INSTANT DOWNLOAD COMPLETE TEST BANK WITH ANSWERS Nursing Interventions & Clinical Skills 6th Edition by Anne Griffin Perry – Potter – Ostendorf – Test Bank Sample Questions Chapter 05: Infection ControlPerry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE
- The patient is in isolation in a negative-pressure room for active tuberculosis. He coughs and spews large amounts of blood-tinged sputum but is too weak to cover his mouth and nose with a tissue. Which is the most important intervention for the nurse to implement for self-protection while providing nursing care?
|a.||Cover the patient’s mouth and nose snugly with a surgical mask.|
|b.||Wear an N-95 mask, gloves, face shield, and isolation gown.|
|c.||Place tissues and a contaminated waste container within reach.|
|d.||Use a properly fitted surgical mask and gloves to help with tissues.|
ANS: BWearing suitable protective barriers is the most important intervention to implement because it protects the nurse from the airborne particles and the pathogens that can land on surfaces from droplets of the patient’s coughing. The nurse wears a mask suitable for airborne precautions to prevent inhalation of suspended Mycobacterium tuberculosis in the air and gloves, gown, and goggles to protect clothing and mucous membranes from contact with body fluids because of the patient’s poor hygiene due to his weakened state. Respirator masks are used in airborne precautions because these masks filter what the wearer inhales. The patient should wear a mask if he or she must leave the room because a surgical mask controls what the wearer exhales; a mask for the patient is not indicated in the isolation room. The nurse can inhale airborne particles through the pores of a surgical mask, regardless of how well it fits, because a surgical mask controls what is exhaled. DIF: Cognitive Level: Analyze REF: Page 84OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation
- The nurse is caring for several patients under contact precautions. Which option is possible for the nurse to use if two of her patients have “like” infections?
|d.||Hand sanitizer only|
ANS: CWhen a hospitalized patient has an infection, a nurse decides on the optimal room placement to minimize the chances of infection spreading to other patients. Two patients with “like” infections can be placed in the same room; this is called cohorting.Double gloving is used during procedures to make it easier to remove one pair. Hand sanitizer is not effective against Clostridium difficile (“C. diff”) or when hands are visibly soiled. DIF: Cognitive Level: Apply REF: Page 76| Page 83OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation
- The nurse bathes a patient who has an infection transmitted by the oral-fecal route such as C. diff and notes a small tear in one glove. Which group of interventions does the nurse use for self-protection?
|a.||Finish the bath, apply fresh gloves, and use hand sanitizer.|
|b.||Continue the bath and change gloves when finished.|
|c.||Apply a new glove over the torn one to finish the bath.|
|d.||Remove the gloves, wash hands, and apply new gloves.|
ANS: DFor self-protection the nurse interrupts the bath to avoid additional exposure to a potential pathogen by removing the gloves, washing both hands with soap and water, and applying fresh gloves for protection against exposure so the nurse can finish the bath. The nurse risks infection by continuing the bath with a portal of entry on the glove. The nurse should perform hand hygiene before applying fresh gloves. Hand sanitizer is not effective with C. diff. Applying clean gloves over the torn gloves encases the potential pathogens and increases the risk of exposure to the pathogen. DIF: Cognitive Level: Apply REF: Page 76OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation
- A patient is in isolation in a negative-pressure room for tuberculosis, and the nurse notes that the respirator mask is damaged slightly. What is the initial action that the nurse should take?
|a.||Ask to switch the assignment.|
|b.||Check the mask for a tight seal.|
|c.||Borrow a mask from a co-worker.|
|d.||Use the mask if damage is minor.|
ANS: BBefore using the mask to enter the patient’s room, the nurse checks the fit to ensure a tight seal because the purpose of this mask in airborne precautions is to filter inhaled air and thereby protect the nurse against pathogens suspended in the air. The nurse can use the mask if the damage is minor and does not affect the seal. Co-workers do not share respirator masks because each employee is fitted individually. If the mask seal is affected, a new mask will be required. Switching assignments is not an appropriate request. DIF: Cognitive Level: Understand REF: Page 84OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning
- The nurse completes care for the patient on droplet precautions. Which procedure does the nurse implement to prevent transmitting the pathogen to other people?
|a.||Removes gloves and mask at the bedside and gown in hallway|
|b.||Removes all personal protective equipment (PPE) in the soiled utility room|
|c.||Removes gloves first, gown second, and mask third in the patient’s doorway|
|d.||Removes mask first, gloves second, and gown third outside the patient’s room|
ANS: CThe nurse removes PPE to prevent self-contamination. He or she removes the gloves first to avoid contaminating the head, then removes the gown by unfastening neck ties and pulling it away and rolling into a bundle, then removing mask. These actions occur in the patient’s doorway to contain the pathogen and prevent transmission to people outside the room. The nurse risks contamination if the gloves and mask are removed at the bedside; if the mask is removed before the contaminated gloves, the nurse risks contaminating the head while untying the strings of the mask. PPE should be removed together, at the same location, and away from the source of contamination to facilitate containment of the pathogen. Removing PPE in the hallway or utility room would risk transmitting the pathogen to others. DIF: Cognitive Level: Apply REF: Page 87OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation
- A patient on isolation precautions tries to leave the isolation room because of loneliness despite repeated instructions to remain in the room. Which action should the nurse implement as a patient advocate?
|a.||Allow visitors to remove masks while in the patient’s room.|
|b.||Talk with the patient about ways to reduce the sense of loneliness.|
|c.||Remind the patient that the isolation is for the patient’s benefit.|
|d.||Leave the door open slightly so the patient can see into hallway.|
ANS: BThe nurse sets specific times to remain in the patient’s room as a patient advocate to help him or her develop coping strategies for handling the loneliness of isolation and provide periodic company. Visitors should not enter the room without a properly fitted respirator mask for their protection. The nurse can remind the patient about the purpose of isolation to help him or her understand the plan of care. The door cannot remain ajar because the risk of transmitting the infection is increased with the door open. DIF: Cognitive Level: Apply REF: Page 75OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning
- Gloves are effective protective barriers from pathogens when caring for patients in isolation. Which patient factor associated with the gloves should the nurse investigate for patients in isolation?
|a.||Patient resistance to therapy|
|b.||Transmission mode of organism|
|c.||Patient potential for latex allergy|
|d.||Virulence of infectious organism|
ANS: CThe patient potential for latex allergy is the most important patient factor related to using gloves with patients in isolation. Allergic reactions to latex may be triggered even if latex does not touch the patient. Wear unpowdered latex-free gloves. Several alternatives to latex gloves exist. If the patient is allergic to latex, the nurse can use nonlatex gloves to prevent hypersensitivity reactions. Neither virulence nor transmission mode of a pathogen is a patient factor. DIF: Cognitive Level: Understand REF: Page 84OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Assessment
- The nurse is getting ready to provide a sterile dressing change. Which nursing action is consistent with principles used to prepare a sterile field?
|a.||Identify that items below waist height are contaminated.|
|b.||Use opened packages of dressing supplies within the same shift.|
|c.||Identify that sterile drapes have a 5.08 cm (2-inch) contaminated border.|
|d.||Replace bottle caps if the inside of the cap is not touched.|
ANS: AItems below waist level are considered contaminated and are discarded quickly to avoid contaminating the rest of the sterile field. Packages of sterile supplies must be sealed to be considered sterile. Sterile drapes have a 2.54 cm (1-inch) perimeter that is considered contaminated. Replace bottle caps if the inside of the cap and the edge of the bottle remain sterile. DIF: Cognitive Level: Understand REF: Page 90OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Assessment
- The nurse teaches the patient the proper handwashing technique before discharge and asks for a return demonstration. Which hand hygiene technique indicates that patient teaching by the nurse is effective?
|a.||The patient washes hands with running water.|
|b.||Soap, water, and friction are used by the patient.|
|c.||The patient washes hands with very hot water.|
|d.||A basin with warm soapy water is used.|
ANS: BThe patient understands that proper handwashing requires soap, water, and friction to remove microorganisms from the skin and rinse them away. Running water is insufficient to wash hands properly because water alone cannot remove as many microorganisms as soap and water can remove. The patient risks tissue damage, dry skin, and irritation from hot water. Washing hands in a basin may remove surface debris, but the hands are not decontaminated because the debris remains in the rinse water. DIF: Cognitive Level: Apply REF: Page 78OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Evaluation
- The nurse cared for a patient diagnosed with tuberculosis (TB) 3 days ago. Which of the following actions should the nurse implement in response to the potential exposure?
|a.||Take a leave of absence.|
|b.||Have a chest x-ray taken.|
|c.||Request a sputum culture.|
|d.||Get a QFT-G blood test.|
ANS: DThe CDC now recommends the QuantiFERON-TB Gold (QFT-G) blood test to determine the presence of TB antibodies followed by a sputum test or a chest x-ray to confirm the presence of Mycobacterium tuberculosis. A leave of absence is not necessary unless the nurse displays clinical indicators of TB such as fever, night sweats, weight loss, and coughing. DIF: Cognitive Level: Apply REF: Page 84OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning
- The nurse is caring for a patient who is 4 years old and in isolation. Which approach should the nurse implement to reduce the patient’s anxiety?
|a.||Put the child in a room with a locked door.|
|b.||Ask the parents to keep the child in the room.|
|c.||Explain isolation to the child by using a cartoon.|
|d.||Put the mask, gown, and gloves on in view of the child.|
ANS: DThe nurse should let the child see her face before putting on the mask so the child knows who is behind the mask and is not frightened. The nurse could even bring a mask for the child to play with in the nurse’s presence to reduce anxiety. The nurse should explain isolation to the child and use educational material suitable to the patient’s developmental level. However, the child is unlikely to grasp the meaning and implications of isolation, necessitating repeated explanations and guidance. Although the nurse may ask for the parents’ help in keeping the child in the room, the nurse retains the responsibility for maintaining transmission precautions and the child’s safety. Locking the door is a restraint and puts the child at risk in an emergency. DIF: Cognitive Level: Apply REF: Page 88OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning
- In which of the following situations should the nurse use surgical asepsis?
|a.||Performing urinary catheter care|
|b.||Inserting a nasogastric tube|
|c.||Inserting a Foley catheter|
|d.||Performing nasogastric tube care|
ANS: CNurses use surgical aseptic techniques at the patient’s bedside during procedures that involve inserting devices into normally sterile body cavities such as insertion of a Foley catheter. A nasogastric tube is not going into a sterile cavity. Clean technique is used for the other situations. DIF: Cognitive Level: Apply REF: Page 74OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning
- The nurse is caring for a 4-year-old child who has rubella. Which transmission precautions should the nurse implement to prevent rubella exposure?
ANS: BThe nurse implements droplet precautions for the patient with rubella because large droplets expelled by the patient during coughing, talking, or sneezing transmit the virus. Contact and airborne precautions are not indicated because rubella is not transmitted by direct contact or suspended particles in the air. Standard precautions are suitable for all patients but do not prevent rubella transmission without additional droplet precautions. DIF: Cognitive Level: Apply REF: Page 83OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning
- The nurse evaluates the handwashing technique of nursing assistive personnel (NAP). Which behavior by NAP requires additional training by the nurse?
|a.||Rubs sudsy hands for 5 to 10 seconds|
|b.||Uses warm running water and soap|
|c.||Dries the hands from the fingers to the wrists|
|d.||Keeps the hands and forearms below the elbows|
ANS: AThe nurse improves the NAP’s handwashing technique by providing feedback to increase the length of hand scrubbing to 15 to 30 seconds for thorough removal of microorganisms. The nurse finishes the feedback by directing the NAP to rinse the hands under running water without recontaminating them. Using warm, running water and soap effectively loosens microorganisms from the skin and rinses them off the hands. Drying hands from fingers to wrists is good technique because the hands are dried from the cleanest to the least clean area. Keeping the hands in a dependent position is good handwashing technique because it prevents hand contamination from water that touched the unwashed section of the arm. DIF: Cognitive Level: Apply REF: Page 78OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Evaluation
- The nurse assists the healthcare provider during the insertion of a central venous catheter. Which is the most effective intervention for the nurse to implement to prevent patient infection?
|a.||Adhere to the principles of surgical asepsis.|
|b.||Close the door of the sterile procedure room.|
|c.||Sterilize working surfaces for the procedure.|
|d.||Restrict foot traffic into the sterile procedure room.|
ANS: AAdhering to principles of surgical asepsis is the best method of preventing an infection during a sterile procedure because it is the most comprehensive step. The remaining options are proper actions for the nurse who is adhering to the principles of the surgical asepsis. DIF: Cognitive Level: Analyze REF: Page 74OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation
- The nurse sets up a sterile field and notes several tiny holes in the sterile drape of the table that served as the wrap for the pack. What does the nurse do to facilitate completion of the procedure?
|a.||Uses a sterile towel to cover the existing holes|
|b.||Replaces the entire sterile field and the supplies|
|c.||Moves the sterile supplies to a replacement drape|
|d.||Avoids using any of the sterile items near the holes|
ANS: BThe nurse removes the entire sterile field, including any supplies added to the setup, because the holes compromised the sterility of the pack and its contents; in addition, contacting the contaminated drape contaminates every sterile item added to the sterile field. Even if the contents of the pack remained sterile, once the drape was used as a sterile field, the field was contaminated by the holes. The nurse cannot proceed with a sterile procedure using a contaminated field despite the goal of facilitating the procedure. Ignoring the potential contamination increases the risk of infection. DIF: Cognitive Level: Apply REF: Page 89OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation
- The nurse completes preparation of the sterile field to change a patient’s dressing when the patient’s dinner tray arrives. Which action should the nurse take?
|a.||Use the sterile field on another patient in another room.|
|b.||Change the dressing using clean technique to save time.|
|c.||Set the tray aside and proceed with the dressing change.|
|d.||Cover the setup with a sterile drape and let the patient eat.|
ANS: CThe nurse should set the dinner tray aside and proceed with the dressing change. Discarding the sterile setup would waste both time and money. The nurse avoids moving the sterile field to another patient’s room to decrease the risk of contamination from air currents and accidental contact. The nurse should explain to the patient why the dinner tray is being set aside, efficiently finish the dressing, offer to rewarm the meal, delegate serving the tray to nursing assistive personnel (NAP), and thank the patient for patience and understanding. The timing of the dressing change should be rescheduled to prevent this from happening again. DIF: Cognitive Level: Apply REF: Page 89OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning
- While setting up a sterile field for a procedure, the nurse knocks a linen-wrapped sterile package to the floor. Which reaction allows the nurse to maintain safe practice?
|a.||Inspect the package for tears.|
|b.||Brush away the visible debris.|
|c.||Record the procedure as clean.|
|d.||Replace the sterile package.|
ANS: DThe nurse replaces the linen-wrapped sterile package dropped on the floor because touching the floor contaminates the package. If the package had a plastic wrapper, the contents may be usable, depending on agency policy, because dust and moisture do not penetrate plastic like they can penetrate the linen. Clean technique may not be substituted when sterile technique is required. DIF: Cognitive Level: Apply REF: Page 93OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation
- The nurse helps the healthcare provider get supplies and monitor the patient during an emergency insertion of a femoral line at the patient’s bedside. Which nursing behavior helps to maintain the sterile environment?
|a.||Avoid reaching over the field.|
|b.||Wear a sterile cap and booties.|
|c.||Use sterile examination gloves.|
|d.||Place a face mask on the patient.|
ANS: AThe nurse avoids reaching over the sterile field to avoid contamination. A head cover and booties are not sterile, even when used during a sterile procedure. Sterile gloves are not indicated for the tasks the nurse is performing to assist the healthcare provider. There is no need to place a face mask on the patient for a procedure occurring on the upper thigh. DIF: Cognitive Level: Apply REF: Page 90OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Evaluation
- The nurse is preparing to put on sterile gloves. What should the nurse do to begin this procedure?
|a.||Pull the first glove up and over the nondominant hand.|
|b.||Place the fingers of the dominant hand under the cuff of the first glove.|
|c.||Let the cuff of the glove roll up over the hand for more coverage.|
|d.||Hold the inside surface of the first glove to pull over the hand.|
ANS: DTo begin donning sterile gloves, the nurse slips the fingers of the nondominant hand into the glove to lift it and pull it over the dominant hand. As long as the cuff does not roll up and the glove remains intact, the exterior of the glove remains sterile. DIF: Cognitive Level: Remember REF: Page 94-95OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning
- The nurse has just finished a sterile dressing change. Which technique should he or she use to remove sterile gloves?
|a.||Pull the first glove off with the sterile glove hand.|
|b.||Reach inside the first glove to pull it off quickly.|
|c.||Pull the edge of the glove down to create a cuff.|
|d.||Wipe off the gloves with an antiseptic wipe first.|
ANS: ATo remove sterile gloves, the nurse pulls the first glove off with the opposite sterile hand and discards the glove; then he or she inserts a bare finger under the remaining glove to pull it down and inside out. The nurse discards this glove as well. He or she avoids reaching inside the first glove with a gloved hand to prevent self-contamination. DIF: Cognitive Level: Remember REF: Page 96OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Implementation
- The nurse is caring for a patient with C. diff. What type of precautions should she use?
ANS: CThe nurse implements contact precautions because C. difficile spores live in the environment and on surfaces, including healthcare workers’ hands, and are spread through contact. There is no need for airborne or droplet precautions because C. difficile spores are not transmitted by those routes. Protective precautions are used for immunocompromised patients. DIF: Cognitive Level: Apply REF: Page 82-83OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning
- The nurse is preparing a sterile field with several items on it. Which action should the nurse implement to maintain a sterile field?
|a.||Flip sterile objects onto the sterile field.|
|b.||Put fluid holders near the edge of the field.|
|c.||Wear sterile gloves to open sterile packs.|
|d.||Open the inner flaps of the sterile packages first.|
ANS: BThe nurse places holders for fluid near the edge of the sterile field, allowing the circulating nurse to pour fluids into the holders without reaching over and contaminating the sterile field. Flipping sterile objects onto the sterile field increases the risk of contamination. Sterile gloves are unnecessary to open sterile packages because the outside of the package is clean; the nurse can use bare hands to open the package and retain package sterility. The nurse opens the outer flaps of sterile packages first because it is impossible to open the inner flaps first since they are covered with an outer wrap. DIF: Cognitive Level: Comprehension REF: Page 75, Box 5-2OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning
- The nurse is orientating a nursing assistant and is discussing handwashing principles. Which statement from the nursing assistant indicates a good understanding of those principles?
|a.||If my hands are visibly soiled, I cannot use an alcohol rub.|
|b.||I do not need to wash my hands if I have used gloves.|
|c.||I must always use soap and water after a dressing change.|
|d.||I can always use an alcohol rub instead of soap and water.|
ANS: AThe nurse must always use soap and water when hands are visibly soiled or when caring for a patient with C. diff. Hand hygiene with an alcohol-based hand rub can be used in all other situations and also must be done after removing gloves. DIF: Cognitive Level: Apply REF: Page 76OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning
- The nurse is preparing to transfer a sterile voided urine specimen from the patient’s bathroom to the laboratory. What supplies should he or she gather to complete this procedure?
|a.||Clean gloves, biohazard bag, mask|
|b.||Plastic bag, gown, gloves|
|c.||Sterile gloves, gown, biohazard bag|
|d.||Clean gloves, plastic bag, biohazard label|
ANS: DClean gloves are used even though the specimen is sterile. After the outside of the container is dried, the clean gloves are removed; the specimen container is placed in a plastic bag, and a biohazard label is attached if not already printed on the bag. A mask or gown is not needed unless splashing is a possibility, and there is no information in the question about the chance of splashing. Sterile gloves are not needed to obtain a sterile voided urine specimen. DIF: Cognitive Level: Apply REF: Page 74-75| Page 83| Page 86OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning
- The nurse is preparing to enter a room for the patient on contact precautions. In which order should she put on her personal protection equipment?
|a.||Gloves, gown, cap, eyewear|
|b.||Gown, cap, eyewear, gloves|
|c.||Cap, eyewear, gown, gloves|
|d.||Eyewear, cap, gloves, gown|
ANS: BThe nurse should don her PPE in the following order: Gown, cap, mask (if worn), protective eyewear (goggles, face shield), and then gloves, which should pull over the sleeves of the gown. DIF: Cognitive Level: Apply REF: Page 80-81OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning MULTIPLE RESPONSE
- Which of the follow elements are present in the chain of infections? (Select all that apply.)
|a.||Source of growth|
|b.||Mode of transmission|
|e.||Portal of exit|
|g.||Port of entrance|
ANS: A, B, C, D, E, GThe presence of a pathogen does not mean that an infection will begin. An infection develops in a cyclical process called the chain of infection, which includes six elements: (1) an infectious agent or pathogen, (2) a reservoir or source for pathogen growth, (3) a portal of exit from the reservoir, (4) a method or mode of transmission, (5) a portal of entrance into the host, and (6) a susceptible host. An infection develops if the chain remains intact. DIF: Cognitive Level: Comprehension REF: Page 74OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Planning
- The nurse is screening a patient for latex allergy. Which factors should she consider that place the patient at a higher risk for latex allergies? (Select all that apply.)
|a.||High latex exposure|
|b.||History of using condom catheters|
|d.||History of multiple childhood surgeries|
ANS: A, B, C, DRisk factors for latex allergies include spina bifida, congenital or urogenital defects, history of indwelling catheters or repeated catheterization, history of using condom catheters, high latex exposure (e.g., healthcare workers, housekeepers, food handlers, tire manufacturers, workers in industries that use gloves routinely), history of multiple childhood surgeries, and people with family history of allergies such as hay fever or hives. DIF: Cognitive Level: Apply REF: Page 93OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: Assessment
- The nurse is orientating a new graduate nurse. Which statement by the orientee indicates a high level of understanding about the principles of hand hygiene? (Select all that apply.)
|a.||I need to perform hand hygiene before and after having direct contact with patients.|
|b.||I can use alcohol rub when my hands are not visibly soiled.|
|c.||I need to perform hand hygiene after I remove my gloves.|
|d.||I only need to wash my hands with soap and water when they are visibly soiled.|
|e.||I should perform hand hygiene before a sterile procedure.|
ANS: A, B, C, EHand hygiene is performed before and after contact with patients, after removing gloves, and before performing sterile procedures. Alcohol-based rubs can be used except when hands are visibly soiled or when caring for patients with C. difficile. DIF: Cognitive Level: Apply REF: Page 76-77OBJ: NCLEX: Safe and Effective Care TOP: Nursing Process: ImplementationChapter 06: Vital SignsPerry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE
- The patient’s oral temperature is 39° C. Which conclusion can the nurse make about the patient on the basis of this information?
|a.||The patient is febrile.|
|b.||The patient is afebrile.|
|c.||An infection is present.|
|d.||Inflammation is present.|
ANS: AA temperature of 39° C is above normal, and the patient with an above-average temperature is febrile. Afebrile indicates a lack of fever but does not necessarily imply a subnormal temperature. An infection often causes a fever in the patient, but a physical examination and laboratory work or culture are necessary before concluding that the patient has an infection. A patient with an inflammation can have a fever, but the patient can have an inflammation without being febrile. DIF: Cognitive Level: Comprehend REF: Page 112OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Diagnosis
- The nurse is preparing to obtain a set of vital signs. Which is the most important factor for the nurse to consider when measuring patient vital signs?
|a.||Documentation of vital signs requires timely and accurate recording.|
|b.||Normal limits are very narrow and are generally the same for all patients.|
|c.||Measuring equipment must be used correctly and appropriately.|
|d.||Environmental factors play a minor role on patient vital signs.|
ANS: CIt is important that each device be used correctly and appropriately to ensure patient safety and to obtain correct, complete patient information. Improper equipment distorts the results, increasing the risk of patient injury. If data are obtained with improper equipment and patient treatment is based on the faulty data, the people who use the improper equipment and the faulty data are liable for the results. This is especially important when assessing temperature and blood pressure since a variety of devices are available for measuring these vital signs. Documentation is an important part of taking vital signs; however, if the nurse uses improper equipment or technique to obtain vital signs, accurate and prompt recording is to no avail. Depending on the parameter, the normal limits are not relatively narrow. The benefit of a wider normal range is that the body is able to respond to stress and recover while remaining within normal limits. Environmental factors play a significant role on vital signs (e.g., an overly warm room affects patient temperature). DIF: Cognitive Level: Apply REF: Page 99OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- A patient has a severe upper respiratory and ear infection and has been experiencing diarrhea. Assessment of the temperature would be most accurate if the nurse checked the temperature using which site?
|c.||Under the tongue|
|d.||The tympanic membrane|
ANS: BThe axilla is the only area listed where there is no infection or health issue and where there is no interference to its accuracy. The rectum is an inappropriate site because of the diarrhea. The oral route, under the tongue, is an inappropriate site because of the severe upper respiratory infection. If the patient cannot breathe through the nose, mouth breathing occurs, and the mouth cannot be closed to create a seal for an accurate temperature measurement. The tympanic membrane is an inappropriate site because of the ear infection. DIF: Cognitive Level: Analyze REF: Page 101OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The nurse is validating the measurement of an infant’s pulse by a nursing student. Which method should the nurse use to obtain the most accurate count?
|a.||Compress the bell of the stethoscope over the apex of the heart.|
|b.||Locate the pulsations in the antecubital space.|
|c.||Palpate the superficial artery on the medial side of the wrist.|
|d.||Place the thumb and forefinger along the ridge on the outer side of the wrist.|
ANS: BCounting the pulsations in the antecubital fossa from the brachial artery would give the most accurate count. Compressing the bell of the stethoscope turns it into a diaphragm; the bell is never compressed during use. Placing the thumb and forefinger along the ridge on the outer side of the wrist locates the radial artery, the preferred site for measuring an adult’s pulse. DIF: Cognitive Level: Apply REF: Page 115OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- A patient born without arms needs to have a blood pressure assessment. Which artery should the nurse use to most accurately obtain this measurement?
ANS: DThe nurse can use the popliteal artery to measure blood pressure by applying a properly sized cuff to the patient’s thigh. The femoral artery does not provide an area for assessment of the blood pressure. The brachial arteries are in the arm. The carotid artery, which is in the neck, is impossible to use for blood pressure measurement because applying cuff pressure to temporarily occlude both carotid arteries would stop blood flow to the brain and risk cerebral hypoxia. DIF: Cognitive Level: Apply REF: Page 121-122OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The nurse is running a blood pressure screening clinic at the community health center. Which action should the nurse implement to obtain an accurate measurement of a patient’s blood pressure on an upper extremity?
|a.||Use a cuff with a cuff width that is 40% wider than the circumference of the arm.|
|b.||Limit the cuff deflation rate to 10 mm Hg per second or heartbeat.|
|c.||Record the second Korotkoff sound as the systolic pressure.|
|d.||Apply the diaphragm of the stethoscope lightly over the brachial artery.|
ANS: AFor accurate results, a properly sized blood pressure cuff is at least 40% wider than the circumference of the patient’s arm on which the blood pressure is measured. Deflating the cuff at 10 mm Hg is excessively fast. The systolic blood pressure is the first Korotkoff sound. The diaphragm is placed firmly over the brachial artery to prevent environmental sound from interfering with blood pressure auscultation. DIF: Cognitive Level: Apply REF: Page 105OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The patient is unstable; so the nurse is using an electronic blood pressure device to measure blood pressures every 15 minutes. What should the nurse do to verify the accuracy of the electronic blood pressure measurements?
|a.||Check when the device was last calibrated.|
|b.||Know that the device adheres to current medical industry standards.|
|c.||Take a manual blood pressure within several minutes of the electronic reading.|
|d.||Verify that the systolic pressure is within 20% of patient baseline.|
ANS: CIf the blood pressure readings from the electronic blood pressure measurement device are close to the patient’s blood pressure on auscultation using a sphygmomanometer, the nurse assumes that the electronic device is accurate. Knowing when the device was calibrated does not guarantee its current accuracy. Medical industry standards do not exist for electronic blood pressure devices. A systolic measurement accurate within 20% of the patient’s baseline is grossly inaccurate, and using such a measurement can potentially lead to catastrophic results. DIF: Cognitive Level: Apply REF: Page 125OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
- A patient has an electronic blood pressure cuff that inflates every 15 minutes for a reading. Which activity by the nursing student would require the nurse to intervene?
|a.||The cuff is positioned carefully on the gown sleeve for comfort.|
|b.||The cuff is removed every 2 hours for a skin assessment.|
|c.||The alarm limits on the electronic device are checked frequently.|
|d.||The cuff is rotated to the other extremity every few hours as possible.|
ANS: AThe cuff should be directly on the patient’s skin, not over the gown, for an accurate reading. All other actions are appropriate. DIF: Cognitive Level: Remember REF: Page 125OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse delegates temperature measurement to nursing assistive personnel (NAP). For which patient should the nurse instruct the NAP to use the tympanic thermometer?
|a.||10-year-old patient with a left leg fracture|
|b.||12-hour-old infant in the newborn nursery|
|c.||5-year-old patient with bilateral otitis media|
|d.||15-year-old patient with postbilateral tympanoplasties|
ANS: AThe 10-year-old patinet is a suitable candidat for use of the typmanic thermometer if the NAP uses proper technique for positioning the sensor becaue of the age and condition of the child. The anatomy of the ear canal makes it difficult to position the probe accurately in neonates. Whenever ear infections are present, a tympanic thermometer can cause injury and record an inaccurate reading because of fluid, wax, or infectious material in the ear. Tympanic temperatures are prohibited when ear surgery has just been performed because they increase the risk for injury and infection. DIF: Cognitive Level: Apply REF: Page 101, Table 6-2OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse needs to measure the adult patient’s temperature, but the patient has just finished a cup of coffee. Which is the best type of temperature for the nurse to obtain accurate results efficiently?
ANS: CThe nurse obtains a tympanic temperature because the hot coffee will affect an oral reading. A tympanic temperature is a more reliable indicator of body temperature than the oral reading because a tympanic temperature is a core temperature. Rectal temperatures for adult patients are reserved for occasions when continuous temperature monitoring is required or if no other core temperature site is available; in addition, rectal temperatures are embarrassing for an alert adult patient. Axillary temperatures are not as reliable as tympanic temperatures and do not reflect core temperature. Disposable thermometers are the least accurate method. DIF: Cognitive Level: Apply REF: Page 101OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse is preparing to obtain a rectal temperature. Nursing care is correct if the nurse inserts the thermometer how far into the rectum of an adult?
|a.||1.3 cm (1/2 inch)|
|b.||3.5 cm (1 1/2 inches)|
|c.||5.1 cm (2 inches)|
|d.||6.4 cm (1 1/2 inches)|
ANS: BThe nurse inserts the thermometer 2.5 to 3.5 cm (1 to 1 1/2 inches) to obtain a rectal temperature on an adult. The sensor tip will be deep enough into the rectum to eliminate environmental effects but not too deep to risk penetration or trauma to intestinal tissue. 1.3 cm (1/2 inch) is not far enough for an accurate reading. 5.1 and 6.4 cm (2 and 2 1/2 inches) are too far to insert the thermometer into an adult. DIF: Cognitive Level: Comprehend REF: Page 109OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- While inserting a rectal thermometer, the nurse encounters resistance. What action should the nurse take?
|a.||Remove the thermometer immediately.|
|b.||Ask the patient to take a few deep breaths.|
|c.||Apply mild pressure to advance the thermometer.|
|d.||Remove the thermometer and reinsert gently.|
ANS: AIf resistance is felt, the nurse should remove the thermometer probe. Applying pressure to advance the thermometer is contraindicated to prevent complications such as harm to the mucosa. If there is an obstruction or a large amount of stool, having the patient take a few deep breaths is useless. The obstruction or impaction will have to be dealt with first. If the nurse removes and then reinserts the thermometer, the stimulation reactivates the sphincter reflex. The resistance will more than likely still be present. DIF: Cognitive Level: Apply REF: Page 109OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse notes that the patient’s tympanic temperature is 37.88° C (100.2° F) at 4 PM on the patient’s second postoperative day. What should the nurse do initially?
|a.||Check the leukocyte count.|
|b.||Collaborate for cultures.|
|c.||Ask the patient to drink some fluid.|
|d.||Offer the patient another blanket.|
ANS: CThe nurse should ask the patient to drink more fluid and cough and deep breathe because low-grade temperatures frequently indicate dehydration and atelectasis in postoperative patients; in addition, patient temperatures generally peak in late afternoon. The nurse evaluates the patient’s temperature again in 2 hours and expects to obtain a lower temperature. If not, the nurse assesses the patient for infection and collaborates with the provider to plan care. Until the nurse tries fluid and verifies the temperature, collaborating for specimen cultures is premature; in addition, the provider potentially will not want to culture for a low-grade temperature. DIF: Cognitive Level: Analyze REF: Page 100| Page 112OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
- The nurse is teaching a family member how to check a teenager’s temperature using a tympanic thermometer. Which step is most important for the nurse to include in order to obtain an accurate reading?
|a.||Pull the pinna down and back.|
|b.||Pull the pinna up and back.|
|c.||Place the probe loosely into the ear canal.|
|d.||Point the probe toward the eye.|
ANS: BTo obtain a tympanic temperature using proper technique, the nurse inserts the thermometer tip into the ear, and pulls the pinna up and back for children older than 3. The tip must fit securely in the ear canal to block environmental effects. The tip of the thermometer should point toward the patient’s nose for proper positioning. DIF: Cognitive Level: Comprehend REF: Page 110OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- A patient has been experiencing some circulatory issues, and an apical-radial pulse is ordered. Nursing care is correct if which procedure is followed?
|a.||One nurse counts the apical pulse at the same time another nurse counts the radial pulse.|
|b.||The nurse delegates this procedure to an experienced licensed practical nurse/licensed vocational nurse (LPN/LVN) and nursing assistive personnel (NAP) with 10 years’ experience.|
|c.||The nurse counts the apical pulse for 60 seconds and then the radial pulse for 60 seconds.|
|d.||The apical pulse is counted for 30 seconds, the radial pulse for 30 seconds, and the results are doubled.|
ANS: AThe pulse rate must be counted for 60 seconds at the two sites at the same time by two different people. If the patient is unstable or experiencing problems, this cannot be delegated to NAP. The radial and apical pulses are counted at the same time by two different people. The apical and radial pulses are counted for a full minute, not 30 seconds. DIF: Cognitive Level: Comprehend REF: Page 118OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The nurse is preparing to measure the patient’s blood pressure with an electronic blood pressure device. Which concept is most important for the nurse to consider?
|a.||Use the extremity closest to the nurse.|
|b.||The cuff size must match the extremity being used.|
|c.||The brachial artery is always the best one to use.|
|d.||The temporal artery is used if neither arm is available.|
ANS: BThe cuff must be the appropriate size for the extremity used. If the thigh is used, the nurse must use a larger cuff. The extremity used has nothing to do with proximity to the nurse. It depends on the patient’s status. In some instances the brachial artery in the upper arm is not available for blood pressure assessment such as after a mastectomy, if the extremity is injured, or if an intravenous line is in place. The temporal artery is impossible to use for blood pressure measurement because the temporal arteries are on the lateral aspects of the skull. DIF: Cognitive Level: Comprehend REF: Page 112OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse is preparing to assess the apical pulse. At which location should the nurse listen to obtain an accurate apical pulse on an adult patient?
|a.||At the fifth intercostal space at the left sternal border|
|b.||At the fifth left intercostal space at the midclavicular line|
|c.||At the second intercostal space at the left midclavicular line|
|d.||At the second right intercostal space at the midclavicular line|
ANS: BTo auscultate an adult’s apical pulse, the nurse places the stethoscope at the left fifth intercostal space at the midclavicular line directly over the point of maximal impulse and the location for auscultating the mitral valve. The fifth left intercostal space at the left sternal border locates the tricuspid valve. The second intercostal space at the left midclavicular line locates the pulmonic valve. The second right intercostal space at the midclavicular line locates the aortic valve. DIF: Cognitive Level: Remember REF: Page 102OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The nursing assistant reports the following vital signs for four patients just evaluated. Which patient should the nurse see first?
|a.||25 respirations per minute for a toddler|
|b.||38 respirations per minute for a newborn|
|c.||12 respirations per minute for an 8-year-old child|
|d.||14 respirations per minute for an adult patient|
ANS: CThe 8-year-old child is the nurse’s priority because the rate is too slow for the patient’s developmental stage. The normal range for a child is 20 to 30 breaths per minute. The range for respirations for a toddler is 25 to 32 breaths per minute; thus 25 breaths are within the normal limits. The range for respirations for a newborn is 35 to 40 breaths per minute; thus 38 breaths are within the normal limits. The range for respirations for an adult is 12 to 20 breaths per minute; thus 14 breaths are within the normal limits. DIF: Cognitive Level: Apply REF: Page 120OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- At what distance above the antecubital fossa does the nurse position a blood pressure (BP) cuff when using the brachial artery to measure BP?
|a.||2.5 cm (1 inch)|
|b.||0.6 cm (1/4 inch)|
|c.||1.3 cm (1/2 inch)|
|d.||5.1 cm (2 inches)|
ANS: AThe nurse positions the BP cuff 2.5 cm (1 inch) above the antecubital fossa when using the brachial artery. This allows proper placement of the stethoscope. DIF: Cognitive Level: Comprehend REF: Page 122OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The patient is morbidly obese and the nurse uses a blood pressure (BP) cuff that is too narrow for the patient’s arm. What problem will the nurse encounter because of the cuff used?
|a.||The Korotkoff sounds will not be heard.|
|b.||Only a palpable BP can be obtained.|
|c.||The stethoscope cannot be positioned correctly.|
|d.||A false high BP reading will occur.|
ANS: DUsing a cuff that is too narrow results in a false high BP measurement and makes care planning impossible. A properly sized cuff should be obtained as quickly as possible. Until it arrives, the nurse should continue to measure BP with the smaller cuff and observe the patient to ensure safety. Obesity potentially leads to diminished Korotkoff sounds. The assessment finding will warrant further investigation such as rechecking the blood pressure in several minutes. A palpable BP provides a systolic pressure only; the nurse obtains a palpable BP by inflating the cuff to occlude the artery and then palpating the brachial or radial pulse. The point at which the pulse returns is the systolic pressure. The nurse should have less difficulty positioning the stethoscope because the narrow cuff exposes more skin. DIF: Cognitive Level: Application REF: Page 106OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
- The nurse is assessing a new orientee’s knowledge of when to take vital signs. The following statement indicates a need for more education.
|a.||I should take vital signs upon admission.|
|b.||I should take vital signs when there is any change in condition.|
|c.||I should take vital signs at the beginning and end of a blood transfusion.|
|d.||I should take vital signs if a patient reports feeling different.|
ANS: CVital signs should be taken in all of those situations including before and after blood transfusions, but they also need to be taken during blood transfusions. The nurse would want to clarify that statement to make sure the nurse knows to check the vital signs during blood transfusions. DIF: Cognitive Level: Apply REF: Page 100, Box 6-1OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- While positioning the patient for a routine blood pressure check, the patient asks the nurse why a support was placed under the arm before the BP cuff was applied. Which response by the nurse is most accurate?
|a.||“This method prevents any problems in obtaining an accurate reading.”|
|b.||“This method helps the arm relax so the reading will be correct.”|
|c.||“I want you to be as comfortable as possible during this time.”|
|d.||“Just sit back and relax and let me get this reading right now.”|
ANS: BSupporting the arm ensures the muscles are relaxed, improving the likelihood for an accurate reading. Comfort is important but not the primary reason for providing support. Many variables can cause an inaccurate reading, including the wrong cuff size or improper placement of the stethoscope. Telling the patient to just “sit back and relax” ignores the patient’s question and is not an appropriate response. DIF: Cognitive Level: Apply REF: Page 121OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse assesses the patient’s respirations and sees that they are abnormally shallow (i.e., two to three breaths followed by an irregular period of apnea). Documentation by the nurse would be correct if which phrase were used?
ANS: AThis is an accurate description of Biot’s respirations. Cheyne-Stokes respirations have an irregular rate and depth characterized by alternating periods of apnea and hyperventilation. Kussmaul’s respirations are abnormally deep but regular. Hyperpneic respirations are increased in depth and can often be seen during exercise. DIF: Cognitive Level: Comprehend REF: Page 105OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The nurse is caring for a lethargic, 18-year-old patient with a respiratory rate of 32 breaths per minute. What is the first action the nurse should take?
|a.||Place the patient in high-Fowler’s position.|
|b.||Assess the remaining vital signs.|
|c.||Reassess the respiratory rate.|
|d.||Notify the healthcare provider.|
ANS: AThe patient’s head should be elevated quickly to promote better lung expansion. The remaining vital signs can be assessed after taking actions to improve the patient’s breathing. The healthcare provider will be notified, but the nurse’s first responsibility is to the patient. DIF: Cognitive Level: Analyze REF: Page 119OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- You have delegated the task of obtaining a pulse oximetry reading to the NAP. Which of the following statements by the NAP indicates a need for further education?
|a.||“The pulse oximetry reading was 95%.”|
|b.||“The patient’s pulse rate was 78 according to the readout.”|
|c.||“I made sure the patient did not have nail polish on.”|
|d.||“I made sure the patient was not receiving a respiratory treatment.”|
ANS: BPulse oximetry should not be used to obtain heart rates because they will not detect an irregular pulse. The patient’s nail polish should be removed and the patient should not be receiving respiratory treatments or PT during the readings because it can affect them. The readings are given in percentages. DIF: Cognitive Level: Apply REF: Page 126OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The patient’s oral temperature is 37.1° C (98.78° F) at 1 PM. Which of the following actions should the nurse take next? (Select all that apply.)
|a.||Administer acetaminophen (Tylenol) 650 mg by mouth now.|
|b.||Off the patient an additional blanket.|
|c.||Document that the patient is normotensive.|
|d.||Compare this with the patient’s prior readings.|
ANS: CThis temperature is within normal limits. Because the temperature reading is within normal limits, other intervnetions are not needed. Providing a blanket would increase the temperature. Comparing the temperature with other readings would be done if the temperature was outside of the normal range. Treating the patient with acetaminophen would be done if the patient’s temperature was elevated and you had a healthcare provider order. DIF: Cognitive Level: Apply REF: Page 112OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation MULTIPLE RESPONSE
- The nurse is going to measure the patient’s pulse oxygen saturation. She knows pulse oximetry readings can be influenced by several factors. (Select all that apply.)
|c.||Poor circulation to the site|
ANS: A, B, C, D, EThere are many factors that can influence pulse oximetry readings, including nail polish on the fingers where the reading is taken, poor circulation to the extremities, tremors, and hemoglobin or hematocrit levels. It is important to select the correct site to take the reading to get the best accuracy. DIF: Cognitive Level: Apply REF: Page 126OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: ImplementationChapter 09: Diagnostic ProceduresPerry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE
- The patient asks the nurse why an x-ray film with contrast medium is needed. How should the nurse respond?
|a.||“Most patients ask me that question.”|
|b.||“It enhances visualization of the internal structures.”|
|c.||“It guarantees total accuracy of the x-ray film interpretation.”|
|d.||“Let me have you speak to the radiologist.”|
ANS: BThe radiologist uses contrast medium to visualize internal structures not seen with regular x-ray films. The dye saturates the affected area for the x-ray film, and the image stands out against the tissue without dye. Because the healthcare provider and radiologist know the normal contour and appearance of internal structures, they can spot abnormalities such as filling defects, tumors, fistulas, and fractures. The nurse needs to be direct and answer the patient’s question. DIF: Cognitive Level: Apply REF: Page 218OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- A contrast medium study is being scheduled. Which statement by the patient during the assessment warrants further investigation by the nurse?
|a.||“I’m allergic to shellfish.”|
|b.||“I have small veins in my left arm.”|
|c.||“I’m really worried about the test results.”|
|d.||“I need to urinate in the middle of the night.”|
ANS: AThe nurse needs to establish whether the patient is truly allergic to shellfish, indicating sensitivity to iodine. The antiseptic used for the test has an iodine base and might cause a reaction; if so, the nurse or provider uses chlorhexidine or another agent for the skin preparation before the study. In addition, because many contrast mediums have an iodine base, the provider needs to choose an alternative dye. Establishing the nature of the reaction is important because the information provides valuable data for the radiologist to aid in choosing the proper contrast medium. It also establishes baseline data necessary when preparing for postprocedure nursing care. Small veins and urinary patterns do not pose potential problems for this type of test. Although the nurse should provide the patient with information to ease anxiety about the test, the allergy information is key to patient safety during this procedure. DIF: Cognitive Level: Analyze REF: Page 218-219OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- A patient is being monitored in the left femoral artery 2 hours after an angiogram. What assessment by the nurse is of greatest priority?
|a.||The patient is a little sleepy and can’t remember the procedure.|
|b.||The left pedal and posterior tibial pulses are palpable.|
|c.||The patient hasn’t voided yet.|
|d.||Both of the patient’s feet are cool and pink.|
ANS: BThe radiologist inserts the angiographic catheter in the groin for a femoral angiogram. Because a major vessel is accessed for the procedure, the patient has a high risk for postprocedure bleeding and thromboembolic events. For early detection of postangiographic bleeding, the nurse monitors the patient for subcutaneous discoloration, a change in the pulses distal to the insertion site, and bright red bleeding. The peripheral pulses detect a thromboembolic event early, which helps to prevent tissue damage or loss. It would not be unusual for a patient to be sleepy and amnesic after this procedure. If both feet are cool, it is probably because of room temperature since nothing invasive was done on the patient’s right side. DIF: Cognitive Level: Apply REF: Page 219-220OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The patient is being monitored by the nurse during a gastroscopy. Which patient data need to be communicated to the healthcare provider doing the procedure?
|a.||The patient has been placed in the left lateral position.|
|b.||An anterior gastric erosion ulcer is present.|
|c.||The blood pressure has dropped 30 mm Hg.|
|d.||The patient is lethargic but can follow directions.|
ANS: CInserting the endoscope can stimulate the vagus nerve, potentially leading to a slower heart rate and hypotension. Left lateral Sims’ position is suitable for gastroscopy. The patient should be drowsy with the medication used but able to follow basic directions. The nurse and healthcare provider use the gastric erosion identified during the gastroscopy to plan nursing care and patient therapy. DIF: Cognitive Level: Apply REF: Page 223| Page 234OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
- The nurse provides patient teaching before a lumbar puncture. Which information does the nurse include about patient activity during the procedure?
|a.||“We’ll want to know if you are hurting.”|
|b.||“I’ll place you in a semi-Fowler’s position.”|
|c.||“It is essential to remain still during the procedure.”|
|d.||“We’ll restrict your fluids after the test is done.”|
ANS: CThe nurse instructs the patient to maintain the lateral position and lie without moving during the procedure, especially while the provider inserts the needle, because the goal is to put the needle in the subarachnoid space. Unexpected patient movement potentially leads to needle misplacement, patient injury, and increased risk of postprocedural headache and infection from leaking cerebrospinal fluid. The local anesthetic injection stings, and insertion of the needle potentially elicits a sharp, stabbing, or shooting pain that causes patients to flinch. The nurse assists the patient to maintain the position and offers reassurance and information. The nurse instructs the patient to indicate verbally that pain is present during the procedure but not to move. Unless fluids are contraindicated, providers typically prescribe flat positioning and normal fluid intake following the procedure. DIF: Cognitive Level: Apply REF: Page 227OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- A patient has had increasing respiratory difficulty as a result of abdominal cancer. Which information does the nurse provide to the patient about the purpose of having a paracentesis?
|a.||It will relieve pressure and some of the discomfort in your abdomen.|
|b.||It will allow for analysis of the thoracic fluid for cytology.|
|c.||Fluid from the lung will be examined.|
|d.||The examination will allow for extraction of a sample of bone marrow.|
ANS: AParacentesis is the removal of abdominal fluid for examination and relief of pressure from severe ascites. The removal of the fluid can increase patient comfort. A thoracentesis removes fluid from the chest cavity. Lung fluid is not obtained during a paracentesis. A bone marrow aspiration recovers bone marrow cells. DIF: Cognitive Level: Apply REF: Page 226OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The nurse is explaining the procedure for a paracentesis. Which intervention by the nurse can help prevent a complication of the procedure?
|a.||Have the patient hold the breath for a few seconds.|
|b.||Ensure that the patient voids before the procedure.|
|c.||Place the patient in a supine position.|
|d.||Check vital signs every 2 hours after the procedure.|
ANS: BThe nurse instructs the patient to void before the paracentesis because an empty bladder reduces the risk of an accidental bladder puncture. The patient doesn’t need to hold his or her breath. The nurse helps the patient into a sitting position because sitting decreases the size of the peritoneal cavity. Vital signs are measured every 15 minutes for 2 hours. DIF: Cognitive Level: Apply REF: Page 227OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- A patient develops low back pain radiating to both sides of the body after a femoral approach has been used for a cardiac catheterization. What should the nurse do while contacting the healthcare provider?
|a.||Ambulate the patient to see if the pain diminishes.|
|b.||Monitor the vital signs every 5 minutes.|
|c.||Encourage oral intake of fluids as desired by the patient.|
|d.||Sit the patient in a high-Fowler’s position.|
ANS: BThe patient is experiencing retroperitoneal bleeding, which is an emergency. Surgery will most likely be required; therefore the patient needs to be NPO and kept in a position that supports the blood pressure best, which is supine. The patient’s status must be monitored frequently because of the severity of the situation. DIF: Cognitive Level: Analyze REF: Page 223OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
- The patient arrives in the postanesthesia care unit after a cardiac catheterization via the left femoral artery to assess the right atrium. Which patient datum is the nurse’s priority to assess perfusion of the affected extremity after the procedure?
|a.||Checking the left femoral region for bleeding|
|b.||Monitoring patient vital signs every 15 minutes|
|c.||Applying direct pressure at the patient’s intravenous (IV) site|
|d.||Palpating the right pedal pulse for pulsations|
ANS: ATo access the right heart, the provider used a femoral approach, which is the site where bleeding would occur after the procedure. The nurse measures vital signs every 15 minutes after a cardiac catheterization; however, unless the femoral vein is bleeding, the vital signs provide secondary evidence about the perfusion to the affected extremity. The nurse palpates the unaffected extremity as a comparison for the affected extremity. Applying pressure is a nursing intervention and will not provide patient data regarding perfusion. DIF: Cognitive Level: Analyze REF: Page 223OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The nurse prepares a patient for a pulmonary angiogram. What information should the nurse include in patient teaching to prevent a postprocedure hemorrhage?
|a.||The chemicals in the dye injection help prevent hemorrhage.|
|b.||The patient will be sleepy; so movement will be minimal.|
|c.||The patient’s affected leg will be immobilized after the procedure.|
|d.||Postprocedure analgesia will manage patient discomfort.|
ANS: CThe nurse explains that the patient’s hips and knees will be kept straight and positioned for little movement for 2 to 6 hours after the procedure. The nurse also explains that flat straight extremities allow adequate hemostasis to prevent postprocedure bleeding by protecting the integrity of the insertion site. Sleepiness is expected after the procedure and is not involved in prevention of a postprocedure hemorrhage. The contrast dye and postprocedure analgesia will not interfere with the ability of the blood to clot. DIF: Cognitive Level: Analyze REF: Page 222OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse is caring for the patient immediately after an angiogram has been finished. Which action does the nurse take to prevent a complication of this procedure?
|a.||Limit the patient’s total fluid intake.|
|b.||Encourage early patient ambulation.|
|c.||Elevate the head of the bed 30 degrees.|
|d.||Apply constant pressure to the insertion site.|
ANS: DSignificant pressure applied to the insertion site of the angiographic catheter helps to ensure hemostasis and prevent a postangiographic hemorrhage. The pressure is kept in place for many hours because angiograms always involve the access of major vessels and thus increase the risk of hemorrhage. The nurse complements pressure at the insertion site with continuous visualization of the site and assessment of peripheral perfusion to the affected extremity. Fluid intake increases after an angiogram to flush the dye from the system quickly to prevent renal damage. Following the angiogram, the patient is kept supine. DIF: Cognitive Level: Apply REF: Page 222OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The nurse cares for a patient who had an angiogram of the aorta with a contrast medium approximately 4 hours ago. Which is the priority patient assessment for the nurse to monitor for early detection of an allergic reaction to the dye?
ANS: CThe nurse monitors the patient’s respiratory and cardiac status for any indication of a hypersensitivity reaction to the dye. Other clinical indicators include flushing, itching, and urticaria. Pallor is usually an indicator of altered cardiovascular status. Pruritus and cool skin may be an indication of allergic reactions; however, they are not as high on the patient’s hierarchy of needs as breathing. DIF: Cognitive Level: Analyze REF: Page 220OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The nurse admits the patient to rule out leukemia and prepares him for definitive diagnostic testing. Which is the best question to ask the patient before the procedure?
|a.||“Do you ever feel claustrophobic?”|
|b.||“Are you allergic to iodine or shellfish?”|
|c.||“Have you ever had an electrocardiogram?”|
|d.||“Can you lie on your stomach for 20 to 30 minutes?”|
ANS: DTo rule out leukemia, the patient needs to have a bone marrow biopsy to examine the marrow for malignant white blood cells. A bone marrow biopsy requires the patient to lie in the lateral or prone position when the provider chooses to obtain the bone marrow specimen from the iliac crest. These positions provide access to the hip and allow the provider to apply enough pressure to reach the marrow with the hollow core needle. If the patient cannot tolerate the positioning, the provider can choose the sternum. Allergies to shellfish and iodine are of key interest when performing tests that use contrast medium. Claustrophobia is important to determine before computed tomography or magnetic resonance imaging. The nurse asks about previous electrocardiograms to compare with current electrocardiograms. DIF: Cognitive Level: Apply REF: Page 224OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse is teaching an older patient before a bronchoscopy. What information is the most important for the patient to know to prevent a possible postprocedure complication?
|a.||Deep breathe during the insertion of the bronchoscope for easy passage of the scope.|
|b.||Do not eat or drink anything after the procedure until the nurse says it is safe to drink.|
|c.||Turn on your right side while the bronchoscope is passed through the nose and throat.|
|d.||Avoid food and fluids for at least 3 hours before the procedure.|
ANS: BThe nurse cautions the patient to avoid taking anything by mouth after the bronchoscopy until approved by the nurse because the nurse determines when the gag reflex returns. The healthcare provider sprays a local anesthetic agent to depress the gag reflex before passing the bronchoscope. Ingesting oral food or fluid potentially causes choking or aspiration with a depressed gag reflex. The patient is NPO for 8 hours before the bronchoscopy to help prevent aspiration of gastric contents. Intravenous sedation is often used to relax the patient, allowing for easy passage of the bronchoscope. The bronchoscope passes through the oropharynx into the trachea, not through the nose. DIF: Cognitive Level: Apply REF: Page 232OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The patient arrives in the intensive care unit after a bronchoscopy. Which patient assessment is the nurse’s priority?
|a.||Status of the gag reflex|
|b.||Level of sedation|
ANS: DRespiratory status is the priority assessment in the immediate postprocedure period because bronchoscopy includes manipulation of a scope through the trachea and bronchi, potentially stimulating bronchospasm, laryngospasm, and respiratory distress. Cardiovascular status, or circulation, is the next patient priority on the hierarchy of needs. After the respiratory and cardiovascular assessments, the nurse assesses the patient’s neurological status and sedation level to monitor for return of function. The nurse assesses the gag reflex before administering anything by mouth. DIF: Cognitive Level: Analyze REF: Page 230OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The nurse is preparing to position a patient for a gastroscopy. Which action should the nurse implement before getting the patient into position?
|a.||Remove the patient’s dentures.|
|b.||Suction the oral cavity.|
|c.||Provide a sip of clear fluid.|
|d.||Position the patient upright in bed.|
ANS: AThe nurse assists the patient in removing dentures before the procedure to protect the dentures, prevent accidental dislodgement, and facilitate patient comfort. Suctioning is not indicated before positioning. The nurse positions the patient in the left lateral Sims’ position during the procedure and in the semi-Fowler’s or the recovery position after the procedure. The patient should be NPO prior to the procedure. DIF: Cognitive Level: Remember REF: Page 235OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- An older patient with renal insufficiency has been NPO for 8 hours before a bronchoscopy. When the patient returns from the test, which patient datum is the nurse’s priority assessment?
|b.||Level of orientation|
|c.||Skin integrity status|
|d.||A reaction to contrast medium used|
ANS: AOlder patients are especially prone to dehydration, and the risk increases after a prolonged NPO period because the nurse withholds food and fluid to prepare the patient for the procedure. The patient’s urinary output needs to be watched after hydration has been established. Emptying the stomach decreases the risk of aspiration of gastric contents during and after the procedure. Disorientation is a reasonable assessment for an older adult who has received inadequate fluid and risks dehydration; it may be a clinical indicator of dehydration. The risk of skin breakdown is increased with dehydration. It is not as important as early detection of dehydration because preventing dehydration helps to prevent skin breakdown. A contrast medium is not used during a bronchoscopy. The procedure is a direct visualization. DIF: Cognitive Level: Analyze REF: Page 224OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- A patient is having a contrast medium study and has several allergies. During the injection of the dye, the patient complains of having a brief, severe hot flash and slight chest pain. What nursing action is most indicated?
|a.||Ask the patient how he or she is feeling since the dye was injected.|
|b.||Tell the patient that many patients feel the same way.|
|c.||Assess the patient’s vital signs while reassuring him or her.|
|d.||Explain to the patient that this is a normal sensation for this test.|
ANS: CObtaining objective data is the best indicator of the patient’s status. Asking the patient how he feels may be helpful, but it results in only subjective data. Telling the patient that others feel the same way is nontherapeutic. The patient concern should be answered honestly and completely. Many of the contrasts such as those for angiography can cause a sensation of warmth shortly after the injection, but specific evaluation of the patient’s status is required. DIF: Cognitive Level: Apply REF: Page 221OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The nurse is caring for a patient who had a lumbar puncture (LP) 1 hour ago. The patient is drowsy and his pupils are dilated. After notifying the healthcare provider, what should the nurse do?
|a.||Maintain airway and monitor vital signs.|
|b.||Reduce total fluid intake.|
|c.||Lie the patient flat.|
|d.||Maintain pressure on the LP site.|
ANS: AA patient undergoing an LP can develop an excessive loss of CSF, which causes reduced LOC, dilated pupils, and increased BP. The nurse should notify the healthcare provider, monitor vital signs, and prepare to transfer the patient to the ICU. The patient should not be flat because that would compromise the airway. Pressure on the site will not stop the leak, and the patient should have not fluids restricted. DIF: Cognitive Level: Apply REF: Page 229OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The nurse is preparing a tired older patient for a thoracentesis. Which ability should the nurse assess for when determining if the patient can tolerate the procedure safely?
|a.||Cough only when requested.|
|b.||Swallow and clear the throat.|
|c.||Remain sitting but motionless.|
|d.||Inhale during needle insertion.|
ANS: CThe nurse should assess the patient’s ability to remain motionless in a sitting position during the procedure so the provider can precisely place the needle in the fluid without puncturing adjacent structures inadvertently, including the heart and great vessels. The nurse instructs the patient to avoid coughing and throat clearing during a thoracentesis to prevent accidental injury. The nurse instructs the patient to hold his or her breath during a thoracentesis to prevent accidental injury to adjacent thoracic structures. DIF: Cognitive Level: Apply REF: Page 227OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- A patient asks the nurse why being NPO for 6 to 8 hours before a contrast study is necessary. Which response by the nurse is most accurate?
|a.||“Decreasing the hydration status decreases the chance of an allergic response to the contrast medium.”|
|b.||“Excessive hydration causes dilution of the contrast medium, which does not permit as clear a picture of the area as needed.”|
|c.||“It reduces the chance of postprocedure infection.”|
|d.||“Nausea is prevented if the stomach is empty.”|
ANS: BExcessive hydration causes dilution of the contrast medium, making structures more difficult to see. The hydration status has not affected the chance of an allergic response to the contrast medium. Postprocedure infection is rare with a contrast study, and being NPO has nothing to do with its occurrence. Having an empty stomach does not prevent nausea. Nausea may result from the contrast medium used for the study. DIF: Cognitive Level: Apply REF: Page 220OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- A patient is recovering after receiving sedation for a contrast medium study and has a score of 1 using the Modified Ramsay Sedation Scale. What action by the nurse is most appropriate at this time?
|a.||Document these normal findings.|
|b.||Prepare to increase the oxygen flow.|
|c.||Administer a drug-reversal agent.|
|d.||Listen to the breath sounds.|
ANS: AA score of 1 is the highest score possible and reflects optimum recovery. There is no need to increase the oxygen flow based on the patient’s optimum status. A drug-reversal agent is not needed based on current assessment data. There are no data that point to the need to assess breath sounds at the current time. DIF: Cognitive Level: Apply REF: Page 217, Table 9-1OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
- An hour after a patient has a thoracentesis, the patient’s oxygen saturation is 88, and respiratory rate is 34. What actions by the nurse are priorities?
|a.||Raise the head of the bed and call the nursing supervisor.|
|b.||Give oxygen to the patient and notify the physician.|
|c.||Look at the chest excursion and notify respiratory therapy.|
|d.||Open a chest tube insertion kit and notify the patient’s family.|
ANS: BThe patient most likely has a punctured lung and needs respiratory support. He or she must not be left alone. Oxygen is needed, and the physician must be notified immediately. Raising the head of the bed does not increase the flow of oxygen. Further assessment is not a priority until the oxygen is on and either the physician or respiratory therapy is at the bedside. The nurse should not assume that a chest tube will be inserted. The tray must be kept closed until immediately before being used. The physician needs to be called before the family is called. DIF: Cognitive Level: Apply REF: Page 229OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The nurse is caring for a patient who received opioids for sedation during his procedure. After the procedure the patient experiences oversedation that required the administration of a reversal agent. Which agent would the nurse administer?
ANS: BIf a patient is oversedated, be prepared to administer emergency medications or reversal agents (e.g., naloxone [Narcan] [reversal of opioids] or flumazenil [Romazicon] [reversal of benzodiazepines]). Other support drugs may also be given. Benadryl would be given for an allergic reaction. DIF: Cognitive Level: Apply REF: Page 217OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation MULTIPLE RESPONSE
- A patient is going to have a cardiac procedure that requires moderate sedation. The nurse is explaining to the patient what is included in the pre-sedation assessment. Which statement(s) indicates the nurse has a good understanding? (Select all that apply.)
|a.||“Have you arranged for someone to drive you home after the procedure?”|
|b.||“How frequently do you drink alcohol?”|
|c.||“Have you had any problems with anesthesia before?”|
|d.||“Do you have any drug allergies?”|
|e.||“Do you currently use any drugs? How frequently have you used drugs in the past?”|
|f.||“Is there a family history of drug use or abuse?”|
ANS: A, B, C, D, EOne of the risks for moderate sedation is if it progresses past the point and becomes deep sedation. Because of this risk, only trained individuals can give the sedation and a pre-assessment is completed to help ensure patient risk factors are known. The patient’s level of tolerance for the sedatives used can be affected by his or her history of drug and alcohol use. The patient must also arrange for someone to take him or her home after the procedure. Current drug allergies will prevent an allergic reaction. Past family history does not impact the patient. DIF: Cognitive Level: Apply REF: Page 217-218OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- You are describing the “time-out” verification procedure to a nursing orientee. Which statement by the orientee indicates a good level of understanding? (Select all that apply.)
|a.||The time-out is done at the start of every invasive procedure.|
|b.||The time-out prevents wrong site errors.|
|c.||The time-out prevents wrong patient errors.|
|d.||The time-out is done by the surgeon.|
|e.||The time-out is required by The Joint Commission (TJC).|
ANS: A, B, C, EThe time-out verification procedure is required by TJC and is done before every invasive procedure by the physician and all involved personnel. This is a safety procedure that prevents wrong patient, wrong site, and wrong procedure errors. DIF: Cognitive Level: Apply REF: Page 232OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The nurse is caring for a patient post cardiac catheterization who experiences a vasovagal response when his sheaths are removed and pressure is applied. Which of the following symptoms is the patient likely to experience? (Select all that apply.)
ANS: A, B, DA patient experiences a vasovagal response (occurs at the time of femoral puncture or after the procedure when femoral pressure is applied). Symptoms include feeling faint, dizzy, light-headed, and possible loss of consciousness for a few seconds. Bradycardic pulse is caused by stimulation of the vagus nerve via baroreceptors. Itching and flushing occur with contrast dye. DIF: Cognitive Level: Apply REF: Page 237OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: AssessmentChapter 13: Pain ManagementPerry et al.: Nursing Interventions & Clinical Skills, 6th Edition MULTIPLE CHOICE
- The nurse teaches the patient progressive self-relaxation techniques. Which should the nurse implement first?
|a.||Direct the patient to envision sailing on a sailboat.|
|b.||Instruct the patient to increase respiratory rate and depth.|
|c.||Establish the patient’s ability to participate and cooperate.|
|d.||Darken the patient’s room significantly and close the door.|
ANS: CThe nurse begins by assessing the patient’s ability to participate and cooperate to tailor the teaching techniques and vocabulary to him or her. This increases the likelihood of the patient benefiting from the instruction. Envisioning pleasant things is part of teaching guided imagery but is not the initial step. After assessing the patient, the nurse provides a brief overview of the technique and sets a proper learning environment. Deep respirations are an indication of relaxation; however, instructing a patient to breathe in a certain way does not induce relaxation. DIF: Cognitive Level: Comprehend REF: Page 326OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse massages the patient to promote relaxation. Which is a suitable intervention for the nurse to implement during the massage?
|a.||Use the friction technique over the spine.|
|b.||Assess for pain, anxiety, and discomfort.|
|c.||Instruct the patient to sit upright and forward.|
|d.||Knead the patient’s scalp with warm lotion.|
ANS: BThe nurse’s goal during a massage is to keep the patient comfortable and relaxed and induce a lingering sense of well-being and relaxation at the completion of the massage. If the patient is in pain, anxious, or uncomfortable, relaxation does not occur until the noxious stimuli are eliminated. The nurse asks the patient about pain and comfort during the massage and does not wait for the patient to offer such statements. The friction technique (i.e., strong, circular strokes enhancing perfusion at the skin’s surface) is contraindicated for bony prominences such as the spine because the regional skin is already thin and under tension by nature of its location over a bone. Sitting upright and forward can be contraindicated or uncomfortable for the patient. Occasionally the patient’s scalp is massaged with a few drops of oil on the fingertips; it is impossible to knead the scalp because the scalp is devoid of large, thick muscles. DIF: Cognitive Level: Comprehend REF: Page 321OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The patient awakens at 3:00 AM requesting pain medication, but the nurse does not administer additional pain medication. What justifies the nurse’s decision to withhold the medication?
|a.||The patient had a reaction to aspirin 5 years ago.|
|b.||The nurse wants to help the patient avoid drug addiction.|
|c.||The patient is asleep when the nurse returns with analgesia.|
|d.||The patient wants pain medication every 3 3/4 hours exactly.|
ANS: CThe nurse receives contradictory messages about the patient’s pain level because the patient is relaxed enough to fall asleep again. To avoid oversedation and complications, the nurse withholds the medication but assesses the patient for other indicators of pain before leaving the room. The nurse promptly administers pain medication if other indicators of pain are present or when the patient awakens. Frequently nurses feel a duty to protect patients from drug addiction and to withhold pain medication when they suspect that the patient exhibits addictive behavior or asks for too much pain medication. Experts, including The Joint Commission, agree that healthcare professionals should rely on the patient’s report of pain. The patient has the right to effective pain management, and the nurse is bound ethically to provide pain relief when the patient asks for it. If the patient asks for pain medication every 3 3/4 hours, he or she may be watching the clock. Many healthcare professionals describe this behavior as “drug seeking,” meaning that the patient is seeking pain medication for unrelated reasons; this description labels the patient unfairly. This behavior can also indicate inadequate pain relief or the onset of a new patient health problem. For these reasons this type of patient request for pain medication warrants further investigation. To manage this situation, the nurse remembers the patient’s right to pain relief and the nurse’s role as patient advocate. DIF: Cognitive Level: Analyze REF: Page 317| Page 328-329OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
- The patient has hypotension, receives as much opioid analgesia as the prescription allows, and continues to have difficulty sleeping at night because of pain. Which should the nurse implement to relieve pain and improve sleep?
|a.||Encourage controlled breathing.|
|b.||Provide a glass of wine at bedtime.|
|c.||Give a sedative 1 hour before sleep.|
|d.||Increase fluids and reposition the patient.|
ANS: AThe nurse encourages the patient with controlled breathing exercises that serve as a distraction to increase relaxation, decrease pain, and promote sleep. The nurse applies a nonpharmacological relaxation technique because the patient has hypotension and additional analgesia is likely to lower the blood pressure further, potentially leading to serious complications, including loss of consciousness, decreased perfusion to vital organs, and cardiopulmonary arrest. Alcohol is contraindicated for use with opioids; in addition, alcohol consumption is likely to lower the blood pressure by vasodilation. The nurse avoids administering a sedative because hypotension is an adverse effect of most sedatives and sedatives will aggravate the patient’s hypotension. The nurse increases fluid if the patient has a fluid volume deficiency; however, restoring fluid balance is unlikely to promote relaxation to relieve pain and improve sleep. Until the patient’s hypotension is resolved, the nurse repositions him or her in the supine position or with the head slightly elevated to prevent increasing venous return from the head to the heart. DIF: Cognitive Level: Analyze REF: Page 330OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse wants to use massage to promote relaxation. In which patient diagnosis would massage be potentially contraindicated?
|a.||Spinal cord injury|
ANS: AMassage may be contraindicated after spinal cord injuries or surgery to head and neck because of risk of further injury. Patients with hypertension, acute asthma, and Crohn’s disease potentially benefit from a massage as relaxation therapy. DIF: Cognitive Level: Comprehend REF: Page 324OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The patient has metastatic bone pain from cancer with nausea and vomiting after receiving periodic opioid analgesia intravenously. Which can the nurse implement to manage the patient’s pain effectively without nausea and vomiting?
|a.||Dispense the opioid 30 minutes after providing food.|
|b.||Combine the opioid with an antiemetic or antihistamine.|
|c.||Collaborate with the healthcare provider for around-the-clock analgesia.|
|d.||Replace the analgesic with a nonsteroidal anti-inflammatory agent.|
ANS: CMetastatic bone pain can be very difficult to control for a patient with cancer. The nurse collaborates with the provider to convert intravenous (IV) opioid administration to around-the-clock (ATC) dosing because ATC administration maximizes the pain relief and minimizes most side effects and drug toxicity. Administering opioids with food is an effective technique to avoid nausea and vomiting but usually only when the opioid is given by mouth. Although administering an antiemetic and/or an antihistamine with an opioid analgesic is a reasonable method of managing the patient’s nausea and vomiting, the periodic schedule is not as effective as ATC dosing. Nonsteroidal antiinflammatory agents may be used in combination with opioids for bone pain, but they do not replace the opioids. DIF: Cognitive Level: Apply REF: Page 328| Page 329OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The patient receives opioid analgesia with naproxen (Naprosyn) after a total abdominal hysterectomy. Which patient datum is the nurse’s priority?
|a.||The patient has not had a bowel movement since surgery.|
|b.||The patient declines a massage after analgesic administration.|
|c.||Respiratory rate drops from 22 to 16 breaths/min.|
|d.||The patient receives famotidine (Pepcid) for esophageal reflux.|
ANS: DA patient history of esophageal reflux is usually a contraindication for nonsteroidal antiinflammatory drug (NSAID) administration because of the increased risk of bleeding from prostaglandin inhibition. Constipation is a complication of surgery and opioid analgesia, but the nurse manages patient constipation by increasing patient ambulation and intake of fiber, fluid, and stool softeners. Declining a massage after receiving pain medication potentially indicates that the patient is satisfied with her comfort and relaxation status. Respirations at 16 breaths/min are within normal limits. DIF: Cognitive Level: Analyze REF: Page 329OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The nurse prepares an oral opioid analgesic for the patient who has dementia and pain. After checking the patient’s medication administration record (MAR) for the last administration time and the patient’s response to pain medication, the nurse chooses the correct analgesic and compares the patient’s picture and wristband to the medical record. Which is the most important intervention for the nurse to implement before administering pain medication to the patient?
|a.||Fill the pitcher with water.|
|b.||Record the administration time.|
|c.||Check the medication dose.|
|d.||Help the patient to sit upright.|
ANS: CThe most important intervention is to check the MAR and verify the correct dose before administration to prevent adverse effects and toxicity. This is important from a safety standpoint and follows the rights of medication preparation and administration. Filling the water pitcher can be delegated to nursing assistive personnel (NAP). Assisting the patient to a particular position may be required, but it is not the most important intervention in medication administration. Administering the correct dose is much more important. The nurse should be focused on safety during the preparation and administration of medication. Medication documentation occurs after the medication is administered. DIF: Cognitive Level: Analyze REF: Page 329OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse decides that collaboration with the healthcare provider is needed to review and possibly adjust the dose of analgesic for an 87-year-old patient. What is the rationale for this request?
|a.||Older adults have higher risks of injury with intramuscular (IM) injections.|
|b.||Analgesics aren’t necessary for older adults because of decreased pain sensation.|
|c.||Impaired cognition impairs reporting of pain by older patients.|
|d.||Liver and kidney metabolism is usually slower in older adults.|
ANS: DAs the adult ages, hepatic and renal clearance of medication usually decreases or slows, so medication has a longer duration of action, and doses exert a stronger effect than in younger people. The nurse helps to maintain patient safety and prevent injury by collaborating to adjust the dose of the analgesic. Risk of injury from an IM injection refers to the route of administration and is not dependent on the dose. Nothing in the question indicates that an IM injection is the mode of administration. The nurse uses the patient’s self-report of pain felt to help determine the need for pain relief; reporting pain refers to patient assessment. This option does not address the reason for adjusting the dosage. DIF: Cognitive Level: Apply REF: Page 331OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The patient who receives morphine sulfate intravenously by patient-controlled analgesia (PCA) tells the nurse that the pain level is 8 on a scale of 0 to 10. Which is the best intervention for the nurse?
|a.||Check the volume of morphine in the PCA syringe.|
|b.||Check the frequency of patient-controlled dosing.|
|c.||Collaborate with the provider to increase basal rate.|
|d.||Instruct the family to activate the patient-controlled dose.|
ANS: BThe PCA dose includes a basal rate to establish and maintain a therapeutic morphine serum level and a supplemental dose of morphine, the patient-controlled dose, for patient pain management. The nurse checks the frequency of patient self-dosing to gather additional information for a nursing assessment. If the patient is not supplementing the basal dose, the nurse instructs the patient to use the patient-controlled dose by directing the patient to depress the PCA button for pain control. The nurse allows 30 minutes to 1 hour to evaluate the plan. If the patient is using the PCA properly, the patient may benefit from an increased basal rate. If the patient is depressing the PCA button, the syringe of morphine may be empty; however, the PCA has an alarm to indicate low volume, and the nurse monitors the volume for narcotic control and intake and output (I&O), so it is unlikely that an empty syringe will be the problem. Collaborating with the provider to increase the PCA dose is premature because the nurse has not completed an assessment or implemented nursing interventions that potentially resolve the patient’s pain. The nurse avoids instructing the family to assist the patient because PCA is for patient use only, and families are unauthorized users of the patient’s PCA. DIF: Cognitive Level: Analyze REF: Page 336OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The nurse cares for several postoperative patients using patient-controlled analgesia (PCA) pain management with a combination of an opioid and a local anesthetic agent on the first postoperative day. Which patient should the nurse assess first?
|a.||A patient after a bowel resection for recurrent colon cancer|
|b.||A patient after an internal fixation of an ankle fracture|
|c.||A first-time hospitalized patient after amputation of a leg|
|d.||A patient with emphysema who had a lung tumor resection|
ANS: CThe nurse assesses the patient with the amputation first. Since this is the patient’s first hospitalization, it is unknown how he or she will react to the pain medications, and they can cause respiratory depression. The patient with chronic obstructive pulmonary disease (COPD) is probably the second patient the nurse assesses because the disease is pulmonary. If the patient hypoventilates because the pain is too great, he or she is likely to retain additional carbon dioxide, inadequately oxygenate, and potentially have respiratory acidosis and respiratory failure. The other patients would be assessed as soon as possible. DIF: Cognitive Level: Analyze REF: Page 332OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse assesses the patient who is 2 days postoperative to determine the need for continuing patient-controlled analgesia (PCA). Which information should the nurse use to decide that the patient is ready for oral administration of analgesia?
|a.||Patient is hypoventilating.|
|b.||Pain level ranges from 2 to 4.|
|c.||Sedation level is consistent.|
|d.||BP is 168/96, HR 110, RR 26.|
ANS: BThe nurse uses the patient’s pain level ranging from 2 to 4 to help determine that oral analgesia is suitable for him or her because the patient’s pain level is consistently below the mid-range on the pain scale. PCA is more suitable for moderate-to-severe pain, and oral analgesia is more suitable for low-to-moderate pain. Hypoventilation is an adverse effect of opioid analgesia, regardless of the administration method. Hypoventilation indicates that the patient potentially receives an excessive dose of opioid or that the dose remains inadequate and the patient is hypoventilating to prevent pain. A consistent sedation level is vague and provides little information about patient status. It can indicate a serious neurological impairment or excessive dosing and warrants further investigation. An elevated blood pressure, heart rate, and respiratory rate are nonverbal indicators of pain and indicate inadequate pain relief. However, these readings alone give no indication of the best route for administration of analgesia. DIF: Cognitive Level: Analyze REF: Page 328OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Evaluation
- The patient who receives patient-controlled analgesia (PCA) with an opioid analgesic reports that the pain level is 9 on a scale of 0 to 10. Which does the nurse implement to increase patient pain control?
|a.||Elevates the head of the bed (HOB) to 30 degrees|
|b.||Increases the interval between demand doses|
|c.||Increases the demand and the basal doses|
|d.||Checks patient manipulation of the PCA button|
ANS: DThe nurse checks to ensure that the patient understands and executes depression of the PCA button for on-demand doses. If the patient does not operate the button or does so ineffectively, he or she receives inadequate pain control. The nurse can elevate the HOB if the patient is oversedated and difficult to arouse unless it is contraindicated. By elevating the HOB, the nurse repositions and enables the patient to receive more environmental stimulation. The patient receives less medication when the time between demand doses is increased. The nurse avoids increasing the basal rate and demand dose simultaneously to prevent oversedation because increasing each rate of administration increases the total potential dose twice. DIF: Cognitive Level: Application REF: Page 336OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The nurse receives the patient in the postanesthesia recovery unit and assesses the epidural analgesic infusion. Which is the nurse’s priority?
|a.||The filter needle is attached to the catheter tubing.|
|b.||The distal end of the tubing is attached to the catheter.|
|c.||The infusion contains an opioid and a local anesthetic.|
|d.||The pump settings match the provider prescription.|
ANS: CCombining an opioid with a local anesthetic agent increases the patient’s risk of complications from epidural analgesia because adding another agent exposes the patient to the risks of both medications, risks from drug-drug interactions, and risks of epidural analgesia. The filter needle is used to remove microscopic debris as the medication is withdrawn from the medication vial and is removed before injecting the medication into the infusion fluid. A filter needle piggybacked into the epidural catheter is likely to increase the pressure necessary to pump the infusion through the catheter and activate the high-pressure alarm on the infusion pump. The nurse should replace the filter needle with a standard needle or needleless adapter. Attaching the distal end of the tubing to the epidural catheter is correct. Matching the pump settings to the provider prescription is expected nursing behavior. DIF: Cognitive Level: Analyze REF: Page 328| Page 337OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- A patient is receiving care for a soft tissue sports injury. Which explanation by the nurse explains part of the treatment using the acronym PRICE?
|a.||“I’ll be alternating ice and heat to the injured area.”|
|b.||“You’ll be exercising with ice packs for a while.”|
|c.||“Rest is indicated before and after cold treatments.”|
|d.||“The cold therapy decreases venous congestion.”|
ANS: DPRICE means protect from further injury, rest, ice, compression, and elevation, the standard treatment for a sports injury. The treatment decreases venous congestion as follows: rest decreases the gravitational pull on fluid to the extremity; ice vasoconstricts to limit edema, bleeding, and inflammation; compression prevents venous pooling; and elevation increases the gravitational pull on fluid from the affected region. Applying heat to an injury is usually contraindicated because it increases blood flow to the affected tissue. Exercise after a sports injury is applicable in selected cases and follows RICE therapy. The nurse usually recommends rest with a sports injury, but this is not the intended meaning of RICE. DIF: Cognitive Level: Comprehension REF: Page 350OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The patient complains of a slight burning-like pain and numbness on the skin under a cold compress. Which action should the nurse take immediately?
|a.||Reassure the patient that some numbness is expected.|
|b.||Assess the entire patient before continuing the treatment.|
|c.||Remove the compress and assess the affected area.|
|d.||Provide a warm blanket for the patient’s treatment.|
ANS: CAlthough sensation in the affected region changes during cold therapy, the nurse should first remove the compress and assess the area in response to the patient complaint. The patient will first sensation feel cold, followed by analgesia, burning skin pain, and numbness. Tingling is often associated with numbness as an indication of nerve impairment; thus the nurse assesses the patient before continuing therapy. The patient’s skin potentially benefits from passive rewarming and another nursing assessment to rule out tissue damage. Numbness in the affected region is associated with an increased risk of adverse effects from cold therapy. The nurse wants the patient to feel the cold and analgesic phases of cold therapy sensations. He or she assesses the tissue before discontinuing the cold therapy. Providing a blanket is a reasonable intervention as cold therapy begins to prevent shivering. However, although shivering consumes massive amounts of oxygen, the blanket is unlikely to affect the sensation of tissue treated with cold therapy. DIF: Cognitive Level: Application REF: Page 350| Page 353OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse teaches the patient in ambulatory care to apply ice packs to an injured knee. What instructions should the nurse include in patient teaching?
|a.||Leave the ice on for no more than 5 minutes.|
|b.||Remove the ice pack when the ice melts completely.|
|c.||A cold pack has the potential to cause tissue damage.|
|d.||Apply ice for an hour and then apply a heating pad.|
ANS: CThe nurse should explain that prolonged application of ice can lead to tissue damage from prolonged vasoconstriction. The patient should be instructed to apply the ice for 10 to 20 minutes, then remove the ice for 30 minutes and check affected tissue before repeating the cycle to prevent tissue damage. Applying ice for 5-minute increments is subtherapeutic treatment. The nurse avoids teaching the patient to leave the ice in place until it melts because it is likely to result in ice application exceeding 20 minutes and increase the risk for tissue damage. Application of ice for 1 hour exceeds the 20-minute recommendation to prevent tissue damage. DIF: Cognitive Level: Application REF: Page 351OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The school nurse provides first aid to the 10-year-old student with a new uncomplicated arm fracture. The nurse wants to provide nonpharmacological pain relief and minimize regional edema. Which first-aid treatment does the nurse provide for the patient?
|a.||A cold compress|
|b.||A covered ice bag|
|c.||An aquathermia pad|
|d.||A moist heat compress|
ANS: BThe nurse applies an ice bag with a cover between it and the student’s arm to reduce pain, swelling, and bleeding because cold therapy provides a regional anesthetic effect and vasoconstricts to limit regional blood flow. The nurse protects the student’s arm from thermal injury by wrapping the ice bag before the application. A cold compress is inadequate to provide regional vasoconstriction for a fractured arm. Heat application from an aquathermia pad or a moist compress is contraindicated for the fracture because both therapies increase blood flow and promote vasodilation. The fluid pressure in the area can increase from the heat to increase patient pain, bleeding, and edema. DIF: Cognitive Level: Application REF: Page 350OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- The nurse plans care for four patients receiving heat therapy. Which patient admission diagnosis presents the highest risk of injury to an extremity?
ANS: DThe patient admitted for a peripheral neuropathy has the highest risk for a heat therapy injury because he or she has impaired sensation to the extremities, meaning that the patient has difficulty sensing pain, heat, and pressure. This patient is more likely to incur tissue damage from heat therapy because he or she has impaired ability to sense excessive heat. The patient with osteoarthritis can have a slightly higher risk of thermal injury from heat therapy if patient mobility is impaired because a self-protective mechanism is withdrawal from noxious sensations such as excessive heat. Patients with nephrolithiasis, kidney stones, and chronic bronchitis can be suitable candidates for heat therapy because these diagnoses are unrelated to peripheral perfusion, sensation, or movement. DIF: Cognitive Level: Analyze REF: Page 348OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The nursing assistive personnel (NAP) reports that the patient is dizzy during a warm sitz bath. Which action should the nurse take before moving the patient?
|a.||Check the patient’s pulse rate.|
|b.||Dry off the patient completely.|
|c.||Ask the patient if he or she is able to ambulate.|
|d.||State that dizziness is common.|
ANS: AThe nurse should assess the patient’s pulse rate to determine if the patient is stable enough to either continue the bath or ambulate back to bed with assistance. Unless a sphygmomanometer is readily available, taking the pulse is a good clinical indicator to evaluate hypotension indirectly because when the blood pressure falls, the heart rate increases to maintain the cardiac output. The patient should remain in place until the nurse assesses him unless he has a cardiovascular or chronic pulmonary condition and is shivering. If one of these conditions is present, the nurse and the NAP should dry off the patient, provide warm clothing, and return him to bed. Dizziness is a common response to a warm bath for patients who are older or who have cardiovascular, neurovascular, or chronic pulmonary conditions, but the nurse needs to assess the patient before deciding what is happening. DIF: Cognitive Level: Apply REF: Page 348OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse admits a patient with left hand and wrist cellulitis. Which action does the nurse take when applying dry heat to the area using an aquathermia pad?
|a.||Keeps the fluid chamber in the device empty|
|b.||Covers the pad with a towel or pillowcase|
|c.||Positions the patient directly on the pad|
|d.||Sets the aquathermia temperature at 36.6° C (98° F)|
ANS: BTo implement dry heat with an aquathermia pad, the nurse covers the pad with a layer of insulation to help prevent skin exposure to excessive heat that potentially leads to maceration. The nurse sustains the fluid in the aquathermia pad reservoir because the heat that it provides radiates from warm fluid circulating through the pad. The nurse avoids positioning a patient directly on an aquathermia pad for heat therapy because it increases the risk of burns and tissue maceration. An aquathermia pad is usually set at 40.5° C (105° F). DIF: Cognitive Level: Apply REF: Page 346OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Implementation
- In the postanesthesia care unit the nurse applies an ice bag to the patient’s leg at the surgical site. Which therapeutic effect does the nurse expect from this treatment?
|a.||Decreased pain and diaphoresis|
|b.||Decreased bleeding and vasoconstriction|
|c.||Vasodilation and decreased blood flow|
|d.||Increased oxygenation and increased inflammation|
ANS: BThe nurse applies cold therapy to the patient’s surgical site for regional vasoconstriction, which also decreases bleeding. Diaphoresis commonly occurs with dry heat therapy, but decreased pain can occur with cold or heat therapy, depending on the type of injury. Cold therapy causes vasoconstriction, not vasodilation, and blood flow is decreased as a result of vasoconstriction. DIF: Cognitive Level: Comprehend REF: Page 350OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The patient received treatment for a sprained ankle and is receiving home care instructions regarding cold therapy. Which instructions should the nurse include?
|a.||Place the gel pack on the ankle for 30 minutes every 4 hours for the first 48 hours after the injury.|
|b.||Wrap the ankle with a lightweight cloth before applying the ice bag to it.|
|c.||Wrap the elastic bandage firmly before applying the ice to the ankle.|
|d.||Immerse the foot in a pan of ice water every 4 hours for as long as the patient can wiggle his toes.|
ANS: BThe patient needs to prevent direct exposure of the skin to the ice bag. The gel pack must be wrapped before being put against the ankle. The elastic bandage can interfere with circulation if wrapped too tightly, and the wrap itself can prevent the cold from being effective. Immersion would require the patient to place his foot in a dependent position, which can increase swelling. DIF: Cognitive Level: Apply REF: Page 351OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MULTIPLE RESPONSE
- The nurse assesses the patient and realizes that patient pain is interfering with postoperative therapies. Which does the nurse determine before using medication and relaxation techniques simultaneously to reduce patient pain? (Select all that apply.)
|a.||The patient has used guided imagery in the past successfully.|
|b.||Nonpharmacological relaxation methods appeal to the patient.|
|c.||The patient moves in the bed and disrupts the nurse incessantly.|
|d.||The provider plans to discharge the patient to home in 2 days.|
|e.||The patient understands written information on relaxation techniques.|
|f.||The patient cannot receive additional analgesia for unresolved pain.|
ANS: A, B, C, FAn integrated approach using pharmacological and nonpharmacological therapies is the most effective method of pain management. Patients who potentially benefit the most from integrated therapies share certain qualities, including successful use of nonpharmacological therapies in the past. A patient who uses relaxation techniques such as guided imagery and massage is more likely to find these techniques appealing as long as the patient achieves success with the technique. Another patient likely to benefit from an integrated approach is the patient with anxiety or fear; excessive movements and disruptions are indications of a problem, including anxiety or fear, which potentially the patient cannot identify. A patient who cannot receive additional pain medication despite continuing pain is likely to benefit from integrated therapy as well. The discharge date is unrelated to assessing the patient before relaxation and guided imagery. The nurse can explain and demonstrate relaxation therapies and guided imagery without the patient reading. DIF: Cognitive Level: Apply REF: Page 319OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning
- The nurse caring for a female patient 1 day after a thoracotomy assesses that the patient is in pain, but the patient states that she has no pain. Which does the nurse use to confirm the patient’s pain?(Select all that apply.)
|a.||Facial grimacing during linen changes|
|b.||Eats a full liquid diet without assistance|
|c.||Uses the incentive spirometer every hour|
|d.||Patient’s culture forbids complaints of pain|
|e.||Has received nothing for pain since surgery|
|f.||Heart rate 110, blood pressure 169/90|
ANS: A, D, E, FTo confirm the pain assessment for a patient who states that she has no pain, the nurse looks for information consistent with a patient in pain. The patient’s verbal message and nonverbal cues are contradictory because facial grimacing is a hallmark sign of pain and discomfort, especially when the patient moves. A potential explanation for the inconsistent verbal and nonverbal messages is that the patient’s culture forbids admitting to pain, necessitating the use of other pain indicators. A thoracotomy usually has a painful postoperative course because the surgical incision is stretched every time the patient breathes; thus a patient who receives no analgesia on the first postoperative day is very unusual. Tachycardia and hypertension are good clinical indicators of pain when the patient expresses contradictory messages about pain. The blood pressure increases because the patient becomes tense and contracts muscle, increasing the force necessary to drive blood through the vasculature. The heart rate increases from the stress response to pain and the resultant surge of epinephrine from the sympathetic nervous system. Eating and breathing deeply are inconsistent with a patient in pain. DIF: Cognitive Level: Analyze REF: Page 317-318OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Assessment
- The nurse assesses a patient who has an epidural catheter for patient-controlled analgesia (PCA) on the second postoperative day. Which patient data does the nurse group together to establish the nurse’s priority? (Select all that belong to the group.)
|a.||Temperature 38.1° C (100.6° F)|
|b.||Patient ready for oral analgesia|
|c.||Low tension on epidural catheter|
|d.||Respiratory rate 14, sedation level 1|
|e.||Epidural drainage looks like medication|
|f.||Hemoglobin 15 mg/dL, leukocytes 14,500|
ANS: A, E, FAccording to the nursing process, the nurse groups interrelated data together to draw a conclusion. This patient is febrile with leukocytosis and clear epidural drainage, clinical indicators of a potential infection. Because fluid is leaking from the insertion site, microorganisms have a potential portal of entry, even though the fluid is of unknown origin. The nurse collaborates with the provider to discontinue the epidural catheter, initiate therapy to eradicate potential infection, and provide adequate pain management by another route. If the fluid is cerebrospinal fluid (CSF), the patient is at risk for a devastating neurological infection and sepsis. Patient readiness for oral analgesia is not as important to patient health and well-being as dealing with the potential infection. Low tension on the catheter, a respiratory rate within normal limits, and a low sedation level are desirable patient data. They are not disregarded by the nurse in formulating nursing care but are less important than a potential infection. The nurse plans nursing care to enhance positive patient assessments to promote health and well-being. DIF: Cognitive Level: Analyze REF: Page 339OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Diagnosis
- The nurse prepares patient-controlled analgesia (PCA) for a postoperative patient in the postanesthesia recovery unit (PACU). To rule out contraindications to therapy, which should the nurse assess before the patient receives PCA?(Select all that apply.)
|a.||Consider patient cognitive level.|
|b.||Evaluate patient communication.|
|c.||Confirm two separate intravenous (IV) infusions.|
|d.||Determine patient physical ability.|
|e.||Assess for history of constipation.|
|f.||Verify patient medication allergies.|
ANS: A, B, D, FThe nurse assesses the patient’s cognitive level to verify suitability of PCA for pain management. If the patient cannot understand instructions, PCA will have little value to the patient in managing pain. The nurse evaluates communication to ensure patient ability to relate pain levels effectively; if the patient does not speak English or is cognitively impaired, the nurse establishes a method of nonverbal communication to determine pain level and effectiveness of therapy. The nurse ensures the patient’s physical ability to depress the PCA button. He or she checks patient allergies to medication before initiating PCA to prevent hypersensitivity reactions. One IV infusion is sufficient for PCA if the infusion is continuous or only infuses the PCA. If PCA is infused through the same tubing as intermittent infusions, the nurse risks bolus administration of the opioid and possibly the local anesthetic agent; this increases the risk of respiratory depression. Constipation does not contraindicate the use of PCA. DIF: Cognitive Level: Apply REF: Page 332OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: Planning MATCHING The nurse prepares to administer pain medication to a patient. Place the following nursing interventions in order, beginning with the initial action of the nurse to administer pain medication safely.
|a.||Compare routes on an equianalgesic chart.|
|b.||Determine the patient response to analgesia.|
|c.||Ask the patient to rate the pain a scale of 1 to 10.|
|d.||Check the last analgesia administration time.|
- Step 1
- Step 2
- Step 3
- Step 4
- ANS: C DIF: Cognitive Level: Apply REF: Page 329
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: PlanningMSC: When changing to another route, the nurse refers to the opioid equianalgesic chart to ensure equal potency of two or more routes of the same medication. This helps to make sure that the patient receives the same-strength dose when the administration route changes.
- ANS: D DIF: Cognitive Level: Apply REF: Page 329
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: PlanningMSC: After administering the analgesic, the nurse asks the patient to quantify the pain, to evaluate the effectiveness of the analgesic, and allows a suitable time interval after administration.
- ANS: A DIF: Cognitive Level: Apply REF: Page 329
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: PlanningMSC: The process begins as the nurse asks the patient to quantify the pain to help assess the need for analgesia and establish baseline data.
- ANS: B DIF: Cognitive Level: Apply REF: Page 329
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: PlanningMSC: To avoid the risk of adverse effects and administering pain medication before the interval specified on the prescription, the nurse checks the medication administration record (MAR) for the last administration time of the analgesic. The nurse prepares to administer patient-controlled analgesia (PCA) to a patient. Rank the nursing interventions in sequential order.
|a.||Allow the patient to depress the PCA system button before infusion begins.|
|b.||Prime the tubing with medication from the drug reservoir.|
|c.||Instruct the patient that lockout time prevents overdose.|
|d.||Insert the PCA tubing into the injection port nearest the patient.|
- Step 1
- Step 2
- Step 3
- Step 4
- ANS: B DIF: Cognitive Level: Apply REF: Page 333
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: PlanningMSC: The nurse initiates PCA administration by explaining the purpose and demonstrating the function of PCA to the patient and family to ensure patient understanding of PCA and to fulfill a patient right to information and informed consent.
- ANS: C DIF: Cognitive Level: Apply REF: Page 333
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: PlanningMSC: Part of patient preparation for PCA is to provide an opportunity for the patient to try the PCA button before beginning the infusion.
- ANS: A DIF: Cognitive Level: Apply REF: Page 333
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: PlanningMSC: The nurse properly programs the PCA infusion device according to agency policy and then primes the PCA tubing before inserting it into the intravenous (IV) port.
- ANS: D DIF: Cognitive Level: Apply REF: Page 333
OBJ: NCLEX: Physiological Integrity TOP: Nursing Process: PlanningMSC: To avoid filling a long length of IV tubing with opioid medication, the nurse uses the port closest to the patient; the shorter the distance between the medication and the patient, the lower the amount of medication in the tubing, and the smaller the potential dose of accidental bolus administration.