Chapter 22: Care of Patients with Alterations in Health My Nursing Test Banks

Chapter 22: Care of Patients with Alterations in Health

Cooper and Gosnell: Foundations and Adult Health Nursing, 7th Edition

MULTIPLE CHOICE

1.Why should the nurse instill eye irrigation from the inner to the outer canthus?

a. To avoid harming the sclera
b. To include the conjunctiva in the irrigation
c. To keep the pupil constricted
d. To protect the nasolacrimal ducts

ANS: D

The irrigation flow is directed to the outer canthus to protect the nasolacrimal ducts from contaminants.

PTS: 1 DIF: Cognitive Level: Application REF: Page 615

OBJ:1TOP:Eye irrigation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2.When an order for eye irrigation is received, to whom can the nurse delegate the procedure to?

a. The patient
b. Another nurse
c. A nursing assistant
d. A family member

ANS: B

Performing eye irrigation requires the skills of a licensed nurse.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 615

OBJ: 1 TOP: Delegation KEY: Nursing Process Step: Planning

MSC:NCLEX: Safe, Effective Care Environment

3.To what temperature should water for eye compress be heated?

a. 95 F
b. 110 F
c. 115 F
d. 120 F

ANS: D

Water for an eye compress may be heated to no more than 120 F.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Pages 618, Skill 22-2

OBJ:2TOP:Eye compress

KEY:Nursing Process Step: Implementation

MSC:NCLEX: Safe, Effective Care Environment

4.When a patient complains of progressive hearing loss, crackling and ringing noises in his ear, and progressive ear pain, what should the nurse assess for?

a. A dead battery in the patients hearing aid
b. Cerumen impaction
c. Sinus congestion
d. A middle ear infection

ANS: B

Symptoms of cerumen impaction are progressive hearing loss, bothersome noises in the ear, and progressive ear pain.

PTS: 1 DIF: Cognitive Level: Application REF: Page 617

OBJ:1TOP:Cerumen impaction

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5.When a patient asks if he can keep the heating pack on his leg all the time, the nurse reminds him of which of the following complication of long-term heat application?

a. The heat can cause extreme vasoconstriction.
b. The heat can increase the possibility of infection.
c. The heat can cause the blood pressure to increase.
d. The heat can damage epithelial cells.

ANS: D

Prolonged contact with heat can cause damage to the epithelial cells.

PTS: 1 DIF: Cognitive Level: Application REF: Page 622

OBJ:2TOP:Heat applications

KEY:Nursing Process Step: Implementation

MSC:NCLEX: Safe, Effective Care Environment

6.How does an Aquathermia pad differ from a traditional heating pad?

a. The Aquathermia pad can be folded to fit the anatomic location snugly.
b. The Aquathermia pad can be placed under the patient.
c. The Aquathermia pad has circulating water for temperature control.
d. The Aquathermia pad can be left on for as long as 2 hours.

ANS: C

The Aquathermia pad should not be folded or placed under the patient, nor should it be left on for longer than 20 minutes. The Aquathermia pad has water that circulates and stays warm for the entire time of the treatment with no need to reheat the compress.

PTS: 1 DIF: Cognitive Level: Application REF: Page 626

OBJ:2TOP:Aquathermia pad

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7.What gauge needle should be selected by the nurse when preparing to administer blood?

a. 25
b. 22
c. 21
d. 18

ANS: D

A large-bore needle will allow blood flow without clogging.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 632

OBJ:6TOP:Blood administration

KEY:Nursing Process Step: Implementation

MSC:NCLEX: Safe, Effective Care Environment

8.What is the nurses first priority when a patient receiving IV fluid therapy shows an increase in blood pressure and has bilateral crackles?

a. Raise the head of the bed
b. Slow the infusion
c. Turn the patient to the left side
d. Notify the charge nurse

ANS: B

When signs of circulatory overload are observed, the infusion is slowed down initially, then the nurse should notify the charge nurse.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 636

OBJ:4TOP:Fluid overload

KEY:Nursing Process Step: Implementation

MSC:NCLEX: Safe, Effective Care Environment

9.The nurse notes an edematous area around the insertion site of an IV that is cool to the touch and the skin of which appears blanched. Based on these assessment findings, what is the first priority of the nurse?

a. Apply warm compresses to the area
b. Notify the charge nurse
c. Stop the infusion
d. Reposition the arm to improve the fluid flow

ANS: C

The infusion should be stopped and restarted in another location. Warm compresses are contraindicated. Repositioning the arm will not remedy the infiltration. The charge nurse can be notified after the fact.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 636

OBJ: 4 TOP: Infiltration KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

10.While teaching a patient about the signs of IV therapyassociated phlebitis, how does the nurse describe an area with phlebitis?

a. Warm, edematous, and red
b. Painful and cyanotic
c. Painless and numb
d. Edematous and cool

ANS: A

Areas of phlebitis are warm, edematous, and red.

PTS: 1 DIF: Cognitive Level: Application REF: Page 636

OBJ: 4 TOP: Phlebitis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

11.When an older adult patient with chronic emphysema comes to the emergency department in respiratory distress, at what rate should the nurse begin oxygen per nasal cannula?

a. 2 L/min
b. 3 L/min
c. 4 L/min
d. 5 L/min

ANS: A

Administering O2 at more than 2 L/min to a person with chronic pulmonary disease may cause respiratory failure.

PTS: 1 DIF: Cognitive Level: Application REF: Page 648

OBJ:7TOP:O2 administration

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

12.The nurse instructs a patient receiving home O2 therapy to drink plenty of fluids to help keep bronchial secretions liquefied. What is the recommended fluid?

a. Milk
b. Water
c. Tea with artificial sweetener
d. Coffee

ANS: B

Water is the best option. Drinks with caffeine, sugar, or dairy products are not helpful to liquefy secretions.

PTS: 1 DIF: Cognitive Level: Application REF: Page 648

OBJ: 7 TOP: Fluids KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

13.The wife of a patient with a cuffed tracheostomy asks why the cuff is inflated intermittently. What is the purpose of the inflated cuff?

a. Prevent regurgitation after meals
b. Hold the trachea open until it is completely healed
c. Dilate the tracheal opening for passage of secretions
d. Prevent aspiration when eating

ANS: D

The cuff is inflated to prevent aspiration while eating or when cleaning the tracheostomy tube.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 656

OBJ:9TOP:Cuffed tracheostomy tubes

KEY:Nursing Process Step: Implementation

MSC:NCLEX: Safe, Effective Care Environment

14.After a Foley catheter has been removed,  the nurse should assess the patient for:

a. hemorrhage.
b. constipation.
c. urinary retention.
d. bladder spasm.

ANS: C

While an indwelling urinary catheter is in place, the bladder loses tone and can retain urine after the removal of the catheter.

PTS: 1 DIF: Cognitive Level: Application REF: Pages 674, 675, Skill 22-16

OBJ:11TOP:Catheter removal

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

15.What would be the correct explanation of catheter care?

a. Cleansing the first 2 inches of the catheter with soap and water every shift
b. Disinfecting the entire catheter with alcohol every shift
c. Lubricating the catheter with antiseptic lotion every 24 hours
d. Cleansing the meatal-catheter junction every 24 hours

ANS: A

The first 2 inches of the catheter should be cleaned with soap and water every shift or more often if the patient is incontinent. Alcohol and lotions are contraindicated. Catheter care should be done every shift.

PTS: 1 DIF: Cognitive Level: Application REF: Page 669, Skill 22-14

OBJ:11TOP:Catheter care

KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment

16.Which of the following is an appropriate nursing measure when performing tracheostomy care?

a. Wear clean gloves
b. Insert the catheter without suction
c. Suction for 1 minute before removing the catheter
d. Place the used catheter in a plastic shield for later use

ANS: B

Insertion of the suction catheter without suction reduces the probability of tissue injury. Sterile gloves should be used for tracheostomy care. Suctioning should be done for a maximum of 10 seconds at a time. A used catheter should be disposed of appropriately.

PTS: 1 DIF: Cognitive Level: Application REF: Pages 659-661, Skill 22-12

OBJ:9TOP:Tracheal suction

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

17.During insertion of a Foley catheter, the patient grimaces as the balloon is inflated. What is the immediate reaction of the nurse?

a. Withdraw the catheter
b. Ask the patient to bear down
c. Continue to inflate the balloon
d. Advance the catheter into the bladder

ANS: D

Grimacing is a sign of pain indicating that the balloon might be in the urethra instead of the bladder. The catheter should be advanced before inflation.

PTS: 1 DIF: Cognitive Level: Application REF: Pages 665-668, Skill 22-12

OBJ:11TOP:Catheterization

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

18.When explaining the difference between a colostomy and an ileostomy, the nurse explains which of the following about an ileostomy?

a. It is always permanent
b. It drains semi-liquid stool
c. It has a much larger stoma
d. It does not need a pouch

ANS: B

The ileostomy is higher in the GI tract and drains semi-liquid stool. The ileostomy is very similar in appearance to the colostomy, may not be permanent, and needs a pouch.

PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 685

OBJ: 17 TOP: Ileostomy KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

19.Before inserting a nasogastric tube, what measurement should the nurse take?

a. Tip of the nose to the earlobe to the xiphoid process
b. Bridge of the nose to the xiphoid process
c. Nose to the top of the ear to the stomach
d. Clavicular notch to the stomach

ANS: A

The measurement is from the tip of the nose to the ear lobe to the xiphoid process.

PTS: 1 DIF: Cognitive Level: Application REF: Page 679, Skill 22-18

OBJ:13TOP:Nasogastric (NG) tube

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

20.When irrigating an ear, the nurse should perform which intervention(s)? (Select all that apply.)

a. Heat the water to 115 F
b. Pull the auricle back firmly and hold it
c. Place the tip of the syringe loosely in the ear canal
d. Introduce fluid with a slow, gentle irrigation
e. Use a stronger flow if a foreign body is present

ANS: C, D

The water is heated to body temperature, the auricle is pulled gently back, the tip is placed loosely in the ear canal, and the flow is gently introduced. Irrigation is contraindicated if a foreign body is in the canal.

PTS: 1 DIF: Cognitive Level: Application REF: Pages 619-620, Skill 22-3

OBJ:1TOP:Ear irrigation

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

21.Hot moist compresses have which positive effect(s)? (Select all that apply.)

a. Improvement of circulation
b. Relief of edema
c. Consolidation of exudates
d. Enhancement of scabbing
e. Relief of pain

ANS: A, B, C

Hot moist compresses improve circulation, relieve edema, and consolidate exudate. Compresses may delay scabbing and increase pain.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 623-624

OBJ:2TOP:Hot moist compresses

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

COMPLETION

22.The appliance that connects to an IV drip and delivers a continuous irrigation to the eye is known as a ________ _________ _________.

ANS:

Morgan therapeutic lens

A Morgan therapeutic lens attaches to an IV drip and can deliver continuous eye irrigation.

PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 617

OBJ: 1 TOP: Morgan cup KEY: Nursing Process Step: N/A

MSC:NCLEX: N/A

23.The nurse is alert for a serious condition called ___________ that results from pathogens being introduced into the blood stream.

ANS:

septicemia

Septicemia is a condition that results when pathogens are introduced into the blood stream.

PTS: 1 DIF: Cognitive Level: Application REF: Page 637

OBJ: 5 TOP: Septicemia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

OTHER

24.If a patient has a transfusion reaction, the nurse should perform the following interventions in which priority order? Put a comma and space between each answer choice (A, B, C, D, etc.).

a. Take and record vital signs

b. Notify physician and blood bank

c. Stop the transfusion

d. Monitor urine output

e. Return blood and tubing to the blood bank

ANS:

C, A, B, E, D

The correct sequence of interventions is to stop the transfusion, take and record vital signs, notify physician and blood bank of the reaction, return the blood and tubing to the blood bank, and monitor urine output.

PTS: 1 DIF: Cognitive Level: Analysis REF: Page 645

OBJ:6TOP:Transfusion reaction

KEY:Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

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