Foundations of Nursing 7th EditionBy Kim Cooper- Kelly Gosnell Test Bank

<< Ethics And Issues in Contemporary Nursing 4th Edition by Burkhardt, Margaret A. Test Bank Gould Pathophysiology for the Health Professions, 5th Edition by Karin C. VanMeter Test Bank >>
Product Code: 222
Availability: In Stock
Price: $24.99
Qty:     - OR -   Add to Wish List
Add to Compare

Foundations of Nursing 7th EditionBy Kim Cooper- Kelly Gosnell Test Bank

Description

WITH ANSWERS
Foundations of Nursing 7th EditionBy Kim Cooper- Kelly Gosnell Test Bank

Chapter 2: Legal and Ethical Aspects of Nursing

Cooper and Gosnell: Foundations of Nursing, 7th Edition

 

MULTIPLE CHOICE

 

  1. When a nurse becomes involved in a legal action, the first step to occur is that a document is filed in an appropriate court. What is this document called?
a. Deposition
b. Appeal
c. Complaint
d. Summons

 

 

ANS:  C

A document called a complaint is filed in an appropriate court as the first step in litigation. A deposition is when witnesses are required to undergo questioning by the attorneys. An appeal is a request for a review of a decision by a higher court. A summons is a court order that notifies the defendant of the legal action.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   1

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. The nurse caring for a patient in the acute care setting assumes responsibility for a patients care. What is this legally binding situation?
a. Nurse-patient relationship
b. Accountability
c. Advocacy
d. Standard of care

 

 

ANS:  A

When the nurse assumes responsibility for a patients care, the nurse-patient relationship is formed. This is a legally binding contract for which the nurse must take responsibility. Accountability is being responsible for ones own actions. An advocate is one who defends or pleads a cause or issue on behalf of another. Standards of care define acts whose performance is required, permitted, or prohibited.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   3

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. What are the universal guidelines that define appropriate measures for all nursing interventions?
a. Scope of practice
b. Advocacy
c. Standard of care
d. Prudent practice

 

 

ANS:  C

Standards of care define actions that are permitted or prohibited in most nursing interventions. These standards are accepted as legal guidelines for appropriateness of performance. The laws that formally define and limit the scope of nursing practice are called nurse practice acts. An advocate is one who defends or pleads a cause or issue on behalf of another. Prudent is a term that refers to careful and/or wise practice.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   4

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. An LPN/LVN is asked by the RN to administer an IV chemotherapeutic agent to a patient in the acute care setting. What law should this nurse refer to before initiating this intervention?
a. Standards of care
b. Regulation of practice
c. American Nurses Association Code
d. Nurse practice act

 

 

ANS:  D

It is the nurses responsibility to know the nurse practice act in his or her state. Standards of care, regulation of practice, and the American Nurses code are not laws that the nurse should refer to before initiating this treatment.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   5

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This nurse could be found guilty of:
a. malpractice.
b. harm to the patient.
c. negligence.
d. failure to follow the nurse practice act.

 

 

ANS:  A

The nurse can be held liable for malpractice for acts of omission. Failure to meet a legal duty, thus causing harm to another, is malpractice. The nurse practice act has general guidelines that can support the charge of malpractice.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   2

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. Patients have expectations regarding the health care services they receive. To protect these expectations, which of the following has become law?
a. American Hospital Associations Patients Bill of Rights
b. Self-determination act
c. American Hospital Associations Standards of Care
d. The Joint Commissions rights and responsibilities of patients

 

 

ANS:  A

Patients have expectations regarding the health care services they receive. In 1972, the American Hospital Association (AHA) developed the Patients Bill of Rights. The Self-determination act, American Hospital Associations Standards of Care, and The Joint Commissions rights and responsibilities do not address patients expectations regarding health care.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   3| 4

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed?
a. Physical assessment
b. Interview
c. Informed consent
d. Surgical checklist

 

 

ANS:  C

The doctrine of informed consent refers to full disclosure of the facts the patient needs to make an intelligent (informed) decision before any invasive treatment or procedure is performed. A physical assessment, interview, and surgical checklist are not required before this procedure.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   8

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. When a nurse protects the information in a patients record what ethical responsibility is the nurse fulfilling?
a. Privacy
b. Disclosure
c. Confidentiality
d. Absolute secrecy

 

 

ANS:  C

The nurse has an ethical and legal duty to protect information about a patient and preserve confidentiality. Some disclosures are legal and anticipated, and may not be subject to the rules of confidentiality. None of the information in a chart is considered secret.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   9

TOP:   Confidentiality                               KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. An older adult is admitted to the hospital with numerous bodily bruises, and the nurse suspects elder abuse. What is the best nursing action?
a. Cover the bruises with bandages.
b. Take photographs of the bruises.
c. Ask the patient if anyone has hit her.
d. Report the bruises to the charge nurse.

 

 

ANS:  D

The law stipulates that the health care professional is required to report certain information to the appropriate authorities. The report should be given to a supervisor or directly to the police, according to agency policy. When acting in good faith to report mandated information (e.g., certain communicable diseases or gunshot wounds), the health care professional is protected from liability.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   9

TOP:   Elder abuse    KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. What is the best way for a nurse to avoid a lawsuit?
a. Carry malpractice insurance
b. Spend time with the patient
c. Provide compassionate, competent care
d. Answer all call lights quickly

 

 

ANS:  C

The best defense against a lawsuit is to provide compassionate and competent nursing care. Carrying malpractice insurance is prudent, but it will not avoid a lawsuit. Spending time with patients and answering call lights quickly will not necessarily help avoid a lawsuit.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   8

TOP:   Avoiding a lawsuit                          KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. The nurse is caring for a patient with a do-not-resuscitate (DNR) order. Although the nurse may disagree with this order, what is his or her legal obligation?
a. To question the doctor
b. To seek advice from the family
c. To discuss it with the patient
d. To follow the order

 

 

ANS:  D

When a DNR order is written in the chart, the nurse has a duty to follow the order. Questioning the doctor, seeking advice from the family, and discussing it with the patient are not legal obligations of the nurse.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   10| 14

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. The nurse has strong moral convictions that abortions are wrong. When assigned to assist with an abortion, what is the most appropriate action for the nurse to take?
a. Ask for another assignment
b. Leave work
c. Transfer to another floor
d. Protest to the supervisor

 

 

ANS:  A

The nurse should not abandon the patient, but ask for another assignment.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   9| 16

TOP:   Ethics             KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. The new LPN/LVN is concerned regarding what should or should not be done for patients. What resource will best provide this information?
a. Nurse practice act
b. Standards of care
c. Scope of nursing practice
d. Professional organizations

 

 

ANS:  B

Standards of care define what should or should not be done for patients. The nurse practice act, scope of nursing practice, and professional organizations do not provide the best information as to what should or should not be done for patients.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   5

TOP:   Standards of care                            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What role is the nurse who diligently works for the protection of patients interests playing?
a. Caregiver
b. Health care administrator
c. Advocate
d. Health care evaluator

 

 

ANS:  C

A nurse accepts the role of advocate when, in addition to general care, the nurse protects the patients interests. Caregiver, health care administrator, and health care evaluator are not terms for the nurse who diligently works for the protection of patients.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   9| 12

TOP:   Advocate       KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. When asked to perform a procedure that the nurse has never done before, what should the nurse do to legally protect himself or herself?
a. Go ahead and do it
b. Refuse to perform it, citing lack of knowledge
c. Discuss it with the charge nurse, asking for direction
d. Ask another nurse who has performed the procedure

 

 

ANS:  C

The nurse cannot use ignorance as an excuse for nonperformance. The nurse should ask for direction from the charge nurse, explaining she has never performed the procedure independently.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   8

TOP:   Legal              KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. The nurse is assisting a patient to clarify values by encouraging the expression of feelings and thoughts related to the situation. What is the most appropriate action for the nurse?
a. Compare values with those of the patient
b. Make a judgment
c. Withhold an opinion
d. Give advice

 

 

ANS:  C

The nurse can assist the patient in values clarification without giving an opinion.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   3| 8

TOP:   Values clarification                        KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. What fundamental principle must the nurse first observe when confronted with an ethical decision?
a. Autonomy
b. Beneficence
c. Respect for people
d. Nonmaleficence

 

 

ANS:  C

The first fundamental principle is respect for people. Autonomy, beneficence, and nonmaleficence are not the first fundamental principles to observe when confronted with an ethical decision.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   13| 15

TOP:   Ethics             KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. A nurse working on an acute care medical surgical unit is aware that his or her first duty is to the patients health, safety, and well-being. Given this knowledge, which of the following is most necessary for the nurse to report?
a. Unethical behavior of other staff members
b. A worker who arrives late
c. Favoritism shown by nursing administration
d. Arguments among the staff

 

 

ANS:  A

A member of the nursing profession must report behavior that does not meet established standards. Unethical behavior involves failing to perform the duties of a competent caring nurse.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   13

TOP:   Unethical behavior                         KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A nurse is considering purchasing malpractice insurance. What should the nurse be aware of regarding malpractice insurance provided by the hospital?
a. Only offers protection while on duty
b. Is limited in the amount of coverage
c. Is difficult to renew
d. Can be terminated at any time

 

 

ANS:  A

Most institutional insurance only provides liability coverage if the nurse is on duty at that facility.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   2

TOP:   Malpractice insurance                     KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. Which is a nursing care error that violates the Health Insurance Portability and Accountability Act (HIPAA)?
a. Administering a stronger dose of drug than was ordered
b. Refusing to give a patients daughter information over the phone
c. Informing the patients medical power of attorney of a medication change
d. Leaving a copy of the patients history and physical in the photocopier

 

 

ANS:  D

Leaving the document in the photocopier could expose it to the public. Inappropriate drug administration is possible malpractice. Sharing information with the power of attorney is legal. Refusing to give a patients daughter information over the phone is appropriate practice.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   7

TOP:   Health Insurance Portability and Accountability Act (HIPAA)

KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. Which of the following could cause a nurse to be cited for malpractice?
a. Refusing to give 60 mg of morphine as ordered
b. Giving prochlorperazine (Compazine) to a patient allergic to phenothiazines
c. Dragging an injured motorist off the highway and causing further injury
d. Informing a visitor about a patients condition

 

 

ANS:  B

Standards of care dictate that a nurse must be aware of all the properties of drugs administered. Prochlorperazine (Compazine) is a phenothiazine. Providing confidential information or refusing to give an excessively large narcotic dose is not considered malpractice. Good Samaritan laws generally protect a person giving aid to an injured motorist.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   2

TOP:   Malpractice    KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. A lumbar puncture was performed on a patient without a signed informed consent form. This patient might sue for:
a. punitive damages.
b. civil battery.
c. assault.
d. nothing; no violation has occurred.

 

 

ANS:  B

Civil battery charges can be brought against someone performing an invasive procedure without the patients informed consent legally documented. This patient could not sue for punitive damages or an assault.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   6| 8

TOP:   Informed consent                           KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A physician instructs the nurse to bladder train a patient. The nurse clamps the patients indwelling urinary catheter but forgets to unclamp it. The patient develops a urinary tract infection. What do the nurses actions exemplify?
a. Malpractice
b. Battery
c. Assault
d. Neglect of duty

 

 

ANS:  A

A nurse is liable for acts of commission (doing an act) and omission (not doing an act) performed in the course of their professional duty. A charge of malpractice is likely when a duty exists, there is a breach of that duty, and harm has occurred to the patient.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   2

TOP:   Malpractice    KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. What is true about nurse practice acts?
a. They informally define the scope of nursing practice.
b. They provide for unlimited scope of nursing practice.
c. Only some states have adopted a nurse practice act.
d. The nurse must know the nurse practice act within his or her state.

 

 

ANS:  D

The laws formally defining and limiting the scope of nursing practice are called nurse practice acts. All state, provincial, and territorial legislatures in the United States and Canada have adopted nurse practice acts, although the specifics they contain often vary. It is the nurses responsibility to know the nurse practice act that is in effect for her geographic region.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   1

TOP:   Nurse practice acts                         KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

MULTIPLE RESPONSE

 

  1. How can the medical record be used in litigation? (Select all that apply.)
a. Public record
b. Proof of adherence to standards
c. Evidence of omission of care
d. Documentation of time lapses
e. Evidence by only the plaintiff

 

 

ANS:  A, B, C, D

The information when used in court becomes a public record. The information can be used as proof of adherence to standards, omission of care, and documentation of time lapses. Both plaintiff and defendant can use the document.

 

DIF:    Cognitive Level: Comprehension   REF:   Page               OBJ:   4

TOP:   Legal properties of medical record KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. During a lunch break, an emergency department (ED) nurse truthfully tells another nurse about the condition of a patient who came to the ED last night. What is the ED nurse guilty of? (Select all that apply.)
a. HIPAA violation
b. Slander
c. Libel
d. Invasion of privacy
e. Defamation

 

 

ANS:  A, D

The disclosure is an invasion of privacy and a violation of HIPAA. Because the information is true and verbal, it cannot be considered slander or libel.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   7

TOP:   Disclosure of information              KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

  1. A nurse failed to monitor a patients respiratory status after medicating the patient with a narcotic analgesic. The patients respiratory status worsened, requiring intubation. The patients family claimed the nurse committed malpractice. What must be present for the nurse to be held liable? (Select all that apply.)
a. A nurse-patient relationship exists.
b. The nurse failed to perform in a reasonable manner.
c. There was harm to the patient.
d. The nurse was prudent in her performance.
e. The nurse did not cause the patient harm.
f. Duty does not exist.

 

 

ANS:  A, B, C

For the court to uphold the charge of malpractice, and to find the nurse liable, the following elements must be present: duty exists, there is a breach of duty, and harm must have occurred.

 

DIF:    Cognitive Level: Application          REF:   Page               OBJ:   2

TOP:   Malpractice    KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

COMPLETION

 

  1. Personal beliefs about the worth of an object, idea, custom, or attitude that influence a persons behavior in a given situation are referred to as ___________.

 

ANS:

values

 

Values are personal beliefs about the worth of an object, an idea, a custom, or an attitude. Values vary among people and cultures; they develop over time and undergo change in response to changing circumstances and necessity. Each of us adopts a value system that will govern what we feel is right or wrong (or good and bad) and will influence our behavior in a given situation.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   11| 12

TOP:   Values            KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. Acts whose performance is required, permitted, or prohibited are defined by ___________ of ______________.

 

ANS:

standards, care

 

Standards of care define acts whose performance is required, permitted, or prohibited.

 

DIF:    Cognitive Level: Knowledge          REF:   Page               OBJ:   4

TOP:   Standards of care                            KEY:  Nursing Process Step: N/A

MSC:  NCLEX: N/A

 

Chapter 14: Surgical Wound Care

Cooper and Gosnell: Foundations of Nursing, 7th Edition

 

MULTIPLE CHOICE

 

  1. The nurse is instructing a patient who has a drain in a surgical wound. How will the nurse indicate that the wound will heal?
a. Primary intention
b. Secondary intention
c. Tertiary intention
d. Deliberate intention

 

 

ANS:  C

When wounds are kept open by a drain, they heal by tertiary intention.

 

DIF:    Cognitive Level: Comprehension   REF:   Pages 311-312

OBJ:   4                    TOP:   Tertiary intention

KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What technique will the nurse implement to assist the postoperative patient to cough?
a. Support the patients back
b. Offer an antitussive
c. Splint the abdomen with a pillow
d. Lean patient against the bedside table

 

 

ANS:  C

To assist a postoperative patient to cough, splinting the abdomen with pillow, hands, or a towel roll is helpful to relieve stress on the suture line.

 

DIF:    Cognitive Level: Application          REF:   Page 312        OBJ:   8

TOP:   Suture lines    KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The day following surgery, the nurse notes bloody drainage on the dressing. How will the nurse describe this drainage when documenting?
a. Serosanguineous
b. Sanguineous
c. Serous
d. Purulent

 

 

ANS:  B

The term sanguineous means bloody. It is indicative of active bleeding.

 

DIF:    Cognitive Level: Application          REF:   Page 314, Table 13-2

OBJ:   1                    TOP:   Drainage        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is the advantage of an occlusive dressing?
a. Allows air to the incision
b. Keeps the incision moist
c. Delays epithelialization
d. Does not have to be changed

 

 

ANS:  B

Occlusive dressings keep the incision moist and increase epithelialization.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 315        OBJ:   7

TOP:   Occlusive dressings                        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. When removing the dressing on a patient, the nurse discovers that the gauze dressing has adhered to the wound. What intervention should the nurse implement?
a. Call the RN
b. Gently remove the gauze with sterile forceps
c. Cover with occlusive dressing
d. Moisten the dressing with sterile water

 

 

ANS:  D

When a dressing has adhered to the wound, the nurse may moisten the dressing with sterile water or sterile normal saline to loosen it.

 

DIF:    Cognitive Level: Application          REF:   Page 316        OBJ:   7

TOP:   Dry dressings                                  KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is providing instruction to a patient regarding home wound irrigation. How far should the patient hold the hand-held showerhead from the wound when irrigating the wound?
a. 2.5 inches
b. 6 inches
c. 12 inches
d. 18 inches

 

 

ANS:  C

When wound irrigation is done at home with a hand-held showerhead, the showerhead should be held approximately 12 inches from the wound.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 323        OBJ:   11

TOP:   Wound irrigation                            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is irrigating a leg wound of a patient on the trauma unit. Where should the nurse direct the flow of the irrigant?
a. From the area of least contamination to the area of most contamination
b. Forcefully into the wound
c. Gently over the skin into the wound
d. From a distance of about 12 inches

 

 

ANS:  A

The irrigant should flow from the least contaminated area to the most contaminated area to prevent microorganisms from entering the wound.

 

DIF:    Cognitive Level: Application          REF:   Page 321,       OBJ:   11

TOP:   Wound irrigation                            KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?
a. Call the RN
b. Cover the bowel with a sterile saline dressing
c. Turn the patient to the side of the evisceration
d. Raise the patient up to a high Fowler position

 

 

ANS:  B

Although the RN must be notified, covering the loop of the bowel takes priority. The patient may be raised to a semi-Fowler position to relieve strain on the suture line.

 

DIF:    Cognitive Level: Application          REF:   Page 324        OBJ:   8

TOP:   Evisceration   KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is removing every other staple from a surgical wound, which has been closed with 15 staples. The wound begins to separate after removal of 3 of the 15. What nursing action should be implemented?
a. Remove 7 more alternate staples and securely tape with Steri-Strips
b. Cover with moist dressing and apply a binder
c. Continue to remove staples as ordered because this is an expected outcome
d. Leave the 12 staples in place and record the separation

 

 

ANS:  D

If the wound separates during the removal of staples, cease the removal, cover with a dry dressing, and record the separation.

 

DIF:    Cognitive Level: Application          REF:   Page 325        OBJ:   9

TOP:   Staple removal                                KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The physician has not ordered a dressing change for a draining wound on a patient in an acute care setting. How should the nurse assess the amount of drainage?
a. Weigh the patient to estimate the weight of the saturated dressing
b. Reinforce the dressing
c. Circle and date the outline of the exudate on the dressing
d. Count each dressing as 1 mL of drainage

 

 

ANS:  C

Without an order to change the dressing, the drainage should be circled and dated. Should the dressing become saturated, the dressing can be reinforced but the exudate should still be circled.

 

DIF:    Cognitive Level: Application          REF:   Page 328        OBJ:   7

TOP:   Draining wounds                            KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The Centers for Disease Control and Prevention (CDC) classifies wounds according to the amount of contamination. What is the classification for an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively?
a. Dirty wound
b. Clean-contaminated wound
c. Contaminated wound
d. Clean wound

 

 

ANS:  D

A clean wound is an uninfected surgical wound with less than a 5% chance of becoming infected postoperatively.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 311        OBJ:   5

TOP:   Wounds         KEY:  Nursing Process Step: N/A              MSC:  NCLEX: N/A

 

  1. Hemostasis begins as soon as the injury occurs and a clot begins to form. What is the substance in the clot that holds the wound together?
a. Fibrin
b. Thrombin
c. Protime
d. Calcium

 

 

ANS:  A

Fibrin in the clot begins to hold the wound together.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 311        OBJ:   1

TOP:   Wounds         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. What phase is a wound in when blood and fluid flow into the vascular space and produce edema, erythema, heat, and pain?
a. Healing
b. Inflammatory
c. Reconstruction
d. Maturation

 

 

ANS:  B

During the inflammatory phase, blood and fluid leak out of the blood vessels into the vascular space.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 311        OBJ:   1

TOP:   Wounds         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What marked advantage does primary intention have over other phases of wound healing?
a. Healing is rapid
b. Healing rarely becomes infected
c. Minimal scarring results
d. Healing is painless

 

 

ANS:  C

Wounds that heal by primary intention have minimal scarring.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 311        OBJ:   4

TOP:   Wounds         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient during the first 24 hours following surgery. How often will the nurse assess for bleeding under the dressing?
a. Every 30 minutes
b. Every 60 minutes
c. Every 2 to 4 hours
d. Every 5 to 8 hours

 

 

ANS:  C

The nurse inspects the dressing every 2 to 4 hours for the first 24 hours.

 

DIF:    Cognitive Level: Application          REF:   Page 314        OBJ:   6

TOP:   Wounds         KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is preparing to perform a dressing change on a patient following a total hip replacement. When should the nurse administer an analgesic drug in an attempt to promote patient comfort during the dressing change?
a. After the dressing change
b. At least 15 minutes before the dressing change
c. At least 30 minutes before the dressing change
d. At least 1 hour before the dressing change

 

 

ANS:  C

It may help to give an analgesic at least 30 minutes before exposing the wound.

 

DIF:    Cognitive Level: Application          REF:   Page 316        OBJ:   7

TOP:   Wounds         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry. This drying process causes it to adhere to the wound. What is the result of this intervention when the dressing is removed?
a. Destruction of tissue
b. Bleeding
c. Mechanical debridement
d. Prevention of infection

 

 

ANS:  C

The primary purpose of a wet-to-dry dressing is to debride a wound mechanically.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 318        OBJ:   7

TOP:   Wounds         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse assessing a postoperative patient discovers that the pulse is rapid, blood pressure has decreased, urinary output has decreased, and the dressing is dry. What can the nurse determine is indicated by these findings?
a. Pain shock
b. Dehydration
c. Internal hemorrhage
d. Acute infection

 

 

ANS:  C

If a patient has a rapid pulse, decreased blood pressure, decreased urinary output, and the dressing is dry, then the diagnosis is most likely an internal hemorrhage.

 

DIF:    Cognitive Level: Analysis               REF:   Page 324        OBJ:   3

TOP:   Postoperative                                  KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is the usual length of time before suture removal?
a. 2 to 3 days
b. 4 to 5 days
c. 5 to 6 days
d. 7 to 10 days

 

 

ANS:  D

Sutures are generally removed within 7 to 10 days.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 324        OBJ:   9

TOP:   Wounds         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain. What is the maximum amount of drainage considered normal?
a. 50 mL
b. 100 mL
c. 200 mL
d. 300 mL

 

 

ANS:  D

Drainage greater than 300 mL in 24 hours is considered abnormal.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 327        OBJ:   3

TOP:   Drainage        KEY:  Nursing Process Step: Assessment

MSC:  NCLEX: Physiological Integrity

 

  1. What is the classification for the Jackson-Pratt drainage removal system?
a. Sterile drainage system
b. Closed drainage system
c. Open drainage system
d. Self-measuring drainage system

 

 

ANS:  B

The Jackson-Pratt removal system is a type of closed drainage system.

 

DIF:    Cognitive Level: Knowledge          REF:   Page 329        OBJ:   10

TOP:   Drainage        KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is caring for a patient with a surgical wound. How can the nurse promote healing?
a. Offer fluids every 4 hours
b. Encourage the consumption of large meals
c. Encourage up to 1000 mL of daily fluid intake
d. Encourage the consumption of small frequent meals

 

 

ANS:  D

To promote wound healing, dietary services can provide small frequent feedings. Fluids, when tolerated, should be offered hourly. Unless contraindicated, the nurse should encourage an intake of 2000 to 2400 mL in 24 hours.

 

DIF:    Cognitive Level: Application          REF:   Page 312        OBJ:   2

TOP:   Wound healing                               KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is instructing a patient about the effects of smoking. What accurate information does the nurse provide?
a. Smoking increases the amount of tissue oxygenation.
b. Smoking increases the amount of functional hemoglobin in blood.
c. Smoking may decrease platelet aggregation and cause hypercoagulability.
d. Smoking interferes with normal cellular mechanisms that promote release of oxygen.

 

 

ANS:  D

Smoking reduces the amount of functional hemoglobin in blood, thus decreasing tissue oxygenation. Smoking may increase platelet aggregation and hypercoagulability. Smoking interferes with normal cellular mechanisms that promote release of oxygen to tissues.

 

DIF:    Cognitive Level: Comprehension   REF:   Page 313        OBJ:   6

TOP:   Smoking         KEY:  Nursing Process Step: Implementation

MSC:  NCLEX: Physiological Integrity

 

  1. The nurse is preparing a presentation regarding the effects of diabetes mellitus. What will the nurse include regarding the effects of diabetes mellitus?
a. Improves overall tissue perf

Write a review

Your Name:


Your Review: Note: HTML is not translated!

Rating: Bad           Good

Enter the code in the box below:



 

Once the order is placed, the order will be delivered to your email less than 24 hours, mostly within 4 hours. 

If you have questions, you can contact us here