70 pages of fun!

8/3/2019 70 Pages of Fun!

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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.


13/29

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


16/29

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


17/29

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.


18/29

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-


19/29

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


20/29

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


27/29

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.

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