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Adult Health Nursing 6th Edition By kockrow-Test Bank
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Adult Health Nursing 6th Edition By kockrow-Test Bank
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WITH ANSWERS
Adult Health Nursing 6th Edition By kockrow-Test Bank
Christensen: Adult Health Nursing, 6th Edition
Chapter 02: Care of the Surgical Patient
Test Bank
MULTIPLE CHOICE
- The patient is 38 years old and is in her second postoperative day after placement of an intramedullary rod in her left femur. She is receiving analgesia via a patient-controlled analgesia (PCA) device. The inappropriate intervention related to caring for a patient with a PCA is:
| a. | Maintaining the system. |
| b. | Recording activations of the system. |
| c. | Administering the analgesia to the patient. |
| d. | Monitoring the patients pain. |
ANS: C
With the PCA system of medication administration, the patient can self-administer an analgesic by pressing a control button. The nurse should not give medication doses by pushing the control button.
DIF: Cognitive Level: Application REF: Page 50 OBJ: 13
TOP: Medication administration KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A 73-year-old patient with diabetes was admitted for below-the-knee amputation of his right leg. Removal of his right leg is an example of which type of surgery?
| a. | Palliative |
| b. | Diagnostic |
| c. | Reconstructive |
| d. | Ablative |
ANS: D
Ablative is a type of surgery where an amputation, excision of any part of the body, or removal of a growth and harmful substance is performed.
DIF: Cognitive Level: Comprehension REF: Page 18, Table 2-1
OBJ: 2 TOP: Types of surgery
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- The Patients Bill of Rights states that a patient must give his or her permission for any specific test or procedure to be performed. What is the legal term for this permission?
| a. | Verbal consent |
| b. | Medical documentation |
| c. | Informed consent |
| d. | Informed decision |
ANS: C
The Patients Bill of Rights affirms that the patients must give informed consent (permission obtained from the patient to perform a specific test or procedure) before the beginning of any procedure.
DIF: Cognitive Level: Knowledge REF: Page 24 OBJ: 6
TOP: Informed consent KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment
- An informed consent was to be obtained from the patient for his scheduled open cholecystectomy. Which circumstance could prevent the patient from signing his informed consent?
| a. | Pain radiating to the scapula |
| b. | An injection of Demerol, 75 mg IM, 1 hour ago |
| c. | The presence of jaundice and scleral icterus |
| d. | His concern over his insurance company not covering the procedure |
ANS: B
Informed consent should not be obtained if the patient is disoriented and under the influence of sedatives.
DIF: Cognitive Level: Application REF: Page 25 OBJ: 6
TOP: Informed consent KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
- The anesthesiologist provides ____ anesthesia by inhalation and IV administration routes.
| a. | general |
| b. | regional |
| c. | specific |
| d. | preoperative |
ANS: A
An anesthesiologist gives general anesthetics by IV and inhalation routes through four stages of anesthesia.
DIF: Cognitive Level: Knowledge REF: Page 37 OBJ: 11
TOP: Anesthesia KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- A type of anesthesia that requires a depressed level of consciousness is
| a. | regional anesthesia. |
| b. | specific anesthesia. |
| c. | optional sedation. |
| d. | conscious sedation. |
ANS: D
Conscious sedation is routinely used for procedures that do not require complete anesthesia but rather a depressed level of consciousness.
DIF: Cognitive Level: Knowledge REF: Page 40 OBJ: 12
TOP: Conscious sedation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- The older adult patient may not respond to surgical treatment as well as a younger adult because of
| a. | poor skin turgor resulting in dehydration. |
| b. | disturbed body image related to surgical incision. |
| c. | his or her bodys response to physiological changes. |
| d. | decreased peristalsis related to general anesthesia. |
ANS: C
Of specific concern in older adults is the bodys response to temperature changes, cardiovascular shifts, respiratory needs, and renal function.
DIF: Cognitive Level: Analysis REF: Page 20 OBJ: 7
TOP: Older adult patient KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- A 45-year-old patient has had a repair of a cerebral aneurysm and is presenting signs of increased intracranial pressure (ICP). Which postoperative nursing interventions would be contraindicated?
| a. | Coughing every 2 hours |
| b. | Leg exercises every 2 hours |
| c. | Monitoring intravenous therapy at 50 ml/hr |
| d. | Assessing vital signs every 2 hours |
ANS: A
Coughing increases ICP.
DIF: Cognitive Level: Analysis REF: Page 32, Box 2-6
OBJ: 5 TOP: Postoperative complications
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A male patient, age 80, has had a total hip replacement. Anxiety, hypotension, and jarring during transfer from the recovery room to his room can cause a postoperative increase in which of his vital signs?
| a. | Pulse rate |
| b. | Temperature |
| c. | Blood pressure |
| d. | Pain |
ANS: A
An increase in pulse rate is an objective, detectable sign that the body is responding to pain. Other objective changes include a decrease in blood pressure in the immediate postoperative period, restlessness, diaphoresis, and pallor.
DIF: Cognitive Level: Analysis REF: Page 48, Box 2-8
OBJ: 10 TOP: Postoperative complications
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- A patient, age 65, underwent a right hemicolectomy. On postoperative day 4, her surgical wound dehisced. This means that
| a. | there is partial or complete wound separation. |
| b. | there has been inadequate wound closure. |
| c. | abdominal viscera protrude through the walls. |
| d. | the wound will not heal well when it is resutured. |
ANS: A
A surgical incision may separate; this action of dehiscence (the separation of a surgical incision or rupture of a wound closure) may occur within 3 days to over 2 weeks postoperatively.
DIF: Cognitive Level: Knowledge REF: Page 48, Figure 2-15
OBJ: 1 TOP: Postoperative complications
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- A patient is on postoperative day 2 after a nephrectomy. The nurse is aware that the most effective way to increase her peristalsis is
| a. | ambulation. |
| b. | an enema. |
| c. | encouraging hot liquids. |
| d. | administering a laxative. |
ANS: A
Encouraging activity (turning every 2 hours, early ambulation) assists GI activity.
DIF: Cognitive Level: Application REF: Page 52, Box 2-10
OBJ: 13 TOP: Postoperative complications
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- A patient is transferred from the operating room to the recovery room after undergoing an open reduction and internal fixation (ORIF) of his left ankle. Which is the first assessment to make?
| a. | Check ankle dressings. |
| b. | Check airway for patency. |
| c. | Check intravenous site. |
| d. | Check vital signs. |
ANS: B
Evaluation of the patient follows the ABCs of immediate postoperative observation: airway, breathing, consciousness, and circulation.
DIF: Cognitive Level: Application REF: Page 45, Table 2-6
OBJ: 12 TOP: Nursing assessment
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- Frequent assessment of a postoperative patient is essential. One of the first signs and symptoms of hemorrhage may be
| a. | increasing blood pressure. |
| b. | decreasing pulse. |
| c. | restlessness. |
| d. | weakness, apathy. |
ANS: C
A pulse that increases and becomes thready combined with a declining blood pressure, cool and clammy skin, reduced urine output, and restlessness may signal hypovolemic shock.
DIF: Cognitive Level: Comprehension REF: Page 48 OBJ: 10
TOP: Postoperative complications KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- Frequent monitoring of the postoperative patients vital signs assesses which body system?
| a. | Gastrointestinal |
| b. | Endocrine |
| c. | Neurological |
| d. | Cardiovascular |
ANS: D
Hypotension and cardiac dysrhythmias are the most common cardiovascular complications of the surgical patient, and early recognition and management of these complications before they become serious enough to diminish cardiac output depend on frequent assessment of the patients vital signs.
DIF: Cognitive Level: Comprehension REF: Pages 35, 51, Table 2-4
OBJ: 14 TOP: Postoperative patient
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
- Decreased activity in an obese surgical patient predisposes the patient to which complication?
| a. | Cardiac arrest |
| b. | Pneumonia |
| c. | Incisional hernias |
| d. | Hypoventilation |
ANS: D
Immediate postoperative hypoventilation can result from drugs (anesthetics, narcotics, tranquilizers, sedatives) incisional pain, obesity, chronic lung disease, or pressure on the diaphragm.
DIF: Cognitive Level: Analysis REF: Page 48 OBJ: 13
TOP: Postoperative complications KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- The nurse acknowledges that all preoperative nursing interventions have been performed by signing which document?
| a. | Nurses notes |
| b. | Anesthesia record |
| c. | Preoperative checklist |
| d. | Physicians order sheet |
ANS: C
When the nurse signs the preoperative checklist, that nurse assumes responsibility for all areas of care included on the list.
DIF: Cognitive Level: Knowledge REF: Page 41, Figure 2-10
OBJ: 9 TOP: Preoperative checklist
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
- Which nursing interventions would be appropriate after a wound evisceration?
| a. | Place the patient in high Fowlers position. |
| b. | Give the patient fluids to prevent shock. |
| c. | Replace the dressing with sterile fluffy pads. |
| d. | Apply a warm, moist normal saline sterile dressing. |
ANS: D
Cover the wound with a sterile towel moistened with sterile physiological saline (warm).
DIF: Cognitive Level: Application REF: Page 48, Figure 2-15
OBJ: 13 TOP: Postoperative interventions
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- When should the nurse offer prescribed analgesics to a patient who is 24 hours postoperative?
| a. | Only when the patient asks. |
| b. | Regularly every three to four hours before pain gets severe. |
| c. | Only when the physician orders. |
| d. | Only when the patient is in severe pain. |
ANS: B
The nurse should ask the patient every 3-4 hours if something is needed for pain because some patients will not ask for an analgesic.
DIF: Cognitive Level: Application REF: Page 49 OBJ: 10
TOP: Medication administration KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
- What nursing interventions will minimize the effects of venous stasis?
| a. | Pillows under the knee in a position of comfort |
| b. | Sitting with the feet flat on the floor |
| c. | Early ambulation |
| d. | Gentle leg massage |
ANS: C
Early ambulation has been a significant factor in hastening postoperative recovery and preventing postoperative complications.
DIF: Cognitive Level: Application REF: Page 52, Box 2-10
OBJ: 13 TOP: Interventions
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- Serum potassium levels are usually determined before surgery to
| a. | assess kidney function. |
| b. | determine respiratory insufficiency. |
| c. | prevent dysrhythmias related to anesthesia. |
| d. | measure functional liver capability. |
ANS: C
Serum electrolytes are evaluated if extensive surgery is planned or the patient has extenuating problems. One of the essential electrolytes examined is potassium; if potassium is not available in adequate amounts, dysrhythmias can occur during anesthesia.
DIF: Cognitive Level: Analysis REF: Page 24 OBJ: 9
TOP: Preoperative assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- The nurse is assisting with the sponge and instrument count in the operating room. The operative phase in which the nurse is assisting is called the
| a. | perioperative phase. |
| b. | preoperative phase. |
| c. | intraoperative phase. |
| d. | postoperative phase. |
ANS: C
Counting of sponges, needles, and instruments with the scrub nurse before surgery and before closing the wound is done during the intraoperative phase of the surgery.
DIF: Cognitive Level: Knowledge REF: Page 24, Box 2-7
OBJ: 8 TOP: Intraoperative responsibilities
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
- Which early postoperative observation is abnormal and should be reported immediately?
| a. | Emesis that is red |
| b. | Complaint of feeling cold |
| c. | Nausea |
| d. | Complaint of pain |
ANS: A
Any emesis that is red should be reported immediately.
DIF: Cognitive Level: Analysis REF: Page 46, Box 2-7
OBJ: 10 TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- Sudden chest pain combined with dyspnea, cyanosis, and tachycardia is an indication of
| a. | hypovolemic shock. |
| b. | dehiscence. |
| c. | atelectasis. |
| d. | pulmonary embolus. |
ANS: D
Sudden chest pain combined with dyspnea, tachycardia, cyanosis, diaphoresis, and hypotension is a sign of pulmonary embolism.
DIF: Cognitive Level: Analysis REF: Page 49 OBJ: 13
TOP: Assessment and postoperative complications
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- An appendectomy during a hysterectomy would be classified as
| a. | major, emergency, diagnostic. |
| b. | major, urgent, palliative. |
| c. | minor, elective, ablative. |
| d. | minor, urgent, reconstructive. |
ANS: C
Surgery is classified as elective, urgent, or emergency. Surgery is performed for various purposes, which include diagnostic studies, ablation (an amputation or excision of any part of the body or removal of a growth or harmful substance), and palliative (therapy to relieve or reduce intensity of uncomfortable symptoms without cure), reconstructive, transplant, and constructive purposes.
DIF: Cognitive Level: Comprehension REF: Page 18, Table 2-1
OBJ: 2 TOP: Types of surgery
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- Which patients would be at greatest risk during surgery?
| a. | 78-year-old taking an analgesic agent |
| b. | 43-year-old taking an antihypertensive agent |
| c. | 27-year-old taking an anticoagulant agent |
| d. | 10-year-old taking an antibiotic agent |
ANS: C
Anticoagulants alter normal clotting factors and thus increase risk of hemorrhaging. They should be discontinued for 48 hours before surgery.
DIF: Cognitive Level: Analysis REF: Page 21, Box 2-3, Table 2-5
OBJ: 4 TOP: Individuals ability to tolerate surgery
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- A patient will have an incision in the lower left abdomen. Which intervention by the nurse will help decrease discomfort in the incisional area when she coughs postoperatively?
| a. | Apply a splint directly over the lower abdomen. |
| b. | Keep the patient flat with feet flexed. |
| c. | Turn her on her right side. |
| d. | Apply a splint above and below the incision. |
ANS: A
To ease the pressure on the incision, the nurse helps the patient support the surgical site with a pillow, rolled bath blanket, or the heel of the hand.
DIF: Cognitive Level: Application REF: Pages 31-32, Skill 2-4 Step 10, NCP 2-1
OBJ: 14 TOP: Postoperative nursing interventions
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- Although informed about the proposed surgical procedure, the patient has only vague responses about the postoperative period. A nursing diagnosis at this time would be
| a. | Impaired verbal communication. |
| b. | Impaired gas exchange. |
| c. | Deficient knowledge, postoperative. |
| d. | Acute pain. |
ANS: C
Knowledge, deficient regarding implications of surgery related to information misinterpretation is a correct nursing diagnosis.
DIF: Cognitive Level: Analysis REF: Page 20, Box 2-11
OBJ: 14 TOP: Nursing process/diagnosis
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment
- A patient and a nurse develop a preoperative teaching plan. In teaching the patient to cough effectively after surgery, the nurse should tell her to practice
| a. | breathing through her nose, holding her breath, and exhaling slowly. |
| b. | taking three deep breaths and coughing from the chest. |
| c. | inhaling while contracting the abdominal muscles and exhaling while contracting the diaphragm. |
| d. | taking short, frequent panting breaths and coughing from the throat to clear accumulated mucus. |
ANS: B
Because lung ventilation is vital, the nurse assists the patient to turn, cough, and breathe deeply every 1 to 2 hours until the chest is clear. Having practiced this combination preoperatively, the patient is usually able to adequately remove trapped mucus and surgical gases.
DIF: Cognitive Level: Application REF: Pages 29-30, Skills 2-2, 2-3
OBJ: 13 TOP: Prevention of postoperative complications
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- What is the responsibility of the nurse regarding informed consent?
| a. | Explain the surgical options. |
| b. | Explain the operative risks. |
| c. | Obtain the patients signature. |
| d. | Check form for appropriate signatures. |
ANS: C
A witness is only verifying that this is the person who signed the consent and that it was a voluntary consent. The witness (often a nurse) is not verifying that the patient understands the procedure.
DIF: Cognitive Level: Knowledge REF: Page 25 OBJ: 6
TOP: Informed consent KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
- On the patients return to the medical-surgical unit, the nurse performs an abdominal assessment. To assess bowel sounds, the nurse auscultates the lower abdomen for
| a. | 1 minute. |
| b. | 5 to 20 seconds. |
| c. | as long as it takes to hear a bowel sound. |
| d. | one full inspiration and expiration. |
ANS: A
Normal peristalsis is gauged by hearing 5 to 30 gurgles per minute.
DIF: Cognitive Level: Knowledge REF: Page 52, Box 2-10
OBJ: 10 TOP: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
- Which preoperative fear is linked to postoperative behavior?
| a. | Fear of anesthesia and death |
| b. | Fear of death and malnutrition |
| c. | Fear of unknown and lack of respect |
| d. | Fear of malnutrition and addiction to new medications |
ANS: A
The preoperative anxiety level influences the amount of anesthesia required, the amount of postoperative pain medication needed, and the speed of recovery from surgery.
DIF: Cognitive Level: Assessment REF: Pages 20, 24, Box 2-4
OBJ: 4 TOP: Nursing diagnosis
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- Ideally, preop teaching should be done
| a. | immediately before surgery to eliminate fear. |
| b. | 2 months in advance so the patient can prepare. |
| c. | 1 to 2 days before the surgery when anxiety is not as high. |
| d. | in the surgical holding area. |
ANS: C
Preop teaching is provided 1 to 2 days prior to surgery when anxiety is low.
DIF: Cognitive Level: Implementation REF: Page 24 OBJ: 8
TOP: Nursing diagnosis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- In preparation for the return of the surgical patient, the patients bed and equipment should be in what position?
| a. | Lowest position with side rails elevated with oxygen and suction equipment available |
| b. | Highest position with side rails elevated with IV pole and pump at bedside |
| c. | Lowest position with side rails down on the receiving side |
| d. | Highest position with the side rails down on receiving side and up on opposite side |
ANS: D
In preparation for the return of the surgical patient, the patients bed should be in the highest position to be level with the surgical gurney and should have the side rail down on the receiving side, with the opposite side rail up to prevent the patient from falling out of bed during transfer.
DIF: Cognitive Level: Implementation REF: Page 43 OBJ: 13
TOP: Nursing diagnosis KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
- Southeast Asian and Native American patients often do not make eye contact when preoperative teaching is being performed because
| a. | they arent educated. |
| b. | they arent paying attention. |
| c. | they believe eye contact is disrespectful. |
| d. | they believe they are superior to the nurse. |
ANS: C
Southeast Asians and Native Americans may believe eye contact is disrespectful.
DIF: Cognitive Level: Application REF: Page 22, Cultural Considerations box
OBJ: N/A TOP: Nursing diagnosis
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- What are the high-risk conditions that may affect perioperative procedures? (Select all that apply):
| a. | Age, health, occupation, mental status |
| b. | Financial income, health, nutritional status |
| c. | Age, mental state, nutritional status, health |
| d. | Occupation, age, nutritional status, health |
| e. | Financial Income, occupation, age, health |
ANS: C
Each system of the body is affected by the patients age, health, nutritional status, and mental state.
DIF: Cognitive Level: Assessment REF: Page 24 OBJ: 4
TOP: Nursing diagnosis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
MULTIPLE RESPONSE
- A postoperative patient who had a left inguinal hernia repair is ready for his discharge instructions. Which information should the nurse provide? (Select all that apply.)
| a. | Care of the wound site and any dressings |
| b. | When he may operate a motor vehicle |
| c. | Signs and symptoms to report to the physician |
| d. | Call the physicians office once he arrives home |
| e. | Report bowel movements to the physician |
| f. | Actions and side effects of any medications |
ANS: A, B, C, F
As the day of discharge approaches, the nurse should be certain that the patient has vital information.
DIF: Cognitive Level: Analysis REF: Page 56, Box 2-13
OBJ: 13 TOP: Discharge instructions
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment
- Two considerations for the older adult surgical patient include (Select the two that apply.)
| a. | pre- and postoperative teaching. |
| b. | lower morbidity and mortality. |
| c. | quick assessment skills. |
| d. | surgery causes much physiological stress. |
ANS: A, D
Surgery places greater stress on older than on younger patients. Teaching should be given at the older persons level of understanding.
DIF: Cognitive Level: Application REF: Page 20, Life Span Considerations box
OBJ: 7 TOP: Older adult considerations
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
- In preparing the patient for abdominal surgery, the Assistive Personnel (AP) can perform which interventions? (Select all that apply.)
| a. | Vital signs |
| b. | Insertion of N/G tube |
| c. | Enema |
| d. | Height and weight |
| e. | Obtain operative consent |
| f. | Sterile gowning |
ANS: A, C, D
The AP can perform vital signs, enema, and height and weight.
DIF: Cognitive Level: Application REF: Page 38 OBJ: 16
TOP: Nursing diagnosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
COMPLETION
- ______________ therapy is performed to alleviate or decrease uncomfortable symptoms without curing the problem.
ANS:
Palliative
Palliative therapy is designed to relieve or reduce intensity of uncomfortable symptoms without cure.
DIF: Cognitive Level: Knowledge REF: Page 18, Table 2-1
OBJ: 1 TOP: Palliative therapy
KEY: Nursing Process Step: Assessment MSC: NCLEX: Comprehension
- Discharge planning for a surgical procedure begins in the ______________ period and continues through the _____________ period.
ANS:
preoperative, recuperative
Discharge planning for a surgical procedure begins in the preoperative and continues through the recuperative period.
DIF: Cognitive Level: Knowledge REF: Page 55 OBJ: 15
TOP: Nursing diagnosis KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance
- A patient is transferred from the operating room to the recovery room after undergoing an amputation of his left foot. Place the interventions in the correct order for immediate assessment once the patient enters the PACU. Place a comma between each answer choice (a, b, c, d, etc.).
| a. | System review |
| b. | Breathing |
| c. | Circulation |
| d. | Airway |
| e. | Level of consciousness |
ANS: D, B, E, C, A
DIF: Cognitive Level: Application REF: Page 45, Table 2-6
OBJ: 12 TOP: Nursing assessment
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
Christensen: Adult Health Nursing, 6th Edition
Chapter 16: Care of the Patient with HIV/AIDS
Test Bank
MULTIPLE CHOICE
- A patient, age 25, has just been admitted to the unit with a diagnosis of AIDS. The nurses colleague says, Im pregnant. It is not safe for me or my baby if I am assigned to his case. The nurses response should be
| a. | This patient would not be a risk for your baby if you use standard precautions and avoid direct contact with blood or body fluids. |
| b. | You should ask for a transfer to another unit because contact with this patient would put you and your baby at risk for AIDS. |
| c. | Wear a mask, gown, and gloves every time you go into his room and use disposable trays, plates, and utensils to serve his meals. |
| d. | We should recommend that this patient be transferred to an isolation unit. |
ANS: A
HIV is transmitted from human to human through infected blood, semen, cervicovaginal secretions, and breast milk. The utilization of standard precautions by all staff members for all patients all the time simplifies this issue.
DIF: Cognitive Level: Application REF: Pages 736, 737, 758, 763
OBJ: 6 TOP: Transmission of AIDS
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
- Members of the local emergency medical service unit have just transported an accident victim to the emergency department. They tell the ED nurse that the victim has AIDS, and they have blood on their hands and clothing. The nurse advises them to wash their hands and to change any clothing that is wet with blood. The nurse talks to them about getting a baseline HIV test and about future testing. They ask the nurse how long it will take before they will know if they are infected. The nurses response should be
| a. | You will need to be tested in 6 weeks and regularly for the next 10 years, because that is the average length of time it takes to detect the virus by testing. |
| b. | You will need to be tested in 3 months and again in 6 months, because 95% of people seroconvert to antibody-positive in 3 months and 99% in 6 months. |
| c. | Transmission by occupational exposure is rare. There is no need for you to be concerned. |
| d. | You will need to be tested in 3 weeks, because most people seroconvert in that length of time. |
ANS: B
Seroconversion is the development of antibodies from HIV, which takes place approximately 5 days to 3 months after exposure, generally within 1 to 3 weeks.
DIF: Cognitive Level: Analysis REF: Page 745 OBJ: 6
TOP: Prevention of infection KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment
- The patient, age 21, has been treated for chlamydia and has a history of recurrent herpes. What should the nurse plan to do next?
| a. | Counsel this patient about her sexual history, risk reduction measures, and testing for HIV. |
| b. | Refer this patient to a family planning clinic. |
| c. | Counsel this patient about testing for HIV and what the test results mean. |
| d. | Counsel this patient about abstinence and a monogamous relationship. |
ANS: A
Unfortunately, the risk of acquiring HIV and other sexually transmitted disease still exists.
DIF: Cognitive Level: Analysis REF: Page 771, Table 16-9
OBJ: 8 TOP: Risk for infection
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance
- A patient has just been told by his physician that he is HIV-positive. He asks the nurse, When will I get AIDS? The nurses response should be
| a. | Most people get AIDS within 3 to 12 weeks after they are infected with HIV. |
| b. | Dont worry. You may never get AIDS if you eat properly, exercise, and get plenty of rest. |
| c. | It varies with every individual, but the average time is 8 to 10 years from the time a person is infected, and some go much longer. |
| d. | You can expect to develop signs and symptoms of AIDS within 6 months. |
ANS: C
A typical progressor of HIV has a period of relative clinical latency, occurring immediately after the primary infection, that can last for several years. Long-term nonprogressors remain symptom-free for 10 years or more.
DIF: Cognitive Level: Analysis REF: Page 742 OBJ: 4
TOP: Progression of disease KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
- A patient asks the nurse, How does HIV cause AIDS? The nurses response should be
| a. | HIV attacks the immune system, a system that protects the body from foreign invaders, making it unable to protect the body from organisms that cause diseases. |
| b. | HIV breaks down the circulatory system, making the body unable to assimilate oxygen and nutrients. |
| c. | HIV attacks the respiratory system, making the lungs more susceptible to organisms that cause pneumonia. |
| d. | HIV attacks the digestive system, decreasing the absorption of essential nutrients and causing weight loss and fatigue. |
ANS: A
HIV disease results from the progressive deterioration of the immune system over time; a diagnosis of AIDS is made in a later stage of this progression.
DIF: Cognitive Level: Analysis REF: Page 742, Table 16-2
OBJ: 7 TOP: Progression of disease
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Adaptation
- In reviewing a patients chart to determine whether she has progressed from HIV disease to AIDS, the nurse should look for
| a. | CD4+ count below 500, chronic fatigue, night sweats. |
| b. | HIV-positive test result, CD4+ count below 200, history of opportunistic disease. |
| c. | weight loss, persistent generalized lymphadenopathy, chronic diarrhea. |
| d. | fever, chills, CD4+ count below 200. |
ANS: B
Patients who have progressed from HIV disease to AIDS will have the condition in which the CD4+ cell count drops below 200 cells/mm3.
DIF: Cognitive Level: Comprehension REF: Pages 736, 747, Box 16-2, Table 16-1
OBJ: 5 TOP: Progression of disease
KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
- A patient is advised to be tested for HIV because of his multiple sexual partners and injectable drug use. The nurse should ensure that this patient understands the test by informing him that:
| a. | The blood is tested with the highly sensitive test called the Western blot. |
| b. | The blood is tested with an ELISA; if positive, it is tested again with an ELISA, followed by a Western blot if the second ELISA is positive. |
| c. | A series of HIV tests is performed to confirm if the patient has AIDS. |
| d. | If the HIV tests are seronegative, John can be assured that he is not infected. |
ANS: B
The individuals blood is tested with ELISA or enzyme immunoassay (ELA), antibody tests that detect the presence of HIV antibodies. If the ELA is positive for HIV, then the same blood is tested a second time. If the second ELA is positive, a more specific confirming test such as the Western blot is done. Blood that is reactive or positive in all three steps is reported to be HIV-positive.
DIF: Cognitive Level: Application REF: Pages 736, 747, Box 16-2, Table 16-1
OBJ: 8 TOP: Diagnostic procedures
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenanc
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