or cooked vegetables are appropriate. Apple juice does not contain fiber and is acceptable for a low-residue diet.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Diverticular disease | nutritional requirements
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Basic Care and Comfort
A nurse reviews the laboratory findings of a patient with a urinary tract infection. The laboratory report notes a “shift to the left” in a patient’s white blood cell count. What action would the nurse take?
a. Request that the laboratory perform a differential analysis on the white blood cells.
b. Notify the provider and start an intravenous line for parenteral antibiotics.
c. Collaborate with the unlicensed assistive personnel (UAP) to strain the patient’s urine for renal calculi.
d. Assess the patient for a potential allergic reaction and anaphylactic shock.
ANS: B
An increase in band cells creates a “shift to the left.” A left shift most commonly occurs with urosepsis and is seen rarely with uncomplicated urinary tract infections. The nurse will be administering antibiotics, most likely via IV, so he or she would notify the provider and prepare to give the antibiotics. The shift to the left is part of a differential white blood cell count. The nurse would not need to strain urine for stones. Allergic reactions are associated with elevated eosinophil cells, not band cells.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Cystitis | assessment/diagnostic examination
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse assesses a patient with polycystic kidney disease (PKD). Which assessment finding would alert the nurse to immediately contact the healthcare provider?
a. Flank pain
b. Periorbital edema
c. Bloody and cloudy urine
d. Enlarged abdomen
ANS: B
Periorbital edema would not be a finding related to PKD and would be investigated further. Flank pain and a distended or enlarged abdomen occur in PKD because the kidneys enlarge and displace other organs. Urine can be bloody or cloudy as a result of cyst rupture or infection.
PTS: 1 DIF: Cognitive Level: Applying KEY: Polycystic kidney disease
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
After educating a caregiver of a home care patient, a nurse assesses the caregiver’s understanding. Which statement indicates that the caregiver needs additional education?
a. “I can help him shift his position every hour when he sits in the chair.”
b. “If his tailbone is red and tender in the morning, I will massage it with baby oil.”
c. “Applying lotion to his arms and legs every evening will decrease dryness.”
d. “Drinking a nutritional supplement between meals will help maintain his weight.”
ANS: B
Massage of reddened areas over bony prominences such as the coccyx, or tailbone, is contraindicated because the pressure of the massage can cause damage to the skin and subcutaneous tissue layers. The other statements are appropriate for the care of a patient at home.
PTS: 1 DIF: Cognitive Level: Applying KEY: Skin breakdown
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Health Promotion and Maintenance
After teaching a patient with irritable bowel syndrome (IBS), a nurse assesses the patient’s understanding. Which menu selection indicates that the patient correctly understands the dietary teaching?
a. Ham sandwich on white bread, cup (236 mL) of applesauce, glass of diet cola
b. Broiled chicken with brown rice, steamed broccoli, glass of apple juice
c. Grilled cheese sandwich, small banana, cup (236 mL) of hot tea with lemon
d. Baked tilapia, fresh green beans, cup (236 mL) of coffee with low-fat milk
ANS: B
Patients with IBS are advised to eat a high-fiber diet (30 to 40 g/day), with 8 to 10 cups (2 to 2.5 L) of liquid daily. Chicken with brown rice, broccoli, and apple juice has the highest fiber content. They should avoid alcohol, caffeine, and other gastric irritants.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Irritable bowel | nutritional requirements
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Basic Care and Comfort
After teaching a patient who is prescribed adalimumab (Humira) for severe ulcerative colitis, the nurse assesses the patient’s understanding. Which statement made by the patient indicates a need for additional teaching?
a. “I will avoid large crowds and people who are sick.”
b. “I will take this medication with my breakfast each morning.”
c. “Nausea and vomiting are common side effects of this drug.”
d. “I must wash my hands after I play with my dog.”
ANS: B
Adalimumab (Humira) is an immune modulator that must be given via subcutaneous injection. It does not need to be given with food or milk. Nausea and vomiting are two common side effects. Adalimumab can cause immune suppression, so patients receiving the medication should avoid large crowds and people who are sick, and should practice good handwashing.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Ulcerative colitis | medication safety
MSC: Integrated Process: Nursing Process/Evaluation
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
After teaching a patient who has stress incontinence, the nurse assesses the patient’s understanding. Which statement made by the patient indicates a need for additional teaching?
a. “I will limit my total intake of fluids.”
b. “I must avoid drinking alcoholic beverages.”
c. “I must avoid drinking caffeinated beverages.”
d. “I shall try to lose about 10% of my body weight.”
ANS: A
Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence. Many people try to manage incontinence by limiting fluids. Alcoholic and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.
PTS: 1 DIF: Cognitive Level: Evaluating KEY: Cystitis | hydration
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Physiological Integrity
A nurse evaluates a patient with acute glomerulonephritis (GN). Which manifestation would the nurse recognize as a positive response to the prescribed treatment?
a. The patient has lost 11 lbs (5 kg) in the past 10 days.
b. The patient’s urine specific gravity is 1.048.
c. No blood is observed in the patient’s urine.
d. The patient’s blood pressure is 152/88 mm Hg.
ANS: A
Fluid retention is a major feature of acute GN. This weight loss represents fluid loss, indicating that the glomeruli are performing the function of filtration. A urine specific gravity of 1.048 is high. Blood is not usually seen in GN, so this finding would be expected. A blood pressure of 152/88 mm Hg is too high; this may indicate kidney damage or fluid overload.
PTS: 1 DIF: Cognitive Level: Applying KEY: Glomerulonephritis
MSC: Integrated Process: Nursing Process/Evaluation
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
After teaching a patient who has psoriasis, a nurse assesses the patient’s understanding. Which statement indicates the patient needs additional teaching?
a. “At the next family reunion, I’m going to ask my relatives if they have psoriasis.”
b. “I have to make sure I keep my lesions covered, so I do not spread this to others.”
c. “I expect that these patches will get smaller when I lie out in the sun.”
d. “I would continue to use the cortisone ointment as the patches shrink and dry out.”
ANS: B
Psoriasis is not a contagious disorder. The patient does not have to worry about spreading the condition to others. It is a condition that has hereditary links, the patches will decrease in size with ultraviolet light exposure, and cortisone ointment would be applied directly to lesions to suppress cell division.
PTS: 1 DIF: Cognitive Level: Applying KEY: Skin lesions/wounds
MSC: Integrated Process: Nursing Process/Evaluation
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A patient with peptic ulcer disease is in the emergency department and reports the pain has gotten much worse over the last several days. The patient’s blood pressure when lying down was 122/80 mm Hg and when standing was 98/52 mm Hg. What action by the nurse is most appropriate?
a. Administer ibuprofen (Motrin).
b. Call the Rapid Response Team.
c. Start a large-bore IV with normal saline.
d. Tell the patient to remain lying down.
ANS: C
This patient has orthostatic changes to the blood pressure, indicating fluid volume loss. The nurse would start a large-bore IV with isotonic solution. Ibuprofen will exacerbate the ulcer. The Rapid Response Team is not needed at this point. The patient should be put on safety precautions, which includes staying in bed, but this is not the priority.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Gastrointestinal disorders | fluid imbalances | nursing assessment
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse assesses a patient who is recovering from an ileostomy placement. Which clinical manifestation would alert the nurse to urgently contact the health care provider?
a. Pale and bluish stoma
b. Liquid stool
c. Ostomy pouch intact
d. Blood-smeared output
ANS: A
The nurse would assess the stoma for color and contact the health care provider if the stoma is pale, bluish, or dark. The nurse would expect the patient to have an intact ostomy pouch with dark green liquid stool that may contain some blood.
PTS: 1 DIF: Cognitive Level: Applying KEY: Ostomy care | postoperative nursing
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Safe and Effective Care Environment: Management of Care
A nurse cares for adult patients who experience urge incontinence. For which patient would the nurse plan a habit training program?
a. A 78-year-old female who is confused
b. A 65-year-old male with diabetes mellitus
c. A 52-year-old female with kidney failure
d. A 47-year-old male with arthritis
ANS: A
For a bladder training program to succeed in a patient with urge incontinence, the patient must be alert, aware, and able to resist the urge to urinate. Habit training will work best for a confused patient. This includes going to the bathroom (or being assisted to the bathroom) at set times. The other patients may benefit from another type of bladder training.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Urinary incontinence | health screening
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse assesses a patient who is hospitalized with an exacerbation of Crohn’s disease. Which clinical manifestation would the nurse expect to find?
a. Positive Murphy’s sign with rebound tenderness to palpitation
b. Dull, hypoactive bowel sounds in the lower abdominal quadrants
c. High-pitched, rushing bowel sounds in the right lower quadrant
d. Reports of abdominal cramping that is worse at night
ANS: C
The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn’s disease. A positive Murphy’s sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds is not commonly found with Crohn’s disease. Nightly worsening of abdominal cramping is not consistent with Crohn’s disease.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Crohn’s disease | assessment/diagnostic examination
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
Which statements are true regarding Standard Precautions? (Select all that apply.)
a. Always wear a gown when performing hygiene on patients.
b. Sneeze into your sleeve or into a tissue that you throw away.
c. Remain 3 feet (1 m) away from any patient who has an infection.
d. Use personal protective equipment as needed for patient care.
e. Wear gloves when touching patient excretions or secretions.
ANS: D, E
Standard Precautions implies that contact with bodily secretions, excretions, and moist mucous membranes and tissues (excluding perspiration) is potentially infectious. Always wear gloves when coming into contact with such material. Other personal protective equipment is used based on the care being given. For example, if face splashing is expected, you will also wear a mask. Wearing a gown for hygiene is not required. Sneezing into your sleeve or tissue is part of respiratory etiquette. Remaining 3 feet (1 m) away from patients is also not part of Standard Precautions.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Infection | infection control | Standard Precautions
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Safe and Effective Care Environment: Safety and Infection Control
A nurse assesses a patient who has appendicitis. Which clinical manifestation would the nurse expect to find?
a. Severe, steady right lower quadrant pain
b. Abdominal pain associated with nausea and vomiting
c. Marked peristalsis and hyperactive bowel sounds
d. Abdominal pain that increases with knee flexion
ANS: A
Right lower quadrant pain, specifically at McBurney’s point, is characteristic of appendicitis. Usually if nausea and vomiting begin first, the patient has gastroenteritis. Marked peristalsis and hyperactive bowel sounds are not indicative of appendicitis. Abdominal pain due to appendicitis decreases with knee flexion.
PTS: 1 DIF: Cognitive Level: Remembering
KEY: Inflammatory bowel disorder | assessment/diagnostic examination
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse cares for a patient with a new ileostomy. The patient states, “I don’t think my friends will accept me with this ostomy.” How would the nurse respond?
a. “Your friends will be happy that you are alive.”
b. “Tell me more about your concerns.”
c. “A therapist can help you resolve your concerns.”
d. “With time you will accept your new body.”
ANS: B
Social anxiety and apprehension are common in patients with a new ileostomy. The nurse would encourage the patient to discuss concerns. The nurse would not minimize the patient’s concerns or provide false reassurance.
PTS: 1 DIF: Cognitive Level: Applying KEY: Ostomy care | coping | support
MSC: Integrated Process: Caring NOT: Patient Needs Category: Psychosocial Integrity
After teaching a patient with a history of renal calculi, the nurse assesses the patient’s understanding. Which statement made by the patient indicates a correct understanding of the teaching?
a. “I should drink at least 3 L of fluid every day.”
b. “I will eliminate all dairy or sources of calcium from my diet.”
c. “Aspirin and aspirin-containing products can lead to stones.”
d. “The doctor can give me antibiotics at the first sign of a stone.”
ANS: A
Dehydration contributes to the precipitation of minerals to form a stone. Although increased intake of calcium causes hypercalcemia and leads to excessive calcium filtered into the urine, if the patient is well hydrated, the calcium will be excreted without issues. Dehydration increases the risk for supersaturation of calcium in the urine, which contributes to stone formation. The nurse would encourage the patient to drink more fluids, not decrease calcium intake. Ingestion of aspirin or aspirin-containing products does not cause a stone. Antibiotics neither prevent nor treat a stone.
PTS: 1 DIF: Cognitive Level: Applying KEY: Urolithiasis | hydration
MSC: Integrated Process: Nursing Process/Evaluation
NOT: Patient Needs Category: Health Promotion and Maintenance
A nurse assesses a patient who presents with an increase in psoriatic lesions. Which questions would the nurse ask to identify a possible trigger for worsening of this patient’s psoriatic lesions? (Select all that apply.)
a. “Have you eaten a large amount of chocolate lately?”
b. “Have you been under a lot of stress lately?”
c. “Have you recently used a public shower?”
d. “Have you been out of the country recently?”
e. “Have you recently had any other health problems?”
f. “Have you changed any medications recently?”
ANS: B, E, F
Systemic factors, hormonal changes, psychological stress, medications, and general health factors can aggravate psoriasis. Psoriatic lesions are not triggered by chocolate, public showers, or international travel.
PTS: 1 DIF: Cognitive Level: Applying KEY: Skin lesions/wounds
MSC: Integrated Process: Nursing Process/Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse plans care for a patient who is immobile. Which interventions would the nurse include in this patient’s plan of care to prevent pressure sores? (Select all that apply.)
a. Place a small pillow between bony surfaces.
b. Elevate the head of the bed to 45 degrees.
c. Limit fluids and proteins in the diet.
d. Use a lift sheet to assist with re-positioning.
e. Re-position the patient who is in a chair every 2 hours.
f. Keep the patient’s heels off the bed surfaces.
g. Use a rubber ring to decrease sacral pressure when up in the chair.
ANS: A, D, F
A small pillow decreases the risk for pressure between bony prominences, a lift sheet decreases friction and shear, and heels have poor circulation and are at high risk for pressure sores, so they would be kept off hard surfaces. Head-of-the-bed elevation greater than 30 degrees increases pressure on pelvic soft tissues. Fluids and proteins are important for maintaining tissue integrity. Patients would be repositioned every hour while sitting in a chair. A rubber ring impairs capillary blood flow, increasing the risk for a pressure sore.
PTS: 1 DIF: Cognitive Level: Applying KEY: Skin breakdown
MSC: Integrated Process: Nursing Process/Implementation
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
A nurse assesses a patient who is hospitalized with an exacerbation of Crohn’s disease. Which clinical manifestation would the nurse expect to find?
a. Positive Murphy’s sign with rebound tenderness to palpitation
b. Dull, hypoactive bowel sounds in the lower abdominal quadrants
c. High-pitched, rushing bowel sounds in the right lower quadrant
d. Reports of abdominal cramping that is worse at night
ANS: C
The nurse expects high-pitched, rushing bowel sounds due to narrowing of the bowel lumen in Crohn’s disease. A positive Murphy’s sign is indicative of gallbladder disease, and rebound tenderness often indicates peritonitis. Dullness in the lower abdominal quadrants and hypoactive bowel sounds is not commonly found with Crohn’s disease. Nightly worsening of abdominal cramping is not consistent with Crohn’s disease.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Crohn’s disease | assessment/diagnostic examination
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse cares for a patient who has been diagnosed with a small bowel obstruction. Which assessment findings would the nurse correlate with this diagnosis? (Select all that apply.)
a. Serum potassium of 2.8 mEq/L (2.8 mmol/L)
b. Loss of 15 lbs (6.8 kg) without dieting
c. Abdominal pain in upper quadrants
d. Low-pitched bowel sounds
e. Serum sodium of 121 mEq/L (121 mmol/L)
ANS: A, C, E
Small bowel obstructions often lead to severe fluid and electrolyte imbalances. The patient is hypokalemic (normal range is 3.5 to 5.0 mEq/L [3.5 to 5.0 mmol/L]) and hyponatremic (normal range is 136 to 145 mEq/L [136 to 145 mmol/L]). Abdominal pain across the upper quadrants is associated with small bowel obstruction. Dramatic weight loss without dieting followed by bowel obstruction leads to the probable development of colon cancer. High-pitched sounds may be noted with small bowel obstructions.
PTS: 1 DIF: Cognitive Level: Applying
KEY: Intestinal obstruction | assessment/diagnostic examination
MSC: Integrated Process: Nursing Process/Analysis
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
A nurse teaches a young female patient who is prescribed amoxicillin (Amoxil) for a urinary tract infection. Which statement would the nurse include in this patient’s teaching?
a. “Use a second form of birth control while on this medication.”
b. “You will experience increased menstrual bleeding while on this drug.”
c. “You may experience an irregular heartbeat while on this drug.”
d. “Watch for blood in your urine while taking this medication.”
ANS: A
The patient should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the medication.
PTS: 1 DIF: Cognitive Level: Understanding KEY: Cystitis | medication safety
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
After treating several young women for UTIs, the college nurse plans an educational offering on reducing the risk of getting a UTI. What information does the nurse include? (Select all that apply.)
a. Void before and after each act of intercourse
b. Consider changing to spermicide from birth control pills
c. Do not douche or use scented feminine products
d. Wear loose-fitting nylon panties
e. Wipe or clean the perineum from front to back
ANS: A, C, E
Woman can reduce their risk of contracting UTIs by voiding before and after intercourse, not douching or using scented feminine products, and wiping from front to back. If spermicides are currently used, the woman should consider another form of birth control. Loose-fitting cotton panties are best.
PTS: 1 DIF: Cognitive Level: Understanding
KEY: Urinary incontinence | patient education
MSC: Integrated Process: Teaching and Learning
NOT: Patient Needs Category: Health Promotion and Maintenance