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Chapter 48: Skin Integrity and Wound Care


1. The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The nurse
recognizes that the risk factors that predispose a patient to pressure ulcer development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain.

2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious.
The nurse is able to identify that the major element involved in the development of a decubitus ulcer is
a. Pressure.
b. Resistance.
c. Stress.
d. Weight.

3. Which nursing observation would indicate that the patient was at risk for pressure ulcer formation?
a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
c. The patient has a raised red rash on the right shin.
d. The patients capillary refill is less than 2 seconds.

4. The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems
to be healing, and healthy tissue is observed. How would the nurse stage this ulcer?
a. Stage I pressure ulcer
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer

5. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the
right heel of the patient. This pressure ulcer would be staged as stage
a. I.
b. II.
c. III.
d. IV.

6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging
an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light

7. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of
a. Primary intention.
b. Partial-thickness wound repair.
c. Full-thickness wound repair.
d. Tertiary intention.

8. The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface
in _____ day(s).
a. 4
b. 2
c. 1
d. 7

9. The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of
a. Eschar
b. Slough
c. Granulation
d. Purulent drainage

10. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by
a. Tertiary intention.
b. Secondary intention.
c. Partial-thickness repair.
d. Primary intention.

11. The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by
a. Tertiary intention.
b. Secondary intention.
c. Partial-thickness repair.
d. Primary intention.

12. Which nursing observation would indicate that a wound healed by secondary intention?
a. Minimal scar tissue
b. Minimal loss of tissue function
c. Permanent dark redness at site
d. Scarring can be severe.

13. The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the patient was
experiencing a complication of wound healing?
a. The incision site has started to itch.
b. The incision site is approximated.
c. The patient has pain at the incision site.
d. The incision has a mass, bluish in color.

14. Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence?
a. Complaint by patient that something has given way
b. Protrusion of visceral organs through a wound opening
c. Chronic drainage of fluid through the incision site
d. Drainage that is odorous and purulent

15. A patient has developed a decubitus ulcer. What laboratory data would be important to gather?
a. Serum albumin
b. Creatine kinase
c. Vitamin E
d. Potassium

16. Which of the following would be the most important piece of assessment data to gather with regard to wound healing?
a. Muscular strength assessment
b. Sleep assessment
c. Pulse oximetry assessment
d. Sensation assessment

17. The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent
discharge, along with increased redness at the wound site. What is the next best step for the nurse?
a. Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results.
b. Notify the charge nurse about the change in status and the potential for infection.
c. Notify the physician by utilizing Situation, Background, Assessment, and Recommendation (SBAR).
d. Notify the wound care nurse about the change in status and the potential for infection.

18. The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a meal plan
that includes increased
a. Fat.
b. Carbohydrates.
c. Protein.
d. Vitamin E.

19. The nurse is completing an assessment on an individual who has a stage IV pressure ulcer. The wound is odorous, and a drain is currently in place.
The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following?
a. I think I will be ready to go home early next week.
b. I am so weak and tired, I want to feel better.
c. I am ready for my bath and linen change as soon as possible.
d. I am hoping there will be something good for dinner tonight.

20. A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable,
the next best step is to
a. Inspect the wound for bleeding.
b. Inspect the wound for foreign bodies.
c. Determine the size of the wound.
d. Determine the need for a tetanus antitoxin injection.

21. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which of these
actions should the nurse take first?
a. Don sterile gloves.
b. Provide analgesic medications as ordered.
c. Avoid accidentally removing the drain.
d. Gather supplies.

22. The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease
in drainage. What would be the nurses next best step?
a. Remove the drain; a drain is no longer needed.
b. Call the physician; a blockage is present in the tubing.
c. Call the charge nurse to look at the drain.
d. As long as the evacuator is compressed, do nothing.

23. The nurse is caring for a patient who has a stage IV pressure ulcer awaiting plastic surgery consultation. Which of the following specialty beds
would be most appropriate?
a. Standard mattress
b. Nonpowered redistribution air mattress
c. Low-air-loss therapy unit
d. Lateral rotation

24. The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this
patient includes
a. Monitoring of the wound.
b. Irrigation of the wound.
c. Dbridement of the wound.
d. Management of drainage.

25. The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the
nurse question?
a. Use a low-air-loss therapy unit.
b. Consult a dietitian.
c. Irrigate with hydrogen peroxide.
d. Utilize hydrogel dressing.

26. The nurse is completing an assessment of the skins integrity, which includes
a. Pressure points.
b. All pulses.
c. Breath sounds.
d. Bowel sounds.

27. The nurse is completing a skin risk assessment utilizing the Braden scale. The patient has some sensory impairment and skin that is rarely moist,
walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. What
would be the patients Braden scale total score?
a. 15
b. 17
c. 20
d. 23

28. The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patients willingness and ability to
increase mobility, which intervention is most important for the nurse to complete?
a. Encourage the patient to sit up in the chair.
b. Provide analgesic medication as ordered.
c. Explain the risks of immobility to the patient.
d. Turn the patient every 3 hours while in bed.

29. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns which of the following nursing diagnoses?
a. Readiness for enhanced nutrition
b. Impaired physical mobility
c. Impaired skin integrity
d. Chronic pain

30. The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the
nurse assign?
a. Ineffective tissue perfusion
b. Risk for infection
c. Imbalanced nutrition: less than body requirements
d. Acute pain

31. The nurse is caring for a patient with a stage III pressure ulcer. The nurse has assigned a nursing diagnosis of Risk for infection. Which intervention
would be most important for this patient?
a. Teach the family how to manage the odor associated with the wound.
b. Discuss with the family how to prepare for care of the patient in the home.
c. Encourage thorough handwashing of all individuals caring for the patient.
d. Encourage increased quantities of carbohydrates and fats.

32. The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. The nurse consults a
a. Respiratory therapist.
b. Registered dietitian.
c. Chaplain.
d. Case manager.

33. The nurse is caring for a patient with a stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious
and bedridden. The nurse is completing the plan of care and is writing goals for the patient. What is the best goal for this patient?
a. The patients family will demonstrate specific care of the wound site.
b. The patient will state what to look for with regard to an infection.
c. The patient will remain free of an increase in temperature and of odorous or purulent drainage from the
d. The patients family members will wash their hands when visiting the patient.

34. The nurse is caring for a postpartum patient. The patient has an episiotomy after experiencing birth. The physician has ordered heat to treat this
condition, and the nurse is providing this treatment. This patient is at risk for
a. Infection.
b. Impaired skin integrity.
c. Trauma.
d. Imbalanced nutrition.

35. The home health nurse is caring for a patient with impaired skin integrity in the home. The nurse is reviewing dressing changes with the caregiver.
Which intervention assists in managing the expenses associated with long-term wound care?
a. Sterile technique
b. Clean dressings and no touch technique
c. Double bagging of contaminated dressings
d. Ability of the caregiver

36. The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which
initial interventions should the nurse select to decrease this risk?
a. Gentle cleaners and thorough drying of the skin
b. Absorbent pads and garments
c. Positioning with use of pillows
d. Therapeutic beds and mattresses

37. The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the
plan of care. How long should the nurse schedule the patient to sit in the chair?
a. At least 3 hours
b. Not longer than 30 minutes
c. Less than 2 hours
d. As long as the patient remains comfortable

38. The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. What is the best
method for repositioning the patient?
a. Obtain assistance and use the drawsheet to place the patient into the new position.
b. Place the patient in a 30-degree supine position.
c. Utilize a transfer sliding board and assistance to slide the patient into the new position.
d. Elevate the head of the bed 45 degrees.

39. The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care
of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage
a. I.
b. II.
c. III.
d. IV.

40. The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What should the nurse
do to decrease the patients anxiety?
a. Tell the patient to close his eyes.
b. Explain the procedure.
c. Turn on the television.
d. Ask the family to leave the room.

41. The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included?
a. Allowing the solution to flow from the most contaminated to the least contaminated
b. Scrubbing vigorously when applying solutions to the skin
c. Cleansing in a direction from the least contaminated area
d. Utilizing clean gauge and clean gloves to cleanse a site

42. The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the
binder. What is the best explanation for the nurse to use when teaching the patient the reason for the binder?
a. The binder creates pressure over the abdomen.
b. The binder supports the abdomen.
c. The binder reduces edema at the surgical site.
d. The binder secures the dressing in place.

43. The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the procedure, which
intervention should the nurse implement?
a. Monitor vital signs every 15 minutes.
b. Apply brace to right knee.
c. Elevate right knee and apply ice.
d. Check pulses in right foot.

44. The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission. The nurse has
implemented interventions for this nursing diagnosis. Upon reassessment, which Braden score would be the best sign that the risk for skin
breakdown is decreasing?
a. 12
b. 13
c. 20
d. 23

Chapter 28: Infection Prevention and Control


1. The nurse is caring for a patient with pneumonia with a new nurse in orientation. Which of the following statements by the new nurse would
indicate an understanding of the nature of this condition?
a. An infectious disease like pneumonia may not pose a risk to others.
b. We need to isolate the patient in a negative pressure room.
c. The patient will not be able to return home.
d. Clinical signs and symptoms are not present in pneumonia.

2. The patient and the nurse are discussing Rickettsia rickettsiiRocky Mountain spotted fever. Which patient statement to the nurse indicates
understanding regarding the mode of transmission of this disease?
a. When I go camping, I will be sure to wear sunscreen.
b. When I go camping, I will drink bottled water.
c. When I go camping, I will be sure to wear insect repellent.
d. When I go camping, I will be sure to use hand gel on my hands.

3. The nurse is providing an educational session for a group of preschool workers. The nurse reminds the group that the most important thing to do to
prevent the spread of infection is to
a. Encourage preschool children to eat a nutritious diet.
b. Encourage parents to provide a multivitamin to the children.
c. Clean the toys every afternoon before putting them away.
d. Wash their hands between each interaction with children.

4. The nurse is admitting a patient with an infectious disease process. What question would be appropriate for a nurse to ask this patient?
a. Do you have a chronic disease, and how long have you had it?
b. Do you have any children living in the home?
c. What is your marital statussingle, married, or divorced?
d. Do you have any cultural or religious beliefs that will influence your care?

5. The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurses assessment
indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patients
temperature is 100.5 F and the WBC is 10,500/mm
. Which nursing action should the nurse take?
a. Plan to change the surgical dressing during the shift.
b. Check to see what solution was used for skin preparation in surgery.
c. Collect supplies to culture the surgical incision.
d. Utilize SBAR to call and communicate the patients needs to the physician.

6. The nurse is providing an education session to an adult community group about the effects of smoking. Which of the following is the most
important point to be included in the educational session?
a. Smoke from tobacco products clings to your clothing and hair.
b. Smoking affects the cilia lining the upper airways in the lungs.
c. Smoking tobacco products can be very expensive.
d. Smoking can affect the color of the patients fingernails.

7. A female adult patient presents to the clinic with reports of a white discharge and itching in the vaginal area. During the health history, which of
these questions should the nurse prioritize?
a. When was the last time you visited the physician?
b. Has this condition affected your eating habits?
c. What medications are you currently taking?
d. Are you able to sleep at night?

8. The nurse is caring for a school-aged child who has injured his leg after a bicycle accident. To determine whether the child is experiencing a
localized inflammatory response, the nurse should assess for which of these signs and symptoms?
a. Fever, malaise, anorexia, and nausea and vomiting
b. Chest pain, shortness of breath, and nausea and vomiting
c. Dizziness and disorientation to time, date, and place
d. Edema, redness, tenderness, and loss of function

9. Which interventions utilized by the nurse would indicate the ability to recognize the inflammatory response?
a. Rest, ice, compression, and elevation
b. Turn, cough, and deep breathe
c. Orient to date, time, and place
d. Passive range-of-motion exercises

10. The nurse is caring for a group of medical-surgical patients. The patient most at risk for developing an infection is the patient who
a. Is in observation for chest pain.
b. Is recovering from a right total hip arthroplasty.
c. Has been admitted with dehydration.
d. Has been admitted for stabilization of atrial fibrillation.

11. The nurse is caring for a patient with leukemia and is preparing to provide fluids through a vascular access device. Which nursing intervention is
priority in this procedure?
a. Position the patient comfortably.
b. Maintain aseptic technique.
c. Gather available supplies.
d. Review the procedure with the patient.

12. The nurse is caring for an adult patient in the clinic who has been evacuated and is a victim of flooding. The patient presents with signs and
symptoms of a urinary tract infection. Along with needed education surrounding this diagnosis, the nurse teaches the patient about rest, exercise,
eating properly, and how to utilize deep breathing and visualization. Which of these explanations would best support these nursing interventions?
a. Urinary tract infections are painful, and these techniques would help with managing the pain.
b. Interventions listed are standard topics taught during health care visits.
c. Stress for long periods of time can lead to exhaustion and decreased resistance to infection.
d. The patient requested this information to teach to extended family at home.

13. The nurse is caring for a patient who is susceptible to infection. Which of the following nursing interventions will assist in decreasing the risk of
a. Teaching the patient about fall prevention
b. Teaching the patient to select nutritious foods
c. Teaching the patient to take a temperature
d. Teaching the patient about the effects of alcohol

14. A diabetic patient presents to the clinic for a dressing change. The wound is located on the right foot and has purulent yellow drainage. Which of
these interventions would be most appropriate for the nurse to provide?
a. Position the patient comfortably on the stretcher.
b. Explain the procedure for dressing change to the patient.
c. Don gloves and other appropriate personal protective equipment.
d. Review the medication list that the patient brought from home.

15. Which of these interventions would take priority and should be included in a plan of care for a patient who presents with pneumonia?
a. Observe the patient for decreased activity tolerance.
b. Assume that the patient is in pain and treat accordingly.
c. Maintain the temperature at 65 F.
d. Provide the patient ice chips as requested.

16. The nurse is inserting a peripherally inserted central catheter (PICC) into the patient. Aware of the potential for health careassociated infection,
the nurse is careful to
a. Prepare the skin with 2% chlorhexidine gluconate.
b. Select a catheter of appropriate size for the appropriate vein.
c. Use nonallergenic tape and dressings on the patient.
d. Utilize local anesthetic on the site as ordered.

17. The infection control nurse is reviewing data for the medical-surgical unit. The nurse notices a spike in postoperative infections on this unit and
categorizes this type of health careassociated infection as _____ infections.
a. Iatrogenic
b. Exogenous
c. Endogenous
d. Nosocomial

18. The patient has contracted a urinary tract infection while in the hospital. Which of these actions would most likely increase the risk of a patient
contracting a urinary tract infection (UTI)?
a. Emptying the urinary drainage bag once a shift
b. Reusing the patients graduated receptacle to empty the drainage bag
c. Allowing the drainage bag port to touch the graduated receptacle
d. Providing perineal hygiene at least once a shift

19. Which of the following nursing actions would most increase a patients risk for developing a health careassociated infection?
a. Use of surgical aseptic technique to suction an airway
b. Urinary catheter drainage bag placed below the level of the bladder
c. Clean technique for inserting a urinary catheter
d. Use of a sterile bottled solution more than once within a 24-hour period

20. The nurse is caring for a patient in labor and delivery. When near completing an assessment of the patient for dilatation and effacement, the
electronic infusion device being used on the intravenous infusion alarms. Which of these actions is most appropriate for the nurse to take?
a. Complete the assessment, remove gloves, and silence the alarm.
b. Discontinue the assessment, and assess the intravenous infusion.
c. Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion.
d. Discontinue the assessment, remove gloves, use hand gel, and assess the intravenous infusion.

21. The nurse is dressed and is preparing to care for a patient in the perioperative area. The nurse has scrubbed her hands and has donned a sterile
gown and gloves. Which action would indicate a break in sterile technique?
a. Touching protective eyewear
b. Standing with hands folded on chest
c. Accepting sterile supplies from the surgeon
d. Staying with the sterile table once it is open

22. The nurse is caring for a patient with an incision. Which of the following actions would best indicate an understanding of medical and surgical
a. Donning sterile gown and gloves to remove the wound dressing
b. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing
c. Donning clean goggles, gown, and gloves to dress the wound
d. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing

23. The nurse is caring for a patient in the endoscopy area. The nurse observes the technician performing these tasks. Which of these observations
would require the nurse to intervene?
a. Washing hands after removing gloves
b. Placing the endoscope in a container for transfer
c. Removing gloves to transfer the endoscope
d. Disinfecting endoscopes in the workroom

24. The nurse is caring for a patient with a nursing diagnosis of risk for infection. Aware of the need for Standard Precautions, the nurse is careful to
a. Teach the patient about good nutrition.
b. Wear eyewear when emptying a urinary drainage bag.
c. Avoid contact with intact skin without wearing gloves.
d. Don gloves when wearing artificial nails.

25. The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the patient for excessive vaginal drainage. It is important
for the nurse to utilize _____ Precautions.
a. Contact
b. Protective
c. Droplet
d. Standard

26. The nurse is caring for a patient in the hospital. The nurse observes the nursing assistant turning off the handle faucet with his hands. What
professional practice supports the need for follow-up with the nursing assistant?
a. The nurse is responsible for providing a safe environment for the patient.
b. This is a key step in the procedure for washing hands.
c. Allowing the water to run is a waste of resources and money.
d. Different scopes of practice allow modification of procedures.

27. The nurse is caring for a patient who becomes nauseated and vomits without warning. The nurse has contaminated hands. The nurses best next
step is to
a. Clean hands with wipes from the bedside table.
b. Wash hands with an antimicrobial soap and water.
c. Use an alcohol-based waterless hand gel.
d. Instruct the patient to wash his face and hands.

28. The nurse is performing hand hygiene before assisting a physician with insertion of a chest tube. While washing hands, the nurse touches the sink.
What is the next action the nurse should take?
a. Inform the physician and recruit another nurse to assist.
b. Rinse and dry hands, and begin assisting the physician.
c. Repeat handwashing using antiseptic soap,
d. Extend the handwashing procedure to 5 minutes.

29. The nurse is caring for a patient on the medical-surgical unit. The nurse and the physician have completed an invasive procedure. What is the next
step in handling the instruments used during the procedure?
a. Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning and
b. Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning and
c. Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning and boiling.
d. Don gloves, gather instruments, place in transport carrier, and send to central sterile for cleaning.

30. The nurse is observing a family member changing a dressing for a patient in the home health environment. Which of these observations would
indicate that the family member has a correct understanding of how to manage contaminated dressings?
a. The family member removes gloves and gathers items for disposal.
b. The family member places the used dressings in a plastic bag.
c. The family member saves part of the dressing because it is clean.
d. The family member wraps the used dressing in toilet tissue before placing in the trash.

31. The nurse is caring for a home health patient. After completing an assessment, the nurse has diagnosed the patient as being at risk for infection.
Which of the following orders would the nurse question?
a. Urinary catheter to bedside drainage bag. May change to leg bag during the day.
b. May reuse nebulizer equipment. Clean with mild soap and warm water, and allow to dry.
c. Prepare enough enteral feedings for 12 hours. Rinse feeding bag and tubing daily.
d. Call for temperature greater than 100.5, heart rate greater than 100, and respiratory rate greater than 24.

32. The home health nurse is teaching a patient and family about hand hygiene in the home. The nurse is sure to emphasize washing hands before
a. And after shaking hands.
b. And after treatments.
c. Opening the refrigerator.
d. And after using a computer.

33. The nurse has been caring for a patient in the perioperative area for several hours. The surgical mask the nurse is wearing has become moist. The
nurses best next step is to
a. Change the mask when relieved.
b. Air-dry the mask while at lunch, and reapply.
c. Ask for relief, step out of the surgical area, and apply a new mask.
d. Not change the mask, if the nurse is comfortable.

34. The nurse is caring for a patient on Contact Precautions. Which of the following actions would be appropriate to prevent the spread of disease?
a. Wear a gown, gloves, face mask, and goggles for interactions with the patient.
b. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only.
c. Place the patient in a room with negative airflow.
d. Transport the patient quickly when going to the radiology department.

35. The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which of the following nursing actions would be appropriate
given this organism?
a. Instruct assistive personnel to use soap and water rather than sanitizer to clean hands.
b. Place the patient on Droplet Precautions.
c. Wear an N95 respirator when entering the patient room.
d. Teach the patient cough etiquette.

36. The nurse is changing linens for a postoperative patient and feels a stick in her hand. A nonactivated safe needle is noted in the linens. This
scenario would indicate that the nurse may be at risk for
a. Hepatitis B.
b. Clostridium difficile.
c. Methicillin-resistant Staphylococcus aureus.
d. Diphtheria.

37. The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood above the glove to intact skin while discontinuing an
intravenous infusion. The nurses best next step is to
a. Obtain an alcohol swab, remove the blood with an alcohol swab, and continue care.
b. Immediately wash the site with soap and running water, and seek guidance from the manager.
c. Delay washing of the site until the nurse is finished providing care to the patient.
d. Do nothing; accidentally getting splashed with blood happens frequently and is part of the job.

38. What would be required after exposure of a nurse to blood by a cut from a scalpel in the perioperative area?
a. Removing sterile gloves and disposing of in kick bucket
b. Placing the scalpel in a needle safe container
c. Testing the patient and offering treatment to the nurse
d. Providing a medical evaluation of the nurse to the manager

Chapter 44: Nutrition

1. The energy needed to maintain life-sustaining activities for a specific period of time at rest is known as
a. BMR.
b. REE.
c. Nutrients.
d. Nutrient density.

2. In general, when energy requirements are completely met by kilocalorie (kcal) intake in food
a. Weight increases.
b. Weight decreases.
c. Weight does not change.
d. Kilocalories are not a factor.

3. In determining kcal expenditure, the nurse knows that carbohydrates and proteins provide 4 kcal of energy per gram ingested. The nurse also
knows that fats provide _____ kcal per gram.
a. 3
b. 4
c. 6
d. 9

4. Some proteins are manufactured in the body, but others are not. Those that must be obtained through diet are known as
a. Amino acids.
b. Dispensable amino acids.
c. Triglycerides.
d. Indispensable amino acids.

5. Knowing that protein is required for tissue growth, maintenance, and repair, the nurse must understand that for optimal tissue healing to occur,
the patient must be in
a. Negative nitrogen balance.
b. Positive nitrogen balance.
c. Total dependence on protein for kcal production.
d. Neutral nitrogen balance.

6. In providing diet education for a patient on a low-fat diet, it is important for the nurse to understand that with few exceptions
a. Saturated fats are found mostly in vegetable sources.
b. Saturated fats are found mostly in animal sources.
c. Unsaturated fats are found mostly in animal sources.
d. Linoleic acid is a saturated fatty acid.

7. Fats are composed of triglycerides and fatty acids. Triglycerides
a. Are made up of three fatty acids.
b. Can be saturated.
c. Can be monounsaturated.
d. Can be polyunsaturated.

8. The patient has been diagnosed with cardiovascular disease and placed on a low-fat diet. The patient asks the nurse, How much fat should I have?
I guess the less fat, the better. The nurse needs to explain that
a. Fats have no significance in health and the incidence of
b. All fats come from external sources so can be easily
c. Deficiencies occur when fat intake falls below 10% of
daily nutrition.
d. Vegetable fats are the major source of saturated fats
and should be avoided.

9. The ChooseMyPlate program was developed to replace MyFoodPyramid as a basic guide for buying food and meal preparations. This system was
developed by the
a. Food and Drug Administration.
b. 1990 Nutrition Labeling and Education Act.
c. Referenced daily intakes (RDIs).
d. U.S. Department of Agriculture.

10. The ChooseMyPlate program includes guidelines for
a. Children younger than 2 years.
b. Balancing calories.
c. Increasing portion size.
d. Decreasing water consumption.

11. The nurse is providing nutrition teaching to a Korean patient. In doing so, the nurse must understand that the focus of the teaching should be on
a. Changing the patients diet to a more conventional
American diet.
b. Discouraging the patients ethnic food choices.
c. Food preferences of the patient, including racial and
ethnic choices.
d. Comparing the patients ethnic preferences with
American dietary choices.

12. When teaching a patient about current dietary guidelines for the general population, the nurse explains referenced daily intakes (RDIs) and daily
reference values (DRVs), otherwise known as daily values. In providing this information, the nurse understands that daily values
a. Have replaced recommended daily allowances (RDAs).
b. Have provided a more understandable format of RDAs
for the public.
c. Are based on percentages of a diet consisting of 1200
d. Are not usually easy to find computer experience is

13. The nurse is teaching the patient about dietary guidelines. In discussing the four components of dietary reference intakes (DRIs), it is important to
understand that
a. The estimated average requirement (EAR) is
appropriate for 100% of the population.
b. The recommended dietary allowance (RDA) meets the
needs of the individual.
c. Adequate intake (AI) determines the nutrient
requirements of the RDA.
d. The tolerable upper intake level (UL) is not a
recommended level of intake.

14. In teaching mothers-to-be about infant nutrition, the nurse instructs patients to
a. Give cows milk during the first year of life.
b. Supplement breast milk with corn syrup.
c. Add honey to infant formulas for increased energy.
d. Remember that breast milk or formula is sufficient for
the first 4 to 6 months.

15. To counter obesity in adolescents, increasing physical activity is often more important than curbing intake. Sports and regular, moderate to intense
exercise necessitate dietary modifications to meet increased energy needs for adolescents. The nurse understands that these modifications include
a. Decreasing carbohydrates to 25% to 30% of total
b. Decreasing protein intake to .75 g/kg/day.
c. Ingesting water before and after exercise.
d. Providing vitamin and mineral supplements.

16. In providing prenatal care to a patient, the nurse teaches the expectant mother that
a. Protein intake needs to decrease to preserve kidney
b. Calcium intake is especially important in the first
c. Folic acid is needed to help prevent birth defects and
d. The mother should take in as many extra vitamins and
minerals as possible.

17. The patient is an 80-year-old male who is visiting the clinic today for his routine physical examination. The patients skin turgor is fair, but he has
been complaining of fatigue and weakness. The skin is warm and dry, pulse rate is 126 beats per minute, and urinary sodium level is slightly
elevated. After assessment, the nurse should recommend that the patient
a. Decrease his intake of milk and dairy products to
decrease the risk of osteoporosis.
b. Drink more grapefruit juice to enhance vitamin C intake
and medication absorption.
c. Drink more water to prevent further dehydration.
d. Eat more meat because meat is the only source of
usable protein.

18. The nurse is assessing a patient for nutritional status. In doing so, the nurse must
a. Choose a single objective tool that fits the patients
b. Combine multiple objective measures with subjective
c. Forego the assessment in the presence of chronic
d. Use the Mini Nutritional Assessment for pediatric

19. The patient has a calculated body mass index (BMI) of 34. This would classify the patient as
a. Unclassifiable.
b. Normal weight.
c. Overweight.
d. Obese.

20. Dysphagia refers to difficulty when swallowing. Of the following causes of dysphagia, which is considered neurogenic?
a. Myasthenia gravis
b. Stroke
c. Candidiasis
d. Muscular dystrophy

21. The patient is elderly and has been diagnosed with Imbalanced nutrition: less than body requirements. Her treatment regimen should include
having the nurse
a. Encourage weight gain as rapidly as possible.
b. Encourage large meals three times a day.
c. Decrease fluid intake to prevent feeling full.
d. Encourage fiber intake.

22. In determining the nutritional status of a patient and developing a plan of care, it is important to evaluate the patient according to
a. Published standards.
b. Nursing professional standards.
c. Absence of family input.
d. Patient input only.

23. In creating a plan of care to meet the nutritional needs of the patient, the nurse needs to explore the patients feelings about weight and food. The
nurse must do this to
a. Determine which category of plan to use.
b. Set realistic goals for the patient.
c. Mutually plan goals with patient and team.
d. Prevent the need for a dietitian consult.

24. The patient is admitted with facial trauma, including a broken nose, and has a history of esophageal reflux and of aspiration pneumonia. Given this
information, which of the following tubes is appropriate for this patient?
a. Nasogastric tube
b. Percutaneous endoscopic gastrostomy (PEG) tube
c. Nasointestinal tube
d. Jejunostomy tube

25. The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted,
the nurse measures from the
a. Tip of the nose to the xiphoid process of the sternum.
b. Earlobe to the xiphoid process of the sternum.
c. Tip of the nose to the earlobe.
d. Tip of the nose to the earlobe to the xiphoid process.

26. Before giving the patient an intermittent tube feeding, the nurse should
a. Make sure that the tube is secured to the gown with a
safety pin.
b. Have the tube feeding at room temperature.
c. Inject air into the stomach via the tube and auscultate.
d. Place the patient in a supine position.

27. At present, the most reliable method for verification of placement of small-bore feeding tubes is
a. Auscultation.
b. Aspiration of contents.
c. X-ray.
d. pH testing.

28. The nurse is concerned about pulmonary aspiration when providing her patient with tube feedings. The nurse should
a. Verify tube placement before feeding.
b. Lower the head of the bed to a supine position.
c. Add blue food coloring to the enteral formula.
d. Run the formula over 12 hours to decrease volume.

29. The patient is to receive multiple medications via the nasogastric tube. The nurse is concerned that the tube may become clogged. To prevent this,
the nurse
a. Irrigates the tube with 60 mL of water after all
medications are given.
b. Checks with the pharmacy to find out if liquid forms of
the medications are available.
c. Instills nonliquid medications without diluting.
d. Mixes all medications together to decrease the number
of administrations.

30. The patient has just started on enteral feedings but is complaining of abdominal cramping. The nurse should
a. Slow the rate of tube feeding.
b. Instill cold formula to numb the stomach.
c. Place the patient in a supine position.
d. Change the tube feeding to a high-fat formula.

31. The patient has just been started on an enteral feeding and has developed diarrhea after being on the feeding for 2 hours. The most likely cause of
the diarrhea would be
a. Clostridium difficile.
b. Antibiotic therapy.
c. Formula intolerance.
d. Bacterial contamination.

32. Patients who are unable to digest or absorb enteral nutrition benefit from parenteral nutrition (PN). However, the goal to move toward use of the
GI tract is constant because PN
a. Can be given only in the hospital setting.
b. Cannot be used in patients in highly stressed situations.
c. Can be given only by way of a peripheral IV line.
d. Can lead to villous atrophy and cell shrinkage.

33. The nurse is caring for a patient who will be receiving PN. To reduce the risk of developing sepsis, the nurse
a. Takes down a running bag of TPN after 36 hours.
b. Runs lipids for no longer than 24 hours.
c. Wears a sterile mask when changing the CVC dressing.
d. Wears clean gloves when changing the CVC dressing.

34. The patient is having at least 75% of his nutritional needs met by enteral feeding, so the physician has ordered the PN to be discontinued. However,
the nurse notices that the PN infusion has fallen behind. The nurse should
a. Increase the rate to get the volume caught up before discontinuing.
b. Stop the infusion and hang a normal saline drip in place.
c. Taper the PN infusion gradually.
d. Hang 5% dextrose if the PN runs out.

35. The patient is on PN and is lethargic. He has been complaining of thirst and headache and has had increased urination. Which of the following
problems would cause these symptoms?
a. Electrolyte imbalance
b. Hypoglycemia
c. Hyperglycemia
d. Hypercapnia

36. In providing diabetic teaching for a patient with type 1 diabetes mellitus, the nurse instructs the patient that
a. Insulin is the only consideration that must be taken into
b. Saturated fat should be limited to less than 7% of total
c. Cholesterol intake should be greater than 200 mg/day.
d. Nonnutritive sweeteners can be used without

37. The patient with cardiovascular disease must be taught how to reduce the risk of cardiovascular disease by balancing calorie intake with exercise to
maintain a healthy body weight. In addition to this, the nurse instructs the patient to
a. Eat fish at least 5 times per week.
b. Limit saturated fat to less than 7%.
c. Limit cholesterol to less than 200 mg/day.
d. Avoid high-fiber foods.

38. The nurse is providing home care for a patient diagnosed with AIDS. In preparing meals for this patient, the nurse should
a. Provide small, frequent nutrient-dense meals.
b. Encourage intake of fatty foods to increase caloric
c. Prepare hot meals because they are more easily
d. Avoid salty foods and limit liquids to preserve

39. To provide successful nutritional therapies to patients, the nurse must understand that
a. Patients will have to change diet preferences drastically
to be successful.
b. The patient will tell the nurse when to change the plan
of care.
c. Expectations of nurses frequently differ from those of
the patient.
d. Nurses should never alter the plan of care regardless of

40. In measuring the effectiveness of nutritional interventions, the nurse should
a. Expect results to occur rapidly.
b. Not be concerned with physical measures such as
c. Expect to maintain a course of action regardless of
changes in condition.
d. Evaluate outcomes according to the patients
expectations and goals.

41. When expected nutritional outcomes are not being met, the nurse should
a. Revise the nurse measures or expected outcomes.
b. Alter the outcomes based on nursing standards.
c. Ensure that patient expectations are congruent with
the nurses expectations.
d. Readjust the plan to exclude cultural beliefs.

Chapter 46: Bowel Elimination


1. The nurse knows that most nutrients are absorbed in which portion of the digestive tract?
a. Stomach
b. Duodenum
c. Ileum
d. Cecum

2. The nurse would expect the least formed stool to be present in which portion of the digestive tract?
a. Ascending
b. Descending
c. Transverse
d. Sigmoid

3. Which of the following is not a function of the large intestine?
a. Absorbing nutrients
b. Absorbing water
c. Secreting bicarbonate
d. Eliminating waste

4. The nurse is caring for a patient who is confined to the bed. The nurse asks the patient if he needs to have a bowel movement 30 minutes after
eating a meal because
a. The digested food needs to make room for recently ingested food.
b. Mastication triggers the digestive system to begin peristalsis.
c. The smell of bowel elimination in the room would deter the patient from eating.
d. More ancillary staff members are available after meal times.

5. A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend?
a. Grape and walnut chicken salad sandwich on whole wheat bread
b. Broccoli and cheese soup with potato bread
c. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing
d. Turkey and mashed potatoes with brown gravy

6. A patient informs the nurse that she was using laxatives three times daily to lose weight. After stopping use of the laxative, the patient had
difficulty with constipation and wonders if she needs to take laxatives again. The nurse educates the patient that
a. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur.
b. Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis.
c. Natural laxatives such as mineral oil are safer than chemical laxatives for relieving constipation.
d. Laxatives cause the body to become malnourished, so when the patient begins eating again, the body
absorbs all of the food, and no waste products are produced.

7. A patient with a hip fracture is having difficulty defecating into a bed pan while lying in bed. Which action by the nurse would assist the patient in
having a successful bowel movement?
a. Administering laxatives to the patient
b. Raising the head of the bed
c. Preparing to administer a barium enema
d. Withholding narcotic pain medication

8. Which patient is most at risk for increased peristalsis?
a. A 5-year-old child who ignores the urge to defecate owing to embarrassment
b. A 21-year-old patient with three final examinations on the same day
c. A 40-year-old woman with major depressive disorder
d. An 80-year-old man in an assisted-living environment

9. A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate?
a. This is probably a false negative; we should rerun the test.
b. Do you take iron supplements?
c. You should schedule a colonoscopy as soon as possible.
d. Sometimes severe stress can alter stool color.

10. Which physiological change can cause a paralytic ileus?
a. Chronic cathartic abuse
b. Surgery for Crohns disease and anesthesia
c. Suppression of hydrochloric acid from medication
d. Fecal impaction

11. Fecal impactions occur in which portion of the colon?
a. Ascending
b. Descending
c. Transverse
d. Rectum

12. The nurse provides knows that a bowel elimination schedule would be most beneficial in the plan of care for which patient?
a. A 40-year-old patient with an ileostomy
b. A 25-year-old patient with Crohns disease
c. A 30-year-old patient with C. difficile
d. A 70-year-old patient with stool incontinence

13. Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs that prevents
a. Elevate the head of the bed 45 degrees 60 minutes after breakfast.
b. Use a mobility device to place the patient on a bedside commode.
c. Give the patient a pillow to brace against the abdomen while bearing down.
d. Administer a soap suds enema every 2 hours.

14. The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which of the following outcomes
would the nurse evaluate as successful for the patient to establish normal defecation?
a. The patient reports eliminating a soft, formed stool.
b. The patient has quit taking opioid pain medication.
c. The patients lower left quadrant is tender to the touch.
d. The nurse hears bowel sounds present in all four quadrants.

15. The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately?
a. Liquid consistency of stool
b. Presence of blood in the stool
c. Noxious odor from the stool
d. Continuous output from the stoma

16. The nurse would anticipate which diagnostic examination for a patient with black tarry stools?
a. Ultrasound
b. Barium enema
c. Upper endoscopy
d. Flexible sigmoidoscopy

17. The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. What is the next priority nursing
a. Preparing the patient for a second tap water enema
b. Donning gloves for digital removal of the stool
c. Positioning the patient on the left side
d. Inserting a rectal tube

18. The nurse should question which order?
a. A normal saline enema to be repeated every 4 hours until stool is produced
b. A hypertonic solution enema with a patient with fluid volume excess
c. A Kayexalate enema for a patient with hypokalemia
d. An oil retention enema for a patient using mineral oil laxatives

19. The nurse is preparing to perform a fecal occult blood test. The nurse plans to properly perform the examination by
a. Applying liberal amounts of stool to the guaiac paper.
b. Testing the quality control section before collecting the specimen section.
c. Reporting any abnormal findings to the provider.
d. Applying sterile disposable gloves.

20. A nurse is preparing a patient for a magnetic resonance imaging scan. Which nursing action is most important?
a. Ensuring that the patient does not eat or drink 2 hours before the examination
b. Removing all of the patients metallic jewelry
c. Administering a colon cleansing product 12 hours before the examination
d. Obtaining an order for a pain medication before the test is performed

21. After a patient returns from a barium swallow, the nurses priority is to
a. Encourage the patient to increase fluids to flush out the barium.
b. Monitor stools closely for bright red blood or mucus, which indicates trauma from the procedure.
c. Inform the patient that his bowel movements are radioactive, and that he should be sure to flush the toilet
three times.
d. Thicken all patient drinks to prevent aspiration.

22. While a cleansing enema is administered to an 80-year-old patient, the patient expresses the urge to defecate. What is the next priority nursing
a. Positioning the patient in the dorsal recumbent position with a bed pan
b. Assisting the patient to the bedside commode
c. Stopping the enema cleansing and rolling the patient into right-lying Sims position
d. Inserting a rectal plug to contain the enema solution

23. A nurse is educating a patient on how to irrigate an ostomy bag. Which statement by the patient indicates the need for further instruction?
a. I can use a fleet enema to save money because it contains the same irrigation solution.
b. Sitting on the toilet lets the irrigation sleeve eliminate into the bowl.
c. I should never attempt to reach into my stoma to remove fecal material.
d. Using warm tap water will reduce cramping and discomfort during the procedure.

24. A patient is diagnosed with a bowel obstruction. The nurse chooses which type of tube for gastric decompression?
a. Salem sump
b. Dobhoff
c. Sengstaken-Blakemore
d. Small bore

25. A patient had an ileostomy surgically placed 2 days ago. Which diet would the nurse recommend to the patient to ease the transition of the new
a. Eggs over easy, whole wheat toast, and orange juice with pulp
b. Chicken fried rice with stir fried vegetables and iced tea
c. Turkey meatloaf with white rice and apple juice
d. Fish sticks with macaroni and cheese and soda

26. A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most appropriate?
a. Changing the skin barrier portion of the ostomy pouch daily
b. Selecting a pouch that is able to hold excess output to reduce the frequency of pouch emptying
c. Thoroughly scrubbing the skin around the stoma to remove excess stool and adhesive
d. Measuring the correct size for the barrier device while leaving a 1/8-inch space around the stoma

27. The nurse knows that the ideal time to change an ostomy pouch is
a. Before eating a meal, when the patient is comfortable.
b. When the patient feels that he needs to have a bowel movement.
c. When ordered in the patients chart.
d. After the patient has ambulated the length of the hallway.

28. The nurse administers a cathartic to a patient. The nurse determines that the cathartic has had a therapeutic effect when the patient
a. Has a decreased level of anxiety.
b. Experiences pain relief.
c. Has a bowel movement.
d. Passes flatulence.

29. An older adults perineal skin appears to be dry and thin with mild excoriation. When providing hygiene after a bowel movement, the nurse should
a. Thoroughly scrub the skin with a wash cloth and hypoallergenic soap.
b. Apply a skin protective lotion after perineal care.
c. Tape an occlusive moisture barrier pad to the patients skin.
d. Massage the skin with deep kneading pressure.

30. Which nursing action best reduces risk of excoriation to the mucosal lining of the nose from a nasogastric tube?
a. Lubricating the nares with water-soluble lubricant
b. Applying a small ice bag to the nose for 5 minutes every 4 hours
c. Instilling Xylocaine into the nares once a shift
d. Changing the tape holding the tube in place once a shift

31. A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for
further education?
a. If I get a positive result, I have gastrointestinal bleeding.
b. I should not eat red meat before my examination.
c. I should schedule to perform the examination when I am not menstruating.
d. I will need to perform this test three times if I have a positive result.

32. A nurse is caring for an older adult patient with fecal incontinence due to cathartic use. The nurse is most concerned about which complication that
has the greatest risk for severe injury?
a. Rectal skin breakdown
b. Contamination of existing wounds
c. Falls from attempts to reach the bathroom
d. Cross-contamination into the upper GI tract

33. The nurse is caring for a patient with Clostridium difficile. Which of the following nursing actions will have the greatest impact in preventing the
spread of bacteria?
a. Monthly in-services about contact precautions
b. Placing all contaminated items in biohazard bags
c. Mandatory cultures on all patients
d. Proper hand hygiene techniques

34. A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse would expect which other assessment
a. Hypoactive bowel sounds
b. Jaundice in sclera
c. Decreased skin turgor
d. Soft tender abdomen

35. A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding would the nurse expect?
a. Increased energy levels
b. Distended abdomen
c. Decreased serum bicarbonate
d. Increased blood pressure

36. The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately?
a. Stoma is protruding from the abdomen.
b. Stoma is moist.
c. Stool is discharging from the stoma.
d. Stoma is purple.

37. A patient has constipation and hypernatremia. The nurse prepares to administer which type of enema?
a. Oil retention
b. Carminative
c. Saline
d. Tap water

38. A guaiac test has been ordered. The nurse knows that this is a test for
a. Bright red blood.
b. Dark black blood.
c. Blood that contains mucus.
d. Blood that cannot be seen.

39. The nurse should place the patient in which position when preparing to administer an enema?
a. Left Sims position
b. Fowlers
c. Supine
d. Semi-Fowlers

40. The nurse is assessing a patient 2 hours after a colonoscopy. Based on the procedure done, what focused assessment will the nurse include?
a. Bowel sounds
b. Presence of flatulence
c. Bowel movements
d. Nausea

Chapter 40: Oxygenation

1. The structure that is responsible for returning oxygenated blood to the heart is the
a. Pulmonary artery.
b. Pulmonary vein.
c. Superior vena cava.
d. Inferior vena cava.

2. Chemical receptors that stimulate inspiration are located in the
a. Brain.
b. Lungs.
c. Aorta.
d. Heart.

3. The nurse knows that the primary function of the alveoli is to
a. Carry out gas exchange.
b. Store oxygen.
c. Regulate tidal volume.
d. Produce hemoglobin.

4. The nurse knows that anemia will result in
a. Hypoxemia.
b. Impaired ventilation.
c. Hypovolemia.
d. Decreased lung compliance.

5. The process of exchanging gases through the alveolar capillary membrane is known as
a. Disassociation.
b. Diffusion.
c. Perfusion.
d. Ventilation.

6. A nurse caring for a patient who was in a motor vehicle accident that resulted in trauma to C4 would expect to find
a. Decreased tidal volumes.
b. Increased perfusion.
c. Increased use of accessory muscles.
d. Decreased hemoglobin.

7. The nurse would expect to see increased ventilations if a patient exhibits
a. Increased oxygen saturation.
b. Decreased carbon dioxide levels.
c. Decreased pH.
d. Increased hemoglobin levels.

8. The nurse recommends that a patient install a carbon monoxide detector in the home because
a. It is required by law.
b. Carbon monoxide tightly bonds to hemoglobin, causing hypoxia.
c. Carbon monoxide signals the cerebral cortex to cease ventilations.
d. Carbon monoxide combines with oxygen in the body and produces a deadly toxin.

9. While performing an assessment, the nurse hears crackles in the patients lung fields. The nurse also learns that the patient is sleeping on three
pillows. What do these symptoms most likely indicate?
a. Left-sided heart failure
b. Right-sided heart failure
c. Atrial fibrillation
d. Myocardial ischemia

10. The nurse knows that a myocardial infarction is an occlusion of what blood vessel?
a. Pulmonary artery
b. Ascending aorta
c. Coronary artery
d. Carotid artery

11. Myocardial blood flow is unidirectional; the nurse knows that the correct pathway is which of the following?
a. Right atrium, right ventricle, left ventricle, left atrium
b. Right atrium, left atrium, right ventricle, left ventricle
c. Right atrium, right ventricle, left atrium, left ventricle
d. Right atrium, left atrium, left ventricle, right ventricle

12. The nurse caring for a patient with ischemia to the left coronary artery would expect to find
a. Increased ventricular diastole.
b. Increased stroke volume.
c. Decreased preload.
d. Decreased afterload.

13. Normal cardiac output is 4 to 6 L/min in a healthy adult at rest. Which of the following is the correct formula to calculate cardiac output?
a. Stroke volume Heart rate
b. Stroke volume/Body surface area
c. Body surface area Cardiac index
d. Heart rate/Stroke volume

14. A patients heart rate increased from 80 bpm to 160 bpm. The nurse knows that what will follow is a(n)
a. Increase in diastolic filling time.
b. Decrease in cardiac output.
c. Increase in stroke volume.
d. Increase in contractility.

15. The nurse is careful to monitor a patients cardiac output because this helps the nurse to determine
a. Peripheral extremity circulation.
b. Oxygenation requirements.
c. Cardiac arrhythmias.
d. Ventilation status.

16. A nurse is assisting a patient with ambulation. The patient becomes short of breath and begins to complain of sharp chest pain. Which action by the
nurse is the first priority?
a. Call for the emergency response team to bring the defibrillator.
b. Have the patient sit down in the nearest chair.
c. Return the patient to the room and apply 100% oxygen.
d. Ask a coworker to get the ECG machine STAT.

17. A patient has inadequate stroke volume related to decreased preload. The nurse anticipates
a. Placing the patient on oxygen monitoring.
b. Administering vasodilators.
c. Verifying that the blood consent form has been signed.
d. Preparing the patient for dialysis.

18. When caring for a patient with atrial fibrillation, the nurse is most concerned with which vital sign?
a. Heart rate
b. Pain
c. Oxygen saturation
d. Blood pressure

19. The nurse would expect a patient with right-sided heart failure to have which of the following?
a. Peripheral edema
b. Basilar crackles
c. Chest pain
d. Cyanosis

20. The P wave is represented by which portion of the conduction system?
a. SA node
b. AV node
c. Bundle of HIS
d. Purkinje network

21. Which statement by the patient indicates an understanding of atelectasis?
a. It is important to do breathing exercises every hour to prevent atelectasis.
b. If I develop atelectasis, I will need a chest tube to drain excess fluid.
c. Atelectasis affects only those with chronic conditions such as emphysema.
d. Hyperventilation will open up my alveoli, preventing atelectasis.

22. The nurse is caring for an African American patient with COPD. The nurse knows that the best location to assess for hypoxia is the
a. Nailbeds.
b. Oral mucosa.
c. Earlobe.
d. Lower extremities.

23. A nurse is caring for a patient whose temperature is 100.2 F. The nurse expects this patient to hyperventilate owing to
a. Increased metabolic demands.
b. Anxiety over illness.
c. Decreased drive to breathe.
d. Infection destroying lung tissues.

24. What assessment finding is the earliest sign of hypoxia?
a. Restlessness
b. Decreased blood pressure
c. Cardiac dysrhythmias
d. Cyanosis

25. A 5-year-old who has strep throat was given aspirin for fever. The nurse knows to expect which change in the childs respiratory pattern?
a. Hyperventilation to decrease serum levels of carbon dioxide
b. Hypoventilation to compensate for metabolic alkalosis
c. Flail chest to decrease the work of breathing
d. Shallow respirations to decrease serum pH

26. A nurse is caring for a patient who suffered a myocardial infarction to the left coronary artery. Upon assessment, the nurse expects to find
a. Blood in the sputum.
b. Distended jugular vein.
c. Peripheral edema.
d. Crackles in the lungs.

27. A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what he should eat for breakfast,
what should the nurse recommend?
a. A bowl of cereal with whole milk and a banana
b. A cup of nonfat yogurt with granola, and a handful of dried apricots
c. Whole wheat toast with butter, a side of cottage cheese
d. Omelet with sausage, cheese, and onions

28. Upon auscultation, the nurse hears a whooshing sound at the fifth intercostal space. The nurse recognizes that this sound is
a. The beginning of the systolic phase.
b. The opening of the aortic valve.
c. S
, the third heart sound.
d. Regurgitation of the mitral valve.

29. A nurse caring for a patient with COPD knows that which oxygen delivery device is most appropriate?
a. Nasal cannula
b. Simple face mask
c. Partial non-rebreather mask
d. Non-rebreather mask

30. The nurse needs to closely monitor the oxygen status of an elderly patient undergoing anesthesia because of which age-related change?
a. Decreased lung defense mechanisms may cause ineffective airway clearance.
b. Thickening of the heart muscle wall decreases cardiac output.
c. Decreased lung capacity makes proper anesthesia induction more difficult.
d. Alterations in mental status prevent patients awareness of ineffective breathing.

31. The nurse determines that an elderly patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention
of infection for the patient?
a. Encourage the patient to stay up to date on all vaccinations.
b. Inform the patient of the importance of finishing the entire dose of antibiotics.
c. Schedule patient to get annual tuberculosis skin testing.
d. Create an exercise routine to run 30 minutes every day.

32. The nurse would expect which change in cardiac output for a patient with fluid volume overload?
a. Increased preload
b. Decreased afterload
c. Decreased tissue perfusion
d. Increased heart rate

33. A nurse is caring for a patient with COPD who is in recovery for a myocardial infarction. Which of the following nursing actions is the priority?
a. Place the patient on continuous cardiac monitoring.
b. Put the patient on 6 L/min of oxygen via nasal cannula.
c. Deep suction the patient every 2 hours.
d. Assess bilateral lung sounds every hour.

34. The nurse expects a patient with angina pectoris to
a. Experience feelings of indigestion after eating a heavy meal.
b. Have decreased oxygen saturation during rest.
c. Hypoventilate during periods of acute stress.
d. Complain of tingling in the left arm that lasts throughout the morning.

35. A nonmodifiable risk factor for lung disease is
a. Allergies.
b. Smoking.
c. Stress.
d. Asbestos exposure.

36. The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best
addresses a short-term goal that the patient could achieve?
a. Running 30 minutes every morning
b. Stopping smoking immediately
c. Sleeping on two to three pillows at night
d. Limiting the diet to 1500 calories a day

37. A nurse is caring for a patient with left sided hemiparesis who has developed bronchitis and has a heart rate of 105, blood pressure of 156/90, and
a respiration rate of 30. Which nursing diagnosis is the priority for this patient?
a. Activity intolerance
b. Risk for skin breakdown
c. Impaired gas exchange
d. Risk for infection

38. Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an elderly patient?
a. Assist patient to cough, turn, and deep breathe every 2 hours.
b. Encourage patient to drink through a straw to prevent aspiration.
c. Discontinue humidification delivery device to keep excess fluid from lungs.
d. Monitor oxygen saturation, and frequently assess lung bases.

39. The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the physician?
a. Clubbing of the fingers
b. Increased anterior-posterior diameter of the chest
c. Hemoptysis
d. Tachypnea

40. A patient with COPD asks the nurse why he is having increased difficulty with his fine motor skills, such as buttoning his shirt. Which response by
the nurse is most therapeutic?
a. Your body isnt receiving enough oxygen to send down to your fingers; this causes them to club and makes
dexterity difficult.
b. Your disease process makes even the smallest tasks seem exhausting. Try taking a nap before getting
c. Often patients with your disease lose mental status and forget how to perform daily tasks.
d. Your disease affects both your lungs and your heart, and not enough blood is being pumped. So you are
losing sensory feedback in your extremities.

41. A patient with a pneumothorax had a chest tube inserted and was placed on low constant suction. Which finding requires immediate action by the
a. Fifty milliliters of blood gushes into the drainage device after the patient coughs.
b. The patient complains of pain at the chest tube insertion site that increases with movement.
c. No bubbling is present in the suction control chamber of the drainage device.
d. Yellow purulent discharge is seen leaking out from around the dressing site.

42. The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance?
a. Suctioning respiratory secretions several times every hour
b. Administering humidified oxygen through a tracheostomy collar
c. Instilling normal saline into the tracheostomy to thin secretions before suctioning
d. Deflating the tracheostomy cuff before allowing the patient to cough up secretions

43. The nurse is educating a student nurse on caring for a patient with a chest tube. The nurse knows that teaching has been effective when the
student states
a. I should strip the drains on the chest tube every hour to promote drainage.
b. If the chest tube becomes dislodged, the first thing I should do is notify the physician.
c. I should clamp the chest tube when giving the patient a bed bath.
d. I should report if I see continuous bubbling in the water-seal chamber.

44. Which nursing diagnosis is the priority when caring for a patient with a traumatic brain injury who had a tracheostomy placed?
a. Risk for skin breakdown
b. Impaired gas exchange
c. Ineffective airway clearance
d. Risk for infection

45. The nurse knows that the most effective method for suctioning a patient with a tracheostomy tube is to
a. Set suction regulator at 150 to 200 mm Hg.
b. Liberally lubricate the end of the suction catheter with a water-soluble solution.
c. Limit the length of suctioning to 10 to 15 seconds.
d. Apply suction while gently rotating and inserting the catheter.

46. The nurse is assessing a patient with a right pneumothorax. Which finding would the nurse expect?
a. Bilateral expiratory crackles
b. Absence of breath sounds on the right side
c. Right-sided wheezes on inspiration
d. Trachea deviated to the right

47. The nurse knows that a closed suction device would be most appropriate for which patient?
a. A 5-year-old with an asthma attack following severe allergies
b. A 24-year-old with a right pneumothorax following a motor vehicle accident
c. A 50-year-old with pulmonary edema following a myocardial infarction
d. A 75-year-old with aspiration pneumonia following a stroke

48. While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. What is the nurses first
nursing action?
a. Press the emergency response button.
b. Place the patient on a face mask delivering 100% oxygen.
c. Insert a spare tracheostomy without the obturator.
d. Manually occlude the tracheostomy with sterile gauze.